Promazine in the treatment of delusional parasitosis

Delusional parasitosis (DP) is an uncommon and complex to treat form of delusional disorder, somatic type. The syndrome may occur in association with a number of psychotic disorders, such as schizophrenia, organic mental disorder, or even in dementia with behavioral and psychological symptoms. Evidence of efficacy of treatment options is weak and there is little known about the specific use of typical and atypical antipsychotics. We report on a case of primary DP in a 75-year-old Caucasian woman with a 3-year-long history of dermatological consultations due to unspecified complains who responded to the typical antipsychotic promazine. This case is unique in pharmacological respect as it presents the first reported DP treatment with promazine. It also raises the issue of efficacy and safety of low-potency typical antipsychotics in the elderly population.

Exanthema medicamentosum as a side effect of promazine

Dermatological side effects of psychopharmacological drugs are fortunately not so often. They are mostly presented in the group of mood stabilizers and antiepileptic drugs, particularly the carbamazepine and lamotrigine, and can be manifested through the Stevens Johnson syndrome, Toxic Epidermal Necrolysis (TEN)/Lyell's syndrome with about 30% lethality. According to the literature the group of phenothiazines is the category of drugs with rare appearances of skin reactions. Promazine, aliphatic phenothiazines antipsychotic, including less frequent side effects in the leaflet states increased skin sensitivity to sun, skin rash-associated with contact dermatitis, allergic reactions, cholestatic icterus. The only reported dermatological side effect of promazine is its metabolites deposition in the cornea. Analyzing the e-data basis we have not found references connecting the Exanthema medicamentosum as a side effect of promazine. A forty-two years old female patient was admitted to the Dermatological Clinic because of suspected exanthema, undoubtedly caused by promazine as a medication for Sy. Borderline.

Comparison of the efficacy of new and conventional antipsychotic drugs in the treatment of behavioral and psychological symptoms of dementia (BPSD)

This double-blind study evaluated the efficacy and safety of risperidone or olanzapine vs. promazine in the treatment of behavioral and psychological symptoms in dementia(BPSD). Patients were required to be 65 years or older, to have DSM-IV diagnoses of Alzheimer's disease (AD), vascular dementia (VD) or a combination of both. A brain computerized tomography (CT) was performed for all the patients; 60 demented patients,27 men (45 %) and 33 women (55 %) were selected for this study. The University of California Los Angeles neuropsychiatric inventory (NPI) was administered at baseline, then after 4 and 8 weeks. Patients had at least a score of 24 or more. The Hoehn and Yahr scale was used for evaluating parkinsonism. The scales were administered by an examinator who was not aware of the kind of treatment of the patients. After a wash-out period of 10 days,20 patients, 9 men and 11 women, mean age 76.6 +/- 6.0 years, were randomly assigned torisperidone 1 mg daily in divided doses (morning and bedtime) (Group A); 20 patients, 9 men and 11 women, mean age 82.5 +/- 9.3 years were randomly assigned to olanzapine 5mg at bedtime (Group B), and 20 patients, 9 men and 11 women, mean age 77.6 +/- 4.6 years, were randomly assigned to promazine 50 mg daily (morning and bedtime) (Group C). In case of lack of clinical response, after 4 weeks, the dose could be increased to 2 mg/day of risperidone, 10 mg/day of olanzapine, and to 100 mg/day of promazine in the respective groups. Repeated measures ANOVA was used for the statistical analysis of rating scales over time (baseline, 4 and 8 weeks). At the end of the 8th week, a global improvement was obtained in 80% of patients treated with risperidone and olanzapine, vs. 65 % of patients treated with promazine (p < 0.01). The results show that risperidone in doses of 1-2 mg/day and olanzapine in doses of 5-10 mg/day are effective and safe in the treatment of BPSD. Risperidone presents a major and dose-dependent antidopaminergic action and seems to be preferable when hallucinations and delusions are prevailing symptoms, even if it gives good results on aggression and wandering. Olanzapine seems to be faster in its sedative effect, probably for H1 receptor blockade. Moreover, 5-HT6 antagonism may favor acetylcholine release and this explains why these patients have not presented a cognitive worsening. However, both drugs are comparable or even superior to promazine, with significantly fewer side effects of both anticholinergic and extrapyramidal character.

Neuroleptic prescribing to the community elderly in Nottingham

DESIGN

A cross-sectional pilot survey of computerized prescribing databases and written general practitioner records. Data were abstracted by the first author using a standard proforma.

SETTING

Six out of 12 general practices situated in an area of north Nottingham known to have a high density of residential and nursing homes cooperated with the exercise (one was excluded because it lacked a computer system, one because the principal had a specialist commitment to old age psychiatry and four were self-excluded).

PATIENTS

Patients recorded as receiving repeat prescriptions of oral preparations of thioridazine, chlorpromazine, promazine, haloperidol or trifluoperazine.

MEASURES

Point prevalence rates of neuroleptic repeat prescribing classed by age group and, in the case of the elderly, residential status. For elderly recipients: median (range) duration on neuroleptics, median (range) time since last review and numbers (percentages) having various characteristics.

RESULTS

Elderly patients were found to be more likely consumers of neuroleptic medication than their younger counterparts. If these results are extrapolated nationwide, then approximately half the patients receiving repeat prescriptions for the commonest oral neuroleptics emerge as elderly and of these about half are in nursing/residential care. Patients in nursing/residential homes suffering dementia formed the largest group of recipients, but have the least monitoring by psychiatric teams.

CONCLUSION

The result highlight a need for a close partnership between primary care, community care facilities and old age psychiatric teams to ensure adequate monitoring and the implementation of psychological strategies to minimize their use.

The duration of the movement aftereffect as an index of psychiatric illness

The duration of the movement aftereffect (MAE) has sometimes been used to make inferences about the subject's state (for example, their level of arousal). Some studies are reviewed in which visual aftereffects (including the MAE) were measured in schizophrenia, with inconsistent results. Some relevant psychopharmacological and neurological evidence is considered. It is concluded that: (i) Differences in the clinical status of the schizophrenic subjects and whether they were receiving medication, but not the method used to measure aftereffects, may underlie the interstudy disagreements. (ii) The effect of schizophrenia is to increase MAE duration, and this is not due to some peripheral artefact. (iii) Longer MAEs in the illness could result from enhanced neurally signalled contrast and/or from the increased adaptability of cortical neurons.

[Effect of phenothiazine derivative on adrenal cortex response of sheep to repeated emotional stress]

The study was aimed at the evaluation of propiopromazine (Combelen, Bayer), a derivative of phenothiazine, as an agent lowering in sheep the response to stress. The stress of emotional origin was induced in sheep by the isolation from herd lasting 1 hour. The isolation experiments were repeated 6 times on the same group of sheep, first three isolations (1-3) in daily intervals and next three (4-6) in weekly intervals. Propiopromazine was administered before each isolation experiment. The reaction of sheep to the isolation stress was weaker after propiopromazine administration. This was suggested by smaller increase in blood serum cortisol and glucose levels when compared to sheep subjected to isolation but not receiving the drug. Such effect was especially conspicuous during the course of the first isolation experiment; during the next experiments the difference concerning the reaction to stress between the sheep isolated from the herd receiving and not receiving the drug was gradually diminishing. It was shown in addition that propiopromazine administration to the sheep not subjected to stress caused an increase in cortisol level by 125 per cent and that in glucose level by 35 per cent. These results suggest that propiopromazine administration protects the organism against the effects of emotional stress only partially. Moreover, the effect of its administration gradually weakens with repeating of the stress inducing experiment, and propiopromazine itself may act as a stress inducing factor. It seems therefore that the use of propiopromazine and similar compounds as anti-stress agents may be questionable.

[Drug therapy of so-called postherpetic neuralgia, the only valid alternative. Clinical experience in 43 treated cases]

The efficacy of tricyclic antidepressants in association with neuroleptics having been demonstrated in patients suffering from so-called tardive post-herpetic neuralgia, 43 patients were given this treatment either alone or in association with transcutaneous nerve stimulation (TENS). Of the 33 patients given drug treatment alone, 25 found relief from pain in 3-18 months, 5 produced a partial result and in 3 the treatment failed. The results obtained suggest that this is the most effective treatment as long as it is continuous and given for at least 3-6 months. The use of TENS produced no benefit.

[Inpatient withdrawal treatment of heroin dependence with neuroleptics--an approach to addicts]

The authors present a setting for abrupt withdrawal treatment with the following targets: 1. To facilitate the addicts the voluntary use of medical and psychiatric service. 2. To develop methods for withdrawal treatment, as riskless and easy to handle as possible. 3. To use the time of inpatient treatment for building up confidence in psychiatric services to motivate the patients for a following therapy. Drugs and dosage of peroral and intravenous neuroleptic treatment and possible complications are discussed. Peroral treatment has the advantage of lower doses, easier handling and lower complication rates. The setting and the used drugs seem to be attractive enough for many addicts to contact the clinic on their own account.

[The value of EEG after sleep deprivation for the diagnosis of epileptic seizures, epilepsy and other cerebral disorders]

114 electroencephalographic and 49 clinical criteria of 1010 patients, including 64 healthy volunteers, were evaluated by means of a computer. In 549 patients with epileptic seizures spike wave (sw) paroxysms were seen in 13.3%. Following a 24-hour period of sleep deprivation sw paroxysms were present in 24.2% cases which represents an increase of 82.0%. The number of cases with focal discharges increased in this group from 21.3% initially to 27.5% after sleep deprivation, representing an increase of only 29.1%. The percentage increase in sw paroxysms and focal discharges following sleep deprivation was approximately as marked also in patients without epileptic seizures, so that sleep deprivation was found to be equally useful in patients with non-epileptic cerebral disorders. The rate of activation is higher in children and juveniles than in adults. Similarly, it is higher in patients with awaking epilepsy than in patients with sleep epilepsy. The influence of sleep deprivation and that of sleep, respectively, upon the provocation of EEG changes was not sharply differentiated. By counting sw paroxysms in the EEG before sleep deprivation, in the waking EEG following sleep deprivation, as well as in the subsequent sleeping EEG further evidence was obtained, however, supporting the suggestion that special significance may be attributed to sleep deprivation as a provocation method. If the activation of sw paroxysms and focal changes is related to sleep and sleep stages it can be shown that their frequency decreases from stage 1 to stage 4. In particular, the short fluctuations in vigilance, the waking reactions frequently occurring under routine laboratory conditions and the transitions between sleep stages were seen to assume trigger functions.

Failure of pyridoxine to effect neuroleptic-induced hyperprolactinemia in psychotic patients

The effects of acute and repeated administration of pyridoxine on serum prolactin levels were studied in 18 chronic schizophrenics, 10 women and 8 men, in whom hyperprolactinemia had been induced by long-term treatment with phenothiazines, haloperidol, sulpiride or clopentixol. The patients were divided into 5 groups: group 1 received 300 mg of the vitamin per os in a single dose; group 2 received 300 mg of the vitamin per os for 7 days; group 3 received 300 mg of the vitamin iv as a single bolus; group 4 received 600 mg of the vitamin iv as a single bolus; group 5 received 1200 mg of the vitamin per os in a single dose. Prolactin levels were examined before and 15, 30, 60, 90, 120 and 150 min after the single administration of pyridoxine, either iv or per os, and on days 3,5, 7 of the chronic administration. There was no decrease in prolactin levels either after oral or iv administration of the drug, given in single or repeated doses. Therefore, this treatment is not useful for the suppression of hyperprolactinemia induced by neuroleptics.

[The treatment of chronic pain symptoms with psychotropic drugs (author's transl)]

The results of longlasting experience in the treatment of severe chronic pain are reported. 82% of 103 in-patients with chronic pain responded to a combined treatment with neuroleptic and antidepressant drugs. A dosing strategy for the combbination of clomipramine and haloperidol is described.

[Psychotropic drugs for behavior disorder treatment in oligophrenic epileptics]

Forty-one patients were treated with promazine, a phenothiazine derivative, for an average of 266 days. The average daily dose was 200 mg. Thirty patients were treated with levomepromazine for an average of 115 days, the daily dose being about 130 mg. The two groups of patients were examined for their contactual, impulsive, and affective behavior before, during, and after treatment. The positive results obtained justify the use of the above-mentioned psychopharmaceuticals for the therapy of abnormal behavior of oligophrenic epileptics.

Acute hypertension immediately after coronary artery surgery

Hypertension immediately after coronary surgery is a problem in about one third of the patients so treated. This report discusses the possible causes of postoperative hypertension and describes several means of controlling the complication.

Recent developments in the drug treatment of schizophrenia

The author reviews six topics relevant to the drug treatment of schizophrenia. The quantitative effectiveness of promazine is of interest with respect to the structural models of the phenothiazines and the dopamine theory of schizophrenia. The quantitative effectiveness of antipsychotic drugs is also important in evaluating new agents and therefore relevant to a discussion of two newly released neuroleptics, molindone and loxapine. The author's discussion of high-dose treatment of typical acute schizophrenics or treatment-resistant patients reviews the available data and calls attention to the fact that these areas of pharmacologic research have not received sufficient attention.

Anxiety/depression in elderly patients. A double-blind comparative study of fluphenazine/nortriptyline and promazine

A double-blind study involving sixty-two patients, aged 65 years or over, treated for twenty-eight days, showed that fluphenazine 0-5 mg/nortriptyline 10 mg three times daily was superior to promazine 50 mg three times daily in relieving symptoms of anxiety and was associated with a lower incidence of side-effects. The results are discussed in the light of the nature of anxiety/depression syndromes in the elderly and it is suggested that since symptoms of anxiety in these disorders are often manifestations of an underlying depressive illness, the antidepressant effect of the nortriptyline may have enhanced the 'anxiolytic' advantage of fluphenazine/nortriptyline.

Mutism induced by phenothiazines

The purpose of this communication is to present a group of patients who, while receiving treatment with one of the phenothiazine derivatives in average range of doses regarded as suitable for adults, developed a syndrome comprising mutism and a number of other neurological features. In the majority of these patients speech loss is almost complete; but, unlike aphasics, they may respond to repeated questioning by simple utterances usually spoken in a whisper, or else are capable on rare occasions, quite unexpectedly, of delivering remarks which are appropriate and may be spoken normally. Speech deprivation is as a rule associated with an inability to communicate either by gestures or writing and also an inability to perform many customary tasks. Mutism is, therefore, not an isolated disability, but is associated with a wide range of disturbances of behaviour and of level of consciousness. In addition, some of the patients exhibit one or more of the neurological toxic phenomena encountered in the course of medication with phenothiazine derivatives, e.g. akathisia, buccal dyskinesias, dystonias, tremor and parkinsonism.