Dystonic reactions, acute

When an antipsychotic is needed, we prefer using one of the newer atypical agents olanzapine, ziprasidone, risperidone, quetiapine, or aripiprazole. Each of these medications reliably reduces agitation and is well tolerated. In particular, they decrease the potential for acute dystonic reactions and tardive dyskinesia caused by the typical antipsychotics. Both ziprasidone and olanzapine are now available in an injectable form that is very rapidly acting and effective in this setting. 

In addition to parkinsonism, another extrapyramidal side effect is the so-called acute dystonic reaction in which muscles (usually of the face or neck) go into an acute spasm. A dystonic reaction is painful and unpleasant, usually occurs early in treatment, and sometimes occurs after the very first dose of an antipsychotic. Another extrapyramidal symptom is akathisia, a restless inability to relax and sit still. Akathisia can range from a mild restlessness to extreme agitation. Rarely, patients have been known to attempt suicide during severe episodes of akathisia. It is easy to overlook akathisia, because it can easily be mistaken for a worsening of psychosis or anxiety. 

Acute dystonic reactions 1 to 2 mL IM or IV usually relieves the condition quickly. After that, 1 to 2 mL orally 2 times/day usually prevents recurrence. 

Extrapyramidal symptoms Extrapyramidal symptoms, manifested primarily as acute dystonic reactions, occur in approximately 0.2% to 1% of patients treated with the usual adult dosages of 30 to 40 mg/day. These usually are seen during the first 24 to 48 hours of treatment, occur more frequently in children and young adults, and are even more frequent at the higher doses used in prophylaxis of vomiting caused by cancer chemotherapy. If symptoms occur, they usually subside following 50 mg diphenhydramine IM. Benztropine 1 to 2 mg IM may also be used to reverse these reactions. 

Most antipsychotics and especially the piperazines and the butyrophenones can cause extrapyra-midal symptoms. Blockade of dopamine receptors mainly in the corpus striatum is held responsible for these extrapyramidal effects. They may become manifest as a variety of clinical symptoms and it should be noted that within 24 8 hours after the beginning of treatment acute dystonic reactions like torticollis, facial grimacing and opisthotonos may occur. Parkinsonism-like symptoms such as bradyki-nesia, rigidity and tremor occur after weeks or months of therapy and are more common in the elderly. Motor restlessness, i.e. akathisia, also mostly occurs not before weeks or months after starting therapy. The tendency of an antipsychotic agent to produce extrapyramidal symptoms appears to be inversely related to its ability to block cholinergic receptors. 

Intramuscular haloperidol is a suitable drug for tranquillizing violent patients, but it can be difficult to determine the correct dosage, and there is the risk of an acute dystonic reaction, particularly in younger patients. The British National Formulary recommends intramuscular injections of from 2 to 10 mg, subsequent doses being given after 4-8 hours but in exceptional cases, initial doses of up to 30 mg may be necessary. 

Acute dystonic reactions IV,IM Initially, 1-2 mg then 1-2 mg PO twice a day to prevent recurrence. 

Treat acute dystonic reactions wit h parenteral diphenhydramine (2 mg/kg to max 50 mg) orbenztropine (2 mg)... 

The most common forms of EPS that occur early in the course of treatment include acute dystonic reactions (ADRs), drug-induced Parkinsonism, and akathisia. The ADRs are involuntary muscle spasms or contractions. An ADR typically involves muscles in the neck and/or the extraocular muscles, and can be painful and... 

Campbell and co-workers conducted several controlled studies of haloperidol in autistic children (Campbell et al., 1978 Cohen et al., 1980 Anderson et al., 1984, 1989). Haloperidol, in doses of 1 to 2 mg/ day, was found to be more effective than placebo for withdrawal, stereotypy, hyperactivity, affective lability, anger, and temper outbursts. Acute dystonic reactions and withdrawal and tardive dyskinesias were not infrequent, however. 

Sleep disorders agitation, acute dystonic reactions... 

EPS include acute dystonic reactions, parkinsonian syndrome, akathisia, tardive dyskinesia, and neuroleptic mahgnant syndrome. Although high-potency conventional antipsychotics are more hkely than low-potency conventional antipsychotics to cause EPS, all first-generation antipsychotic drugs are equally hkely to cause tardive dyskinesia. The atypical antipsychotics cause suhstantially fewer EPS, which is one reason that they are recommended as first-line agents. 

An accurate diagnosis is important because these symptoms may be mistaken for an exacerbation of the psychosis, prompting an escalation in dose when a decrease or an antiparkinsonian drug should be considered. At times, a therapeutic trial with an agent such as procyclidine, benztropine, or diphenhydramine can be diagnostic, because acute dystonic reactions usually respond in minutes to parenteral administration of these agents. 

Acute dystonias are typically seen in the first few days to weeks of treatment and can occur with even limited exposure (e.g., children treated with a single dose of prochlorperazine for nausea). Although dystonias may disappear spontaneously, they should be treated aggressively, as they are often painful and upsetting to the patient. Rarely, laryngeal dystonias may seriously compromise respiration. Occasionally, an acute dystonic reaction is resistant to standard treatment but may respond to parenteral diazepam, caffeine sodium benzoate, or barbiturate-induced sleep. 

Some of the H antagonists, especially diphenhydramine, have significant acute suppressant effects on the extrapyramidal symptoms associated with certain antipsychotic drugs. This drug is given parenterally for acute dystonic reactions to antipsychotics. 

Restlessness, drowsiness, fatigue, lassitude, insomnia, headache, confusion, dizziness, mental depression Extrapyrainidal Reactions Acute dystonic reactions. Parkinsonian-like symptoms Endocrine Disturbances... 

The most common symptomatic dystonias result from the administration of neuroleptics and occur as acute dystonic reactions or as tardive dyskinesia. 

Acute dystonic reactions occurring following the administration of potent neuroleptics are reported primarily in young men and usually develop shortly after the start of therapy. By contrast, tardive dystonia occurs following chronic neuroleptic treatments as with tardive dyskinesia, symptoms often begin after the abrupt withdrawal of the neuroleptic. Although less severe than acute dystonic reactions, tardive dystonia is frequently permanent and difficult to treat. 

Too often, these reactions are mistakenly diagnosed as mental illness. Simpson (1977) observed, Acute dystonic reactions are of sudden onset and consist of bizarre muscular spasms that have been misdiagnosed as... 

There were no changes in lithium pharmacokinetics when risperidone was substituted open-label for another neuroleptic drug in 13 patients (634). On the other hand, an 81-year-old man had an acute dystonic reaction 4 days after lithium was added to a regimen of risperidone, valproic acid, and benzatropine (635). 

Durrenberger S, de Leon J. Acute dystonic reaction to lithium and risperidone. J Neuropsychiatry Clin Neurosci 1999 ll(4) 518-9. 

The CYP2D6 genotype is not a determinant of susceptibility to acute dystonic reactions, but may be a contributory factor in neuroleptic drug-induced movement disorders, including tardive dyskinesia (176). 

Acute dystonic reactions are dramatic, acute-onset muscular spasms that occur within the first 24-48 hours after starting therapy, or in a few cases when the dosage is increased. A circadian pattern of acute dystonic reactions has been described (198). Men are more susceptible than women to this reaction, and the young more so than the elderly (199). Drug-induced dystonia can also be... 

These include postnatal depression and acute dystonic reactions (which may interfere with normal delivery). Hypotonia can persist for months (569) and may respond to diphenhydramine 5 mg/kg/day. Severe rhinorrhea and respiratory distress in a neonate exposed to fluphenazine hydrochloride prenatally has been reported (484). Neonatal jaundice, hyperbilirubinemia, and melanin deposits in the eyes have occurred when neuroleptic drugs were given during the last trimester or longer during pregnancy. 

In a retrospective study of 116 patients taking neuroleptic drugs, 42% of cocaine users versus 14% of non-users developed dystonic reactions (640). This suggests that the use of cocaine may be a major risk factor for acute dystonic reactions secondary to the use of neuroleptic drugs. 

Hegarty AM, Lipton RG, Merriam AE, Freeman K. Cocaine as a risk factor for acute dystonic reactions. Neurology 1991 41 1670-2. 

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