Antipsychotics syndrome

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Other sedative-hypnotic medications, such as barbiturates, may play a useful role in severe withdrawal from this group of drugs. For example, in a case series of GBL withdrawal, use of intravenous pentobarbital in the range of 1-2 mg/kg/hour lowered the total requirement for intravenous lorazepam (Sivilotti et al. 2001). Antipsychotic medications are often used to reduce psychotic agitation. However, because antipsychotic medications lower the seizure threshold and may contribute to loss of central control of temperature leading to hyperthermia or neuroleptic malignant syndrome (NMS), they are not indicated as first-line medications for GHB withdrawal delirium (Dyer and Roth 2001 McDaniel and Miotto 2001 Sharma et al. 2001). If anti-... 

Meyer, J. M., Nasrallah, H. A., McEvoy, J. P., Goff, D. C. et al. (2005). The clinical antipsychotic trials of intervention effectiveness trial clinical comparison of subgroups with and without metabolic syndrome. Schizophr. Res., 80, 9-18. 

Schiilevoort, I., de Boer, A., van der Weide J. et al. (2002). Antipsychotic-induced extrapyramidal syndromes and cytochrome P450 2D6 genotype a case-control study. Pharmacogenetics, 12, 235-40. 

The answer is c. (Hardman, pp 414-4163) Unwanted pharmacologic side effects produced by phenothiazine antipsychotic drugs (e.g., perphenazine) include Parkinson-like syndrome, akathisia, dystonias, galactorrhea, amenorrhea, and infertility. These side effects are due to the ability of these agents to block dopamine receptors. The phenothiazines also block muscarinic and a-adrenergic receptors, which are responsible for other effects. 

The answer is c. (Hardman, pp 574—575.) Phencyclidine is a hallucinogenic compound with no opioid activity Its mechanism of action is amphetamine-like. A withdrawal syndrome has not been described for this drug in human subjects. In overdose, the treatment of choice for the psychotic activity is the antipsychotic drug haloperidol. 

The answer is d. (Hardman, p 420. Katzung, p 4852) Tourette s syndrome is effectively treated with haloperidol, a high-potency antipsychotic. If patients are unresponsive or do not tolerate haloperidol, they might be switched to pimozide. 

Pimozide (Orap). Pimozide is probably the most potent of all antipsychotics, but it is seldom used to treat schizophrenia. Instead, pimozide is most often used to treat Tourette s syndrome. There is actually no reason why pimozide can t be used to treat psychosis and no reason why other antipsychotics are not effective in Tourette s syndrome. Pimozide was simply used first in controlled clinical trials to treat Tourette s syndrome, and the physicians who routinely treat that illness became accustomed to using it. Pimozide is only available in an oral form. The lack of an injectable form to treat agitated patients as well as the lack of availability of data from controlled trials in schizophrenia patients likely explains why it has not been used very often in the treatment of schizophrenia. 

Miscellaneous. In recent years, other medication classes have been tested in the treatment of specihc anxiety syndromes. For example, atypical antipsychotics have been used as adjunctive treatments for OCD and GAD, and mood stabilizers have been used to treat PTSD. These syndrome-specific regimens will be discussed in the following sections. 

One exception is the patient with both ADHD and tic disorders such as Tourette s syndrome. High potency antipsychotics have proved quite effective in treating both vocal and motor tics. 

Yet another neuropsychiatric complication of TBI is a set of behavioral disturbances including impulsivity, irritability, disinhibition, and/or aggression. These symptoms appear to be more likely to arise when the brain injury involves the temporal or orbitofrontal brain regions. Treatment options for these disruptive behavioral syndromes include antidepressants, buspirone, anticonvulsants, antipsychotics, beta blockers, and stimulants (see Table 12.1). 

The so-called atypical antipsychotics represent one of the newest options for managing disruptive behavioral syndromes. Because they have yet to be studied in patients who have suffered a TBI, we certainly cannot recommend the atypical antipsychotics for routine first-line use. Nevertheless, an atypical antipsychotic might prove helpful when other medicines aren t providing satisfactory results in the management of severe behavioral disturbances. Ziprasidone (Geodon) is available in an injectable form that we have found to be particularly helpful in TBI patients. 

Neuroleptic malignant syndrome (NMS) A potentially fatal symptom complex sometimes referred to as NMS has been reported in association with promethazine alone or in combination with antipsychotic drugs. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (eg, irregular pulse or blood pressure, tachycardia, diaphoresis, cardiac dysrhythmias). 

Tardive dyskinesia Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with neuroleptics (eg, antipsychotics). Amoxapine is not an antipsychotic, but it has substantive neuroleptic activity. 

Neuroleptic malignant syndrome (NMS) NMS is a potentially fatal condition reported in association with antipsychotic drugs and with amoxapine. 

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