Dystonia with antipsychotics

Acute dystonia is a recognized complication of treatment with antipsychotic drugs and it can also occur with SSRIs and the anxiolytic drug buspirone. 

Two patients with schizophrenia who developed focal tardive dystonia with atypical antipsychotic drugs (risperidone and olanzapine) had marked sustained improvement when quetiapine was gradually introduced and the other antipsychotic drugs were withdrawn there was no loss of control of psychotic symptoms (10). 

INDIRECT ANTIPSYCHOTICS 1. Case reports of paralytic ileus with trifluoperazine and methylphenidate 2. Case report of acute dystonias with haloperidol and dexamfetamine 3.1 efficacy of chlorpromazine when dexamfetamine was added 1. Additive anticholinergic effect 2. Uncertain possibly due to t dopamine release 3. Uncertain 1. Watch for signs of altered bowel habit 2. Warn patients of this rare interaction 3. Avoid co-administration... 

The authors of the report suggest that this reaction was possibly caused by the additive dystonic effects of the loxapine and sumatriptan, despite the presence of the benzatropine. Dystonia is not an uncommon extrapyramidal reaction associated with antipsychotics, and neck stiffness and dystonia are recognised adverse effects of sumatriptan, but of low incidence. This seems to be the first and only report of this apparent interaction, and therefore its general significance is unclear. 

Among the most significant adverse reactions associated with the antipsychotic dm are the extrapyramidal effects. The term extrapyramidal effects refers to a group of adverse reactions occurring on the extrapyramidal portion of the nervous system as a result of antipsychotic drains. This part of the nervous system affects body posture and promotes smooth and uninterrupted movement of various muscle groups. Antipsychotics disturb the function of the extrapyramidal portion of the nervous system, causing abnormal muscle movement. Extrapyramidal effects include Parkinson-like symptoms (see Chap. 29), akathisia, and dystonia (see Display 32-1). 

Two extrapyramidal conditions, acute dystonia and akathisia, occur early during treatment, while parkinsonism tends to evolve gradually over days to weeks. All three reactions occur most commonly with the high-potency antipsychotics (Table 34.1) and are related to high Dz-receptor occupancy. Acute dystonia, which occurs in about 5% of patients on antipsychotic therapy, consists of uncontrollable movements and distortions of the face, head, and neck. It can be treated with centrally acting an-timuscarinic agents, such as benztropine, while antipsychotic therapy is temporarily discontinued. When this reaction subsides, the anticholinergic can be withdrawn. 

The working assumption that the striatal system is only involved with extrapyramidal function (e.g., parkinsonian side effects, dystonias, and TD) and that the mesolimbic or mesocortical systems are only involved with psychosis may be an oversimplification. Many of the neuroanatomical studies on the identified dopaminergic tracts are done with rats. In the monkey, by contrast, there are many more DA tracts that are either absent in the rat or at least markedly different human systems could be different from the rat s or monkey s. Understanding the neuropharmacology of the antipsychotics is further complicated, given that neither the mesolimbic-mesocortical nor the striatal systems are homogeneous but may also include various subsystems. 

Unfortunately, these drugs—especially the first generation of antipsychotics introduced in the 1950s—have side effects similar to those seen in patients with Parkinson s disease tremors when at rest, reduction of voluntary movement, muscle spasticity and dystonia, or sustained muscle contractions. These symptoms confirm the role of dopamine neurons in the initiation and control of movement. Antipsychotic drugs also block dopamine receptors within a region of the brain that controls... 

Patients taking olanzapine reported a low incidence of dystonias, which may be about 0.3% (SEDA-22, 56). In the light of two new cases of acute dystonia associated with olanzapine in patients with previous history of dystonia or parkinsonism related to antipsychotic treatment, comparative figures have been reported. Acute dystonia occurred in 1.4% of patients who took olanzapine, compared with 5.0-6.3% of those taking haloperidol (84). 

The traditional or typical antipsychotics are dopamine inhibitors that block other neurotransmitters such as acetylcholine, histamine, and norepinephrine. Extrapyramidal symptoms (EPS) are a common side effect with these medications, and the social worker must be able to recognize them. Dystonia is one of the movement problems that may occur, and acute dystonic reactions may present as grimacing, difficulty with speech or swallowing, oculogyric crisis (upward rotation of the eyeballs), muscle spasms of the neck and throat, and extensor rigidity of the back muscles (Carpenter, Conley, Buchanan, 1998). Very often these parkinsonian reactions will occur within the first few days of treatment. It is not uncommon for the client to approach the social worker complaining of a thick or stiff tongue that impairs the ability to speak. 

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