Neuroleptic-Induced Parkinsonism

All drugs that block dopamine—including nearly all of the older and newer neuroleptics—commonly produce a reversible parkinsonism syndrome. They can also cause separate aspects of the syndrome, such as bradykinesia. Van Putten (1974) described the following reaction  

After seven days she complained of unbearable fatigue ... I have slowed down. I talk slower and move slower (objectively this was apparent only after she called our attention to it). I feel like an old lady. I get tired from walking around the block. I feel discouraged about the future. I have no enthusiasm. I can t type nearly as fast at my job (clerk typist)... I want my own personality back. (ellipses original) 

Drug-induced parkinsonism is sometimes confused with a mental disorder like depression or schizophrenia. Davis et al. (1975) warned that psychiatrists should be aware that patients who appear apathetic, lacking in spontaneity, relatively unable to participate in social activities, lifeless, zombielike, or drowsy may have subtle extrapyramidal side effects. As Lavin et al. (1992) confirmed, when clinicians mistakenly attribute 

Similarly, The American Psychiatric Publishing Textbook of Clinical Psychiatry (Marangell et ah, 2003) pointed out  

Akinesia is defined as a behavioral state of diminished spontaneity characterized by decreased gestures, unspontaneous speech, apathy and difficulty with initiating usual activities. Akinesia may appear after several weeks of therapy and often is an element of the Parkinsonism syndrome. 

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I have communicated with neurologists who find that neuroleptic-induced parkinsonism does sometimes become permanent. This is consis-... 

Lavin, M., Rifkin, A. (1992). Neuroleptic-induced Parkinsonism. In J. Kane J. Lieber-man (Eds.), Adverse effects of psychotropic drugs. New York Guilford. 

Choulnard, J., Annable, L, Ross-Choulnard, A., Kropsl, M.I. 1979 Ethopropazlne and Benztroplne in Neuroleptic-Induced Parkinsonism. J. Clin. Psychlat. 40 147-152. 

Common adverse drug-related effects are hip fractures, cognitive impairment, and neuroleptic-induced parkinsonism. 

Binder RL, Kazamatsuri H, Nishimura T, et al Tardive dyskinesia and neuroleptic-induced parkinsonism in Japan. Am J Psychiatry 144 1494-1496,1987... 

Ethaproprazine is used as an adjunct in the treatment of Parkinson s disease or in neuroleptic-induced parkinsonism. Most phenothiazine neuroleptics have weak anticholinergic properties. However, the anticholinergic effects of thioridazine or ethaproprazine are pronounced, and all... 

Lutz EG. Neuroleptic-induced parkinsonism fecilitated ly alcohol. J Med Soc New Jers (1978) 75, 473. ... 

Fleischhauer, J. (1975) Open withdrawal of antiparkinson drugs in the neuroleptic induced parkinson syndrome. Int. Pharmacopsychiat., 10, 222. 

Postmortem studies of patients with idiopathic Parkinson s disease demonstrate cell loss in the striatal system (A-9), directly implicating this tract vis-a-vis the neuroleptic-induced pseudoparkinsonian side effects. The assumption that psychosis is related to the A-10 system is made by exclusion. Evidence also indicates that clozapine may differentially block DA pathways. Specifically, it seems to act on the mesolimbic dopaminergic system (A-10), while being relatively inactive in the striatal system (A-9) however, this remains controversial. Chronic administration of clozapine decreases the firing rate of A-10 mesocortical tract dopamine neurons... 

Drug-induced Parkinsonism may arise following the long-term administration of neuroleptics that block central dopamine receptors or reserpine-like drugs that deplete dopamine stores. Because of their mode of action, neuroleptics should never be coadministered to patients being treated with L-dopa or vice versa. 

Before the profession became so conscious of improving its public and professional image, many psychiatrists connected the parkinsonism syndrome to the therapeutic effect of neuroleptics (described in Davis et al., 1975 Paulson, 1959). Cole (1960) said that in some cases, the use of drug-induced parkinsonism to control the patient was the equivalent of using toxicity as therapy. Cole went so far as to use the phrase pharmacologic straitjacket to describe the drug effect. 

The neuroleptics produce a variety of acute, temporary neurological disorders referred to as extrapyramidal symptoms (EPS) in the great majority of patients. As described in chapter 3, drug-induced parkinsonism is one... 

Different strategies for the treatment of neuroleptic drug-induced parkinsonism have been reviewed (SEDA-18, 48) (SEDA-20, 40) (238,239). The WHO has recommended that anticholinergic drugs should not be given routinely to patients who are starting to take neuroleptic drugs. 

Seborrheic dermatitis has been observed in patients receiving long-term neuroleptic drugs (SEDA-17, 57), and this adverse effect appears to be highly associated with drug-induced parkinsonism. 

Caligiuri MP, Lacro JP, Jeste DV. Incidence and predictors of drug-induced parkinsonism in older psychiatric patients treated with very low doses of neuroleptics. J Clin Psychopharmacol 1999 19(4) 322-8. 

Spivak B, Mester R, Abesgaus J, Wittenberg N, Adlersberg S, Gonen N, Weizman A. Clozapine treatment for neuroleptic-induced tardive dyskinesia, parkinsonism, chrome akathisia in schizophrenic patients. J Clin Psychiatry 1997 58(7) 318-22. 

Whether treatment with olanzapine is useful in psychotic patients with neuroleptic drug-induced parkinsonism, or even in dopaminergic psychosis in Parkinson s disease, remains unclear. In a retrospective study of 19 patients... 

Some antihistaminics such as benztropine (Cogentin) are used in the treatment of parkinsonism and in controlling neuroleptic-induced pseudoparkinsonism. Furthermore, diphenhydramine is most effective in reversing neuroleptic-induced dystonia. The usefulness of these agents in the management... 

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