Neuroleptics agitation from

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-... 

In addition to acute and chronic schizophrenia, the neuroleptics are sometimes used in the management of mania, delirium, and severe agitation, whatever the cause of these symptom complexes. It must be noted that unlike parkinsonism, where a definite dysfunction in the DA system has been established, for schizophrenia and other psychiatric diseases, no unequivocal evidence has yet been presented to prove that there is a disturbance of the DA system (e.g., dopaminergic overactivity or receptor hypersensitivity). In untreated schizophrenics the production of DA metabolites is normal. Conflicting results have been obtained in studies of the DA receptors in schizophrenics (11,12,13), but in the case of patients who have not received neuroleptics, the receptor density and affinity appear to be normal (13). The "dopamine hypothesis" in these disorders derives from the beneficial effects of drugs that block DA receptors. 

Akathisia was first described in association with neuroleptic drugs. The inner agitation associated with akathisia can become extremely uncomfortable, causing the individual to feel tortured from within (see vivid descriptions in Van Putten, 1974, 1975a b Breggin, 1997a), leading to extreme irritability and suicide or violence. 

Prozac and the other SSRIs, as well as any antidepressant that blocks the removal of serotonin from the synapse, can produce a well-documented, severe condition called the serotonin syndrome (Sternbach, 1991). This disorder includes the usual signs of overstimulation, such as euphoria and hypomania, agitation, confusion, and gastrointestinal upset, including diarrhea. However, the serotonin syndrome additionally involves overstimulation of the brain stem and spinal cord, producing fever and chills, severe incoordination, muscle spasms, and hyperactive reflexes. It bears some similarity to neuroleptic malignant syndrome, and like NMS it can also be lethal (chapter 4). 

In the light of evidence from large, randomized, double-blind trials, the authors of a thorough review of the role of atypical neuroleptic drugs in the treatment of psychosis and agitation associated with dementia have concluded that low-dose risperidone (0.25-1.5 mg/day) can be used as first-line treatment (19). 

To a lesser extent, antipsychotics also have been used in the treatment of mania, agitated depression, toxic (such as drug-induced) psychoses, emotionally unstable personalities, and psychoses associated with old age. Antipsychotic medications arc also known as neuroleptics or major tranquilizers (the latter term is used much less frequently now). The term neuroleptic is derived from the Greek word that means to clamp the neuron (Snyder 8c Largent, 1989). Antipsychotics the term more commonly used in the United States, with neuroleptics used more often in Europe. The terms are used interchangeably in this discussion. Representative antipsychotic medications are li.sted in Table 13.1. 

Chlorpromazine produces a tranquihty characterized by a detached serenity without depression of mental faculties or clouding of consciousness. It depresses the CNS selectively by reducing input directed to the reticular formation through collaterals arriving from the sensory pathways. Chlorpromazine-induced sedation differs from that caused by barbiturates in that the patient can be easily aroused. In practice, the more sedative neuroleptics are often prescribed for agitated, overactive patients, and the less sedative agents are used for apathetic, withdrawn patients. However, sedation is not necessary for its antipsychotic property for two reasons (1) tolerance develops to the sedative effects, and (2) fluphenazine, prochlorperazine, and trifluoperazine are excellent neuroleptics that lack pronounced sedative effects. 

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