Withdrawal from neuroleptics

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-... 

The diagnosis of GHB withdrawal may be difficult because it is similar to sedative or alcohol withdrawal syndromes, as well as to withdrawal from sympathomimetic agents such as cocaine, methamphetamine, and ecstasy. GHB withdrawal may also be confused with serotonin syndrome (a reaction caused by a combination of drugs, one of which increases serotonin levels in the body, such as Prozac) and neuroleptic malignant syndrome (a rare reaction to an antiseizure medication). 

Jeste et ah (1993), in an ongoing prospective study, found that 26% of middle-aged and elderly patients developed TD after 12 months. Reviewing the literature on neuroleptic withdrawal, the authors found that almost 60 percent of the patients withdrawn from neuroleptics did not relapse over a mean period of 6 months. They concluded, It seems... 

Withdrawal symptoms often include a temporary worsening of dys-kinetic effects, both painful and frightening. As documented in chapter 5, withdrawal from neuroleptics commonly produces a level of emotional suffering and disturbance more severe than anything the individual experienced prior to starting the medication. In adults, this frequently manifests as psychotic symptoms worse than anything experienced prior to starting on the medication. In children, it can result in very disturbed behavior. 

Because of the withdrawal symptoms, it is often necessary to reduce neuroleptic drugs at a very slow rate. Sometimes withdrawal seems to become impossible. I describe the principles of safely withdrawing from psychiatric drugs in chapter 15. 

During withdrawal from both the older and newer neuroleptics, the individual can experience severe abnormal movements during withdrawal. They can be painful and frightening and can become persistent in the form of tardive dyskinesia (chapter 4). Severe emotional suffering and psychosis are common withdrawal reactions (chapters 4 and 5). Children may undergo severe behavioral worsening. Depression can occur. 

Brooks, G. W. (1959). Withdrawal from neuroleptic drugs. American Journal of Psychiatry, 115, 931-932. 

Simpson DM, Davis GC. Case report of neuroleptic malignant syndrome associated with withdrawal from amantadine. Am J Psychiatry 1984 141(6) 796-7. 

Lim TT, Ahmed A, Itin 1, Gostkowski M, Rudolph J, Cooper S, et al. Is 6months of neuroleptic withdrawal sufficient to distinguish drug-induced parkinsonism from Parkinson s disease Int J Neurosci 2013 123(3) 170-4. 

Benzamides are heterocyclic neuroleptics. These include the gastroenterologic agents metoclopramide and cisapride, which have antiserotonergic as well as anti-D2 receptor dopaminergic actions and also the antipsychotic agents sulpiride and tiapride. Tachyarrhythmias have resulted in the withdrawal of cisapride from general use. 

Clozapine withdrawal symptoms occur after stopping therapeutic doses (range 200 to 900 mg/day) administered from 4 months to several years. In a study, one-third of patients who were switched directly from clozapine to risperidone remained stable, one-third had to be switched back to clozapine, and one-third were treated with combined risperidone-clozapine or risperidone-neuroleptic ( 480). 

Furthermore, at the times they were being evaluated, the patients continued to take the olanzapine, which, like all neuroleptics, suppresses the appearance of TD symptoms while at the same time causing or worsening the underlying disorder (see subsequent section). Therefore, the only way to determine an accurate rate of TD is to withdraw the patients from the offending drug before the final evaluation. In this study, the actual rate of TD would have been much higher than 3% per year if the patients had been withdrawn from the olanzapine before the final TD evaluation. 

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