Antipsychotic Drugs
Sahab Uddin, Rashid Mamunur in Advances in Neuropharmacology, 2020
A number of brain chemicals, including dopamine (DA) and serotonin, may play a role in psychosis development (Rizvi and Maurya, 2007). There is accumulating evidence that stress plays a role in the etiopathogenesis of mental disorders, particularly schizophrenia, and bipolar disorders (BDs), which commonly start at early ages with a first episode psychosis (Kapur, 2003). The conventional antipsychotics produce undesirable effects like hyperprolactinaemia, neuroleptic malignant syndrome (NMS) and extrapyramidal symptoms (EPS), which are associated with high doses. The difference between atypical antipsychotics and conventional antipsychotics can be characterized by its effectiveness, increased safety, and influence on behavior. Atypical antipsychotics possess a high rate of responders, lower risk of suicides, improved quality of life, favorable pharmacoeconomic profile, better functional capacity, and efficiency in patients with refractory disease. Many studies focus on the interaction of the receptor with the drugs as observed by their therapeutic actions.
Anticholinergic and Neuroleptic Drugs
Frank A. Barile in Barile’s Clinical Toxicology, 2019
Acute dystonic reactions appear in 95% of patients, predominantly young males, within 4 days of initiation of therapy or as dosage increases. In contrast, akathisia affects mostly elderly patients in early treatment (the first 60 days) and subsides with lower dosage. Parkinsonism develops within 10 weeks of therapy and affects 90% of patients, although it is reversible at lower doses. It is important to note that the risk of developing a tardive disorder, and the likelihood that it will become irreversible, increases with the duration of treatment and with the total cumulative dose of neuroleptic drug. As neuroleptic agent is withdrawn, dopamine activity increases, and tardive dyskinesia emerges. The effect is probably due to upregulation of dopamine receptors in the corpus striatum, especially with chronic neuroleptic treatment. Neuroleptic malignant syndrome (NMS) is a potentially fatal idiosyncratic complication occurring in 2% of patients on antipsychotic therapy. It is an extreme EPS reaction resulting from excessive antidopaminergic activity. Precipitating factors include abrupt withdrawal of antiparkinson dopamine agonist drugs (L-dopa) or anticholinergic medication, or a rapid increase in the dose of neuroleptics. Meningitis and anticholinergic poisoning mimic NMS and must be ruled out.
Clinical indications for ECT: adults
Alan Weiss in The Electroconvulsive Therapy Workbook, 2018
Neuroleptic malignant syndrome is a medical emergency that can arise as a complication of using antipsychotic medications owing to abnormal dopaminergic activity in the brain. In 2001, a Task Force report of the American Psychiatric Association (American Psychiatric Association, 2001) identified the benefits of using ECT as treatment of this condition. ECT is often considered when medication strategies have failed. Davis, Janicak and Sakkas (1991) noted that those patients who did not receive active treatment had a higher mortality rate than those receiving ECT or medication: 21% compared to 10.3%. Strawn, Keck and Caroff (2007) suggested that, if neuroleptic malignant syndrome did not respond to withdrawal of antipsychotic medication, treatment with a dopamine agonist and muscle relaxant and supportive therapy then ECT should be considered. In a series of 45 case reports, with nine new cases of neuroleptic malignant syndrome treated with ECT, the authors highlighted that ECT is the preferred choice and can be a life-saving treatment in severe cases (Trollor and Sachdev, 1993). Such reports highlight the need for care in the administration of anaesthetic agents, particularly suxamethonium, owing to the high level of autonomic instability. This may result in a potential risk of a malignant hyperthermia a similarly worrying condition (Trimble and Krishnamoorthy, 2005).
Atypical Neuroleptic Malignant Syndrome: Case Reports and Diagnostic Challenges
Published in Journal of Psychoactive Drugs, 2022
Anna Maria Szota, Izabela Radajewska, Aleksander Stanisław Araszkiewicz
Neuroleptic malignant syndrome (NMS) is a rare, severe and possibly fatal condition mainly caused by typical antipsychotic drugs (TAPDs) (Moscovich et al. 2011; Sarkar and Gupta 2017; Ware, Feller, and Hall 2018), but several cases of this syndrome induced by atypical antipsychotic drugs (AAPDs) have been reported (Ananth et al. 2004; Murri et al. 2015; Trollor et al. 2012). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) criteria hyperthermia (> 38°C), muscle rigidity, changes in mental status (delirium, altered consciousness), increased activity of the autonomic nervous system (tachycardia, diaphoresis, blood pressure elevation, urinary incontinence, pallor, tachypnea and creatinine phosphokinase (CPK) > 4-times the upper limit must be present in order to make a diagnosis of NMS (DSM-V 2013).
Malignant catatonia: Severity, treatment and outcome – a systematic case series analysis
Published in The World Journal of Biological Psychiatry, 2022
Maximilian Cronemeyer, Carlos Schönfeldt-Lecuona, Maximilian Gahr, Ferdinand Keller, Alexander Sartorius
To achieve a timely diagnosis and effective therapy, it is essential for physicians to be familiar with clinical characteristics and possible aetiologies of MC. Several differential diagnoses ought to be considered, first and foremost the neuroleptic malignant syndrome (NMS), a condition that is nearly non-distinguishable from MC, but associated with the use of antipsychotics (Heils and Lesch 1997). Further possible aetiologies include various substance-induced disorders (such as serotonin syndrome), infections, autoimmune diseases and neurologic conditions, among others (Mann et al. 2013). Diagnostic workup should hence include complete medical history, physical examination, blood analysis (including creatine phosphokinase, CPK and blood count), cranial computed (CT) or magnetic resonance tomography (MRT), lumbar puncture and electroencephalography (EEG), if necessary complemented by urine or blood culture.
Catatonia revived: a unique syndrome updated
Published in International Review of Psychiatry, 2020
Charles Mormando, Andrew Francis
Another nosologic debate is whether neuroleptic malignant syndrome (NMS) and serotonin syndrome are forms of malignant catatonia (malignant catatonia is defined by the presence of significant autonomic disturbances (such as fever, diaphoresis, elevated or labile blood pressure and heart rate, among others)). These syndromes share many clinical features with catatonia, and reports have shown autonomic disturbances in catatonia, highlighting the clinical overlap. A systematic review of 16 defined NMS cases showed that 15 simultaneously met strict criteria for catatonia, and severity ratings of NMS correlated with the number of catatonic signs (Koch, Chandragiri, Rizvi, Petrides, & Francis, 2000). In addition, lorazepam (Francis, Chandragiri, Rizvi, Koch, & Petrides, 2000; Khaldarov, 2000) and ECT (Petrides, Malur, & Fink, 2004) may treat both catatonia and NMS. A recent systematic review identified 15 cases of NMS treated with bitemporal ECT that resulted in a 73.3% remission rate (Morcos, Rosinski, & Maixner, 2019). The advent of specific rating scales for NMS should allow for systematic research into its treatment and clinical similarity with catatonia (Sachdev, 2005; Yacoub & Francis, 2006).
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