Risperidone and Refusal to Eat After Traumatic Brain Injury

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Back to table of contents Previous article Next article LetterFull AccessRisperidone and Refusal to Eat After Traumatic Brain InjuryYoshito Mizoguchi, M.D., Akira Monji, M.D., Hiroyuki Isayama, M.D., and Nobutada Tashiro, M.D., Yoshito MizoguchiSearch for more papers by this author, M.D., Akira MonjiSearch for more papers by this author, M.D., Hiroyuki IsayamaSearch for more papers by this author, M.D., and Nobutada TashiroSearch for more papers by this author, M.D., Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu University, Fukuoka, JapanPublished Online:1 Feb 2002AboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail SIR: The major clusters of psychiatric symptoms related to traumatic brain injury (TBI) are those of behavioral sequelae and of cognitive impairment. Clinically, these psychiatric symptoms are a very difficult barrier to overcome in rehabilitation programs.We report a case of a brain-injured patient with refusal to eat who responded to risperidone after failing to respond to other treatments.Case Report>A 66-year-old man without any past psychiatric history suffered traumatic brain injury following a traffic accident and was thereafter admitted to a hospital. A left orbitofrontal lobe contusion and a traumatic subarachnoid hemorrhage were documented by a CT scan. Neurosurgical intervention was not indicated in this case.After the head injury, the patient developed psychiatric symptoms. His behavioral symptoms included increased aggression, agitation with yelling, and depression. Cognitive problems involved decreased attention and problems with memory. Residual deficits also included moderate right hemiparesis. The neurobehavioral deficits continued to be a very difficult barrier to rehabilitative progress. Medication trials with conventional antipsychotics (haloperidol, chlorpromazine) at therapeutic dosages were not effective.In addition, about a month after the traffic accident, he started to refuse eating and would not cooperate with any medical treatment. He actively resisted requests to participate in rehabilitation. He refused to allow either food or medicine to be placed in his mouth. He lost weight, and undernourishment made his rehabilitative progress even more difficult. Medication trials with sulpiride 150 mg/day, amantadine 300 mg/day, fluvoxamine 150 mg/day, and some benzodiazepines did not improve the situation.He was referred to our hospital 2 months after the traffic accident. At that time, risperidone was initiated at a dose of 2 mg/day, and 3 weeks later it was increased to 3 mg/day. About a week after the initiation of risperidone, he began to calm down and showed a greatly reduced level of aggression. He also accepted food without resistance. He agreed to participate in physical therapy 2 weeks after starting the risperidone treatment. Cognitive function also improved. He was discharged home 2 months after starting risperidone treatment and has subsequently been maintained on 3 mg/day of risperidone while pursuing outpatient rehabilitation programs.CommentThe patient's refusal to eat and active resistance to instructions were considered to be catatonic signs.1 Catatonia is a clinical syndrome that has multiple causes.2 There is a case report of organic catatonia following frontal lobe injury;3 the patient's catatonic signs included stereotypic movements, iterations, and verbigerations, and she responded well to clozapine. Gamma-aminobutyric acid (GABA) receptors have been suggested to play a crucial role in catatonia,1 but the precise mechanisms by which psychotropic drugs relieve catatonic symptoms have not yet been elucidated.4 There is one case report of catatonic stupor and mutism that were successfully treated with risperidone;5 a CT scan in that case revealed bilateral orbitofrontal atrophy. Whatever the central mechanism, risperidone appears to be an effective treatment for patients who refuse to eat.Further studies are needed to confirm the effectiveness of risperidone for the treatment of refusal to eat after TBI.References1 Rosebush PI, Hildebrand AM, Furlong BG: Catatonic syndrome in a general psychiatric inpatient population: frequency, clinical presentation and response to lorazepam. J Clin Psychiatry 1990; 51:357-362Medline, Google Scholar2 Gomez EA, Comstock BS, Rosario A: Organic versus functional etiology in catatonia: case report. J Clin Psychiatry 1982; 43:200-201Medline, Google Scholar3 Rommel O, Tegenthoff M, Widdig W, et al: Organic catatonia following frontal lobe injury: response to clozapine. J Neuropsychiatry Clin Neurosci 1998; 10:237-238Link, Google Scholar4 Kopala LC, Caudle C: Acute and long-term effects of risperidone in a case of first-episode catatonic schizophrenia. J Psychopharmacol 1998; 12:314-317Crossref, Medline, Google Scholar5 Cook EH, Olson K, Pliskin N: Response of organic catatonia to risperidone. Arch Gen Psychiatry 1996; 53:82-83Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited ByJournal of Critical Care, Vol. 30, No. 4The Use of Atypical Antipsychotics After Traumatic Brain InjuryJournal of Head Trauma Rehabilitation, Vol. 23, No. 2 Volume 14Issue 1 February 2002Pages 87-a-88 Metrics History Published online 1 February 2002 Published in print 1 February 2002