Use Of Neuroleptics Research Articles

The use of neuroleptics in the treatment of hyperkinetic behavioral disorders in children

To compare the efficacy of thioridazine and tiapride in treatment of hyperkinetic behavioral disorders (HBD) in children. The study included 60 children, детей, 42 boys and 18 girls, mean age 8.0±2.0 years. Patients were divided into two equal groups. The duration of the study was 30 days. The Achenbach System of Empirically Based Assessment (ASEBA) was used. Safety was assessed by sedation scores and serum prolactin levels. A positive effect of both drugs was shown. The levels of aggression and delinquency decreased significantly, while a decrease in attention levels was less pronounced. Both drugs were similar by efficacy, but tiapride had better safety profile.

Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors in the Management of Tardive Dyskinesia

Neuroleptic medications are prescribed for the management of mental, gastrointestinal, and neurological disorders. These disorders occur via over-excitation of dopamine in the brain. When neuroleptics are used, dopamine receptors are blocked reducing the excitation. Thus, the disorder becomes controlled. The long-term use of neuroleptics can result in a misfire of the neurons of the brain causing tardive dyskinesia (TD), an irreversible chronic condition of spontaneous movements.

Clinical and Phenomenological Characteristics of Patients with Task-Specific Lingual Dystonia: Possible Association with Occupation.

Lingual dystonia is a subtype of oromandibular dystonia, which is a movement disorder characterized by involuntary sustained or intermittent contraction of the masticatory and/or tongue muscles. Lingual dystonia interferes with important daily activities, such as speaking, chewing, and swallowing, resulting in vocational and social disability. The aim of this study was to investigate a possible relationship between occupation and the development of lingual dystonia. Phenomenological and clinical characteristics of 95 patients [53 females (55.8%) and 42 males (44.2%), mean age 48.0 years] with task-specific, speech-induced lingual dystonia were analyzed. Structured interviews were carried out to obtain information regarding primary occupation, including overtime work and stress during work. The factors that might have influenced the development of lingual dystonia were estimated using multivariate logistic regression analysis of the 95 patients with lingual dystonia and 95 controls [68 females (71.6%) and 27 males (28.4%), mean age 47.2 years] with temporomandibular disorders. Overall, 84.2% of the patients had regular occupations; 73.8% of the patients with regular occupations reported working overtime more than twice a week, and 63.8% of them experienced stress at the workplace. Furthermore, 82.1% of the patients had engaged in occupations that required them to talk to customers or other people under stressful situations over prolonged periods of time for many years (mean: 15.6 years). The most common occupation was sales representative (17.9%), followed by telephone operator (13.7%), customer service representative (10.5%), health care worker (9.5%), waiter or waitress (5.3%), receptionist (5.3%), and cashier (5.3%). Twenty-nine patients (30.5%) had tardive lingual dystonia. Logistic regression analyses revealed that frequent requirements for professional speaking (p = 0.011, odds ratio: 5.66), high stress during work (p = 0.043, odds ratio: 5.4), and neuroleptic use (p = 0.032, odds ratio: 2.52) were significant contributors to the manifestation of lingual dystonia. Professions in which conversations in stressful situations are unavoidable may trigger lingual dystonia. Therefore, speech-induced lingual dystonia can be regarded as occupational dystonia in certain cases.

Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care

ImportanceThe use of benzodiazepines to control agitation in delirium in the last days of life is controversial.ObjectiveTo compare the effect of lorazepam vs placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium in the setting of advanced cancer.Design, Setting, and ParticipantsSingle-center, double-blind, parallel-group, randomized clinical trial conducted at an acute palliative care unit at MD Anderson Cancer Center, Texas, enrolling 93 patients with advanced cancer and agitated delirium despite scheduled haloperidol from February 11, 2014, to June 30, 2016, with data collection completed in October 2016.InterventionsLorazepam (3 mg) intravenously (n = 47) or placebo (n = 43) in addition to haloperidol (2 mg) intravenously upon the onset of an agitation episode.Main Outcomes and MeasuresThe primary outcome was change in Richmond Agitation-Sedation Scale (RASS) score (range, −5 [unarousable] to 4 [very agitated or combative]) from baseline to 8 hours after treatment administration. Secondary end points were rescue neuroleptic use, delirium recall, comfort (perceived by caregivers and nurses), communication capacity, delirium severity, adverse effects, discharge outcomes, and overall survival.ResultsAmong 90 randomized patients (mean age, 62 years; women, 42 [47%]), 58 (64%) received the study medication and 52 (90%) completed the trial. Lorazepam + haloperidol resulted in a significantly greater reduction of RASS score at 8 hours (−4.1 points) than placebo + haloperidol (−2.3 points) (mean difference, −1.9 points [95% CI, −2.8 to −0.9]; P < .001). The lorazepam + haloperidol group required less median rescue neuroleptics (2.0 mg) than the placebo + haloperidol group (4.0 mg) (median difference, −1.0 mg [95% CI, −2.0 to 0]; P = .009) and was perceived to be more comfortable by both blinded caregivers and nurses (caregivers: 84% for the lorazepam + haloperidol group vs 37% for the placebo + haloperidol group; mean difference, 47% [95% CI, 14% to 73%], P = .007; nurses: 77% for the lorazepam + haloperidol group vs 30% for the placebo + haloperidol group; mean difference, 47% [95% CI, 17% to 71%], P = .005). No significant between-group differences were found in delirium-related distress and survival. The most common adverse effect was hypokinesia (3 patients in the lorazepam + haloperidol group [19%] and 4 patients in the placebo + haloperidol group [27%]).Conclusions and RelevanceIn this preliminary trial of hospitalized patients with agitated delirium in the setting of advanced cancer, the addition of lorazepam to haloperidol compared with haloperidol alone resulted in a significantly greater reduction in agitation at 8 hours. Further research is needed to assess generalizability and adverse effects.Trial Registrationclinicaltrials.gov Identifier: NCT01949662

Lorazepam as an adjuvant to haloperidol for agitated delirium at the end of life: A double-blind randomized controlled trial.

10003 Background: Agitated delirium is a highly distressing neuropsychiatric syndrome common in the last days of life. The use of benzodiazepines for agitated delirium is highly controversial. We compared the effect of lorazepam versus placebo as an adjuvant to haloperidol for persistent agitated delirium. Methods: In this double-blind trial, we randomly assigned patients with advanced cancer admitted to an acute palliative care unit with agitated delirium despite scheduled haloperidol to either lorazepam 3 mg IV or placebo, in addition to haloperidol 2 mg IV upon the onset of agitation. The primary outcome was the Richmond Agitation Sedation Scale (RASS) over the first 8 hours, ranging from -5 (unarousable) to +4 (combative). Secondary endpoints were rescue neuroleptic use, perceived comfort, delirium-related distress, adverse effects and overall survival. 26 patients per arm provided 80% power to detect a between arm difference of 0.5 effect size in mean RASS with a=5%. We used the Wilcoxon Rank Sum test for primary comparison. Results: 52 of 58 (90%) patients who received the medications completed 8 h of observation. RASS decreased significantly within 30 min of treatment in both arms (Table). The lorazepam arm was associated with significantly greater reduction of RASS (Table), less rescue neuroleptics (mean haloperidol equivalent dose 1 mg v. 3 mg, P=0.02), and greater comfort as perceived by blinded caregivers (84% v. 37%, P=0.007) and nurses (77% v. 30%, P=0.005) compared to placebo. We found no significant between-group differences in delirium-related distress, adverse effects and overall survival (median 68 v. 73 h, P=0.56). Conclusions: The combination of lorazepam/haloperidol resulted in rapid and significant reduction of agitation compared to haloperidol alone. Our study supports the judicious use of single dose lorazepam/haloperidol for persistent agitated delirium. Clinical trial information: NCT01670097. [Table: see text]

Neuroleptic malignant syndrome: A rare, life-threatening and not fully understood condition

IntroductionNeuroleptic Malignant Syndrome (NMS) is a rare life-threatening idiosyncratic reaction associated with the use of neuroleptics. It is characterized by delirium, muscular rigidity, fever and autonomic nervous system dysregulation. Its diagnosis represents a significant challenge for clinicians and many aspects regarding its epidemiology, etiopathology and nosology remain controversial.ObjectivesSummarize current knowledge to facilitate NMS diagnosis and allow a fast onset of therapeutic and life-saving interventions.MethodsNon-systematic review of the literature–scientific publications from Pubmed and a Psychiatry Textbook.ResultsNMS typically develops during the first week after the neuroleptic is introduced, although it may also appear after years of treatment. Its incidence is of 0.02 to 3% in patients taking antipsychotics; the mean age of its patients is 50 years. Typical symptoms are muscle rigidity and temperature greater than 38hC in a patient on antipsychotic; however, recent reports indicate that these core symptoms may not always be present. Several risk factors have also been identified and must be addressed. NMS may be fatal in 10 to 20% of cases or may produce residual sequelae, like cognitive dysfunction or neurological deficits. NMS must be managed by aggressive use of supportive measures, as well as specific interventions. It recurs in 30% of patients, which can be diminished by specific measures.DiscussionNMS requires timely and accurate diagnosis and treatment. Antipsychotics should be used cautiously in patients at increased risk. When recognizing this condition, prompt withdrawal of the offending agent is the most important step. Wise approaches can diminish morbidity, mortality and recurrence.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The use of guanfacine (Intuniv XR) in the treatment of disruptive mood dysregulation disorder – Clinical experience from telepsychiatry

BackgroundDisruptive mood dysregulation disorders (DMDD) is new to DSM-5 and represents children with rage episodes. Medical treatment is critical but few randomized trials. DMDD may be a replacement for the diagnosis of Bipolar Disorder noted in DSM-IV with a heavy use of atypical neuroleptics. DMDD reflects a more moderate treatment of these symptoms.MethodTelepsychiatry referrals 6–9 year old children randomized into n = 12 = group A (11 males/1 female), n = 13 = group B (11 males/2 females). ANOVA not significant (NS) in age and gender. Group A received guanfacine (GUA) titrated to weight between 3–4 mg. Both groups received behavior support. Group B did not receive medications. Analysis by t-test comparison.ResultsGroup A showed significant improvement in frequency but not in intensity of rage episodes (P &lt; 0.05). Major side effects include sedation and gastric irritation. Dropouts from original sample of 22 per group were based on inability to titrate, cost of drug, inability to swallow pills, worsening of symptoms with addition of an atypical neuroleptic.ConclusionGUA is a possible treatment for DMDD but there are limitations requiring further study. Group B did show improvement reflecting the utility of behavioral strategies (future studies require control groups) but GUA may provide a useful alternative to neuroleptics. Cardiovascular issues were not a problem and were assessed. Future studies are warranted.Disclosure of interestThe author has not supplied his declaration of competing interest.

Editor's Highlight: Off-Target Effects of Neuroleptics and Antidepressants on Saccharomyces cerevisiae.

Over the past years, the use of antidepressants and neuroleptics has steadily increased. Although incredibly useful to treat disorders like depression, schizophrenia, epilepsy, or mental retardation, these drugs display many side effects. Toxicogenomic studies aim to limit this problem by trying to identify cellular targets and off-targets of medical compounds. The baker yeast Saccharomyces cerevisiae has been shown to be a key player in this approach, as it represents an incredible toolbox for the dissection of complex biological processes. Moreover, the evolutionary conservation of many pathways allows the translation of yeast data to the human system. In this paper, a better attention was paid to chlorpromazine, as it still is one of the most widely used drug in therapy. The results of a toxicogenomic screening performed on a yeast mutants collection treated with chlorpromazine were instrumental to identify a set of genes for further analyses. For this purpose, a multidisciplinary approach was used based on growth phenotypes identification, Gene Ontology search, and network analysis. Then, the impacts of three antidepressants (imipramine, doxepin, and nortriptyline) and three neuroleptics (promazine, chlorpromazine, and promethazine) on S. cerevisiae were compared through physiological analyses, microscopy characterization, and transcriptomic studies. Data highlight key differences between neuroleptics and antidepressants, but also between the individual molecules. By performing a network analysis on the human homologous genes, it emerged that genes and proteins involved in the Notch pathway are possible off-targets of these molecules, along with key regulatory proteins.

Neuroleptics in the management of delirium in patients with advanced cancer.

Delirium is the most common and distressing neuropsychiatric syndrome in cancer patients. Few evidence-based treatment options are available due to the paucity of high quality of studies. In this review, we shall examine the literature on the use of neuroleptics to treat delirium in patients with advanced cancer. Specifically, we will discuss the randomized controlled trials that examined neuroleptics in the front line setting, and studies that explore second-line options for patients with persistent agitation. Contemporary management of delirium includes identification and management of any potentially reversible causes, coupled with nonpharmacological approaches. For patients who do not respond adequately to these measures, pharmacologic measures may be required. Haloperidol is often recommended as the first-line treatment option, and other neuroleptics such as olanzapine, risperidone, and quetiapine represent potential alternatives. For patients with persistent delirium despite first-line neuroleptics, the treatment strategies include escalating the dose of the same neuroleptic, rotation to another neuroleptic, or combination therapy (i.e., the addition of a second neuroleptic or other agent). We will discuss the advantages and disadvantages of each approach, and the available evidence to support each strategy. Adequately powered, randomized trials involving proper control interventions are urgently needed to define the optimal treatment strategies for delirium in the oncology setting.

Experience with palliative sedation (PS) in an inpatient oncology setting.

63 Background: Palliative sedation (PS) is an intervention to treat refractory symptoms and to relieve suffering at the end of life. Its prevalence and practice patterns vary widely. Methods: This is a retrospective study of the use of PS in cancer patients who died at our comprehensive cancer center between March 1, 2012 and December 31, 2014. PS was defined as the use of continuous infusion of midazolam or neuroleptics for refractory symptoms as stated in the progress notes. Patients who died in the ICU were excluded. The aim of our study was to evaluate PS practice patterns, describing its frequency, clinical indications and outcomes. Results: During the study period, 556 cancer patients died at the institution and 203 (36.5%) received PS. Main reasons for exclusion were death in the ICU (168 patients) and no use of midazolam or neuroleptics (77 patients). Patients who received PS as compared to those not sedated were younger (67.8 vs. 71.5 years-old, p = 0.007) and more likely to have a primary diagnosis of lung cancer (23% vs. 15% p &lt; 0.001). Patients receiving PS were more likely to be seen by oncology/hematology rather than other specialties (70% vs 45% p &lt; 0.001) and more likely to have a longer hospital stay from admission to death (47.9 days vs 26.2 days p &lt; 0.001). Only 25 patients (12%) were seen by a dedicated palliative care team. The most common indications for sedation were dyspnea (51.5%) and delirium (19.5%) and the most common dugs used were midazolam (52.9%) or midazolam and a neuroleptic (39.2%). Median initial midazolam infusion rate was 0.75 mg/h (interquartile range – IQR - 0.6-1.5) and final rate was 1.5 mg/h (IQR 0.9-3.0). Median time from sedation to death was 27 hours (IQR 12-58). Conclusions: Palliative sedation is a common practice at our hospital and it is not associated with shortening of hospital stay. Further research is needed to identify factors that may affect the frequency and outcomes associated with palliative sedation.

Cardiovascular Autonomic Dysfunction in Patients with Drug-Induced Parkinsonism.

Background and PurposeRecent studies have shown that several nonmotor symptoms differ between Parkinson's disease (PD) and drug-induced parkinsonism (DIP). However, there have been no reports on cardiovascular autonomic function in DIP, and so this study investigated whether cardiovascular autonomic function differs between PD and DIP patients.MethodsThis study consecutively enrolled 20 DIP patients, 99 drug-naïve PD patients, and 25 age-matched healthy controls who underwent head-up tilt-table testing and 24-h ambulatory blood pressure monitoring.ResultsOrthostatic hypotension was more frequent in patients with PD or DIP than in healthy controls. In DIP, orthostatic hypotension was associated with the underlying psychiatric diseases and neuroleptics use, whereas prokinetics were not related to orthostatic hypotension. The supine blood pressure, nighttime blood pressure, and nocturnal blood pressure dipping did not differ significantly between the DIP and control groups. Supine hypertension and nocturnal hypertension were more frequent in PD patients than in controls.ConclusionsThe included DIP patients frequently exhibited orthostatic hypotension that was associated with the underlying diseases as well as the nature of and exposure time to the offending drugs. Clinicians should individualize the manifestations of DIP according to underlying diseases as well as the action mechanism of and exposure time to each offending drug.

Cyamémazine (Tercian®) et syndromes extrapyramidaux : exploration des cas contenus dans la base nationale de pharmacovigilance

Cyamemazine (Tercian®) is currently the most widely prescribed neuroleptic in France. This widespread use is due to its anxiolytics properties and to a claimed good safety profile. Although, prescription of cyamemazine is not devoid of the risks associated with the use of neuroleptics: extrapyramidal syndromes. This study aims at describing extrapyramidal syndromes induced by cyamemazine registered in the French pharmacovigilance database. All spontaneous reports of extrapyramidal syndromes in the French pharmacovigilance database between 1st January 1985 and 31th December 2015 were described and analyzed. During this period 132cases following cyamemazine intake were reported in the French pharmacovigilance database. The extrapyramidal syndromes were considered as "serious" in 77% of cases. More than 80% of the cases were described with a dosage of cyamemazine under 100mg/day and no correlation between drug dose and seriousness of the cases were found. Thirty-six cases were described with a monotherapy of cyamemazine. We should keep in mind that despite its widespread use in various indications (e.g. anxiolytic) cyamemazine remains a neuroleptic and could induce extrapyramidal syndromes even with low dosage. Careful monitoring should be performed when introducing and with long-term use of cyamemazine, mostly in elderly patients or patient already being treated with neuroleptics.

From neuroleptics to neuroscience and from Pavlov to psychotherapy: more than just the "emperor's new treatments" for mental illnesses?

“The drugs don't work” was one of the hit singles from The Verve's album Urban Hymns , released in 1997. The song was written by lead singer Richard Ashcroft relating to his drug abuse, but it might well relate to the modern treatments for mental illnesses. More than half a century after neuroleptics, antidepressants, benzodiazepines, antipsychotics, behavior therapy, and cognitive treatment were introduced, it is prudent to ask whether “the drugs don't work”. During the past 50 years, the industrialized world has seen a dichotomy between loudly proclaimed therapeutic breakthroughs and rapidly rising numbers of people on disability payments because of mental illness. We hear that antipsychotic, antidepressant, and anti‐anxiety drugs as well as behavior therapy and newer treatments have radically improved what was described as a dismal fate of people suffering from mental disorders. Simultaneously, the percentage of disabled mentally ill patients in the USA has risen by more than 600% since the 1950s (Whitaker, 2010) and similar rates are seen in European countries. Most epidemiologists agree that this “epidemic” is not caused by increased incidence. Moreover, the once rapid succession of new therapeutic developments seems to have halted, at least in pharmacology, as big companies are withdrawing from research on mental disorders. How can this apparent contradiction be explained? Could it be that therapeutic progress is much less than we think or are being told? Could it be that the course of depression, anxiety, schizophrenia, or ADHD has been altered for the worse? Could it be that we cannot make therapeutic progress because the concept of mental illness and its treatment is deeply flawed? There are strong reasons to assume that all three suspicions are in fact true. So, what do we know about the efficiency of pharmacological and psychological treatments? In regard to short‐term outcomes, pharmacotherapy is clearly …

THE PROBLEM OF NEUROENDOCRINE DYSFUNCTIONS IN PATIENTS WITH SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDER (literature review)

Neuroendocrine dysfunctions (NED) are often observed in patients with schizophrenia spectrum disorders and could be a component of the etiopathogenesis of the disease as well as effect associated with use of atypical neuroleptics. The most common NED symptoms and syndromes are described in the literature review: neuroleptic-induced hyperprolactinemia syndrome, the frequency of occurrence 2–100 %, metabolic syndrome — a 49.3 %, increasing in body weight (neuroleptics obesity) — 40–92 %, diabetes mellitus type 2 — 6.2–25.0 %, violation of thyroid metabolism — 20–49 %, a polymorphic syndrome — 9.9–32.9 %. Metabolic syndrome is more often observed in patients with schizoaffective disorder than in patients with schizophrenia; however, explanatory factors of this association deserve further research. Patients, receiving atypical neuroleptics, must undergo regular endocrinological examination and psychiatrists must draw attention to the endocrinological component of the patient’s health. Diabetologists and psychiatrists must work together to monitor patients treated with atypical antipsychotics, with the aim of identifying their impaired glucose tolerance and diabetes management.

Akinetic crisis in dementia with Lewy bodies

Background and purposeDementia with Lewy bodies (DLB) is characterised by neuroleptic hypersensitivity. It is unclear, however, whether the neuroleptic hypersensitivity implies an increased incidence of neuroleptic malignant syndrome (NMS) or...

An approach to neuroleptic malignant syndrome from a clinical case

IntroductionNeuroleptic malignant syndrome (NMS) takes place in patients in treatment with neuroleptics and it is potentially lethal, being important an early diagnostic and therapeutic approach.ObjectivesTo analyze from a clinical case the clinical and epidemiological features, and therapeutical approach to NMS.MethodReview of some articles in Mental Health journals and analysis of the following clinical case: 68-year-old woman with bipolar disorder, hospitalized in manic phase. Usual treatment: lithium, trazodone, quetiapine and asenapine. During the admission to hospital, the patient started presenting hyperthermia, sweating, electrolyte disturbances, limb rigidity, and elevation of CPK levels. The suspicion was NMS, so neuroleptics were stopped and fluids and dantrolene were initiated, with favorable evolution.ResultsThe discharge diagnosis was NMS. Neuroleptics were gradually reintroduced under vigilance. The patient is stable and has not had new complications. NMS is an uncommon (0.02% to 3% among patients taking neuroleptic agents), but life-threatening condition. Its symptoms are hyperthermia, autonomic nervous system dysfunction, limb rigidity, altered consciousness… The attendant infections, consume of lithium, dehydration, iron deficiency and sharp changes in neuroleptic treatment are predisposing factors. The withdrawal of neuroleptics is the key of the treatment. Benzodiazepines can improve the prognosis, and electroconvulsive therapy can be necessary if there is no response to previous measures.ConclusionsNeuroleptic malignant syndrome is a life-threatening medical complication we should try to avoid by a correct and careful use of neuroleptics. Additionally, it is important the early treatment, taking withdrawal of neuroleptics as the key starting point.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Pattern of symptoms and symptomatic treatment in adults and the aged population: a retrospective analysis of advanced cancer patients followed at home

Context Data regarding symptom burden and symptomatic drugs in palliative population in different classes of age are lacking.Objective The aim of this retrospective study was to assess the symptom burden, and the profile of symptomatic drugs in the last four weeks of life in adults and older cancer patients followed at home.Methods Charts of 412 patients were retrospectively analyzed by using a backward analysis. Patients were divided into three groups: adults (<65 years, A), old (65–74 years, O1), very old (75–84 years, O2), and the oldest (≥85 years, O3).Results At -4W Karnofsky status was significantly lower for older people (p = 0.03). No significant effect of age on the vector of symptoms was found (p = 0.07). A significant decrease in intensity of pain and nausea, and an increase in intensity of all other symptoms was found through the four weeks of the study (p = 0.00). No differences of drug pattern among the age categories were found. The use of symptomatic drugs decreased over time, except for opioids. Age statistically affected NSAID use, neuroleptic use, and antiemetics over time.Conclusion The burden of symptoms worsened in the last four weeks of life, except for pain and nausea, but did not differ among the age subgroups. The use of NSAIDs, neuroleptics, and antiemetics changed, while the frequency of opioid use was unchanged until death.

Chorea as the Neurological Symptom of Delayed Encephalopathy After Carbon Monoxide Intoxication in a Child.

A 10-year-old boy presented to the emergency department with abnormal movements 8 days after he was rescued from a house fire. At the scene, he was comatose and was found to have soot in his airway. He had an elevated carboxyhemoglobin level (24.5%). He received mechanical ventilation with 100% oxygen for 40 hours. He showed rapid recovery in mental status and was discharged home. Eight days after the injury, he developed tremors, dystonia, and chorea involving his face and all extremities (Video). Brain magnetic resonance imaging showed T2 hyperintensity in the caudate, putamen, and globus pallidus bilaterally, and magnetic resonance spectroscopy showed lactate peaks in the basal ganglia (Figures 1A and ​andB).B). Trihexyphenidyl improved his dystonia and tremor within a month, but the chorea worsened. After he discontinued trihexyphenydyl, chorea gradually resolved. Eight months after the injury, he is still experiencing emotional, behavioral, and academic problems as well as intermittent urinary incontinence. Figure 1. A, T2-weighted axial sequence of brain magnetic resonance imaging (MRI) shows hyperintensities in the bilateral basal ganglia. The signal changes are greater involving the left caudate and putamen and greater involving the right globus pallidus. B, Brain ... Delayed encephalopathy after carbon monoxide (CO) intoxication is characterized by mental deterioration, gait disturbance, speech disorder, seizure, and incontinence preceded by an asymptomatic period of variable duration (from 2 to 40 days) following recovery from the acute stage.1 Additionally, destructive lesions of basal ganglia may result in movement disorders. Parkinsonism has been reported to occur in 9.5% of CO-poisoned patients.2 The incidence of chorea after CO poisoning is known to be rare. Its duration ranges from days to months, and it is usually alleviated through the use of neuroleptics and aggravated by anticholinergics.3

Worsening Psychosis in an Adolescent Female Chronically Abusing Dextromethorphan when Benztropine was added to the Treatment Regimen

Recently, there has been an increase in the use of overthe- counter (OTC) medications as recreational drugs of abuse in adolescents. It is important to recognize that some of these medications, such as Dextromethorphan (DXM) at doses beyond recommended, have detrimental effects to mental health. The symptoms DXM precipitates appear as a mental illness in acute exacerbation rather than intoxication and/or overdose. Having sufficient knowledge on how to treat adequately those patients who abuse OTCs such as DXM is of utmost importance in determining an assertive treatment intended to subside and recuperate successfully. Using the example of DXM, which is a substrate of CYP2D6 and metabolized by the enzyme, we must have awareness that many other medications are affected by this route as well. This case illustrates how Benztropine precipitated symptoms of psychosis and euphoric mood on a 14 year old Hispanic female, which was assumed to be effectively responding with Risperidone treatment. We theorize that chronic DXM abuse evoked an induction of the CYP2D6, which ultimately hindered the antipsychotic treatment efficacy. Risperidone dose was increased whereas Benztropine discontinued on the subsequent day which corresponded to the rapid subside of her psychosis. We recommend caution when adding Benztropine to antipsychotic treatment for a patient having psychotic symptoms precipitated by chronic DXM abuse, as well as considering the use of neuroleptics that are minimally or not metabolized by the CYP2D6 P450 metabolic pathway.

A neuroleptic malignant syndrome case with haloperidol depot

The development of depot antipsychotics are facilitated incompitable patient’s treatment process for in terms of chronic disease course. One of the disadvantages of depot antipsychotics, having various advantages and disadvantages, neuroleptic malignant syndrome (NMS) rate is higher than the oral form. NMS, rare but can be fatal, is an idiosyncratic reaction characterized by confusion, hyperthermia, autonomic dysfunction, muscle rigidity after use of neuroleptics. In this case, a schizophrenia patient used to haloperidol depot, named haldol decanoate in abroad used since1986 (Europe-US) but recently introduced in Turkey, with NMS was reported.