Case Presentation: Iatrogenic Psychosis

Tardive dyskinesia (TD) is a neuromuscular disorder that can precipitate following the administration of dopamine receptor antagonists such as neuroleptics. Withdrawal-emergent dyskinesia (WE-D), a less recognized subtype of TD, can manifest shortly after abrupt cessation of antipsychotic use regardless of the neuroleptic subclass used. Super sensitivity psychosis is another possible symptom of acute withdrawal from neuroleptics that can occur alone or concomitant with WE-D. Because of their ever increasing off-label indications and attenuated extrapyramidal side effect profiles, atypical antipsychotics are becoming ubiquitous in both inpatient and outpatient settings, reflecting their utility. However, it is likely that this trend will also result in a greater prevalence of WE-D and super sensitivity psychosis. Clinicians without expertise in the utilization of neuroleptics are likely to misattribute withdrawal symptoms precipitated by abrupt cessation of antipsychotics with toxicity to these agents and erroneously withhold or delay their reinitiation, thereby exacerbating symptoms and inadvertently prolonging patient distress. This case report will illustrate the unique and perplexing presentation of WE-D and super sensitivity psychosis in an acute setting, and provide an effective diagnostic and treatment approach to resolving these conditions.

A ‘benign’ extrapyramidal side effect masking a life-threatening neuroleptic malignant syndrome

The neuroleptic malignant syndrome is a rare, life-threatening idiosyncratic reaction to neuroleptic medication. The use of newer antipsychotics combined with its rare incidence has made NMS seem as a complication of the past. Here we report a patient in his early 20s suffering from a psychotic disorder developing a life-threatening neuroleptic malignant syndrome on an inpatient psychiatric ward in Canada without the characteristic overt change in autonomic stability. We review the clinical characteristics to facilitate the early recognition of neuroleptic malignant syndromes and discuss why this condition still is highly relevant for practising physicians. doi: https://doi.org/10.12669/pjms.36.6.2963 How to cite this:Dolp R, Ansari MA, Chan M, Hassan T. A ‘benign’ extrapyramidal side effect masking a life-threatening neuroleptic malignant syndrome. Pak J Med Sci. 2020;36(6):1429-1432. doi: https://doi.org/10.12669/pjms.36.6.2963 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A Case of Myotonia Congenita and Schizophrenia: Difficulties in Treatment with Antipsychotics due to Hypersensitivity to Extrapyramidal Symptoms

Myotonia congenita is a rare non-dystrophic skeletal muscle disease characterized by an inability to relax skeletal muscles after abrupt voluntary movements. Patients with this condition have stiff muscles and difficulty with mobility, especially when initiating movement after periods of rest. It is well known that movement disorders are a common side effect of antipsychotics due to their ability to antagonize dopamine 2 receptors in the extrapyramidal part of the basal ganglia. The purpose of this case is to describe the effects antipsychotics had on a 59-year-old Caucasian male with comorbid myotonia congenita and schizophrenia in an inpatient psychiatric hospital setting. Medication trials of ziprasidone, haloperidol and clozapine exacerbated his myotonic symptoms leading to falls and complaints of severe muscle stiffness, which were relieved upon discontinuation of all antipsychotic medications. This suggests that patients with myotonia congenita may have an increased sensitivity to the extrapyramidal side effect profile of antipsychotics. Treatment options for this patient case are discussed with an emphasis on lamotrigine. Keywords: Myotonia congenita; Schizophrenia; Myopathy; Antipsychotics; Extrapyramidal symptoms

Collaborative study of compliance in psychotic patients with risperidone long-acting injection (RLAI) in the last 5 years

IntroductionCompliance is essential to achieve the best results in serious mental illness like schizophrenia.ObjectivesIt was expected that the use of second-generation oral antipsychotics with less extrapyramidal side effect profile would improve the compliance, but the results do not support these expectations except in the case of risperidone long-acting injection.AimsThe aim of this study is to assess the degree of compliance in outpatients who were started treatment with RLAI while they were hospitalized for an acute psychotic episode in psychiatric unit.MethodsA retrospective study was conducted by reviewing medical records of hospitalized patients for psychotic episodes over the past 5 years in three hospitals in Mallorca (Balearic Islands, Spain) -Hospital de Manacor, Hospital son Llatzer and Hospital de Inca). Due to computerization of medical records, we knew the degree of compliance with treatment and outcome in outpatient clinics. We designed a case report data (CRD) to assess specific variables in our study that was completed for each patient.ResultsThe mean duration of treatment in patients who continue with RLAI was 38.8 months. Overall. 69.5% continued with the treatment after 5 years. The patients who continued treatment were rehospitalazed 20% less than the ones who discontinued.ConclusionsThe compliance with RLAI in outpatients was high even in patients with substances abuse. The patients who remain on treatment from hospital discharge have less readmissions. The most common dosis of RLAI is 50 mg. Lack of insight was the most frequent cause of discontinuation.