Antipsychotic extrapyramidal frustration

Description:

Antipsychotic extrapyramidal frustration — a complex of the neurologic complications which are shown motive disturbances connected using drugs neuroleptics (anti-psychotics). Neuroleptics can cause practically all range of extrapyramidal disturbances: parkinsonism, dystonia, tremor, chorea, athetosis, akathisia, tics, myoclonias, stereotypies. According to the American classification of DSM-IV the extrapyramidal motive frustration connected with reception of neuroleptics can be divided into parkinsonism, acute dystonia, an acute akathisia and late dyskinesia.

Symptoms of Antipsychotic extrapyramidal frustration:

The features of antipsychotic parkinsonism distinguishing it from parkinsonism of other etiology are subacute development, symmetry of manifestations, a combination to medicinal diskineziya (dystonia or an akathisia), endocrine disturbances (increase in prolactin), not progressing current, expressiveness of postural instability insignificant (in most cases) and lack of gross postural violations. The symptomatology includes a bradykinesia (slow rate of movements, difficulty of intention movements, difficulty of turns), rigidity (constraint, tension of muscles), a cogwheel symptom (intermittence, gradualness of movements), a tremor of extremities, a mask-like face, hypersalivation. If these symptoms reach the expressed degree, the akineziya indistinguishable from a catatonia can develop. In hard cases the mutism and a dysphagy can also develop.
The typical tremor of rest ("rolling pills") at antipsychotic parkinsonism is noted seldom, but the rough generalized tremor which is coming to light both at rest often meets and at the movement. Sometimes the tremor involving only perioral area ("a syndrome of a rabbit") meets.
Parkinsonism syndrome, as a rule, affects also the mental sphere: the phenomena of so-called mental parkinsonism, or the "zombie syndrome" including emotional (emotional indifference, an angedoniya, lack of pleasure from activity), cognitive (block of thinking, difficulty of concentration of attention, feeling of "emptiness in the head") and social (loss of an initiative, decrease in energy, loss of social relateds) parkinsonism are characteristic. In some cases it is difficult to delimit the secondary negative symptomatology (abulia, an angedoniya, affect flattening, an emotional otgorozhennost, poverty of the speech) representing side effect of psychopharmacotherapy from primary negative symptomatology inherent to frustration of a schizophrenic range; besides psychoemotional displays of medicinal parkinsonism are not always followed by noticeable neurologic disturbances.
The clinical picture of acute dystonia is characterized by the sudden beginning with development of dystonic spasms of muscles of the head and neck. Unexpectedly there are a lockjaw or the forced opening of a mouth, protrusion of language, violent grimaces, a wryneck with turn or a zaprokidyvaniye of the head back, a stridor. There can be also a laryngospasm. At a number of patients okulogirny crises which are shown by the violent consensual assignment of eyeglobes lasting of several minutes till several o'clock are noted. At some patients the nictitating spasm or expansion of palpebral fissures are noted (a phenomenon "stared"). When involving truncal muscles the opisthotonos, a lumbar hyperlordosis, scoliosis can develop. The syndrome of Tower of Pisa which is characterized by tonic lateroflection of a trunk is in certain cases observed. Extremities are involved seldom.
Motor disturbances can be local and arise in typical areas, affecting the isolated group of muscles, or generalized, followed by the general motor excitement with affects of fear, alarm, narrowing of consciousness and vegetative disturbances (profuse sweat, hypersalivation, dacryagogue, vasomotor reactions, etc.).
Dystonic spasms look is repellent and are transferred extremely hard. Some of them (as, for example, a laryngospasm — dystonia of muscles of a throat) are life-threatening. Muscular spasms are sometimes so expressed that dislocations of joints can cause.

The akathisia is subjectively endured as intensive unpleasant feeling of restlessness, need to move which is especially expressed in the lower extremities. Patients become fussy, peretoptyvatsya from a leg on a leg, are forced to go constantly to facilitate concern, cannot sit or stand still within several minutes.
The clinical picture of an akathisia includes touch and motor components. Carry unpleasant internal feelings to a touch component — patients realize that these feelings induce them to move continuously, however often find it difficult to give them specific descriptions. These feelings can have the general character (alarm, internal tension, irritability) or somatic (weight or dizesteziya in legs). The motive component of an akathisia is presented by the movements of stereotypic character: patients can fidget, for example, on a chair, constantly change a pose, shake a trunk, shower a leg on a leg, shake and tap with a leg, knock fingers of hands, touch them, scratch the head, stroke the person, undo and button. In a standing position patients often shift from one foot to the other or mark on site.
The akathisia quite often represents the main reason for non-compliance by patients of the mode with medicinal therapy and refusal of therapy. The constant discomfort can strengthen sense of hopelessness at the patient and is one of the reasons of emergence of suicide thoughts. Even the slight akathisia is extremely unpleasant for the patient, often serves as a cause of failure from treatment, and in the started cases it can be the depression reason. Exist this, testimonial that the akathisia can lead to aggravation of the psychopathological symptomatology which was initially existing at the patient, lead to suicides and to acts of violence.
Existence and degree of manifestation of an akathisia can be objectively measured by means of a scale of an akathisia of Burns.

Reasons of Antipsychotic extrapyramidal frustration:

The term "medicinal extrapyramidal frustration" includes also the disturbances caused by reception of other means changing dofaminergichesky activity: for example, antidepressants, antagonists of calcium, antiarrhytmic drugs, cholinomimetics, lithium, antiparkinsonichesky means, antikonvulsant.

Treatment of Antipsychotic extrapyramidal frustration:

Treatment of antipsychotic parkinsonism includes the necessity of cancellation of the drug parkinsonism which caused development, a dose decline or replacement with its softer anti-psychotic, more rare causing extrapyramidal frustration. Protivoparkinsonichesky means from group of cholinolytics for the term of at least 2 — 3 months is in parallel appointed: trigeksifenidit (Parkopanum, Cyclodolum), either Biperidinum (Akinetonum), or benztropine (когентин); other authors consider desirable purpose of an amantadin who is not less effective and less often causes heavy side effects. Within several months at a considerable part of patients tolerance to extrapyramidal action of an anti-psychotic therefore it is possible to try to cancel protivoparkinsonichesky drug gradually develops; if against the background of drug withdrawal parkinsonism symptoms arise again, it is necessary to continue its reception for a long time. In some sources it is mentioned also desirability of purpose of B6 vitamin.
At cancellation of an anti-psychotic or decrease in its dose of display of parkinsonism usually regress within several weeks, however at a part of patients slower reduction of motive disturbances or their stationary current is noted. Some Russian authors at a long current of extrapyramidal symptomatology at patients with residual cerebral organic insufficiency ("a long extrapyramidal syndrome" according to I. Ya. Gurovich) recommend to appoint high doses of antiparkinsonichesky proofreaders in combination with nootropa, having in parallel reduced a dose of the accepted neuroleptics or having appointed drugs with the minimum extrapyramidal activity; also carrying out extracorporal methods of a detoxication — a plasma exchange and hemosorption is recommended.

The western authors recommend to apply at acute dystonia anticholinergics, such as benztropine (analogs in the Russian market — Cyclodolum and Akinetonum) which intravenous or intramuscular administration leads to sharp improvement. If dystonia is not stopped after two injections, it is recommended to try to apply benzodiazepine (for example, lorazepam). At a dystonia recurrence against the background of the continuing antipsychotic therapy it is necessary to enter the fixed dose of anticholinergic drug within 2 weeks.
The Russian authors recommend use at acute dystonia of the following options of actions:
Cancellation of a typical neuroleptic or decrease in its dose
Transfer of the patient into an atypical neuroleptic
Purpose of an amantadin of sulfate (PC Mertz) intravenously kapelno within 5 days, with the subsequent transition to reception of tablets within 1 month; at return of dystonic symptomatology — reception continuation
Purpose of cholinolytic: trigeksifenidil (Cyclodolum) or Biperidinum (Akinetonum)
Purpose of B6 vitamin
Purpose of benzodiazepines (diazepam)
Purpose of aminazine intramusculary and 20% caffeine solution subcutaneously
At generalized dystonias — co-administration of aminazine or Tisercinum intramusculary and antiparkinsonichesky proofreaders (Akinetonum) also intramusculary
In some Russian and western sources it is recommended in hard cases to enter intravenously antihistamines (Dimedrol), caffeine - Natrium benzoicum or barbiturates.
The dystonia connected with sharp cancellation of a neuroleptic demands its repeated appointment until decreases or the hyperkinesia then the drug dose gradually decreases will disappear completely.

In treatment of an acute akathisia there are two main strategy: traditional approach is the dose decline of the accepted anti-psychotic or transfer of the patient into a nizkopotentny or atypical anti-psychotic; other strategy — use of these or those medicines, effective at an akathisia. Most widely from them beta-blockers, anticholinergics, a clonidine, benzodiazepines are used. The less often appointed drugs, such as амантадин, буспирон, piracetam and amitriptyline, can be applied in cases, resistant to therapy.
Though anticholinergics proved the efficiency at antipsychotic parkinsonism and dystonia, their clinical usefulness at an akathisia remains unproven; preference can be given them when at patients symptoms of an akathisia and parkinsonism are at the same time observed. Lipophilic beta adrenoblockers, such as propranolol, are one of the most effective remedies in treatment of an akathisia. Benzodiazepines have some efficiency, presumably because of their nonspecific antialarming and sedative properties too. The efficiency at an akathisia also blockers of 5-HT2-receptors, in particular ритансерин proved, cyproheptadine, antidepressants миансерин and (in low doses) миртазапин. Are effective at an akathisia and Valproatums, габапентин, прегабалин, weak opioids (codeine, a hydrocodon, the propoxyhair dryer), B6 vitamin.