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44 Cards in this Set

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Dystonia, what is it?
Movement disorder characterized by muscle spasms, commonly involving head/neck but can involve trunk/limbs
Symptoms of dystonia?
Ranges from mild subjective sensation of increased muscle tension to a life-threatening syndrome of severe muscle tetany and laryngeal dystonia (laryngospasm)
What are specific forms of dystonia?
Head and Neck Dystonia - Abnormal posturing

Tongue Dystonia - Dysarthria

Pharyngeal Dystonia - Drooling

Ocular Dystonia - Oculogyric crisis
Risk factors for dystonia?
1) High potency typicals antipsychs
2) Young men
When does dystonia occur?
Early in drug therapy, within days
Treatment of dystonia?
Anticholinergics (Benztropine, Benadryl)

Most cases oral is fine, but if there is swallowing problems then IM

Rarely is intubation needed
Akathisia, what can cause it?
1) Typical antipsychs
2) SSRI
Akathisia, what is it?
Subjective sensation of inner restlessness or strong desire to move one's body
Akathisia, when is it seen?
Shortly after initiation of an antipsychotic
Akathisia, risks?
1) High potency typicals
2) Young men
Akathisia, severe problems?
Severe dysphoria and anxiety
Can drive pts to try suicide
Need to have high suspicion of akathisia because?
If mistaken for agitation or worsening psychosis, may increase antipsychotic dose with resultant worsening of akathisia
Time frame for akathisia?
Within first month of drug initiation, but can occur anytime during treatment
Treatment for akathisia?
First Line - Propranolol

Second Line - Benzos such as Lorazepam

Third Line - Anticholinergics
Signs of Parkinsonism?
1) Lead pipe rigidity
2) Cogwheel rigidity
3) Pill rolling tremor
4) Bradykinesia
5) Akinesia
What is lead pipe rigidity?
Rigidity present continuously throughout passive movement of an extremity
What is cogwheel rigidity?
Rigidity with a catch-and-release character
Risk factors for Parkinsonism
1) Increasing age
2) Female gender
3) High potency typicals
4) Previous incidence
Time frame for Parkinsonism
First few weeks of therapy
Treatment of Parkinsonism
1) Reduce dosage
2) Anticholinergics
3) Levodopa / Amantadine
NMS, what is it and what is it not?
Life threatening complication of antipsychotic drug use

It is NOT an allergic reaction
Symptoms of NMS?
FALTER

Fever
ANS instability (tachy, hyper/hypo)
Leukocytosis
Tremors
Elevated CPK / LFTs
Rigidity (lead pipe)
Risk factors for NMS development?
1) High dose antipsychotics
2) Rapid dose escalation
3) IM Injections of antipsychotics
4) Dehydration
5) Agitation
6) Prior NMS
Treatment of NMS
1) D/C the antipsychotic
2) Supportive interventions
3) Dantrolene (muscle relaxant) to reduce rigidity and myonecrosis
4) Bromocriptine (to restore some dopamine)
NMS vs. Serotonin Syndrome
Many symptoms are similar... But...

In NMS, muscular rigidity with myonecrosis is a predominant feature absent in SS

NMS is from antidopamine drugs
SS is from drugs that increase serotonin
Serotonin Syndrome, what is it caused by mechanistically?
High synaptic levels of serotonin
What is a classic cause of SS?
Serotonin altering medication + MAOI
What is a less obvious cause of SS?
MAOI + Meperidine or Dextromethorphan or other Opiates
Symptoms of SS?
Tachycardia, HTN, hyperthermia, shivering, clonus, hyperreflexia, restless, agitation, delirium, prominent GI symptoms
Mnemonic for SS?
Hyperthemia
Hypertension
Hyperreflexia
Hypermovement (shiver/clonus)
Hyper (agitated/restless)
TX for SS?
1) D/C meds
2) Supportive care
3) Cyproheptadine
What is mechanism of Cyproheptadine?
5HT-2A receptor antagonist
What is Cyproheptadine used for?
Treatment of serotonin syndrome
What is Tardive Dyskinesia?
Movement disorder s/p long term neuroleptic use

(rarely occurs spontaneously in elders without prior medication use)
What are the symptoms of TD?
Choreoathetoid, constant, involuntary movements of head/neck, especially mouth and tongue
Risk factors for TD?
1) Long term treatment with typicals
2) Female gender
3) Presence of a mood disorder
TD course?
It is reversible, but often will stay permanent
Treatment for TD?
1) Reduce dose
2) Change meds
3) Try Clozapine instead
Why choose Clozapine when TD is in the picture?
It seems to work by a different mechanism from the other antipsychotics
What is metabolic syndrome?
Obesity
Insulin Resistance
Hyperlipidemia
What is the side effect all atypicals can cause?
Metabolic disorder
Which atypicals have highest incidence of causing metabolic problems?
Olanzapine
Clozapine
What should be recorded prior to initiation of atypicals? (3)
BMI
Fasting glucose
Lipid Panel
Time course for...

Dystonia
Akathisia
Parkinsonism (EPS)
TD
NMS
Dystonia (first few days)
Akathisia (first few weeks)
EPS (first few weeks)
NMS (first few weeks)
TD (after years)