Antipsychotics for patients with pain

Going back to basics prior to mentioning the use of antipsychotics in patients with pain, the International Association for the Study of Pain (IASP) definition of pain can be summarized as an unpleasant experience, composed of sensory experience caused by actual tissue damage and/or emotional experience caused by potential tissue damage. Less used than antidepressants, antipsychotics have also been used for treating this unpleasant experience as adjuvant analgesics without sufficient evidence from research. Because recently developed atypical antipsychotics reduce the adverse reactions of extrapyramidal symptoms, such as acute dystonia, pseudo-parkinsonism, akathisia, and tardive dyskinesia caused by typical antipsychotics, they are expected to be used more frequently in various painful conditions, while increasing the risk of metabolic syndromes (weight gain, diabetes, and dyslipidemia). Various antipsychotics have different neurotransmitter receptor affinities for dopamine (D), 5-hydroxytryptamine (5-HT), adrenergic (α), histamine (H), and muscarinic (M) receptors. Atypical antipsychotics antagonize transient, weak D₂ receptor bindings with strong binding to the 5-HT(2A) receptor, while typical antipsychotics block long-lasting, tight D₂ receptor binding. On the contrary, antidepressants in the field of pain management also block the reuptake of similar receptors, mainly on the 5-HT and, next, on the norepinephrine, but rarely on the D receptors. Antipsychotics have been used for treating positive symptoms, such as delusion, hallucination, disorganized thought and behavior, perception disturbance, and inappropriate emotion, rather than the negative, cognitive, and affective symptoms of psychosis. Therefore, an antipsychotic may be prescribed in pain patients with positive symptoms of psychosis during or after controlling all sensory components.

Factors Influencing the Subjective Sexual Function in Patients with Schizophrenia Switched to Olanzapine / 대한정신약물학회지

OBJECTIVE: Sexual dysfunction is highly prevalent in both untreated and treated patients with schizophrenia. Sexual dysfunction is a major cause of poor quality of life, negative attitude to therapy and treatment non-compliance. We thereby conducted this study to better understand the predictors of subjective sexual dysfunction. METHODS: The subjects consisted of 83 patients (46 men; 37 women) who participated in an open label study on switching antipsychotics to olanzapine. All subjects met the Tenth Revision of International Classification of Diseases diagnostic criteria for schizophrenia. To better understand the predictors of subjective sexual dysfunction, we used the Liverpool University Neuroleptic Side-effect Rating scale (LUNSERS), a comprehensive self-rating instrument for assessing and quantifying the subjective adverse events during antipsychotic treatment. All patients were taking antipsychotics at the initiation of the study and were assessed using LUNSERS, the Simpson-Angus Scale (SAS), the Barnes Akathisia Rating scale (BARS), Abnormal Involuntary Movement Scale (AIMS), Clinical Global Impression (CGI), and the Positive and Negative Syndrome Scale (PANSS). They were also checked for their serum prolactin levels and vital signs before and after a 6-week treatment with olanzapine. In order to identify the cross-sectional and longitudinal predictors of LUNSERS hormonal side effect, we carried out multiple regression analyses. RESULTS: Prolactin levels, LUNSERS hormonal side effect, CGI, PANSS, SAS, AIMS, and BARS decreased after a 6-week treatment with olanzapine. At initial evaluation, cross-sectional predictors of LUNSERS hormonal side effect were red herring and allergic reaction subscale, but after the 6-week treatment with olanzapine, none of the variables were found to significantly predict LUNSERS hormonal side effect. Longitudinal predictors of LUNSERS hormonal side effect were LUNSERS extrapyramidal system side effect and prolactin levels. CONCLUSION: These findings suggested relationships among prolactin, extrapyramidal symptom, motor function and sexual dysfunction. After switching to olanzapine, sexual function of the patients improved subjectively. More studies are warranted as these results have significant implications for quality of life and treatment adherence.

Concomitant Use of Anticholinergic Agents with Atypical Antipsychotics in Schizophrenic Patients: A Preliminary Report / 대한정신약물학회지

OBJECTIVE: It is well known that antipsychotic drugs induce extrapyramidal symptoms such as dystonia, akathisia and parkinsonian symptoms even early in the treatment. With the advent of atypical antipsychotic drugs, the incidence of extrapyramidal symptoms has decreased, but danger still exists. Hence, anticholinergic agents are often indicated in treatment of schizophrenia with antipsychotics. METHODS: In this observational retrospective study, we examined the use of anticholinergic agents among schizophrenic patients who were initiated on risperidone, olanzapine, or quetiapine, the three most widely prescribed atypical antipsychotics. We reviewed medical records of schizophrenic patients who were initiated on risperidone, olanzapine or quetiapine from January 2004 through December 2004 and continuously treated with the antipsychotics for 6 months. The data were analysed using one way ANOVA, Mann-Whitney U test, chi-square test or Fisher's exact tests. RESULTS: The study yields two major findings. Firstly, compared with risperidone initiators, there were significantly fewer olanzapine initiators who used anticholinergic agent concomitantly. Secondly, there were significantly fewer olanzapine or quetiapine initiators than risperidone initiators who prescribed anticholinergic agent on the same day when antipsychotics was initiated. CONCLUSION: As the use of anticholinergic agent is a proxy for the presence of extrapyramidal symptom, these findings suggest that risperidone may be more associated with extrapyramidal symptoms than olanzapine or quetiapine. Controlled studies comparing them to one another should be of particular interest.

Two Cases of Sporadic Encephalitis Lethargica

We present two patients with clinical features suggestive of a hyperkinetic form of encephalitis lethargica described by von Economo. While undergoing treatment for viral meningoencephalitis, they both developed comatose mentality, oromandibular dyskinesia, chorea, myoclonic jerk, oculogyric crisis, opistotonus, respiratory failure, and autonomic dysfunction. One patient died of autonomic failure while the other improved several months later. In both patients, cerebrospinal fluid exmamination revealed only pleocytosis. A brain MRI and EEG showed no specific findings. In order to control severe hyperkinetism and autonomic failure, medical treatments including L-dopa, clonazepam, and steroid pulse therapy were administereed in both cases while electroconvulsive therapy was tried in one of the cases. However, they all failed. These cases and previous reports informed us of the presence of sporadic form of encephalis.

There Cases of Extrapyramidal Symptoms Following Fluoxetine / 신경정신의학

The selective serotonin reuptake inhibitor fluoxetine is one of the most frequently prescribed drugs for the treatment of depression and other psychiatric disorders. In the few years, there have been several reports of adverse effects encountered during coadministration of fluoxetine with or without other psychotropic drugs. We experienced three cases of extrapyamidal symptoms were developed when administered fluoxetine alone and with neuroleptics. We conclude that there is a probable or possible causal relationship between fluoxetine and extrapyramidal side effects. The pathogenesis of such adverse reactions, which may be hetero-geneous, is unknown, but it has been suggested that they might be caused by serotonergically mediated inhibition of dopaminergic transmission. From reports in those cases, it appears that fluoxetine alone may be associated with extrapyramidal side reactions. Furthermore the potential for increased levels of concomitant psychotropic medicines and increased side effects, should be borne in mind.

Hereditary Spastic Paraplegia

Hereditary spastic paraplegia is a familial disorder which is inherited by autosomal dominant, autosomal recessive or sex linked pattern. We experienced a family who has hereditary spastic paraplegia with mental retardation and extrapyramidal symptom that is thought inherited by autosomal dominant inheritance pattern. A review of literatures was made briefly.

Hereditary Spastic Paraplegia

Hereditary spastic paraplegia is a familial disorder which is inherited by autosomal dominant, autosomal recessive or sex linked pattern. We experienced a family who has hereditary spastic paraplegia with mental retardation and extrapyramidal symptom that is thought inherited by autosomal dominant inheritance pattern. A review of literatures was made briefly.