Download Atypical Antipsychotics Induced Chronic Akathisia: A Case Report

Case Report / Vaka Sunumu
DOI: 10.5455/jmood.20140420094355
Atypical Antipsychotics Induced Chronic Akathisia:
A Case Report
Serap Oflaz1, Hasan Bakay1, Ertuğrul Çekiç2, Hulya Guveli3, Sevda Bağ2
ÖZET:
ABS­TRACT:
Atipik antipsikotiklerin neden olduğu kronik
akatizi: Vaka sunumu
Atypical antipsychotics induced chronic
akathisia: a case report
Akatizi huzursuzluk ve sıkıntı veren istemsiz hareketler
ile karakterize bir hareket bozukluğudur. Akatizinin dört
tipi mevcuttur: akut, tardif, kesilme ve kronik akatizi.
İlacın tetiklediği akatiziden korunma konusunda standart
titrasyon ve ikinci kuşak antipsikotiklerin kullanımı başarılı
yaklaşımlar olarak bilinmektedir. Bununla birlikte, ilacın
tetiklediği akatizi ikinci kuşak antipsikotiklerle de ortaya
çıkabilmektedir. Özellikle akatizi kronikleştiğinde, tedavide
bir takım güçlükler ortaya çıkabilmektedir. Biz bu yayında,
psikotik bozukluk tedavisine yönelik çeşitli ikinci kuşak
antipsikotik ilaçlar verilen ve ilaç tedavileri sonrasında akut
başlangıçlı kronik akatizi gelişen bir hastayı ve bu hastanın
tedavisini tartıştık.
Akathisia is a movement disorder characterized by
involuntary movements resulting in discomfort and
restlessness. The four subtypes of akathisia are as
follows: acute, tardive, withdrawal and chronic akathisia.
Standardized titration and use of second generation
antipsychotics are successful approaches of prevention
from drug-induced akathisia. On the other hand, it is
possible that atypic antipsychotics-induced akathisia
may emerge and there may be some difficulties in
its management, especially when it is persistent. In
this paper, we discussed a patient, who were given
various second generation antipsychotics for treatment
of psychotic disorder and there after developed chronic
akathisia with acute onset and its management.
1
Istanbul University, Istanbul Faculty of
Medicine, Department of Psychiatry,
Istanbul-Turkey
2
Bakirkoy Research and Training Hospital for
Psychiatric and Neurological Diseases,
Istanbul-Turkey
3
Istanbul University, Institute of Oncology,
Department of Preventive Oncology,
Istanbul-Turkey
Ya­zış­ma Ad­re­si / Add­ress rep­rint re­qu­ests to:
Serap Oflaz, Istanbul University, Istanbul
Faculty of Medicine, Department of
Psychiatry, Istanbul- Turkey
Telefon / Phone: +90-212-414-2410
Elekt­ro­nik pos­ta ad­re­si / E-ma­il add­ress:
[email protected]
Ka­bul ta­ri­hi / Da­te of ac­cep­tan­ce:
20 Nisan 2014 / April 20, 2014
Key words: chronic akathisia, atypic antipsychotics
Bağıntı beyanı:
S.O., H.B., E.Ç., H.G., S.B.: Yazarlar bu makale
ile ilgili olarak herhangi bir çıkar çatışması
bildirmemiştir.
Journal of Mood Disorders 2014;4(4):175-7
Declaration of interest:
S.O., H.B., E.Ç., H.G., S.B.: The authors reported
no conflict of interest related to this article.
Anahtar sözcükler: kronik akatizi, atipik antipsikotikler
Journal of Mood Disorders 2014;4(4):175-7
INTRODUCTION
widely 5% to 36.8% (4-5). Various risk factors; higher drug
dosages, rapid increment of dosage, higher-potency
Akathisia,one of the most common acute movement
antipsychotic medication (6), higher age, younger age,
disorders (1), is a syndrome which results in subjective
female sex, negative symptoms, iron deficiency, cognitive
discomfort and movement symptoms. This syndrome
disfunctions and bipolar disorder diagnoses(especially
consists of subjective feelings of inner restlessness and urge
bipolar depression), have been associated with both first and
to move, as well as objective signs, such as rocking while
second generation antipsychotics- induced akathisia (7-8).
standing or sitting, lifting feet as if marching on the spot and
crossing and uncrossing the legs while sitting. While the
according to its onset in relation to the administration of the
patient is lying down, it is possible to observe foot movements
antipsychotic drug and its duration, as an acute, tardive,
and/or myoclonic jerks of the feet (2). Drug induced akathisia
withdrawal and chronic akathisia. Chronic akathisia is
is usually seen with antipsychotic drugs, additionally
defined as persistence of akathisic symptoms for more than
antiemetics (prochlorperazine, metoclopramide),
3 months. The term does not express whether the beginning
antidepressants (tricyclics, SSRIs) and calcium channel
of the symptoms was acute or tardive or withdrawal. This
blockers (cinnarizine, flunarizine, diltiazem) may also lead
term only describes the duration of the symptoms (9).
to acathisia (3). Prevalence rates of antipsychotic induced
akathisia in patients receiving antipsychotic drugs vary
chronic akathisia and its management.
Journal of Mood Disorders Volume: 4, Number: 4, 2014 - www.jmood.org
Antipsychotic-induced akathisia can be classified
Here, we present a case of atipic antipsychotic-induced
175
Atypical antipsychotics induced chronic akathisia: a case report
CASE REPORT
inner restlesness ang urging to move were disappeared.
Forty three-year-old woman with suicide attempts
quetiapine 450 mg/day was applied as antipsychotic
admitted to psychiatry emergency service and hospitalized.
medication due to bizarre behaviors and negative
It was reported that patient had akathisic symptoms for a
symptoms before hospitalization. Akathisia was
long while with suicide thoughts and attempts, decreased
disappeared and patient was discharged with this
appetite, sleep disturbances and nonstop walking at home
treatment.
While decreasing of diazepam and propranolol treatment
for last 3 weeks.
DISCUSSION
retardation and insomnia eight months ago. According to
Atypic antipsychotic-induced chronic akathisia is
her previous documents and information received from
limited; albeit cases of atypic antipsychotic-induced
family, firstly her treatment was initiated with risperidone
akathisia were reported before in the literature. In one of
2-4 mg/day, paroxetine 20-40 mg/day, biperidene 2 mg/day
those cases, nearly 7-month-long persistent akathisia,
and chlorpromazine 100 mg/day. After this medication, it
emerged after atypic antipsychotic medication, with uses of
was documented that psychotic and depressive symptoms
various atypic antipsychotics is reported. In the literature,
were decreased, unluckily akathisic symptoms, feeling of
atypic antipsychotics-induced akathisia was reported to be
inner restlessness and urging to move had began at the 2
present in 0-39% of clozapine, 13-25% of risperidone, 2.4% of
week of the medication. Olanzapine (10-20 mg/day),
olanzapine receiving patients (2,8). The incidence of
aripipirazole (10-20 mg/day), propranolol (40-80 mg/day),
akathisia was 3.3% with quetiapine monotherapy compared
sertralin (100 mg/day), fluoksetine (20 mg/day) were
with 6.1% with placebo in bipolar manic patients on four
prescribed for treatment during seven months. The last
randomized placebo-controlled double-blind trials (10).
medication was olanzapine 10 mg/day when she applied to
emergency service.
to further psychotropic intervention that exacerbating
Initial psychiatric examination: She was seemed her
akathisia (such as increases in dosage) may be mistaken
chronological age and her selfcare was not sufficient. Eye
with akathisia. We thougt that previous drug changes had
contact was decreased with increased psychomotor
been done for this reason. Unfortunately we also attend
activation, fairly decreased spontaneous speech, anxious
high dose of antipsychotics at the begining of treatment.
mood, suicidal plans, no hallucinations and delusions.
This clinic continued with antipsychotic treatment and then
Patient was in restlessness and she was pacing in room.
regressed with medication used for akathisia, so we excluded
When she tried to sit, patient couldn’t stop to walk more than
psychotic agitation. The differentiated diagnosis is also
20 or 30 seconds. Her physical examination, routine
necessary between restless legs syndrome and akathisia.
biochemistry and thyroid hormone profiles were assessed as
Idiopathic restless legs syndrome, a dyssomnia in which the
normal. Results of brain MRI and EEG were normal. She has
person feels a strong urge to move the lower limbs, bears
no any family history for psychiatric disorders.
some resemblance to akathisia because of the subjective
At the first interview we thought patient’s clinic was
sensation which may result in the need to get up and pace.
likely to be psychotic agitation. We increased olanzapine 20
The diagnose of our patient is chronic akahtisia that persists
mg/day. Because significant symptoms of akathisia with
for 7 months due to the symptoms that feeling of inner
pacing continuously and insomnia, antypschotic
restlessness, urging to move begins at second weeks of
medication was stopped at the 3 day of treatment. Then,
antipsycotic treatment.
alprazolam 1.5-3 mg/day, propranolol 40 mg/day
medications were applied. Within one week complaints of
benzodiazepines seem to be the most consistently effective
patient were decreased, sleep time was increased but the
treatment for antipsychotic-induced akathisia.
feeling of inner restlesness and urging to move continued.
Amantadine or clonidine can be tried in nonresponders,
Treatment was mediated with diazepam 10 mg/day and
although there is no evidence that they are more beneficial
propranolol 40 mg/day. At the end of 3 week, feeling of
(2). Recently, mirtazapine was found to be effective in the
The patient reported that she applied to psychiatry
outpatient clinic with auditory hallucinations, anhedonia,
nd
rd
rd
176
Agitation and behavior problems which can be leading
Propranolol or other lipophilic beta-blockers and
Journal of Mood Disorders Volume: 4, Number: 4, 2014 - www.jmood.org
S. Oflaz, H. Bakay, E. Çekiç, H. Guveli, S. Bağ
treatment of akathisia, especially if propranolol is
antipsychotics to quetiapine because of preexisting
contraindicated, mirtazapine may be considered as a
extrapyramidal side-effects (12).
significant treatment option for acute antipsychotic-
induced akathisia (11). Moreover, it was reported that a
induce chronic movement disorders, especially chronic
significant reduction in parkinsonism and akathisia in
akathisia. Quetiapine may be an alternative antipsychotic
patients with schizophrenia by switching from previous
treatment in patients with chronic akathisia.
In conclusion, second generation antipsychotics may
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