Tardive dystonia. Prevalence, risk factors, and comparison with tardive dyskinesia in a population of 200 acute psychiatric inpatients

Globus Pallidus Internus Deep Brain Stimulation for Dystonic Opisthotonus in Adult-Onset Dystonia: A Personalized Approach

Introduction

Dystonic opisthotonus is defined as a backward arching of the neck and trunk, which ranges in severity from mild backward jerks to life-threatening prolonged severe muscular spasms. It can be associated with generalized dystonic syndromes or, rarely, present as a form of axial truncal dystonia. The etiologies vary from idiopathic, genetic, tardive, hereditary-degenerative, or associated with parkinsonism. We report clinical cases of dystonic opisthotonus associated with adult-onset dystonic syndromes, that benefitted from globus pallidus internus (GPi) deep brain stimulation (DBS).

Methods

Clinical data from patients with dystonic syndromes who underwent comprehensive medical review, multidisciplinary assessment, and tailored medical and neurosurgical managements were prospectively analyzed. Quantification of dystonia severity pre- and postoperatively was performed using the Burke-Fahn-Marsden Dystonia Rating Scale and quantification of overall pain severity was performed using the Visual Analog Scale.

Results

Three male patients, with age of onset of the dystonic symptoms ranging from 32 to 51 years old, were included. Tardive dystonia, adult-onset dystonia-parkinsonism and adult-onset idiopathic axial dystonia were the etiologies identified. Clinical investigation and management were tailored according to the complexity of the individual presentations. Although they shared common clinical features of adult-onset dystonia, disabling dystonic opisthotonus, refractory to medical management, was the main indication for GPi-DBS in all patients presented. The severity of axial dystonia ranged from disturbance of daily function to life-threatening truncal distortion. All three patients underwent bilateral GPi DBS at a mean age of 52 years (range 48–55 years), after mean duration of symptoms prior to DBS of 10.7 years (range 4–16 years). All patients showed a rapid and sustained clinical improvement of their symptoms, notably of the dystonic opisthotonos, at postoperative follow-up ranging from 20 to 175 months. In some, the ability to resume activities of daily living and reintegration into the society was remarkable.

Conclusion

Adult-onset dystonic syndromes predominantly presenting with dystonic opisthotonus are relatively rare. The specific nature of dystonic opisthotonus remains a treatment challenge, and thorough investigation of this highly disabling condition with varying etiologies is often necessary. Although patients may be refractory to medical management and botulinum toxin injection, Globus pallidus stimulation timed and tailored provided symptomatic control in this cohort and may be considered in other carefully selected cases.

Movement disorders in psychiatric patients

The observability of movement gives it advantages when trying to draw connections between brain and mind. Disturbed motor function pervades schizophrenia, though it is difficult now to subtract the effects of antipsychotic treatment. There is evidence from patients never exposed to these drugs that dyskinesia and even parkinsonism are to some degree innate to schizophrenia. Tardive dyskinesia and drug-induced parkinsonism are the most common movement disorders encountered in psychiatric practice. While D2 dopamine receptor blockade is a causative factor, both conditions defy straightforward neurochemical explanation. Balanced against the need to manage schizophrenic symptoms, neither prevention nor treatment is easy. Of all disorders classified as psychiatric, catatonia sits closest to organic neurology on the neuropsychiatric spectrum. Not only does it occur in the setting of unequivocally organic cerebral disease, but the alterations of consciousness it produces have ‘organic’ qualities even when the cause is psychiatric. No longer considered a subtype of schizophrenia, catatonia is defined by syndromic features based on motor phenomenology. Both severe depression and obsessive-compulsive disorder may be associated with ‘soft’ extrapyramidal signs that resemble parkinsonian bradykinesia. As functional neuroimaging studies suggest, movement and psychiatric disorders involve the same network connections between the basal ganglia and the cerebral cortex.

Tardive syndrome: An update and mini-review from the perspective of phenomenology

Tardive syndrome (TS) is a group of movement disorders caused by the long-term use of dopamine receptor blocking agents. The phenotypic presentation of TS is diverse, ranging from the most well-characterized symptom of tardive dyskinesia to other symptoms, including dystonia, akathisia, myoclonus, parkinsonism, tremor, and tics. These tardive symptoms are distinct not only in their phenomenology but also in their clinical outcomes. However, our knowledge of the pathophysiology and management of TS is almost exclusively based on tardive dyskinesia. First-generation antipsychotics have a higher risk of inducing TS and have largely been replaced by second-generation antipsychotics with a lower risk of TS. However, patients with off-label use of second-generation antipsychotics are still at risk of developing TS. Thus, the management of TS remains a challenging and important issue for physicians. In this review, we update the information on the epidemiology, phenomenology, and treatment of TS from the perspective of the specific form of TS.

Assessment of drug-related movement disorders in schizophrenia

Conventional antipsychotic drugs remain one of the mainstays of treatment of schizophrenia and related psychotic disorders. The therapeutic efficacy of these drugs is well established, both for treatment of acute symptoms and in relapse prevention. Unfortunately, they are associated with a broad range of side-effects, the most prominent of which is the development of a variety of movement disorders (see Box 1). Compared with the conventional antipsychotic agents, the newer, atypical antipsychotics have a lower liability for the acute extrapyramidal side-effects (EPS) and, for a few of the new drugs, there is some evidence of a lower risk of tardive dyskinesia (Barnes & McPhillips, 1999). Nevertheless, even with these newer agents, movement disorders are seen in a significant proportion of patients.

An Unexpected Circumstance: Acute Dystonic Reaction in the Setting of Clozapine Administration

Clozapine is a second-generation antipsychotic typically reserved for refractory psychotic disorders due to its high-risk side effect profile to include agranulocytosis, with its attendant need for regular blood draws. While reports of extrapyramidal symptoms (EPS), including acute dystonic reactions, are exceedingly rare, we present the case of a 44-year-old male with a long-standing history of treatment-resistant schizoaffective disorder and no history of EPS who experienced an acute buccal dystonic reaction in the setting of clozapine initiation and discontinuation of depot and oral risperidone. This case report presents one of the few documented episodes of acute dystonic reactions occurring in the setting of clozapine administration. Based upon the patient's history and the dosing time line of the medications, we propose that an interaction between the clozapine and residual risperidone was responsible for the development of the acute buccal dystonia.

Drug-Induced Movement Disorders

Drug-induced movement disorders (DIMDs) pose a significant burden to patients, often resulting in nonadherence, disease relapse, and decreased quality of life. Dopamine-receptor blocking agents such as conventional antipsychotics (eg, haloperidol and chlorpromazine) and antiemetics (eg, metoclopramide and prochlorperazine) are most commonly implicated. DIMDs can be categorized by the onset of symptoms: acute reactions occurring hours to days after exposure, subacute DIMDs appearing within weeks, and tardive occurring months to years after drug exposure. The DIMDs of akathisia, tardive dyskinesia, dystonia, and parkinsonism are reviewed. Their epidemiology, mechanism, clinical presentation and differential diagnosis, risk factors, morbidity and mortality, and prevention and management are discussed. For many of these disorders, treatment inconsistently provides benefit, and therefore, primary prevention is essential. Clinicians and other healthcare professionals play a key role in the identification of patients with DIMDs, or those at risk, and in implementing prevention and treatment plans.

Management of aripiprazole-induced tardive Pisa syndrome: a case report and literature review

Pisa syndrome (PS) is characterized by an abnormally sustained posture with flexion of the body and head to one side and slight axial rotation of the trunk. PS has been related to the use of neuroleptics and is clinically classified as either an acute or a tardive dystonia. This is the first report describing a case of late-onset PS, occurring in a young patient treated with aripiprazole for 2 years. To establish optimal treatment management, we reviewed the literature on aripiprazole-induced PS and tardive dystonia. In light of current knowledge, we proposed a multistep algorithm to aid in the clinical management of this condition.

Ziprasidone-induced tardive laryngeal dystonia: a case report

Tardive laryngeal dystonia, a rare form of dystonic syndrome, was only reported to be induced by typical antipsychotics. Here, we report one case of ziprasidone-induced tardive laryngeal dystonia in a schizophrenic female patient, who showed dysphonia, hoarseness and dyspnea after taking ziprasidone 120 mg/day for 8 months. These symptoms were significantly improved after discontinuing ziprasidone and increasing the dose of trihexyphenidyl for 1 week. Although atypical antipsychotics are associated with a lower risk of extrapyramidal symptoms, caution should be taken for any tardive dystonic movement when using these medications.

Effects of Chronic Haloperidol and/or Clozapine on Oxidative Stress Parameters in Rat Brain

Decreased antioxidant activity is considered as one of the causes of tardive dyskinesia in schizophrenic patients in a prolonged neuroleptic treatment course. Haloperidol (HAL) has been hypothesized to increase oxidative stress, while clozapine (CLO) would produce less oxidative damage. The objective was to determine whether CLO for 28 days could reverse or attenuate HAL-induced oxidative damage in animals previously treated with HAL for 28 days. HAL significantly increased thiobarbituric acid reactive substances levels in the cortex (CX) and striatum and increased protein carbonyls in hippocampus (HP) and CX and this was not attenuated by CLO treatment. In the total radical trapping antioxidant parameter assay there was a decrease in the HP total antioxidant potential induced by HAL and by treatment with HAL + CLO. Our findings demonstrated that the atypical antipsychotic CLO could not revert oxidative damage caused by HAL.

Deep brain stimulation of the internal globus pallidus for refractory tardive dystonia

We report a rapid, dramatic and sustained improvement following bilateral pallidal stimulation in two patients affected by intractable generalized tardive dystonia. Both patients had a chronic psychiatric disorder and developed chronic disabling generalized dystonic symptoms persisting despite prolonged withdrawal of neuroleptics and all available symptomatic treatment. The clinical benefit in both patients persisted throughout all the follow up period of 13 and 7 months. The favorable and prolonged response in our two patients suggests that deep brain stimulation may be an effective treatment for medically refractory tardive dystonia.

Long-term high-frequency bilateral pallidal stimulation for neuroleptic-induced tardive dystonia

✓ The authors report the results of long-term bilateral high-frequency pallidal stimulation in two patients affected by neuroleptic-induced dystonia.

The first patient, a 33-year-old man, experienced a dystonic posture of the trunk, with involvement of the neck and upper and lower limbs after 11 years of treatment with neuroleptic drugs. The second patient, a 30-year-old man, presented with a torsion dystonia, spasmodic torticollis, and involuntary movements of the upper limbs, which appeared after 4 years of neuroleptic treatment. Both of these dystonias worsened even after the neuroleptic treatment had been discontinued, and neither patient responded to clozapine or benzodiazepine therapy. The time lapse between the first appearance of dystonia and surgery was, respectively, 5 and 3 years. In each case bilateral stereotactic implantation of electrodes within the globus pallidus internus (GPI) was performed while the patient was in a state of general anesthesia. The electrodes were placed at the following anterior commissure—posterior commissure line—related coordinates: 20 mm lateral to the midline, 6 mm below the intercommissural plane, and 3 mm anterior to the midcommissural point. Electrical stimulation (130 Hz, 1 V, 90 µsec) was begun on the 1st postoperative day. In both patients, a genetic analysis positively ruled out a mutation in the DYT1 gene, and magnetic resonance imaging yielded normal findings in both cases.

Extrapyramidal symptoms and dystonia disappeared almost completely and dramatically in both patients just a few days after high-frequency bilateral pallidal stimulation commenced. Both patients regained autonomy and neuroleptic treatment was reinitiated. The follow-up period for both cases was 1 year. Long-term bilateral high-frequency stimulation of GPI resulted in a dramatic and long-lasting improvement of neuroleptic-induced tardive dystonia.

Mouvements anormaux d’origine médicamenteuse : les syndromes tardifs

Persistent drug-induced movement disorders (tardive syndromes) remain an important clinical problem and consist of a variety of involuntary movements appearing in a patient exposed to a dopamine-blocking agent. The current state of knowledge on this topic is summarised in this article. Clinical aspects (tardive dyskinesia, tardive dystonia and other forms), prevalence, risk factors, prevention and management are discussed.

Possible antioxidant and neuroprotective mechanisms of FK506 in attenuating haloperidol-induced orofacial dyskinesia

Tardive dyskinesia is a serious motor side effect of chronic neuroleptic therapy. The pathophysiology of this disabling and commonly irreversible movement disorder is still obscure. It may be caused by a loss of dopaminergic cells, due to free radicals as a product of high synaptic dopamine levels. Chronic treatment with neuroleptics leads to the development of abnormal oral movements in rats called vacuous chewing movements. Vacuous chewing movements in rats are widely accepted as an animal model of tardive dyskinesia. Chronic haloperidol (1 mg/kg for 21 days) treatment significantly induced vacuous chewing movements and tongue protrusions in rats, and FK506 (Tacrolimus) [[3S-[3R*[E(1S*,3S*,4S*)],4S*,5R*,8S*,9E,12R*,14R*,15S*,16R*,18S*,19S*,26aR*]]-5,6,8,11,12,13,14,15,16,17,18,19,24,25,26,26a-hexadecahydro-5, 19-dihydroxy-3-[2-(4-hydroxy-3-methoxycyclohexyl)-1-methylethenyl]-14, 16-dimethoxy-4,10,12, 18-tetramethyl-8-(2-propenyl)-15, 19-epoxy-3H-pyrido[2,1-c][1,4] oxaazacyclotricosine-1,7,20, 21(4H,23H)-tetrone, monohydrate] dose dependently (0.5 and 1 mg/kg) reduced these haloperidol-induced movements. Biochemical analysis revealed that chronic haloperidol treatment significantly induced lipid peroxidation and decreased the levels of glutathione and of the antioxidant defense enzymes, superoxide dismutase and catalase, in the brains of rats. Co-administration of FK506 dose dependently (0.5 and 1 mg/kg) and significantly reduced the lipid peroxidation and restored the decreased glutathione levels induced by chronic haloperidol treatment. It also significantly reversed the haloperidol-induced decrease in brain superoxide dismutase and catalase levels. The major findings of the present study suggest that oxidative stress-induced neuronal death might play a significant role in neuroleptic-induced orofacial dyskinesia. In conclusion, FK506 could be a useful drug for the treatment of neuroleptic-induced orofacial dyskinesia.

Tardive dystonia and genetic polymorphisms of cytochrome P4502D6 and dopamine D2 and D3 receptors: a preliminary finding

Tardive dystonia is an uncommon but intractable and distressing complication of neuroleptic treatment. It is suggested that individual predisposing vulnerability plays a major role in the development of the side effect. This study aimed to investigate relationship tardive dystonia and several genetic factors such as polymorphism of cytochrome P4502D6, and receptor polymorphisms of dopamine D(2) (TaqI A and -141C Ins/Del polymorphisms) and D(3) (Ser(9)Gly polymorphism). Nine patients with tardive dystonia were genotyped for these genetic polymorphisms. No specific genotypes or alleles were overpresented in the patients. This study suggests that these polymorphisms are not related to the development of tardive dystonia.

Drug-induced Pisa syndrome (pleurothotonus): epidemiology and management

Long-term administration of antipsychotics occasionally produces persistent dystonia of the trunk, a disorder known as Pisa syndrome (or pleurothotonus). The development of Pisa syndrome is most commonly associated with prolonged treatment with antipsychotics; however, it has also been reported, although less frequently, in patients who are receiving other medications (such as cholinesterase inhibitors and antiemetics), in those not receiving medication (idiopathic Pisa syndrome) and in those with neurodegenerative disorders. Drug-induced Pisa syndrome predominantly develops in females and in older patients with organic brain changes. It sometimes occurs after the addition of another antipsychotic to an established regimen of antipsychotics or insidiously arises in antipsychotic-treated patients for no apparent reason. The condition generally disappears after antipsychotic drugs are discontinued. Although a pharmacological therapy for drug-induced Pisa syndrome has not been established, we have reported that anticholinergic drugs are effective in about 40% of patients who have episodes of Pisa syndrome with the remaining patients responding to the withdrawal or reduction of daily doses of antipsychotic drugs. The characteristics of its development and prognosis indicate that drug-induced Pisa syndrome consists of two types of dystonia. Some patients develop clinical features of acute dystonia, whereas others develop symptoms similar to tardive dystonia. Like that of tardive dystonia, Pisa syndrome responds better than tardive dyskinesia to a relatively high daily dose of an anticholinergic. However, the significant improvement caused by the withdrawal of antipsychotic drugs in Pisa syndrome differentiates it from tardive dystonia. Thus, Pisa syndrome including these features is considered to be an atypical type of tardive dystonia. These clinical characteristics suggest that the underlying pathophysiology of drug-induced Pisa syndrome is complex. A dopaminergic-cholinergic imbalance, or serotonergic or noradrenergic dysfunction, may be implicated. Asymmetric brain functions or neural transmission may also be considered as underlying mechanisms of the development of Pisa syndrome that is resistant to anticholinergic drugs. Idiopathic Pisa syndrome is characterised by an adult-onset, segmental truncal dystonia in patients with no previous exposure to antipsychotics. It occurs rarely but shows a complete resolution with high doses of anticholinergic drugs.

Treatment of patients with tardive dystonia with olanzapine

Tardive dystonia represents a complication of long-term use of neuroleptics and its treatment is often unsatisfactory. Atypical neuroleptics appear to improve tardive dystonia, and cases of tardive dystonia successfully managed with clozapine have been reported. The aim of this open-label video-blinded study was to evaluate the antidystonic efficacy of olanzapine, a new atypical neuroleptic with a low risk of agranulocytosis, in a group of four patients (one man and three women) with tardive cervical dystonia. They developed severe dystonia after several years of neuroleptic treatment. Extensive laboratory evaluations, as well as neurophysiologic and neuroradiologic investigations, were negative. Olanzapine was started at a dose of 5 mg/d and increased up to 7.5 mg/d. All patients were evaluated at baseline and after 2, 4, 8, and 12 weeks of treatment, using the Toronto Western Spasmodic Torticollis Rating Scale, and videotaped. At the end of the trial, the videotapes were reviewed and scored by a blind observer. A self-rating visual analog scale completed the disability evaluation.A moderate to marked improvement in dystonia was observed in all patients, and significant differences were observed in Toronto Western Spasmodic Torticollis Rating Scale scores and videotape ratings after 8 and 12 weeks of treatment compared with the basal values (p < 0.05). The average percentage of improvement in Toronto Western Spasmodic Torticollis Rating Scale score and visual analog scale was 26.4% and 42.6%, respectively. No serious side effects were reported at the maximum dosage reached (7.5 mg/d). This study warrants a larger controlled study to conclusively demonstrate the efficacy of olanzapine in tardive dystonia.

The current status of tardive dystonia

Tardive dystonia (TDt), a persistent dystonia associated with exposure to neuroleptic drugs, is an uncommon disorder. It differs from tardive dyskinesia (TDk) in epidemiology, clinical features, risk factors, pathophysiology, course, prognosis, and treatment outcome. TDt seems to develop faster and is more painful, distressing, and disabling than tardive dyskinesia. In this article, evidence is reviewed on the face, descriptive, construct, and predictive validity of this iatrogenic complication of antipsychotic drugs. It is suggested that TDt should not be lumped together with TDk. It deserves a separate nosological status as an independent diagnostic category. The subclassification of TDt into various subtypes based on coexistence of other movement disorders is suggested.

Tardive dyskinesia in a chronically institutionalized population of elderly schizophrenic patients: prevalence and association with cognitive impairment

BACKGROUND

Chronically hospitalized geriatric inpatients with schizophrenia are at particular risk for both tardive dyskinesia (TD) and cognitive impairment but have been insufficiently studied in this regard. Similarly, the relationship between TD and cognitive impairment has not be adequately addressed in this population.

OBJECTIVES

(1) To determine the prevalence of TD in a cohort of chronically institutionalized schizophrenic geriatric inpatients. (2) To examine the relationship between the manifestations of TD in various body regions and several potentially related variables including current pharmacological regimen, age, age at first hospitalization and cognitive status.

METHOD

TD was assessed by the Modified Simpson Dyskinesia Scale and cognitive status by the Mini-Mental State Examination (MMSE). The relationship between manifestations of TD and other variables was examined by t-tests, ANOVA, MANOVA and correlational analysis.

RESULTS

The prevalence of TD was 60%. Prevalence increased with age but was not related to current antipsychotic or anticholinergic regimen. Mean MMSE score did not differ between groups of patients with and without TD as defined by the criteria of Schooler and Kane (1982); however, the mean MMSE score was significantly (p < 0.0004) lower in subjects with orofacial TD as defined by Waddington and Youssef (1996), and the difference was not entirely accounted for by the older age of the latter group.

CONCLUSIONS

TD and cognitive impairment both increase with age. However, TD alone does not account for the severity of cognitive impairment in this population. The present study provides further support for the hypothesis that the correlation between TD and cognitive impairment holds primarily for the orofacial manifestations of TD.

Managing antipsychotic-induced acute and tardive dystonia

Antipsychotic-induced extrapyramidal adverse effects continue to be a serious problem in the treatment of psychotic disorders. While the pathophysiology of these adverse effects is not well understood, much recent research has focused on improving our ability to use available pharmacotherapy in the most effective and least toxic manner. Acute dystonic reactions only occur within the first days of antipsychotic treatment. They are often distressing and frightening for the patient and may even be dangerous. However, they can be effectively prevented or reversed with anticholinergics. Furthermore, the growing use of the new atypical antipsychotics will lead to a significant decrease in the rate of acute dystonic reactions. In contrast, tardive dystonia is a long-lasting menace in the course of antipsychotic treatment, for which there is no established therapy. Tardive dystonia is sometimes disabling or disfiguring and, like other tardive disorders, is potentially irreversible. Because, in most cases, patients need to continue taking the antipsychotic that has caused the adverse effect to prevent relapse of the mental illness, preventive measures are crucial. Antipsychotics should be prescribed only for patients affected by psychotic disorders, when definitely indicated and at the lowest effective dosage. The use of clozapine and other novel antipsychotic agents is also likely to represent an important step in the prevention and treatment of tardive dystonia. Compared with traditional antipsychotics, most of the new antipsychotics are characterised by a low acute extrapyramidal adverse effects liability and they also bring the hope of reducing the risk of tardive disorders. If tardive dystonia has occurred, switching to clozapine or another atypical antipsychotic and treatment with tetrabenazine, reserpine and botulinum toxin are possible options.

Severe antecollis during antipsychotics treatment: a report of three cases

1. The authors report on three patients with severe antecollis that developed after chronic treatment with antipsychotics. These patients had been treated with neuroleptics for their delusions and hallucinations. Antecollis is a rare form of tardive dystonia that has drawn little attention. To our knowledge, there have been no reports on this disorder. 2. The patients developed the symptom after receiving a number of antipsychotics for 4 months to 14 years. Neither discontinuation of antipsychotics nor administration of anticholinergic agents affected the symptom. 3. Although spontaneous improvement of dystonia was obtained after several months without any specific treatment in one patient, the symptom persisted for several years in another. The last patient could not be followed after discharge from our hospital since she and her family did not come to the hospital. 4. Severe antecollis may cause disturbances in various functions, such as vision, speaking and swallowing. Forward bending of the neck may cause inspiratory obstruction. Severe antecollis may not be unusual and psychiatrists should be aware of this symptom in routine clinical practice.

Drug-induced movement disorders

Drug-induced movement disorders are often unrecognized, especially when not due to dopamine receptor blockers. This review discusses acute, subacute, and chronic syndromes. Pathophysiology relates almost always to dopaminergic transmission. Patient-dependent vulnerability and drug-dependent sensitivity are contributing factors. Young patients are more prone to acute reactions, and tardive or chronic conditions are more frequent in the elderly. Subclinical Parkinsonism can be unmasked by medication exposure. Treatment of tardive dyskinesia remains a challenging task for the clinician, but novel antipsychotics and dopamine depleting agents can be beneficial.

Tardive dystonia. Prevalence, risk factors and clinical features

In order to replicate the results of our previous study of tardive dystonia (TDt) and to enlarge the studied sample, we examined 154 consecutive psychiatric in-patients who had been exposed to neuroleptic drugs for a cumulative period of at least three months. The present study provides further data supporting a distinction between TDt and tardive dyskinesia (TDk). The patients with TDt tend to be younger, male, less exposed to neuroleptic drugs, and to have a more severe movement disorder. TDt appears to be the most frequent form of secondary dystonia, and there is evidence that its prevalence has so far been underestimated.