Catatonic variants, hyperthermic extrapyramidal reactions, and subtypes of neuroleptic malignant syndrome

What clinical analysis of antipsychotic-induced catatonia and neuroleptic malignant syndrome tells us about the links between these two syndromes: A systematic review

OBJECTIVES

Antipsychotic-induced catatonia (AIC) and neuroleptic malignant syndrome (NMS) are life-threatening adverse reactions to antipsychotic medication. We conducted a systematic review of literature following the PRISMA statement guidelines to obtain a description of these syndromes (population, context of occurrence, antipsychotic agents implicated) and draw conclusions about their links.

METHODS

We searched Medline and Web of science databases from January 1951 to May 2019 (further restricted from 2000 to 2019) using search terms including "catatonia", "neuroleptic malignant syndrome" and "antipsychotic agents" for case reports, case series and analytic studies. After screening 4082 records, 410 full-text articles (describing 555 events) were assessed for eligibility. We included events of AIC and/or NMS according to Diagnostic and Statistical Manual (DSM) criteria and extracted data about patients' characteristics, context of occurrence, antipsychotic agent(s) involved and treatment outcomes.

RESULTS

We included 165 events (16 AIC, 129 NMS and 20 AIC + NMS) from 144 case reports and case series. The most reported diagnosis was schizophrenia. Comorbid pre-existing conditions such as central nervous system diseases and acute medical events were common. Most of the events (63.3 %) occurred during antipsychotic monotherapy. Second-generation antipsychotics (SGAs, 63.8 %) were overall more implicated than first-generation antipsychotics (FGAs, 36.2 %).

DISCUSSION

Our findings highlight that any antipsychotic medication, even SGA monotherapy prescribed at recommended dose, is at risk for these side effects. FGAs and polypharmacy seem to represent risk factors for malignant catatonia in AIC. The clinical overlap observed between AIC and NMS events in our review suggests a clinical continuum between catatonia and NMS.

A Rare Case Report of a Corpus Callosal Splenial Lesion in the Context of Atypical Neuroleptic Malignant Syndrome

In this report, we describe a case of atypical neuroleptic malignant syndrome (NMS) presenting with an isolated lesion in the splenium of the corpus callosum (ILSCC). There is a paucity of information regarding this topic within the literature and only 7 previous case reports have been published at the time of writing. To our knowledge, this case report is also the first to describe an atypical NMS variant in the context of an ILSCC. In this report, we describe the important considerations in formulating differential diagnosis for ILSCC and are the first report to propose a possible pathophysiological mechanism relating ILSCC with NMS.

Neuroleptic Malignant Syndrome or Catatonia? A Case Report

Introduction

A review of the literature has shown that there are many similarities in the presentation of neuroleptic malignant syndrome (NMS) and catatonia. Attempts to reconcile the differences have been made by suggesting that NMS and catatonia may represent different presentations of the same illness or that they lie within the same spectrum of a poorly understood clinical syndrome. The described case is of a patient who presented with NMS and catatonia which was difficult to diagnose, but which responded to treatment with intravenous diazepam.

Case presentation

The case concerns a 22-year-old male admitted for pulmonary hypertension to an intensive care unit (ICU). Three days following admission, he developed a high fever that did not respond to antibiotics. The patient then developed rigidity, nocturnal agitation, decreased responsiveness, and somnolence. Without the use of bromocriptine (Novartis, Basel, Switzerland) or dantrolene (Par Pharmaceuticals, Chestnut Ridge, USA) discontinuation of neuroleptics combined with intravenous diazepam (Pfizer, NY, USA) led to a very rapid response and marked improvement in the case.

Conclusions

Early recognition and management of NMS and MC in a complex, gravely ill patient, may be accomplished in the ICU despite obfuscation of traditional signs and symptoms of the NMS and MC syndrome. Such interventions can have life-saving effects on patients in danger of fatal autonomic instability.

A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency

OBJECTIVE

To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review.

METHOD

EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association.

RESULTS

Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals.

CONCLUSION

NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.

Catatonia & neuroleptic malignant syndrome

The relationship between catatonia and neuroleptic malignant syndrome (NMS) has, in the last three decades, generated considerable interest and controversies. This article provides a critical overview of our understanding of the relationship between the two enigmatic syndromes. It examines various conceptualizations of NMS, published data supporting a close relationship between the two syndromes, hypotheses proposed and controversies generated regarding how the two are related, and the clinical and pathophysiological implications of the relationship.

Spatial learning in the Morris water maze in mice genetically different in the predisposition to catalepsy: the effect of intraventricular treatment with brain-derived neurotrophic factor

Hereditary catalepsy in mice is accompanied with volume reduction of some brain structures and high vulnerability to inflammatory agents. Here an association between hereditary catalepsy and spatial learning deficit in the Morris water maze (MWM) in adult mouse males of catalepsy-resistant AKR, catalepsy-prone CBA and AKR.CBA-D13Mit76 (D13) strains was studied. Recombinant D13 strain was created by means of the transfer of the CBA-derived allele of the major gene of catalepsy to the AKR genome. D13 mice showed a low MWM performance in the acquisition test and high expression of the gene coding proinflammatory interleukin-6 (Il-6) in the hippocampus and cortex compared with mice of the parental AKR and CBA strains. An acute ivc administration of 300 ng of brain derived neurotrophic factor (BDNF) normalized the performance in the MWM, but did not decrease the high Il-6 gene expression in the brain of D13 mice. These results indicated a possible association between the hereditary catalepsy, MWM performance, BDNF and level of Il-6 mRNA in the brain, although the relation between these characteristics seems to be more complex. D13 recombinant mice with deficit of spatial learning is a promising model for study of the genetic and molecular mechanisms of learning disorders as well as for screening potential cognitive enhancers.

Catatonia in DSM-5

Although catatonia has historically been associated with schizophrenia and is listed as a subtype of the disorder, it can occur in patients with a primary mood disorder and in association with neurological diseases and other general medical conditions. Consequently, catatonia secondary to a general medical condition was included as a new condition and catatonia was added as an episode specifier of major mood disorders in DSM-IV. Different sets of criteria are utilized to diagnose catatonia in schizophrenia and primary mood disorders versus neurological/medical conditions in DSM-IV, however, and catatonia is a codable subtype of schizophrenia but a specifier for major mood disorders without coding. In part because of this discrepant treatment across the DSM-IV manual, catatonia is frequently not recognized by clinicians. Additionally, catatonia is known to occur in several conditions other than schizophrenia, major mood disorders, or secondary to a general medical condition. Four changes are therefore made in the treatment of catatonia in DSM-5. A single set of criteria will be utilized to diagnose catatonia across the diagnostic manual and catatonia will be a specifier for both schizophrenia and major mood disorders. Additionally, catatonia will also be a specifier for other psychotic disorders, including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, and substance-induced psychotic disorder. A new residual category of catatonia not otherwise specified will be added to allow for the rapid diagnosis and specific treatment of catatonia in severely ill patients for whom the underlying diagnosis is not immediately available. These changes should improve the consistent recognition of catatonia across the range of psychiatric disorders and facilitate its specific treatment.

Effect of glial cell line-derived neurotrophic factor on behavior and key members of the brain serotonin system in mouse strains genetically predisposed to behavioral disorders

The effect of glial cell line-derived neurotrophic factor (GDNF) on behavior and on the serotonin (5-HT) system of a mouse strain predisposed to depressive-like behavior, ASC/Icg (Antidepressant Sensitive Cataleptics), in comparison with the parental "nondepressive" CBA/Lac mice was studied. Within 7 days after acute administration, GDNF (800 ng, i.c.v.) decreased cataleptic immobility but increased depressive-like behavioral traits in both investigated mouse strains and produced anxiolytic effects in ASC mice. The expression of the gene encoding the key enzyme for 5-HT biosynthesis in the brain, tryptophan hydroxylase-2 (Tph-2), and 5-HT1A receptor gene in the midbrain as well as 5-HT2A receptor gene in the frontal cortex were increased in GDNF-treated ASC mice. At the same time, GDNF decreased 5-HT1A and 5-HT2A receptor gene expression in the hippocampus of ASC mice. GDNF failed to change Tph2, 5-HT1A , or 5-HT2A receptor mRNA levels in CBA mice as well as 5-HT transporter gene expression and 5-HT1A and 5-HT2A receptor functional activity in both investigated mouse strains. The results show 1) a GDNF-induced increase in the expression of key genes of the brain 5-HT system, Tph2, 5-HT1A , and 5-HT2A receptors, and 2) significant genotype-dependent differences in the 5-HT system response to GDNF treatment. The data suggest that genetically defined cross-talk between neurotrophic factors and the brain 5-HT system underlies the variability in behavioral response to GDNF.

Rediscovering catatonia: the biography of a treatable syndrome

OBJECTIVE

Catatonia, a disorder of movement and mood, was described and named in 1874. Other observers quickly made the same recognition. By the turn of the century, however, catatonia was incorporated as a type within a conjured syndrome of schizophrenia. There, catatonia has lain in the psychiatric classification for more than a century.

METHOD

We review the history of catatonia and its present status. In the 1970s, the tie was questioned when catatonia was recognized among those with mood disorders. The recognition of catatonia within the neuroleptic malignant syndrome offered effective treatments of high doses of benzodiazepines and electroconvulsive therapy (ECT), again questioning the tie. A verifying test for catatonia (the lorazepam sedation test) was developed. Soon the syndromes of delirious mania, toxic serotonin syndrome, and the repetitive behaviors in adolescents with autism were recognized as treatable variations of catatonia.

RESULTS

Ongoing studies now recognize catatonia among patients labeled as suffering from the Gilles de la Tourette's syndrome, anti-NMDAR encephalitis, obsessive-compulsive disease, and various mutisms.

CONCLUSION

Applying the treatments for catatonia to patients with these syndromes offers opportunities for clinical relief. Catatonia is a recognizable and effectively treatable neuropsychiatric syndrome. It has many faces. It warrants recognition outside schizophrenia in the psychiatric disease classification.

A new synthetic varacin analogue, 8-(trifluoromethyl)-1,2,3,4,5-benzopentathiepin-6-amine hydrochloride (TC-2153), decreased hereditary catalepsy and increased the BDNF gene expression in the hippocampus in mice

RATIONALE

The creation of effective psychotropic drugs is the key problem of psychopharmacology. Natural compounds and their synthetic analogues attract particular attention.

OBJECTIVES

The effect of a new synthetic analogue of varacin, 8-(trifluoromethyl)-1,2,3,4,5-benzopentathiepin-6-amine hydrochloride (TC-2153), on the behavior and the expression of the genes coding BDNF (Brain-Derived Neurotrophic Factor, Bdnf) and CREB (cAMP response element-binding protein, Creb) implicated in the mechanism of psychotropic drug action as well as gp130 (Il6st) implicated in the mechanism of hereditary catalepsy in the brain of mice of ASC (Antidepressant Sensitive Catalepsy) strain was studied.

RESULTS

Acute per os administration of 20 or 40 mg/kg, but not 10 mg/kg of TC-2153 significantly decreased catalepsy. At the same time, in the open field test, 10 or 20 mg/kg of TC-2153 did not influence the locomotor activity, grooming or time spent in the center, while the highest dose of the drug (40 mg/kg) significantly reduced time in the center without any effect on locomotion and grooming. Chronic TC-2153 treatment (10 mg/kg for 12-16 days) did not influence the behavior in the open field but significantly attenuated catalepsy, increased Bdnf mRNA and decreased Il6st mRNA levels in the hippocampus.

CONCLUSIONS

The results suggest: 1) TC-2153 as a new drug with potential psychotropic and anticataleptic activities and 2) the involvement of BDNF and gp130 in the molecular mechanism of TC-2153 action.

Measuring catatonia: a systematic review of rating scales

BACKGROUND

Despite a growing scientific and clinical interest in catatonia, its precise definition remains debated.

AIM

The aim of this study was to offer a systematic review of the different rating scales that have been developed to assess catatonia in clinical practice.

METHODS

A Medline-search was performed, up to December 2010.

RESULTS

Seven catatonia rating scales were retrieved: the Modified Rogers Scale, the Rogers Catatonia Scale, the Bush-Francis Catatonia Rating Scale (BFCRS), and its revision, the Northoff Catatonia Rating Scale (NCRS), the Braunig Catatonia Rating Scale (BCRS), and the Kanner Scale.

CONCLUSION

Several catatonia rating scales are proposed to detect the catatonic syndrome and to evaluate treatment response. BFCRS, NCRS and BCRS are reliable for use in variable populations in which catatonia is prevalent. The BFCRS is preferred for routine use, because of its validity and reliability, and its ease of administration.

Psychogenic unresponsiveness

Unresponsive patients with or without catatonic motor signs are etiologically heterogeneous, and all require a comprehensive neurodiagnostic assessment to rule out organic causes. Most cases prove to be due to primary psychiatric disorders, mostly mood disorders, especially mania, rather than schizophrenia. These patients respond to lorazepam administered by any route and, failing this, electroconvulsive therapy. Those patients with associated fever and autonomic instability are medical emergencies and need urgent treatment.

A case of catatonia and neuroleptic malignant syndrome probably associated with antipsychotic in Korea

Several studies have reported on catatonia caused by the use of antipsychotic drugs and on the association between catatonia and neuroleptic malignant syndrome (NMS), but none has reported such a case in Korea. Here, we report the case of a 20-year-old woman whose catatonia and NMS appeared associated with the administration of an atypical antipsychotic drug. We discuss the association between NMS and catatonia due to neuroleptic use.

Neuroleptic malignant syndrome: mechanisms, interactions, and causality

This review focuses on new data from recent publications concerning how compounding interactions between different thermoregulatory pathways influence the development of hyperthermia and/or neuroleptic malignant syndrome (NMS), and the fundamental issue of the presumed causal role of antipsychotic drugs. The formal criteria for substantiating cause-effect relationships in medical science, established by Hill, are applied to NMS and, for comparison, also to malignant hyperthermia and serotonin toxicity. The risk of morbidities related to hyperthermia is reviewed from human and experimental data: temperatures in excess of 39.5°C cause physiological and cellular dysfunction and high mortality. The most temperature-sensitive elements of neural cells are mitochondrial and plasma membranes, in which irreversible changes occur around 40°C. Temperatures of up to 39°C are "normal" in mammals, so, the term hyperthermia should be reserved for temperatures of 39.5°C or greater. The implicitly accepted presumption that NMS is a hypermetabolic and hyperthermic syndrome is questionable and does not explain the extensive morbidity in the majority of cases, where the temperature is less than 39°C. The thermoregulatory effects of dopamine and acetylcholine are outlined, especially because they are probably the main pathways by which neuroleptic drugs might affect thermoregulation. It is notable that even potent antagonism of these mechanisms rarely causes temperature elevation and that multiple mechanisms, including the acute phase response, stress-induced hyperthermia, drugs effects, etc., involving compounding interactions, are required to precipitate hyperthermia. The application of the Hill criteria clearly supports causality for drugs inducing both MH and ST but do not support causality for NMS.

Neuroleptic-induced catatonia: clinical presentation, response to benzodiazepines, and relationship to neuroleptic malignant syndrome

Neuroleptic-induced catatonia (NIC), manifested in an extrapyramidal-catatonic syndrome, has been sporadically reported in the literature. Confusion surrounds its relationship to neuroleptic malignant syndrome (NMS) and extrapyramidal reactions to neuroleptics. This study examined (a) its clinical presentation and response to benzodiazepines, (b) the hypothesis that NIC and NMS are on the same spectrum with a continuum of symptom progression, and (c) its possible relationship to extrapyramidal reactions. Of 127 episodes of acute catatonia prospectively identified, 18 were diagnosed with NIC. All catatonia episodes received benzodiazepines. The NIC episodes were analyzed noting their clinical presentations, laboratory findings, and responses to treatments. Their responses to benzodiazepines were compared, with retrospective rating on a 7-point scale, to that for catatonia episodes associated with mania and schizophrenia. The progression of symptoms in each NIC episode was reviewed. The NIC episodes presented predominantly in the stuporous form associated with parkinsonism. Delirium, autonomic abnormality, and elevated serum creatine phosphokinase were all common. Neuroleptic malignant syndrome was diagnosed in 3 episodes (17%). The 3 catatonia groups did not differ significantly in their benzodiazepines responses: 78% (14/18) of NIC, 75% (12/16) of manic catatonia, and 67% (34/51) of schizophrenic catatonia episodes showed full responses. A spectrum of presentation across episodes was noted with simple NIC without delirium, autonomic disturbances, or fever at one end and NMS or malignant NIC at the other end. Symptoms in individual episodes showed a similar continuum progression. No extrapyramidal reactions immediately preceded the NIC episodes. Findings of this study support the hypothesis that NIC and NMS are disorders on the same spectrum and reveal no indication that extrapyramidal reactions progress to NIC.