A child with schizophrenia was on medications. Suddenly he developed neck stiffness 8t spasm. What is most probable cause?
ANSWER: (B)Acute dystoniaREF: Kaplan and sadocks synopsis in psychiatry 10th ed page 992This is a case of acute dystonia due to neuroleptic medicationsSee APPENDIX-38 below for "NEUROLEPTICS SIDE EFFECTS" APPENDIX - 38Neuroleptics; Side Effects Acute DystoniaAkathisiaParkinsonismTardive DyskinesiaNeurolepticMalignantSyndrome EarlyIntermediateIntermediateLate (tardive)AnyONSETWithin 7 days of therapy or | doseWithin 3 months of therapy or | doseWithin 3 months of therapy or | dose> 3-6 months(| dose may unmask dyskinesia)Anytime during therapy (| dose or high potency drugs)INCIDENCE15-20% with typical neuroleptics. 5% with atypical20%30%5% per year of therapy i.e. 50% In 10 years0.5%(20-30%mortality)MECHANISMUnclear, dopamine hypo function at basal gangliaD2 receptor blockage in mesocortical pathwayD2 receptor blockage at striatumD2 receptor blockage at striatumIdiosyncratic, Relative depletion of dopamine in CNSRISKFACTORSMale, young, mental retardation, h/o ECT, dose elevationElderly,female, mental retardation, Iron deficiency, Affective disorders, dose elevationElderly ,Females,dementia,underlyingparkinsonism,AIDS, doseelevationElderly, female, h/o ECT, substance abuse, iron deficiency, Mental retardation. Mood disorder, Organic brain damage, Antkholine rgic Dose decreaseMale, young, dose elevationSYMPTOMSSlow, irregular, continuous contractions, oculogyric movements of tongue, torticollis, trismus, abnormal posture, blepherospasmUncontrolledrestlessness,pacing,compulsive foot taping, rocking movement, adversity to stand still, rapid alternation of standing St- sittingR = rigidityA = akinesia (me)T = tremor(atyp ical-coarse, not pill rolling, late) RABBIT SYNDROME = Lip & perioral tremorsRapid, irregular, continuous or intermittent contractions, orofasciolingual or limb/trunkal, | by stress activity,Life threateningF = feverE =EncephalopathyV - Vitals unstableE = ElevatedCPK, WBCR = RigidityTREATMENTAnticholine rgics: Benzatropine Antihistaminics: DiphenhydramineReduce doseSt/or changeantipsychotic.Propranolol= doc, poortreatmentoutcomeAnticholinergics:BenzatropineAntihistaminics:Amantadine,DiphenhydramineReplace by atypical antipsychotic (clozapine is best), lithium & carbamazepine for psychosis, BZD: buspirone for dyskinesiaBromocriptine,lisuride,carbidopa-levodopa,dantrolenesodium, ECT
Conversion disorder
Acute dystonia
Akathisia
Tardive dyskinesia