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Patients Receiving Antipsychotic Drugs: Neuroleptic Syndrome

Introduction

The neuroleptic syndrome results from the side effects of antipsychotic drugs. The most vulnerable groups are those with mental illnesses. Incidences of accidental or intentional overdose with regards to these drugs are on the rise. In the past couple of decades, mortality rates have remained at an average of 15% among patients diagnosed with the condition. The fatal nature of the syndrome requires a thorough diagnosis to be carried out. Routine check-ups help in the early detection of the syndrome. Early detection and management reduces chances of death in the long term. Death is brought about by renal failure and other complications. The essay makes a case for early diagnosis. The procedure should be thorough to avoid overlooking any hidden symptoms.

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Neuroleptic syndrome is one of the conditions reported among patients undergoing a neurological examination. Interestingly, it is noted that the condition is rare in the neurological field. The syndrome results from the side effects of antipsychotic medication [1]. That is why it is commonly associated with patients receiving mental health services. The syndrome is characterized by hyperthermia and muscle rigidity. In other cases, patients experience significant changes in their cognitive abilities [2].

Neuroleptic syndrome is fatal, although mortality rates have reduced from 30% to around 11% in recent years [1]. Cardiovascular collapse, renal failure, and respiratory complications are some of the causes of death. Intravascular coagulation and arrhythmia may also lead to fatalities.

In the larger field of psychiatry, patients with this condition receive various forms of medications in efforts to alleviate their symptoms. Depending on the nature of the diagnosed condition, practitioners prescribe medications intended to control or minimize the effects of the syndrome on the overall health of the patient. One such psychiatric disorder is psychosis. Patients who suffer from this mental condition tend to experience hallucinations and delusions [3]. The medication given to them is what constitutes antipsychotic drugs [4].

There are two types of antipsychotic medications. They include the first and the second generation drugs. When administered to a patient, both regimens tend to localize their actions on the brain’s dopamine pathways [5]. Consequently, the receptors in that region end up being blocked. Clozapine and olanzapine are two common examples of antipsychotic drugs used in this case [4, 6].

Neuroleptic syndrome resulting from these drugs is more evident in cases where typical antipsychotic medication is used. It is advisable that persons exposed to antipsychotic medication undergo routine check-ups. Regular screening helps in the early detection of the condition. As a result, the threat of death is reduced [6].

A Review of Neuroleptic Syndrome

Research is ongoing to determine the pathophysiology of this syndrome [5, 7]. Studies reveal that the aforementioned blockage of receptors in the brain of the patient is what contributes to the development of the disorder [5, 7]. The receptors that are affected by this blockage include the D2.

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Butwicka et al. carried out a study to examine the syndrome among patients with deficiencies in CYP2D6 [8]. Adolescents were the participants in this study. The findings made indicated that the patients had high concentrations of antipsychotic drugs in their systems [8]. The symptoms exhibited by these individuals indicated that they were afflicted by the neuroleptic syndrome. As a result, the researchers established a link between the drugs used and the disorder.

Diagnosis

The most common symptom involves sustained mental instability [8, 9]. In most cases, such patients display some sense of unease in their normal levels of ‘stability’. In addition, the condition is characterized by extrapyramidal symptoms. In such cases, a patient is unable to initiate movement owing to impediments on their locomotive abilities [7, 9]. Another trait associated with neuroleptic syndrome is hyperpyrexia. In this case, the patient experiences an extremely high fever [10].

Compared to other common neurological conditions, diagnosis of neuroleptic syndrome is not straightforward. The most obvious reason for this absence of a proper diagnosis framework is the lack of consensus among practitioners with regards to the appropriate approach [11]. However, there are few publications that make reference to the criteria used in diagnosing this condition. In most cases, clinicians are able to identify the disorder by relying on the symptoms presented.

One such publication that makes reference to possible diagnostic criteria is The Diagnostic and Statistical Manual of Mental Disorders [6]. The manual explains that an analysis of the condition should begin with the identification of the main symptoms associated with it [8, 12]. As a result, when a patient complains of high fever, which is accompanied by severe rigidity of their muscles after using antipsychotic drugs, there are enough grounds to believe that they might be suffering from the disorder.

A complete diagnosis must ensure that the patient exhibits additional symptoms. Such other signs include mutism, elevated blood pressure, and dysphagia. Incontinence and disphoresis are also evident among these patients [13, 14]. A complete diagnosis requires a patient to exhibit two of the additional symptoms [15, 16]. When presented together with fever and muscle rigidity, such traits as leukocytosis make for a strong diagnosis [17, 18].

Figure 1 below is an illustration of a scan to verify leukocytosis associated with the condition. Such scans help practitioners to detect the syndrome early enough to minimize fatalities.

Cystic Leukocencephalopathy.
Figure 1: Cystic Leukocencephalopathy. Source: Smail et al. [18].

Fatalities in neuroleptic syndrome are associated with cystic leukocencephalopathy [18, 19]. Figure1 is an MRI of a patient who had an overdose of olonzapine, venlafaxine, quetipine, and propranolol. The four are common antipsychotic drugs. As evidenced by the white matter in the scan, the patient has developed cystic leukocencephalopathy [20, 21].

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A test for the leukocyte count in an individual helps to strengthen the diagnosis. The reason is that a reduced count increases the possibilities of the syndrome’s presence [14]. It is important to appreciate that neuroleptic syndrome can be experienced in various degrees [22]. As such, a practitioner is advised to adopt a critical diagnostic approach. Table 1 explains the criteria for the determination of the disorder. The table makes a case for major and minor manifestations of neuroleptic syndrome.

Table1: Diagnostic Criteria for Neuroleptic Syndrome. Source: Smail et al. [18].

MANIFESTATION
SYMPTOM
MINOR MAJOR
Fever X
Leukocytosis X
Tachycardia X
Tachypoea X
Muscle Rigidity X
Altered consciousness X
Elevated Creatine X
Abnormal blood pressure X
Elevated creatine X
Phosphokinase Level X

In the table, ‘X’ indicates the symptom corresponding to the degree of the syndrome’s manifestation [15]. However, it is important to note that the said diagnosis should be arrived at under specified circumstances. It should be made in the event that a toxicology report suggests the presence of a particular antipsychotic drug [23, 24]. Such an approach confirms that neuroleptic syndrome is a side effect of antipsychotic drugs.

Sa et al. carried out a study to determine the relationship between olanzapine and the malignant form of neuroleptic syndrome [15]. In their study, they found that schizophrenic patients using this antipsychotic drug exhibited symptoms that suggested they had acquired the condition. The study confirmed that neuroleptic syndrome results from the use of such antipsychotics. Patients suffering from schizophrenia and psychosis are usually given the same drug, albeit in different doses [14, 16].

In a literature review, Croarkin, Emslie, and Mayes sought to determine whether the symptoms are exhibited differently or not depending on one’s age [13]. The information obtained was limited to patients below 18 years. The study by Croarkin et al. revealed that between 1991 and 2007, prevalence of the syndrome was higher among adults compared to teenagers. The findings established a link between the condition and age. To this end, the study indicated that the symptoms associated with this disorder were similar among adults [13, 22].

Regardless of the disparities in the prevalence of this condition among adults and children, psychiatrists are advised to exercise caution when making antipsychotic prescriptions to young patients [13, 19]. The argument is based on the undeniable fact that neuroleptic syndrome is closely associated with the unintended effects of these drugs. Antipsychotic medication poses health risks to children given their low levels of immunity. As such, practitioners in this field are encouraged to handle their young patients with a lot of care [25].

Conclusion

The malignant version of neuroleptic syndrome is quite rare [21, 24]. However, the risk of fatality is high regardless of whether the condition is malignant or not. Due to this, questions are raised in relation to the preferred treatment approach. The mere fact that one can be accurately diagnosed with the condition is not enough to address these concerns. In their study, Berman points out that the first step in dealing with this syndrome is to ensure that the effects of the causative agent are dealt with as soon as possible [20]. The treatment option should be implemented fast enough to reduce chances of fatality.

References

Syu YP, Chang CK, Hayes RD, Harrison S, Lee W, Broadbent W, et al. Retrospective chart review on exposure to psychotropic medications associated with neuroleptic malignant syndrome. Acta Psychiatr Scand 2013; Nov. 15. (PMID: 24237642) Web.

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Petersen AB, Andersen SE, Christensen M, Larsen HL. Adverse effects associated with high-dose olanzophine therapy in patients addicted to psychiatric care. Clin Toxicol 2014; 52(1): 39-43. (PMID: 243137745) Web.

Mitsuhiro N, Hideo Y, Hiroaki M, Takafumi S, Hiromasa H, Da Shinya M. Mortality of neuroleptic malignant syndrome induced by typical antipsychotic drugs: a propensity-matched analysis from the Japanese diagnosis procedure database. Journal of Clin Psyc 2012; 73(4): 427-430.

Trollor NJ, Chen X, Chitty K, Sachdev SP. Comparison of neuroleptic malignant syndrome induced by first-and second- generation antipsychotics. B Jo of Psy 2012; 201: 52-56. Web.

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Khan YF, Qusan JM. Neuroleptic malignant syndrome. Neurosciences 2008; 2(2): 104-106.

Butwicka A, Krystyna S, Retka W, Wolanczyk T. Neuroleptic malignant syndrome in an adolescent with CYP2D6 deficiency. Eur J Pediatr 2013. 20. (PMDI: 24253372)

Nakamura M, Yasunaga H, Miyata H, Shimada T, Horiguchi H, Matsuda S. Mortality of neuroleptic malignant syndrome induced by typical and atypical antipsychotic drugs: a propensity-matched analysis from the Japanese diagnosis procedure incubation database. J Clin Psychiatry 2012; 73(4): 427-30. (PMID: 22154901) Web.

Burkhard PR. Acute and subacute drug-induced movement disorders. Parkinsonism Relat Disord 2014; 1: 108-12. (PMID: 24262159) Web.

Khaldi S, Kornreich C, Choubani Z, Gouveritch R. Neuroleptic malignant syndrome and atypical antipsychotics. Encephale 2008; 34(6): 618–24. (doi: 10. 1016/j.encep.2007.11.007)

Neuhut R, Lindenmayer JP, Silva R. Neuroleptic malignant syndrome in children and adolescents on atypical antipsychotic medication: a review. J Child Adolesc Psychopharmacol 2009; 19(4): 415-22. (PMID: 19702483) Web.

Croarkin PE, Emslie GJ, Mayes TL. Neuroleptic malignant syndrome associated with atypical antipsychotics in pediatric patients: a review of published cases. J Clin Psychiatry 2008; 69(7): 1157-65.

Gurrera RJ, Caroff SN, Cohen A, Carroll BT, DeRoos F, Francis A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method. J Clin Psychiatry 2011; 72: 1222-1228. (PMID: 21733489) Web.

Sa YK, Yang H, Jung HK, Son JW, Lee SS, Kim SR, et al. Olanzapine-induced diabetic katoacidosis and neuroleptic malignant syndrome with rhabdomyolysis: a case report. Endocrinol Metab 2013; 28(1): 70-75. Web.

Patra BN, Khandelwal SK, Sood M. Olanzopine induced neuroleptic malignant syndrome. Indian J Pharmacol 2013; 45(1): 98-99. Web.

Seitz DP, Gill SS. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of literature. Psychosomatics 2009; 50(1): 8-15. Web.

Smail CR, Tetlow H, Siddiqi MS, Stevens S, McClogan P. A case of toxic cystic leukoencephalopathy after anti-psychotic overdose. J Neurol Neurosurg Psychiatry 2012; 83(2): 61. Web.

El-Gaaly S, St. John P, Dunsmore S, Bolton JM. Atypical neuroleptic malignant syndrome with quetipine: a case report and review of literature. J Clin Psychopharmacol 2009; 29(5): 497-499. Web.

Berman BD. Neuroleptic malignant syndrome: a review for neurohospitalsts. Neurohospitalsts 2011; 1(1): 41-47.

Gentile S. Adverse effects associated with second generation antipsychotic long acting treatment: a comprehensive review. Pharmacotherapy 2013; 33(10): 1087-106.

Yang CW, Lu C, Wu CC, Wen SC. Coexistence of neuroleptic malignant syndrome and a hyperosmolar hyperglycemic state. Am J Emerg Med 2012; 30(5): 833.e1-2. (PMID: 21514763) Web.

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StudyCorgi. (2022, July 13). Patients Receiving Antipsychotic Drugs: Neuroleptic Syndrome. Retrieved from https://studycorgi.com/patients-receiving-antipsychotic-drugs-neuroleptic-syndrome/

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StudyCorgi. (2022, July 13). Patients Receiving Antipsychotic Drugs: Neuroleptic Syndrome. https://studycorgi.com/patients-receiving-antipsychotic-drugs-neuroleptic-syndrome/

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StudyCorgi. "Patients Receiving Antipsychotic Drugs: Neuroleptic Syndrome." July 13, 2022. https://studycorgi.com/patients-receiving-antipsychotic-drugs-neuroleptic-syndrome/.

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