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Parkinsonism and Rabbit Syndrome After Discontinuation of Low-Dose

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Parkinsonism and Rabbit Syndrome After Discontinuation of Low-Dose Letters to the Editors Journal of Clinical Psychopharmacology & Volume 32, Number 1, February 2012 5. Goldsmith DR, Wagstaff AJ, Ibbotson T, et al. lamotrigine, which were both discontinued While an unmasking of TD was con- Lamotrigine: a review of its use in bipolar because of ineffectiveness against past de- sidered, TD generally involves signifi- disorder. Drugs. 2003;63:2029Y2050. pression, and quetiapine, which was dis- cantly slower and less regular movements 6. Sotero de Menezes MA, Rho JM, Murphy P, continued because of weight gain. For than was seen in this patient and often et al. Lamotrigine-induced tic disorder: report of the past 9 months, she was maintained on involves the tongue. In addition, there was five pediatric cases. Epilepsia. 2000;41:862Y867. ziprasidone 40 mg twice a day, although a good response to anticholinergics as has 7. Ahmad S, Fowler LJ, Whitton PS. she was not taking these doses with food. been reported in rabbit syndrome, in con- Lamotrigine, carbamazepine and phenytoin However, for the past month, she had trast to TD, which responds poorly to an- 17 differentially alter extracellular levels of worsening depression and agreed to a ticholinergics and occasionally worsens. 5-hydroxytryptamine, dopamine and amino course of electroconvulsive therapy, which Furthermore, the concurrent presentation acids. Epilepsy Res. 2005;63:141Y149. led to remission of her depression 2 years of parkinsonism suggests a hypodopami- 8. Alkin T, Onur E, Ozerdem A. prior. Two days before her scheduled ad- nergic state in contrast to the predominant Co-occurence of blepharospasm, mission, her ziprasidone was abruptly dis- hypothesis that TD represents a dopami- tourettism and obsessive-compulsive continued, and she was started on sertraline nergic supersensitivity in the nigrostria- symptoms during lamotrigine treatment. 50 mg daily, which had reportedly been tal pathway. Indeed, it has been proposed Prog Neuropsychopharmacol Biol efficacious years earlier. On admission, she that rabbit syndrome may be the patho- Psychiatry. 2007;31:1339Y1340. was found to have new-onset mild brady- physiological ‘‘converse’’ of TD and may kinesia, masked facies, shuffling gait, and be more closely related to neuroleptic- 9. Mantegazza M, Curia G, Biagini G, et al. 18 Voltage-gated sodium channels as therapeutic a high-amplitude tremor of her right leg induced parkinsonism. targets in epilepsy and other neurological without subjective restlessness. In addition, Another issue is whether these symp- disorders. Lancet Neurol. 2010;9:413Y424. she had prominent high-frequency chewing toms were secondary to the discontinuation 10. Swartz CM, Shen WW. Is episodic obsessive movements with occasional lip puckering, of ziprasidone, the initiation of sertraline, compulsive disorder bipolar? A report of four without obvious tongue involvement and or a combination of both. Although an- cases. J Affect Disord. 1999;56:61Y66. which she could not voluntarily suppress. tipsychotic withdrawal-induced EPS has No choreoathetoid or other involuntary generally been reported to occur 2 to movements were noted. Her sertraline was 4 weeks after discontinuation,19 symptoms Parkinsonism and Rabbit discontinued, and she was given imme- here appeared within 24 hours suggesting Syndrome After diate doses of benztropine 2 mg and zip- an immediate decrease in dopaminergic rasidone 60 mg followed by ziprasidone tone, possibly suggesting a primary role Discontinuation of Low-Dose 40 mg twice a day. Symptoms of her for sertraline in mediating these symp- Ziprasidone and parkinsonism and orofacial dyskinesia re- toms. Indeed, SSRI-induced EPS including Concomitant Initiation of portedly improved within hours and were sertraline-induced have been well described.20 completely resolved within 18 hours. Her It should be noted, however, that this pa- Sertraline ziprasidone was tapered over the course tient had no reported EPS while previously of 3 days with no reemergence of EPS. on sertraline monotherapy at doses up to To the Editors: She was subsequently discharged on lith- 200 mg/d. It is possible, then, that long- iprasidone is an atypical antipsychotic ium, which she had reportedly never taken, term ziprasidone treatment and/or abrupt Z that is chemically unlike any other to be titrated and monitored by her outpa- withdrawal led to enhanced sensitivity to current antipsychotic medication, has a high tient psychiatrist. sertraline-induced EPS. 5-hydroxytryptamine 2A (HT2A)/D2 recep- What might be a theoretical mecha- tor affinity ratio, and has a low liability 1 DISCUSSION nism for this patient’s presentation? At low for extrapyramidal symptoms (EPS). Re- This is the first case report of par- doses, ziprasidone is predicted to have sub- cent studies have suggested that ziprasi- kinsonism and orofacial dyskinesias as a stantial 5-HT2A and 5-HT2C antagonism done dosages greater than 120 mg/d may 1 possible effect of the discontinuation of without significant D2 antagonism. Block- be needed to attain sufficient D2 receptor ziprasidone and initiation of sertraline. In ade of 5-HT receptors increases striatal 2,3 2 occupancy for antipsychotic effects. As the case presented, the orofacial dyski- dopamine release, mediating the reduced patients are prescribed higher ziprasidone nesias are consistent with a diagnosis of EPS liability of ziprasidone and the other doses, it remains to be seen if there will rabbit syndrome, a rare form of EPS char- atypical antipsychotics. However, chroni- be an increased incidence of ziprasidone- acterized by involuntary 5-Hz, rhythmic, cally increased dopamine release may result induced EPS. Indeed, there have been re- 4 5 vertical movements of the mouth and lips in a down-regulation of striatal D2 recep- ports of acute dystonia, parkinsonism, without involvement of the tongue.10 Un- tors, leading to a sensitization to potential 6 7,8 oculogyric crisis, tardive dyskinesia (TD), like TD and other types of oral dyskinesias, EPS. On abrupt discontinuation of ziprasi- and withdrawal akathisia9 associated with rabbit syndrome cannot be voluntarily sup- done, the removal of 5-HT2 blockade would ziprasidone. In contrast, this is an intrigu- pressed by the patient.11 Rabbit syndrome allow the serotonin-induced inhibition of ing case of parkinsonism and rabbit syn- has classically been reported with long- dopamine release, further decreasing ni- drome after the abrupt discontinuation of term typical antipsychotic use; however, grostriatal dopaminergic tone. The addi- low-dose ziprasidone and concomitant ini- there are recent case reports with atypical tion of serotonin reuptake inhibition, then, tiation of sertraline. 12 antipsychotics including quetiapine and by acutely enhancing 5-HT2 activation, paliperidone.13 In addition, withdrawal- might be expected to exacerbate the do- CASE REPORT emergent14 and selective serotonin reup- pamine blockade leading to the EPS. A 58-year-old white woman with a take inhibitor (SSRI)Yinduced cases15 have In conclusion, it seems that this pa- diagnosis of bipolar disorder has had 2 been reported. In addition, rabbit syn- tient, who tolerated high-dose sertraline remote manic episodes and recurrent, often drome has most frequently been reported in the past, developed an enhanced sensi- treatment-refractory depression. She had in middle-aged women,16 consistent with tivity to sertraline-induced EPS on the past medication trials of aripiprazole and this report. abrupt withdrawal of long-term low-dose 142 www.psychopharmacology.com * 2012 Lippincott Williams & Wilkins Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Journal of Clinical Psychopharmacology & Volume 32, Number 1, February 2012 Letters to the Editors ziprasidone treatment. Given the increased 12. Wu CC, Su KP. Quetiapine-induced rabbit in which a larger amount of food (than nor- use of atypical antipsychotics in mood syndrome in a patient with bipolar disorder. mal) is eaten during a short period of time disorders, this case may serve as caution Prog Neuropsychopharmacol Biol (within a 2-hour period) along with a sense against abruptly discontinuing ziprasidone Psychiatry. 2008;32:2002Y2003. of lack of control over eating. Additional and initiating an SSRI. 13. Teng PR, Lai TJ. Paliperidone-related features include eating rapidly; when not rabbit syndrome. J Clin Psychopharmacol. hungry; or alone owing to embarrassment 2011;31:379Y380. and feeling uncomfortably full, guilty, or AUTHOR DISCLOSURE disgusted. Night eating syndrome must INFORMATION 14. Nishimura K, Tsuka M, Horikawa N. also be differentiated from the sleep-related The author declares no conflicts of Withdrawal-emergent rabbit syndrome eating disorder (SRED) characterized by interest. during dose reduction of risperidone. Eur Neuropsychopharmacol. abnormal eating during the night while still John A. Gray, MD, PhD 2001;11:323Y324. asleep, without any recollection of doing Department of Cellular and 15. Parvin MM, Swartz CM. Dystonic so. Additional features are weight gain, non- Molecular Pharmacology refreshing sleep, and diabetes mellitus. University of California rabbit syndrome from citalopram. San Francisco, CA Clin Neuropharmacol. 2005;28: Successful pharmacological treatment [email protected] 289Y291. of NES includes medication affecting se- 4 16. Wada Y, Yamaguchi N. The rabbit rotonin modulation with specific evidence syndrome and antiparkinsonian medication in for the selective serotonin reuptake inhibitor 5 REFERENCES schizophrenic
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