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J Neurol Neurosurg : first published as 10.1136/jnnp.44.8.728 on 1 August 1981. Downloaded from

Joutrnal of , , and Psychiatry, 1981, 44, 728-730

Short report An extrapyramidal choreiform syndrome caused by addiction

H LUNDH AND K TUNVING From the Departments of Neuro.logy and Psychiatric Research, University of Lund, Sweden

SUMMARY Four cases are described to demonstrate the extrapyramidal clinical syndrome sometimes appearing in chronic amphetamine users. The symptoms are dominated by choreiform or athetoid movements, ataxia and disturbances of gait. The syndrome develops during am- phetamine abuse and may be observed also during . The symptoms usually disappear within a week when the is discontinued, but may remain for years. Protected by copyright. The mental symptoms, including psychosis, caused showed slower more athetoid movements of his trunk, by amphetamine intoxication are well-known,' arms and fingers. The strong reeling involuntary but neurological side-effects sometimes appearing movements of the trunk rendered a dancing or are much less recognised. Choreo-athetoid move- drunken appearance to the gait and the patient was known as "the screw." Symptoms were more pro- ments caused by high doses of amphetamine have nounced just after an injection of amphetamine but been mentioned in the literature2 3 and a "jerking did not disappear during periods of abstinence. When syndrome" was reported by Rylander.4 We give performing voluntary motor activities like the finger- a more comprehensive description of this syn- nose or heel-knee test the involuntary movements drome and point out that it may remain for years diminished and the patient could play different sorts after finishing drug abuse. of ballgames. After he stopped amphetamine abuse the involun- Case reports tary movements gradually diminished but not until 1978, a year afterwards, did they decrease markedly. Case 1 Three years afterwards, in 1980, the patient still A man, now aged 27 years, during the period 1971- suffered from teeth grinding and involuntary grimacing 1977 injected himself intravenously with high doses of his face. Apart from this his motor performance http://jnnp.bmj.com/ (gram doses) of amphetamine one to four times a day and gait now is normal. except for short periods of abstinence. A few months Case 2 after starting to inject amphetamine he suffered from At the age of 20 years this man began to abuse am- more or less constant grinding of his teeth and in- phetamine and during the following 4-5 years inter- voluntary choreiform movements of his face around mittently injected several grams of amphetamine his mouth. Only a few months later he developed weeks. generalised choreiform and athetoid movements of intravenously daily for periods of one to several disturbed, At the age of 24 years he stopped using amphetamine arms, legs and body. His gait was markedly and changed to . He claimed he changed on September 25, 2021 by guest. his legs flung erratically and irregularly sideways, there because of adverse reactions after amphetamine in- were constant large and small involuntary movements addict of his arms, and different parts of his body rapidly jections. During his period as an amphetamine backwards. he was admitted twice to the psychiatric ward for jerked from side to side and forwards and detoxification. Each time he showed dramatic extra- Quick choreiform movements dominated, but he also pyramidal symptoms. His gait was markedly ataxic and he could not walk straight forward but con- Address for reprint requests: Dr H Lundh, Department of Neurology, stantly pushed against the walls of the corridor, his University Hospital, S-221 85 Lund, Sweden. legs vigorously jerking irregularly and his arms per- Accepted 18 May 1981 forming large, abrupt, rapid ballistic movements like 728 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.8.728 on 1 August 1981. Downloaded from

An extrapyramidal choreiform syndrome caused by amphetamine addiction 729

the arms of a windmill. His head moved abruptly chloride (a neuroleptic drug) at the low dosage of and irregularly in all directions. He was treated by 1 mg three times a day without obvious effect on the large intravenous doses of biperiden hydrochloride choreiform movements. Sedative of different (Akineton) and haloperidol but his involuntary move- kinds had a positive effect. Computed tomography of ments continued, and 48 hours passed before he could the head in 1980 was normal. sleep. His involuntary movements almost disappeared during sleep. Within a week his involuntary move- Discussion ments diminished and, finally, vanished completely. These case reports describe the choreatic syndrome Case 3 sometimes appearing in amphetamine addicts. man was to at age of This admitted the ward the movements described 20 years after one year of continuous intravenous Besides the choreo-athetoid abuse of large doses of amphetamine. He was hyper- by Rylander4 this extrapyramidal syndrome in- active and unable to sit or stand and continually cludes ataxia and abnormal gait often resembling changed his position. There were almost continuous the gait seen in Huntington's chorea. Usually these choreiform movements of his facial muscles, body, symptoms were most obvious for the first days arms and legs. The patient's gait was wide-based and after admission to the ward and generally dis- obviously ataxic, being fast and stiff with rapid jerking appeared within a week of abstinence as in case 2. movements somewhat like an actor in a fast moving However, as demonstrated by our other cases these film resembling the gait seen in Huntington's chorea. choreiform movements may persist for long This patient was treated orally by central cholinergic blocking drugs (the atropine group of drugs), and periods, perhaps indefinitely, after stopping drug became almost free of symptoms. A month after ad- abuse. It is of interest that in animals ampheta- mission to the ward he ran away and again injected mine is known to cause stereotyped movements5-7 amphetamine, but he soon returned with an exacerba- resembling the so-called punding of amphetamine Protected by copyright. tion of choreiform movements. In the following years addicts,4 but also obvious choreiform movements.8 the patient had several of drug abuse and This is attributed to increased release of dopa- every time the neurological symptoms reappeared. mine,5 and the same pathophysiological mechan- Finally he stopped drug abuse and after that the ism may be operating in humans. Since choreiform movements gradually decreased and dis- receptor blocking drugs are used in the acute appeared entirely after more than a year. treatment of amphetamine abuse, it is possible Case 4 that such drugs contribute to the fast disappear- This man, now aged 35 years, from 1965 to 1972 ance of neurological symptoms in most cases. almost continuously took amphetamine by mouth at However, we observed no beneficial effect on the a dose of about 0 3 gram two or three times a day. extrapyramidal symptoms persisting for years in During that time he suffered from general hyper- former amphetamine addicts. In these cases, it activity with stereotyped, compulsive behaviour such is probable that amphetamine has induced plas- as repetitively buttoning and unbuttoning his jacket ticity changes of synaptic transmission in parts of or tidying up over and over again, i.e. punding.4 From the brain controlling extrapyramidal movements. 1972 to 1977 the patient took amphetamine intra- Computed tomography showed no abnormality in high doses (about one gram per injection). venously cause cerebrovas- After daily injections for six months continuous although amphetamine might http://jnnp.bmj.com/ 9 jerking involuntary movements of arms and legs cular accidents.1 began, most pronounced in proximal muscles, together with involuntary grinding of his teeth. On several References occasions there were short episodes of spasmodic torticollis which always disappeared when treated I Gunne L-M. Effects of in humans. with diazepam. His choreiform movements continued Handbook of Experimental Pharmacology 1977; even during periods of drug abstinence for weeks or 45/11:247-75. months and did not diminish when the patient did 2 Bonhoff G, Lawrenz H. Uber Weckamine. Heidel- not inject amphetamine for one year 1977-1978. He berg: Springer 1954. on September 25, 2021 by guest. had a short into abuse in 1978, but after that 3 Mattson R, Calvery JR. - he has not used drugs for three years. Since 1978 his sulfate-induced dyskinesias. JAMA 1968; 204: involuntary movements have diminished but not dis- 108-10. appeared. They are temporarily suppressed by vol- 4 Rylander G. Psychoses and the punding and untary movements and do not interfere with fine choreiform syndromes in addiction to central motor activity and disappear during sleep. They are drugs. Psychiat Neurol Neurochir less pronounced w.hen the patient is calm and relaxed (Amsterdam) 1972; 75:203-12. and become more obvious when he is tired or nervous. 5 Randrup A, Munkvad I. Biochemical, anatomical In 1980 this patient was treated wvith flupenthixol and psychological investigations of stereotyped J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.44.8.728 on 1 August 1981. Downloaded from

730 H Lundh and K Tunving behaviour induced by amphetamines. In: Costa drawal from Garattini chronic amphetamine intoxication E, S, eds. Amphetamines and related on exploratory and stereotyped behavior in the compounds. New York: Raven Press 1970; 693- rat. 713. Psychopharmacol 1977; 54:295-302. 8 Randrup A, Munkvad I. Stereotyped activities 6 Ellinwood EH. Behavioral and EEG changes in produced the amphetamine by amphetamine in several animal model of psychosis. In: Usdin species and man. Psychopharmacologia (Berlin) E, ed. Neurop5ychopharmacology of monoamines 1967; 11:300-10. and their regulatory enzymes. New York: Raven 9 Delaney P, Estes M. Intracranial hemorrhage Press 1974; 281-97. with amphetamine abuse. Neurology (Minneap) 7 Hitzemann RJ, Tseng LF, Hitzemann BA, 1980; 30:1125-8. Sampath-Khanna S, Loh HH. Effects of with- Protected by copyright. http://jnnp.bmj.com/ on September 25, 2021 by guest.