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Persistent Akathisia Associated with Early Tardive Dyskinesia THOMAS R Postgrad Med J: first published as 10.1136/pgmj.60.703.359 on 1 May 1984. Downloaded from Postgraduate Medical Journal (May 1984) 60, 359-361 Persistent akathisia associated with early tardive dyskinesia THOMAS R. E. BARNES WALTER M. BRAUDE M.B., B.S., M.R.C.Psych. M.B., Ch.B., D.P.M., M.R.C.Psych. Psychiatric Research Unit, University of Cambridge Clinical School, Addenbrooke's Hospital, Trumpington Street, Cambridge CB2 2QE Summary admitted to hospital in July 1981 and diagnosed as Two psychiatric patients developed moderate or suffering from a schizophrenic illness. This was the severe oro-facial dyskinesia, and limb dyskinesia, at a first occasion that she had been prescribed antipsy- relatively young age and within a year of starting chotic medication, although there was evidence that antipsychotic drug-treatment. This early appearance psychotic symptoms, principally delusions, had been of tardive dyskinesia was preceded by akathisia that present for several years. She was treated initially had developed at the beginning of drug therapy and with oral chlorpromazine to a maximum dose of 500 persisted, despite the reduction of their drug doses to mg per day. Following a test dose of fluphenazine maintenance levels. The possibility that persistent decanoate (Modecate), 12-5 mg i.m., she was started akathisia may herald the early onset of tardive on regular injections of this depot drug, 37.5 mg i.m. dyskinesia, is discussed. every 3 weeks. Within a few days ofthe first injection she complained of an inability to keep her legs still copyright. KEY WORDS: schizophrenia, parkinsonism. and the need to pace up and down persistently. Her feelings of restlessness were most distressing when Introduction standing, when she would rock from foot to foot, or walk around, to gain respite. Myoclonic jerking of Tardive dyskinesia is a movement disorder associ- the feet was also observed. These signs and symptoms ated with the administration of antipsychotic (dop- are characteristic of severe akathisia according to amine antagonist) drugs and, as its name suggests, criteria derived from our recent has been considered as a side-effect oflate-onset. It is diagnostic study (Braude et al., 1983). However, only minimal signs of http://pmj.bmj.com/ characterized by oro-facial and limb dyskinesia. parkinsonism were present; rating 0-4 on the Simpson Akathisia is a syndrome of motor restlessness also and Angus (1970) Extrapyramidal Rating Scale related to antipsychotic medication and usually (EPRS). There was no evidence oftardive dyskinesia. described as an acute, dose-related phenomenon. In She was treated with procyclidine, 5 mg tds, for 4 our recent study (Braude, Barnes and Gore, 1983) of weeks without benefit. akathisia developing during the in-patient treatment She was discharged to outpatient care in Novem- of acute psychiatric patients, the condition was ber 1981. Despite a further course of treatment with invariably ameliorated by a reduction in drug dose. procyclidine, 5 mg bd, her akathisia persisted un- on September 27, 2021 by guest. Protected This finding is in accord with the clinical literature on changed. The condition remained severe and dis- akathisia which suggests that dosage reduction is the tressing, and proved to be a profound social handicap only consistently effective treatment strategy (Hodge, as she was unable to tolerate standing still for even 1959; Raskin, 1972; Van Putten, 1974). In the two the shortest periods of time. By February 1982 she patients described here, akathisia persisted despite a had developed moderate oro-facial dyskinesia, ac- reduction in the dose of their antipsychotic medica- cording to the videotape rating technique for tardive tion, from high doses of oral drugs during hospital dyskinesia described by Barnes and Trauer (1982). admission to maintenance doses of depot prepara- Six months later the oro-facial dyskinesia was rated tions. This persistent akathisia heralded the early as severe, and choreiform movements of all four appearance of tardive dyskinesia. limbs were present. Since discharge from hospital, her antipsychotic medication had remained un- Case 1 changed, fluphenazine decanoate 37-5 mg i.m. every A 32-year-old unemployed single woman was 3 weeks. Postgrad Med J: first published as 10.1136/pgmj.60.703.359 on 1 May 1984. Downloaded from 360 Clinical reports Case 2 here, oro-facial dyskinesia, which represents the core A 37-year-old male welder was admitted for the sign of any definition of tardive dyskinesia, was first time in February 1981 with a full range of assessed using a rating method with established Schneiderian first-rank symptoms of schizophrenia. reliability and validity (Barnes and Trauer, 1982). He was diagnosed as having paranoid schizophrenia Coexistent limb dyskinesia was choreiform in nature and prescribed chlorpromazine to a maximum of 500 in one case, and dystonic in the other. mg per day and trifluoperazine to a maximum of 30 For both patients, their psychiatric histories and mg per day. This was the first occasion that he had the presentation of their schizophrenic illness were received antipsychotic medication. Within 10 days of not unusual, and the drug treatment administered starting drug treatment he developed moderately was representative of current practice. Neither had a severe akathisia, manifesting fidgety leg movements family history of movement disorders, and on admis- while seated, rocking from foot to foot when standing sion there had been no clinical evidence of neurologi- and complaining of being unable to keep his legs still. cal pathology, or systemic illness. Thus, the clinical Parkinsonism was also moderately severe, scoring 1-4 features and management of these cases were not on the EPRS. There was no evidence of tardive atypical. The only remarkable factor, common to dyskinesia at this time. Procyclidine was prescribed, both cases, was the presence of akathisia which had up to 15 mg per day, which partially ameliorated his persisted despite drug dose reduction. Evidence from parkinsonism to a score of 0 8, but his akathisia was a number of clinical studies shows that akathisia and unaffected. The chlorpromazine and trifluoperazine tardive dyskinesia can co-exist (Brandon, McClel- were gradually withdrawn and replaced by fluphena- land and Protheroe, 1971; Kennedy, Hershon and zine decanoate 37-5 mg i.m. three weekly. However, McGuire, 1971; Wojcik et al., 1980; Mukherjee et al., his akathisia persisted unaltered. Four months after 1982; Barnes, Kidger and Gore, 1983). Such an admission he was noted to have mild oro-facial association may appear paradoxical, as akathisia is dyskinesia. Two months later his oro-facial dyskine- an acute, dose-related condition which tends to occur sia was rated as moderate, and dystonic movements at the start of antipsychotic drug therapy and is of the legs had appeared. Over the following 6 readily reversible with a reduction in drug dosage, months his depot medication was gradually reduced, while tardive dyskinesia usually emerges during so that by February 1982 he was receiving fluphena- stable, maintenance medication or on drug with-copyright. zine decanoate 25 mg every four weeks. The signs drawal, and is more common in older patients. and symptoms of akathisia and the severity of his The cases reported here suggest one possible oro-facial and limb dyskinesia remained explanation for the association of these two condi- unchanged. tions, namely that acute akathisia which persists with Discussion maintenance antipsychotic medication may be a specific antecedent of early tardive dyskinesia. There By virtue of their age, the two patients described are isolated clinical reports in the literature that lend above might be considered to be at a low risk of support to this view. Based on their clinical observa-http://pmj.bmj.com/ developing tardive dyskinesia (Jus et al., 1976; Smith tions, Chouinard et al. (1979) considered that a and Baldessarini, 1980; Kane and Smith, 1982). patient with tremor or akathisia, which they de- However, within a year of starting antipsychotic drug scribed as 'hyperkinetic' symptoms of parkinsonism, therapy they had developed marked oro-facial dyski- was more likely to manifest tardive dyskinesia than a nesia and prominent limb dyskinesia. These abnor- patient with 'hypokinetic symptoms' such as akinesia mal movements were considered to represent tardive and rigidity. DeVeaugh-Geiss (1982) elaborated on dyskinesia, although stereotyped, rhythmic move- this idea, suggesting that, in certain patients, akathi- ments occurring relatively early in drug treatment, sia can represent a stage in a progression from on September 27, 2021 by guest. Protected and resembling tardive dyskinesia, have been ob- hypokinetic parkinsonism to the development of oro- served by Gerlach (1979), and could be a source of facial and trunk and limb dyskinesia. Munetz and diagnostic confusion. He labelled these phenomena Cornes (1982) discussed this hypothesis, and specu- 'initial hyperkinesia'. However, there is little evi- lated further on the relationship between the two dence, at present, to support the claims that this conditions. They suggested that tardive dyskinesia hyperkinesia constitutes a phenomenologically dis- may be preceded by a form of akathisia where only tinct clinical entity, or may be distinguished from the motor signs are present; the subjective, distressing tardive dyskinesia in terms of response to drug aspects originally in evidence, having progressively treatments. Tardive dyskinesia itself lacks precise diminished. Simpson (1977) has also commented on phenomenological description and, as generally ap- the absence of subjective symptoms in chronic plied, the term may encompass a wide variety of akathisia, and, in addition, has noted the existence of abnormal movements (Mackay, 1982; Barnes, Rosser a late-onset type of akathisia which he considered to and Trauer, 1983b). In the two patients described be 'frequently associated' with tardive dyskinesia. Postgrad Med J: first published as 10.1136/pgmj.60.703.359 on 1 May 1984. Downloaded from Clinical reports 361 Braude and Barnes (1983) have proposed that late- ment Disorders (Ed.
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