Increased extrapyramidal symptoms in patients with schizophrenia and a comorbid substance use disorder

Few data have been gathered about the impact of psychoactive substances on extrapyramidal symptoms (EPS) in schizophrenia, and so far, inconsistent results have been reported. We studied 41 outpatients with schizophrenia (based on DSM-IV criteria), who were divided into two groups: with (n = 17) and without (n = 24) a substance use disorder (alcohol, cannabis, and/or cocaine). Both groups were matched for sociodemographic data and psychiatric symptoms (Positive and Negative Syndrome Scale). EPS were evaluated with the Extrapyramidal Symptoms Rating Scale and the Barnes Akathisia Scale, and all patients were stable on either quetiapine or clozapine. Patients receiving anticholinergic drugs were excluded. Analyses of variance were conducted on both groups and showed that schizophrenia patients with a comorbid substance use disorder (especially cocaine) displayed more EPS compared with non-abusing patients.     

Plasma substance P level in patients with schizophrenia: a cross-sectional study

Aspiration pneumonia is a serious health concern in older patients with schizophrenia. In this study, we examined clinical and demographic variables that could impact the plasma substance P level, which is a useful predictive biomarker of aspiration. Thirty-four patients were included (mean age ± SD: 70.9 ± 10.8 years). A greater number of cigarettes/day and a higher antipsychotic dosage were found to be associated with a lower plasma substance P level, while age showed a trend-level effect. This finding suggests the need for intensive observation for prevention of aspiration pneumonia in heavy smokers who are receiving a higher antipsychotic dose in this senior population.     

Quetiapine demonstrates good tolerability and is associated with improvements in extrapyramidal symptoms in patients with schizophrenia switched from other antipsychotics: results of a naturalistic study

Objectives. Compared with conventional agents, atypical antipsychotics such as quetiapine (Seroquel®; AstraZeneca) show improved tolerability and a lower liability to cause extrapyramidal symptoms (EPS). In the routine treatment of schizophrenia, it is usual practice to consider a change of medication when the current treatment is ineffective or poorly tolerated, although few studies are available to guide clinicians. This paper reports the results from the Seroquel Method. Patient Evaluation on Changing Treatment Relative to Usual Medication (SPECTRUM) trial, a 12-week, open-label, noncomparative study that evaluated clinical benefit and tolerability of switching patients with schizophrenia from their existing antipsychotic to quetiapine. Patients were switched because of intolerance to, or lack of efficacy with, their previous antipsychotic. Quetiapine was titrated to 400 mg/day over 7 days, then dosed flexibly up to 750 mg/day over the remaining weeks (mean modal dose 505 mg/day). Results. In the overall population of 506 evaluable patients, quetiapine was well tolerated, with a low incidence of adverse events and minimal requirement for anticholinergic medication. Significant improvements in EPS, including parkinsonism and akathisia, were observed, irrespective of reason for switching, although greatest improvements were observed in patients switching because of EPS. Conclusions. This study provides further evidence for the utility and tolerability of quetiapine, in patients with schizophrenia who had been switched from a previous antipsychotic, following problems with efficacy or tolerability.     

Aripiprazole in the acute treatment of male patients with schizophrenia: effectiveness, acceptability, and risks in the inner-city hospital setting

Aripiprazole, a novel atypical antipsychotic that acts as a partial agonist at the dopamine D₂ receptors, has been reported to be effective in the treatment of chronic schizophrenia. However, the risks and benefits of using aripiprazole in the acute hospital setting to treat severe psychotic disorders are unclear. This naturalistic study assessed the effectiveness of aripiprazole monotherapy in a group of actively psychotic male patients (n = 10) with schizophrenia who were admitted to an inner-city acute psychiatric unit. Most patients (n = 7) responded to aripiprazole treatment, which was well tolerated and significantly ameliorated psychotic symptoms after 2–3 weeks. Patients who responded to it could be safely discharged on aripiprazole monotherapy. Side effects observed were mostly mild and transient, and included extrapyramidal symptoms (n = 1) and neutropenia (n = 1). Aripiprazole also remarkably attenuated dyskinetic movements in 1 patient with severe tardive dyskinesia, thereby suggesting that it may be useful in the treatment of other disorders that are also associated with dopamine dysfunction. Results showed that aripiprazole can be safely and effectively employed in the hospital setting to treat severely psychotic patients with schizophrenia, but further studies are required to establish the full range of adverse reactions and therapeutic indications associated with its use.     

拉莫三嗪对精神分裂症阴性症状的辅助治疗作用

目的：探讨拉莫三嗪合并抗精神病药,治疗精神分裂症阴性症状的疗效与安全性。方法：对以阴性症状为主的精神分裂症患者50例,按入院顺序随机分为抗精神病药物合并拉莫三嗪组,（合用组）和单用抗精神病药物组（单用组）,疗程12用。采用阳性与阴性症状量表（PANSS）评定疗效．用治疗中出现的症状量表（TESS）评定不良反应,于治疗前及治疗4、8、12周各评定一次。结果：合用组显效率64％,单用组硅效率40％。从治疗4周起,合用组PANSS总分及阴性症状分均显著低于单用组。结论：以阴性症状为主的精神分裂症患者．在使用抗精神病药物同时联用拉莫三嗪,可改善阴性症状,两组不良反应无明显差异．     

A comparison of schizophrenic patients with or without coexisting substance use disorder

Increasing numbers of research investigations have documented psychosocial, demographic, and treatment course differences between schizophrenic patients with and without additional substance use disorder. However, many of these studies have failed to control for additional psychiatric diagnoses. This study sought to elucidate differences between schizophrenic patients with versus without coexisting substance use disorder, while controlling for the possible confounding impact of additional Axis I or Axis II diagnoses. We explored the records of 308 psychiatric inpatients who were either solely diagnosed with schizophrenia or solely diagnosed with coexisting schizophrenia and substance use disorder. We compared these two groups on a variety of psychosocial, demographic, and clinical variables shown in prior research to differentiate these two types of patients. Findings revealed that substance use interacts with schizophrenia to increase psychiatric admissions and decrease lengths of stay upon admission. Findings also revealed that patients with coexisting substance use and schizophrenia have unique psychosocial and demographic presentations that reflect more challenging life circumstances. Differences were not revealed between groups in terms of legal and criminal involvement. Based on pure diagnostic groupings, findings indicate that an additional substance use disorder is associated with psychosocial, demographic, and treatment course differences among individuals with a schizophrenia diagnosis. When screening, developing treatment, and planning aftercare, it is crucial to not view individuals with schizophrenia diagnoses as a monolithic group, but rather to consider the presence of a substance abuse diagnosis; such consideration will increase the likelihood of appropriate treatment and successful outcomes.     

Clozapine use and relapses of substance use disorder among patients with co-occurring schizophrenia and substance use disorders

BACKGROUND: Previous correlational research with schizophrenic patients has suggested that the second-generation antipsychotic medication clozapine helps to induce remissions of substance use disorder in patients with co-occurring psychosis and substance abuse. This research, however, could be biased by selection factors. Studying patients who are currently in substance abuse remission could control for level of motivation to stop using substances and other methodological confounds. METHODS: To test whether clozapine was associated with prevention of substance abuse relapses, we examined patients with schizophrenia or schizoaffective disorder who were in their first 6-month remission of substance use disorder during a prospective 10-year follow-up study. All patients received yearly multimodal assessments of substance use. Antipsychotic medications were prescribed by community doctors as part of usual clinical care. RESULTS: Patients using clozapine at the first 6-month period of substance abuse remission (n = 25) were much less likely to relapse over the next year compared with those on other antipsychotic medications (n = 70): 8.0% vs 40.0%, chi(2) = 8.73 (df = 1), P = .003. Although medication assignment was not randomized, several potential confounders were similar between the groups. CONCLUSION: Clozapine should be considered for the treatment of patients with schizophrenia and co-occurring substance use disorder to prevent relapses to substance abuse.     

The influence of switching from risperidone to paliperidone on the extrapyramidal symptoms and cognitive function in elderly patients with schizophrenia: A preliminary open-label trial

Objective. This study was to evaluate the effects on clinical symptoms and cognitive function of switching the treatment of elderly patients with schizophrenia from risperidone to paliperidone (PAL). Methods. This study was a 12-weeks, preliminary open-label trial. The subjects were 17 inpatients. Their extrapyramidal symptoms (EPS) were assessed using the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS), Abnormal Involuntary Movement Scale (AIMS), and Barnes Akathisia Scale (BAS), and their cognitive function was assessed using the Brief Assessment Cognition in Schizophrenia: Japanese language version (BACS-J), and their clinical symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression-Severity of illness scale (CGI-S) at the 0 and 12 weeks. Results. The DIEPSS and BAS significantly improved after switching from risperidone to PAL. Furthermore, improvement was found on AIMS. The mean change from baseline in z-score of the digit sequencing task was significantly increased. All items on the PANSS and CGI-S were not significant; however, changes in some cognitive function were correlated with changes in EPS. Conclusions. The results of this study suggest the possibility that switching elderly patients from risperidone to PAL may have improved pre-existing EPS, and may also have helped improve working memory.     

Co-occurring medical and substance use disorders in patients with schizophrenia: a systematic review

Comorbid medical and substance use disorders are common in people with schizophrenia. The aim of this systematic review was to summarize evidences on co-occurring medical and substance use disorders (SUDs) in patients with schizophrenia. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) review was conducted. Medline, CinAHL, Embase, PsycINFO, and the Cochrane Library were searched to August 31, 2016 without restriction by publication status. Publications were screened according to predefined inclusion criteria. Qualitative analysis was undertaken for this systematic review. Twenty-six materials published from 1990 to 2015 were included in a qualitative analysis. From a total of 202 articles identified, 26 articles were eligible for systemic review. The evidence shows that 18.5 to 90% of people with schizophrenia develop any SUDs at some point in their lives including nicotine and 18.5% to 61.5% excluding nicotine. Nicotine use disorders are particularly common in people with schizophrenia, with a lifetime prevalence of roughly 58–90% followed by alcohol, khat, and cannabis use disorders, respectively. In addition, up to 80% of people with schizophrenia have recognizable medical disorders of which approximately up to 50% remain undetected and medical problems may explain or exacerbate their condition in about 20% of people with schizophrenia. This systematic review indicates that comorbid medical disorders and SUD are common in people with schizophrenia. Routine screening and integrated management of medical and substance use disorders is implicated in persons with schizophrenia.     

Prevalence of movement disorders in adolescent patients with schizophrenia and in relationship to predominantly atypical antipsychotic treatment

Objective To examine prevalence of movement disorders (MDs) such as tardive dyskinesia (TD), parkinsonism or akathisia in an adolescent population with schizophrenia and in relationship to predominantly atypical antipsychotic treatment. Method Ninety-three patients (aged 19.6±2.2 years) were ascertained in this cross-sectional/retrospective study. 76 patients (81.7%) received atypical, 10 (10.8%) typical antipsychotics and 7 (7.5%) combinations of atypical/typical antipsychotics. MD symptoms were assessed using Tardive Dyskinesia Rating Scale (TDRS), Abnormal Involuntary Movement Scale (AIMS), Extrapyramidal Symptom Scale (EPS), Barnes Akathisia Scale (BAS). Results Movement disorder symptoms were found in 37 patients (39.8%) fulfilling strict/subthreshold criteria for TD (5.4/11.8%), parkinsonism (2.2/25.8%) or akathisia (1.1/11.8%), respectively. Patients treated with typical antipsychotics displayed a significantly higher EPS-score (P=0.036) and a tendency towards a higher BAS-score (P=0.061) compared to patients with atypical antipsychotics. Treatment durations with typical/atypical antipsychotics showed trends towards advantages of atypical antipsychotics with regard to parkinsonism/akathisia symptoms (P=0.061; P=0.054), but not with regard to TD symptoms (P=0.003), possibly due to confounding effects. Conclusion Under treatment with atypical antipsychotics MD symptoms are less prevalent and less pronounced than under typical antipsychotics. We speculate that the finding of relatively high prevalence rates of subthreshold MD symptoms may be, at least partially, explained by previous or combined therapy with typical antipsychotics.     

精神分裂症患者认知功能与精神症状相关性研究

目的：探讨精神分裂症患者认知功能与精神症状的相关性。方法：对40例精神分裂症患者于治疗前、治疗12周末分别进行韦氏成人智力量表（WAIS-R）、韦氏记忆量表（WMS）、H—R神经心理成套测验（HRB）中的连线测验A、威斯康星卡片分类测验（WCST）及言语流利性测验及简明精神病评定量表（BPRS）评定。结果：治疗前焦虑抑郁因子分与总记忆商数（MQ）分显著相关,迟滞因子分与WCST完成类别数、智力显著相关;治疗12周末焦虑抑郁因子分与总智商（IQ）显著相关,迟滞因子分与WCST持续反应数、言语IQ、操作IQ显著相关,猜疑因子分与WCST持续反应数显著相关。结论：精神分裂症患者部分认知功能与精神症状显著相关。     

慢性精神分裂症患者的抑郁症状研究

目的:了解慢性精神分裂症患者的抑郁症状及其相关的影响因素。方法:对180名住院慢性精神分裂症患者测试卡尔加里精神分裂症抑郁量表(CDSS)、阳性症状量表(SAPS)、阴性症状量表(SANS)、治疗中出现的症状量表(TESS)及自编的相关因素调查表。结果:慢性精神分裂症患者的抑郁症状发生率为40.6%;有无抑郁发生的两组比较,在总病程、住院次数、文化程度、家庭经济水平、社会支持、自知力恢复及药物种类、剂量、时间及不良反应、阳性阴性症状和合并躯体疾病等方面差异有显著性。Logistic回归分析显示,精神分裂症患者出现抑郁症状的相关影响因素依次为:阴性症状、合并躯体疾病、抗精神病药的种类、社会支持、自知力及药物不良反应。结论:慢性精神分裂症患者抑郁症状发生率高、影响因素多,需从多方面对精神分裂症患者的抑郁进行预防和治疗。     

Co-occurrence of Axis I and Axis II disorders in substance abusers

OBJECTIVE: This study examined the co-occurrence of anxiety/mood and personality disorders (PDs) in substance abusers, the impact of anxiety/ mood disorders on the symptom profiles of PDs, and the impact of anxiety/mood disorders and PDs on pre-treatment status. METHOD: Current anxiety/mood disorders and PDs and pre-treatment status were assessed using semi-structured interviews in 370 treated substance abusers. RESULTS: Anxiety/mood disorders and PDs frequently co-occurred, with the overall pattern of associations being non-specific. The strongest associations were of social phobia with avoidant and schizotypal PD, and of major depression with borderline PD. However, symptom profiles of PDs were not associated with anxiety/mood disorders. Finally, anxiety/mood disorders and PDs were both independently and differentially associated with poor pre-treatment characteristics. CONCLUSION: The findings suggest the clinical importance of obtaining both Axis I and Axis II diagnoses in treated substance abusers, and highlight the distinctiveness of the Axis I and Axis II disorders.     

Long-term clinical course of patients with acute polymorphic psychotic disorder without symptoms of schizophrenia

Few studies have investigated the long-term course of patients with acute polymorphic psychotic disorder, despite the clinical relevance. The present study focused on the frequency of acute polymorphic psychotic disorder without symptoms of schizophrenia (F23.0) and the prognosis of patients with the disorder over a long period. A total of 388 inpatients with nonaffective psychosis were examined and cases with F23.0 were retrospectively investigated regarding clinical course over 12 years with reference to clinical charts. A total of 16 cases were diagnosed with F23.0 according to first episode. After 12 years, five cases were rediagnosed with schizophrenia, and one case with borderline-type emotionally unstable personality disorder, although the diagnosis of F23.0 was not changed in 10 older patients. Of the four cases with >2 repeated episodes of F23.0, the same clinical picture as in the first episode was observed in three, while one case showed continuous residual symptoms. F23.0 does not represent a homogeneous clinical entity. In some cases, diagnosis changes to schizophrenia, but others display repeated episodes of F23.0.     

Criminality in men with major mental disorder with and without comorbid substance abuse

Violent and criminal behavior in the mentally ill remains an issue of major importance and in this context the role of comorbid substance abuse must be addressed. Data on criminal behavior in 282 men with schizophrenia and 261 men with affective disorder were studied. Samples of patients with and without additional substance abuse were compared. Also, non-abusing patients from both diagnostic groups were compared with matched controls from the general population. Substance abuse was found in half of all men in both groups of major mental disorders, and substance abusers had twice as high a probability of having a criminal record. However, compared with the matched sample from the general population, violent criminality was increased in schizophrenic patients without comorbid substance abuse, and patients with affective disorders without substance abuse had a higher probability of committing crimes against property. Men with major mental disorder have an increased probability of becoming criminal even when there is no comorbid substance abuse.     

Prevalence of alcohol use disorders in schizophrenia – a systematic review and meta‐analysis

Objective: Our aim was to present recent studies of alcohol use disorders (AUDs) in patients with schizophrenia, estimate overall prevalence and characteristics affecting the prevalence of AUDs. Method: We conducted a search using three literature databases and a manual search on articles published in 1996–2008. Meta‐regression was used to study how prevalence is affected by different study characteristics. Articles that reported diagnoses according to DSM or ICD diagnostic systems were included. Results: Altogether 60 studies met our criteria. The median of current AUD prevalence was 9.4% (inter‐quartile range, IQR 4.6–19.0, 18 studies) and median of lifetime AUD prevalence 20.6% (IQR 12.0–34.5, 47 studies). In studies using DSM‐III‐R median prevalence was higher than that in studies using DSM‐IV, ICD‐9 or ICD‐10 (32/17/11/6%). Conclusion: Approximately every fifth patient with schizophrenia had lifetime AUD diagnosis. When contrasted with the most recent review, there might be a descending trend in AUD prevalence in patients with schizophrenia.     

Reasons for substance use in schizophrenia

Abuse of and de pendence on drugs, alcohol and other substances in schizophrenia are being increasingly recognized and well documented in the literature. It has been suggested that up to 60% of patients with schizophrenia use illicit drugs. A total of 41 subjects who fulfilled DSM-III-R criteria for schizophrenia and substance abuse or dependence were asked to describe their reasons for using such substances, the reasons why they might stop and the subjective effects of the substances. Drugs were reportedly used to increase pleasure, to‘get high’ and to reduce depression. However, subjective effects of increased depression and positive symptoms were also reported. These results are considered in the context of potential treatment strategies.     

Motor behavior abnormalities in drug‐naïve patients with schizophrenia spectrum disorders

Prevalence and correlates of primary motor abnormalities in schizophrenia are presently ill defined. This study was aimed at examining the prevalence, syndromic structure, external correlates, and response to antipsychotic medication of a broad array of primary motor abnormalities. Two‐hundred antipsychotic‐naive patients with schizophrenia spectrum disorders were examined for motor abnormalities using the Modified Rogers Scale. Thirty‐one motor signs were subjected to factor analysis, and the resulting factors examined for association with a number of risk factors, clinical and psychopathological variables. One‐hundred and eighty‐nine patients were reassessed for motor abnormalities after completing a 4‐week trial with antipsychotic medication. Prevalence rates for at least one motor sign and syndrome at baseline were 66% and 40%, respectively. Motor signs clustered together into seven clinically interpretable factors: abnormal involuntary movements, hypokinesia, retarded catatonia, echo‐phenomena, excited catatonia, catalepsy, and parkinsonism. All motor domains but parkinsonism were inter‐related. Abnormal involuntary movements were associated with variables indicating both neurodevelopmental dysfunction and illness severity, and most motor domains were closely related to negative or disorganization symptoms. Change scores in motor domains after treatment with antipsychotic medication indicated improvement for abnormal involuntary movements, hypokinesia, retarded catatonia, excited catatonia and echophenomena, and worsening for parkinsonism. It is concluded that primary motor dysfunction is a prevalent and heterogeneous condition of schizophrenia. Motor abnormalities segregate into various syndromes, which have different clinical correlates and a differential response pattern to antipsychotic medication. It is hypothesized that the existence of a differential dopaminergic dysfunction in the nigroestriatal circuitry is responsible for the generation of those motor domains that improve and worsen with antipsychotic drugs. © 2010 Movement Disorder Society     

Relations between movement disorders and psychopathology under predominantly atypical antipsychotic treatment in adolescent patients with schizophrenia

Objective To examine relations between movement disorders (MD) and psychopathological symptoms in an adolescent population with schizophrenia under treatment with predominantly atypical antipsychotics. Method MD symptoms and psychopathology were cross-sectionally assessed in 93 patients (aged 19.6 ± 2.2 years) using Tardive Dyskinesia Rating Scale (TDRS), Abnormal Involuntary Movement Scale (AIMS), Extrapyramidal Symptom Scale (EPS), Barnes Akathisia Scale (BAS), Brief Psychiatric Rating Scale (BPRS) and the Schedule for Assessment of Negative/Positive Symptoms (SANS/SAPS). Results All patients with MD symptoms (n = 37; 39.8 %) showed pronounced global psychpathological signs (SANS/SAPS, BPRS: p = 0.026, p = 0.033, p = 0.001) with predominant anergia symptoms (p = 0.005) and inclinations toward higher anxiety- and depression-related symptoms (p = 0.051) as well as increased thought disturbance (p = 0.066). Both negative symptoms and anergia showed trends for positive correlations with tardive dyskinesia (p = 0.068; p = 0.065) as well as significant correlations with parkinsonism symptoms (p = 0.036; p = 0.023). Akathisia symptoms correlated significantly with hostile and suspicious symptoms (p = 0.013). A superfactor-analysis revealed four factors supporting the aforementioned results. Conclusion MD symptoms and psychopathology are in some respects related to each other. Motor symptoms representing on the one hand trait characteristics of schizophrenia might additionally be triggered by antipsychotics and finally co-occur with more residual symptoms within a long-term treatment.