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Drug-induced Dystonia

Drug-induced dystonia is a movement disorder caused primarily by the effects of antipsychotic and antiemetic drugs on the extrapyramidal system. It causes a variety of involuntary and abnormal movements and postures.


Presentation

Drug-induced dystonia is reversible and presents as acute, disorganized contraction of muscle groups. It generally occurs soon after the administration of antipsychotic, antiemetic, antidepressant and antiepileptic drugs, however other drugs have also been known to induce the condition [1] [2] [3]. It is thought that this is due to the drugs' inhibitory effect on the dopamine system in the central nervous system. It appears commonly when the drug is initiated or when the dose of the drug is increased. Higher doses and greater potency of causative drugs, particularly neuroleptic drugs are associated with as higher incidence [4]. In addition, first-generation antipsychotics, such as haloperidol, have been implicated more than second-generation antipsychotics. Symptoms appear within hours of administration of the initial dose of antipsychotics, and up to one month after antidepressants are started [5]. Younger patients, concurrent substance use, particularly alcohol and cocaine, family history of dystonia are associated with a higher risk of the condition [6].

Drug-induced dystonia is seldom a source of fatalities [7]. It does, however, cause significant patient distress, and is frequently misdiagnosed [8]. It usually involves the muscles of the face and neck but is not restricted to these. Episodes are characterized by sustained uncontrollable motions that may or may not be heralded by voluntary movement. Facially, the muscles of the eye can be affected, causing what may appear to be excessive blinking. The muscles may also constantly contract, forcing the gaze to remain in a certain direction resulting in an oculogyric crisis. Involvement of the facial muscles causes twitching of the lips, dysarthria, dysphonia and buccolingual crisis; if laryngeal or pharyngeal musculature are affected then there could be airway compromise [9] while torticollis results from sternocleidomastoid muscle involvement.

On the torso, distortion of the spine, opisthotonus, as well as a tortipelvic crisis, which involves rigidity of the pelvic and abdominal musculature, can occur. Any muscle group can be affected, and it can eventually become painful with the formation of contractures [10]. Moreover, a serious and debilitating form of the disorder called tardive dystonia may follow.

Gingival Overgrowth
  • […] drug-induced constipation drug-induced cystitis drug-induced disease Drug-induced dystonia Drug-Induced Extra-Pyramidal Symptoms Scale drug-induced gingival hyperplasia drug-induced gingival hyperplasia drug-induced gingival hyperplasia Drug-Induced Gingival[encyclopedia2.thefreedictionary.com]
Dystonia
  • The highest frequencies of dystonia occurred among recipients of haloperidol and the long-acting injectable fluphenazines. For all patients at risk, dystonia was more common in men and in younger patients.[ncbi.nlm.nih.gov]
  • Moreover, a serious and debilitating form of the disorder called tardive dystonia may follow. There are no tests tailored to diagnose drug-induced dystonia.[symptoma.com]
  • Abstract Neuroleptic-induced tardive dystonia is frequently refractory to therapy. We describe a 13-year-old girl with neuronal ceroid-lipofuscinosis who developed dystonia after beginning treatment with thioridazine for acute psychosis.[ncbi.nlm.nih.gov]
  • METHODS: We describe 2 examples, accompanied by videos, of acute drug-induced oro-mandibular dystonia, both subsequent to occasional haloperidol intake.[ncbi.nlm.nih.gov]
  • Thirty-one percent of the young patients developed dystonia, compared to 2% of the elderly patients.[ncbi.nlm.nih.gov]
Extrapyramidal Symptoms
  • Extrapyramidal symptoms after exposure to calcium channel blocker-flunarizine or cinnarizine. Jhang KM, Huang JY, Nfor ON, Tung YC, Ku WY, Lee CT, Liaw YP Sertraline induced mandibular dystonia and bruxism.[medicbind.com]
  • Therefore, physicians must be cautious of prescribing metoclopramide and should consider other antiemetics such as domperidone, which has less frequent extrapyramidal symptoms [ 5 ].[ceemjournal.org]
  • Most of us learned in our professional training that neuroleptic agents cause movement disorders, or extrapyramidal symptoms (EPS).1 Neuroleptics, the older class of antipsychotic agents, which includes dopamine receptor blocking agents (DRBA), can cause[the-hospitalist.org]
  • Rainier-Pope, CR. (1979) Treatment with diazepam of children with drug-induced extrapyramidal symptoms. South African Medical Journal. Suid-Afrikaanse Tydskrif Vir Geneeskunde, 55(9) pp. 328-30.[rcemlearning.co.uk]
  • BMC Research Notes 2017 10 :32 The Author(s) 2017 Received: 28 October 2016 Accepted: 14 December 2016 Published: 7 January 2017 Abstract Background Metoclopramide is a commonly used anti-emetic drug known to cause extrapyramidal symptoms as adverse effects[bmcresnotes.biomedcentral.com]
Slurred Speech
  • Abnormal posturing of the head and neck in relation to the body, spasms of jaw muscles, impaired swallowing, tics (spasmodic contractions, particularly of the face), slurred speech, tongue protrusion, deviation of eyes (up, down, or sideways) and abnormal[clinicaladvisor.com]
Rabies
  • […] clinically Chronic neurologic: Parkinson's with dystonia Electrolyte imbalance: low magnesium or calcium (carpopedal spasm) Drug ingestion or poisoning: strychnine Drug withdrawal: benzodiazepines, barbiturates Infection: tetanus, meningitis, encephalitis, rabies[clinicaladvisor.com]

Workup

There are no tests tailored to diagnose drug-induced dystonia. It should be suspected and considered as a possible etiology of symptoms, based on patient history and physical findings. The condition readily responds to treatment and this may indirectly confirm the diagnosis. However, a psychiatrist consult may be required if the diagnosis is doubtful.

Treatment

  • RESULTS: Management and treatment of this movement disorder are often difficult: neuroleptics withdrawal, treatment with benzodiazepines, and anticholinergics are recommended. CONCLUSION: Alternative treatment options are also discussed.[ncbi.nlm.nih.gov]
  • […] can be a side effect of treatment with antipsychotic drugs and other drugs, and it may occur at an early stage of treatment. 1 2 Acute dystonia is often frightening and may seriously disturb the relationship between the doctor and the patient.[bmj.com]
  • We describe a 13-year-old girl with neuronal ceroid-lipofuscinosis who developed dystonia after beginning treatment with thioridazine for acute psychosis.[ncbi.nlm.nih.gov]
  • Botulinum toxin injections to a particular muscle group are an additional option for treatment. Like the treatment of tardive dystonia, the treatment of other tardive dyskinesias is very specific to the individual patient.[dystonia-foundation.org]
  • There is no clear way to predict which treatments will work for each person. Where other treatments are not effective, deep brain stimulation (DBS) may be an appropriate alternative.[dystonia.org.uk]

Prognosis

  • It is not intended to provide instruction and you should not rely on this information to determine diagnosis, prognosis or a course of treatment. It should not be used in place of a professional consultation with a doctor.[dystonia.org.uk]
  • Prognosis There is no effect on life expectancy, but quality of life is severely affected. The documents contained in this web site are presented for information purposes only.[orpha.net]
  • We collected the patients’ age, sex, suspected causative drugs, initial diagnosis of the prescribing physician, duration of drug-taking, diagnostic evaluations, treatment methods, and prognosis. Results Seventy-nine patients were enrolled.[ceemjournal.org]
  • Learning Bite Acute dystonia should be treated with IM/IV anticholinergics (e.g. procyclidine) Prognosis & Followup strategies Acute dystonia is commonly induced by anti-psychotics, anti-emetics or antidepressants but has been attributed less commonly[rcemlearning.co.uk]
  • Prognosis What is my prognosis? If dystonia develops in childhood, particularly if it starts in the legs, then in many (but not all) cases it will spread to other parts of the body and become generalised.[brainfoundation.org.au]

Etiology

  • Use Additional Use Additional Help Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10data.com]
  • It should be suspected and considered as a possible etiology of symptoms, based on patient history and physical findings. The condition readily responds to treatment and this may indirectly confirm the diagnosis.[symptoma.com]
  • Patient should have basic electrolytes checked including calcium and magnesium, toxicology screen, and complete blood count (CBC) for infectious etiologies.[clinicaladvisor.com]
  • Codes with this note are Etiology codes and must be followed by a Manifestation code or codes.[icd.codes]
  • […] the head, neck, and tongue and often occurs as an adverse effect of a medication. dystonia Neurology Involuntary, often acute movement and prolonged contraction of one or more muscles, resulting in twisting body motions, tremor, and abnormal posture Etiology[medical-dictionary.thefreedictionary.com]

Epidemiology

  • In this chapter we review current knowledge regarding the clinical features, epidemiology, pathophysiology, and treatment of acute dystonic reactions (ADRs) and tardive dystonia (TDT).[discovery.ucl.ac.uk]
  • Summary Epidemiology The prevalence is unknown. Fewer than 100 patients have been described worldwide to date.[orpha.net]
  • Accessed May 17, 2017. }} Health Program Information The State of Alaska Epidemiologic Profile on Substance Use, Abuse and Dependency is available at: [].[ibis.dhss.alaska.gov]
  • Our small sample size could not represent all pediatric DID patients, especially in the aspects of treatment and the epidemiology of commonly prescribed causative drugs.[ceemjournal.org]
  • No adequate epidemiologic data exist regarding whether any particular psychiatric diagnosis constitutes a risk factor for the development of tardive reactions to medications; however, the duration of exposure to antipsychotics that is required to cause[pocketdentistry.com]
Sex distribution
Age distribution

Pathophysiology

  • In this chapter we review current knowledge regarding the clinical features, epidemiology, pathophysiology, and treatment of acute dystonic reactions (ADRs) and tardive dystonia (TDT).[discovery.ucl.ac.uk]
  • The pathophysiology of bruxism is unknown. The most cogent theory describes bruxism as a neuromotor dysregulation disorder. This theory proposes that bruxism occurs because of the failure to inhibit jaw motor activity during a sleep state arousal.[pocketdentistry.com]
  • What is the underlying pathophysiology of this condition? Acute dystonic reactions result from an imbalance of dopaminergic and cholinergic neurotransmission.[lifeinthefastlane.com]
  • Marsden CD, Jenner P (1980) The pathophysiology of extrapyramidal side-effects of neuroleptic drugs. Psychol Med 10: 55-72. Burstein AH, Fullerton T (1993) Oculogyric crisis possibly related to pentazocine. Ann Pharmacother 27: 874-876.[omicsonline.org]
  • The pathophysiological mechanism is still unknown.[journals.lww.com]

Prevention

  • Therefore, every doctor who prescribes dopamine blocking agents should be familiar with the prevalence of and the risk factors for acute dystonia and should know how to prevent and treat the condition.[bmj.com]
  • Avoidable - 0% Emergent - ED Care Needed - Not Preventable/Avoidable - 0% Primary diagnosis of injury 0% Primary diagnosis of mental health problems 0% Primary diagnosis of substance abuse 0% Primary diagnosis of Alcohol 0% Unclassified 100% Health Topic[codelay.com]
  • Now in its second edition, this popular and essential comprehensive resource provides a detailed analysis of how to identify, prevent, and manage drug-induced diseases. Edited by James E. Tisdale and Douglas A.[books.google.de]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • The National Institute of Mental Health is similarly committed to preventing further cases of drug-induced movement disorders in individuals who benefit from neuroleptic treatment.[dystonia-foundation.org]

References

Article

  1. Elliott ES, Marken PA, Ruehter VL. Clozapine-associated extrapyramidal reaction. Ann Pharmacother. 2000;34(5):615-618.
  2. Jhee SS, Zarotsky V, Mohaupt SM, Yones CL, Sims SJ. Delayed onset of oculogyric crisis and torticollis with intramuscular haloperidol. Ann Pharmacother. 2003;37(10):1434-1437.
  3. Tekin U, Soyata AZ, Oflaz S. Acute focal dystonic reaction after acute methylphenidate treatment in an adolescent patient. J Clin Psychopharmacol. 2015;35(2):209-211.
  4. van Harten PN, Hoek HW, Kahn RS. Acute dystonia induced by drug treatment. BMJ. 1999;319(7210):623–626.
  5. Hawthorne JM, Caley CF. Extrapyramidal Reactions Associated with Serotonergic Antidepressants. Ann Pharmacother. 2015;49(10):1136-1152.
  6. Zakariaei Z, Taslimi S, Tabatabaiefar MA, Arghand Dargahi M. Bilateral dislocation of temporomandibular joint induced by haloperidol following suicide attempt: a case report. Acta Med Iran. 2012;50(3):213-215.
  7. Freudenreich O. Atypical laryngeal dystonia caused by an antiemetic. Am Fam Physician. 2004;69(7):1623.
  8. Dingli K, Morgan R, Leen C. Tetanus versus acute dystonic reaction caused by metoclopramide. BMJ. 2007;334(7599):899–900.
  9. Munhoz RP, Moscovich M, Araujo PD, Teive HA. Movement disorders emergencies: a review. Arq Neuropsiquiatr. 2012;70(6):453–461.
  10. Dystonias information page. National Institute of Neurological Disorders and Stroke. Accessed March 26,2017.

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Last updated: 2018-06-22 02:08