Manu Arora

Clozapine-induced sialorrhea: pathophysiology and management strategies

RationaleClozapine is an atypical antipsychotic agent with proven efficacy in refractory schizophrenia, but its widespread use is limited by adverse effects such as agranulocytosis, seizures, sedation, weight gain, and sialorrhea. Clozapine-induced sialorrhea (CIS) is bothersome and has socially stigmatizing adverse effects, which result in poor treatment compliance. The pathophysiology of this condition is poorly understood and the treatment options available are based mostly on case reports and open-label studies.ObjectiveTo review the available studies on CIS.MethodAll relevant studies available through PUBMED search supplemented with manual search were undertaken.ResultThe clinical features, complications, assessment, pathophysiology, and management of CIS are discussed.ConclusionAlthough the studies evaluating the therapeutic options has limitations and no drug has been found to be superior, judicious use of pharmacological agents along with behavioral methods will reduce this troublesome side effect and enhance compliance.

Inhalant abuse (typewriter correction fluid) in street children.

Background:Inhalant abuse is a growing concern in India among street children. Aim:To describe the sociodemographic and clinical characteristics of 9 street children and adolescents with typewriter correction fluid abuse. Method:Nine street children who presented to the psychiatry department of Dr. Ram Manohar Lohia Hospital, New Delhi for treatment of inhalant abuse were interviewed. Findings:The inhalant abusers were boys of 10 to 17 years, school dropouts who had run away from villages of Bihar and Uttar Pradesh. In two-third of children there was domestic violence and conflict in their family, along with physical abuse by family members; in one-third it was due to alcoholic fathers. They used to “huff” typewriter correction fluid, and abused other substances as well. Conclusion:There is a need to systematically study inhalant abuse in the street children in India.

Butterfly glioma of corpus callosum presenting as catatonia

Catatonia can occur with functional psychiatric disorders as well as organic conditions. In this case report, catatonia occurred with a butterfly glioma originating from the corpus callosum with bilateral medial frontal extensions. Medial frontal lobe structures have been implicated in the pathophysiology of catatonia.

Asperger disorder in adults.

Asperger disorder was first described in 1944 by the Austrian pediatrician, Hans Asperger. It was introduced as a separate diagnostic category from autistic disorder in DSM-IV and ICD-10. The pattern of comorbidity in Asperger disorder is different from autistic disorder, with a higher level of psychosis, violent behavior, anxiety, and mood disorders. We present three cases of Asperger disorder diagnosed for the first time in adulthood, with psychosis being the predominant reason for the referral. In each case, the psychosis improved with antipsychotic treatment, although core autistic symptoms remained the same.

Clozapine Effective in Olanzapine-Induced Pisa Syndrome

Objective: To report a case of olanzapine-induced Pisa syndrome that improved after treatment with clozapine. Case Summary: A 22-year-old male with paranoid schizophrenia presented with insidious onset tonic truncal flexion with axial rotation and difficulty in walking after exposure to olanzapine in doses up to 15 mg/day for 9 months. An objective causality assessment suggested that Pisa syndrome was probably related to olanzapine. There was improvement in his symptoms after 6 weeks of treatment with clozapine in doses gradually titrated to 350 mg/day. Discussion: Pisa syndrome is a type of dystonia that has been associated with both typical and atypical antipsychotics. Both acute and insidious onset cases have been described in the literature, which have different course and treatment response. Clozapine was found to be effective in reducing the severity of olanzapine-induced Pisa syndrome. Conclusion: Clozapine may be a useful treatment option for Pisa syndrome that has been caused by olanzapine.

Prevalence of conduct disorder in schoolchildren of Kanke

Background: Prevalence estimates of conduct disorder, one of the most frequently diagnosed psychiatric conditions in children, vary widely from 0.2% to 8.7%. Aim: To find out the prevalence of conduct disorder and its DSM-IV subtypes and comorbid attention deficit hyperactivity disorder (ADHD) in 4 schools of Kanke block among students of classes V to X. Methods: A total of 240 students, selected by stratified random sampling, were subjected to the Schedule for Affective Disorders and Schizophrenia for School Age Children: Present and Lifetime Version (K-SADS-PL) screening interview. Nineteen students who qualified were subjected to conduct disorder and ADHD supplement of K-SADS-PL with additional information from parents. Results: Conduct disorder was found in 4.58%; the ratio of boys to girls being 4.5:1. Childhood onset was found in 73% and adolescent onset in 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in none. Comorbid ADHD was found in 36%, hyperactive-impulsive being predominant. Significant difference was found in temperament between students with and without conduct disorder with difficult temperament predominating in the former and easy in the latter (p=0.004). Lying, bullying and cruelty to animals were most frequent symptoms. Conclusion: The prevalence of conduct disorder was 4.58%, more common in boys, the majority had childhood onset, and one-third had comorbid ADHD.

Atypicality in presentation of neuroleptic malignant syndrome caused by olanzapine

Neuroleptic malignant syndrome (NMS) is the most serious of acute neurological side effects produced by antipsychotic medication, characterized by hyperthermia, rigidity, altered consciousness and autonomic dysfunction, the prevalence of which varies from 0.4-1.4%. NMS is usually seen in treatment with high potency typical antipsychotics and very rarely with atypical antipsychotics. However, NMS cases have been reported with risperidone, clozapine, olanzapine and quetiapine. The presentations of NMS have often varied and we report another atypicality in presentation of NMS due to olanzapine use.

Nonfatal suicidal olanzapine overdose: a case report.

There is an increase in the usage of olanzapine because of its relatively benign adverse effect profile. We report a case of suicidal overdose who survived after ingestion of 1600 mg of olanzapine requiring minimal intervention. Fluctuation in mental status suggestive of toxic delirium was noted during recovery from overdose. There was minimal alteration in the clinical and biochemical parameters. Olanzapine is safe in monointoxication as evident from this case study.

Antipsychotic-induced paroxysmal perceptual alteration.

Paroxysmal perceptual alteration is the brief and recurrent episodes of perceptual alterations that have been reported to occur occasionally with the use of antipsychotics. We report a case of paroxysmal perceptual alteration that occurred with exposure to typical antipsychotics wherein the frequency and duration of occurrence decreased after the substitution of antipsychotic with olanzapine. It seems that patterns on the surfaces are perceived vividly, which is specific of paroxysmal perceptual alteration.

Amisulpride Augmentation in Acute Catatonia

Benzodiazepines are the first-line treatment of catatonia, but a substantial number of patients do not respond to them. Amisulpride is one of the atypical antipsychotic that has been effective for negative symptoms of schizophrenia. We examined the effect of augmentation of oral low doses of amisulpride with lorazepam on resolution of catatonic symptoms. Fifteen patients with catatonia were treated with a combination of oral lorazepam (2–4 mg) with amisulpride (100 mg). Catatonic symptoms were rated using the Bush Francis Catatonia Rating Scale at the baseline and daily thereafter. There was complete resolution of catatonic symptoms on the third day in all patients. There was significant reduction of the total Bush Francis Catatonia Rating Scale score over time (F = 181.38, P < 0.001) with a strong effect size (partial &eegr;2 = 0.96). Augmentation of lorazepam with low-dose amisulpride can be a reliable strategy for management of catatonia.