[Neuroleptic malignant syndrome]. / Das maligne neuroleptische Syndrom.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is a rare but severe undesired complication of psychopharmacological treatment. The mortality has shown a significant decrease since its first description. Knowledge of NMS is important for every clinician because of the need for rapid diagnosis and treatment. OBJECTIVE: This article presents a review and critical appraisal of the current study situation for NMS. Recommendations for diagnostics, differential diagnostics and treatment are presented particularly from a clinical perspective. MATERIAL AND METHODS: A literature review with the keywords "neuroleptic malignant syndrome", "Malignes neuroleptisches Syndrom" and various psychotropic drugs was performed in PubMed. The database of the Working Group for Pharmaceutical Treatment of Psychiatric Diseases (Arbeitsgemeinschaft für Arzneimitteltherapie bei psychiatrischen Erkrankungen, AGATE) was analyzed with respect to registered cases of the undesired side effect NMS. RESULTS: In contrast to the first description, which also led to the name, there are now case reports of clinical conditions similar to NMS, which were obviously triggered by several groups of psychotropic drugs not just antipsychotic agents (German: Neuroleptika). Treatment recommendations exist whereby the effectiveness cannot always be scientifically substantiated; however, it is still undisputed that a rapid initiation of treatment is of great importance. DISCUSSION: The psychiatrist must be familiar with the symptoms of NMS, its differential diagnosis and the therapeutic options for a rapid and effective treatment. Further studies are urgently needed for scientific substantiation of the pathophysiology of NMS and to develop evidence-based guidelines for treatment.

A Validation Study of the International Consensus Diagnostic Criteria for Neuroleptic Malignant Syndrome.

BACKGROUND: Neuroleptic malignant syndrome requires prompt recognition for effective management, but there are no established diagnostic criteria. This is the first validation study of recently published international expert consensus (IEC) diagnostic criteria, which include priority points assigned on the basis of the importance of each criterion for making a diagnosis of neuroleptic malignant syndrome. METHODS: Data were extracted from 221 archived telephone contact reports of clinician-initiated calls to a national telephone consultation service from 1997 to 2009; each case was given a total priority point score on the basis of the IEC criteria. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR) research criteria, in original form and modified to accept less than "severe" rigidity, served as the primary diagnostic reference standard. Consultants' diagnostic impressions were used as a secondary reference standard. Receiver operating characteristic curve analysis was used to optimize the priority point cutoff score with respect to the reference standards. RESULTS: Area under the receiver operating characteristic curve ranged from 0.715 (95% confidence interval, 0.645-0.785; P = 1.62 × 10) for consultant diagnoses to 0.857 (95% confidence interval, 0.808-0.907; P < 5 × 10) for modified DSM-IV-TR criteria. The latter was associated with 69.6% sensitivity and 90.7% specificity. CONCLUSIONS: Agreement was best between IEC criteria with a cutoff score of 74 and modified DSM-IV-TR criteria (sensitivity, 69.6%; specificity, 90.7%); this cutoff score demonstrated the highest agreement in all comparisons. Consultant diagnoses showed much better agreement with modified, compared with original, DSM-IV-TR criteria, suggesting that the DSM-IV-TR criterion of "severe" rigidity may be more restrictive than what most knowledgeable clinicians use in practice.

Catatonia and neuroleptic malignant syndrome: two disorders on a same spectrum? Four case reports.

We present the history of four bipolar patients who developed neuroleptic malignant syndrome (NMS) after antipsychotic treatment, focusing on the relationship between NMS and catatonia. In all cases, the administration of antipsychotics has been suspended as soon as fever and autonomic disturbances occurred. A supportive therapy was initiated to stabilize general conditions, then every patient started electroconvulsive therapy (ECT) in combination with benzodiazepines (BDZ). The risk of complications was reduced by the quick adoption of supportive care, whereas the combination of ECT and BDZ was effective in resolving the clinical picture. These cases may provide further support to the hypothesis that catatonia and NMS are disorders pertaining to the same spectrum of illness because the onset or exacerbation of catatonic symptoms coincided with the administration of antipsychotics. Our experience confirms the efficacy and safety of ECT in combination with BDZ as treatment of NMS and residual catatonia.

Diagnosing subtypes of neuroleptic malignant syndrome: an introduction to the Lee-Carroll Scale.

BACKGROUND: Neuroleptic malignant syndrome (NMS) shares common features with catatonia and serotonin syndrome (SS). For instance, catatonia is a risk factor for the development of NMS. METHODS: We performed a pilot study to examine if the Lee-Carroll Scale is able to differentiate the proposed NMS subtypes and explore possible relationship between NMS and SS. A consecutive series of cases reported to the Neuroleptic Malignant Syndrome Information Service (NMSIS) were reviewed with 29 cases of "definite NMS." The Hynes-Vickar Scale (an NMS scale), Hegerl Scale (a SS scale), and Lee-Carroll Scale (an NMS subtype scale) were applied to these case report forms. CONCLUSIONS: Although the groups were too small for statistical analysis, the 2 catatonic NMS subtypes appear to have higher NMS scores on the Hynes-Vickar Scale, and lower SS scores on the Hegerl Scale than the non-catatonic NMS subtype. The scores on the Lee-Carroll Scale were highest for non-catatonic NMS subtype. This pilot study suggests that the Lee-Carroll scale may help differentiate the subtypes of NMS, and provides some support that non-catatonic NMS may be a form of SS. NMS subtypes may be important in the early detection and treatment of NMS.

Clozapine withdrawal catatonia and neuroleptic malignant syndrome: a case report.

Catatonia as a clozapine withdrawal syndrome has not been documented. We report a case of excited catatonia with fever, autonomic instability, and delirium--a picture of malignant catatonia (lethal catatonia) after abrupt clozapine withdrawal. The use of conventional neuroleptics transformed the excited malignant catatonia into a stuporous state resembling neuroleptic malignant syndrome (NMS). Such a transformation of excited lethal catatonia into NMS has been described in the literature, providing support for the hypothesis that NMS is a variant of catatonia. Opinions, however, have been conflicting whether lethal catatonia and NMS are indistinguishable. We argue that NMS may be regarded as a neuroleptic-induced retarded (stuporous) subtype of malignant catatonia, clinically indistinguishable from nonneuroleptic retarded malignant catatonia but different from the excited form. To differentiate between the two subtypes of malignant catatonia would help resolve the controversy. The nosological status of excited catatonia, a poorly studied condition, remains unclear. The two subtypes of catatonia may differ in pathophysiology and responses to treatment. Clinicians should be alert to catatonia as a possible clozapine withdrawal phenomenon, and excited catatonia deserves more research attention.

Classification system of complications in neuroleptic malignant syndrome.

Our group treated 13 cases of neuroleptic malignant syndrome (NMS) over a period of 8 years. Based on the clinical severity of complications, the cases were classified into three types: mild, with no complications; moderate, with only respiratory disturbance; and severe, with respiratory disturbance and renal failure. The major complications affecting the prognosis of NMS are respiratory disturbance and renal failure. Renal failure is also associated with the occurrence of disseminated intravascular coagulation and rhabdomyolysis. The proposed classification system for NMS patients is useful in selecting the appropriate therapeutic strategy for this disorder. The clinical data were analyzed to determine the factors in the process of deterioration in NMS.

Síndrome neuroléptico maligno. Algunas propuestas para un nuevo concepto y clasificación / Neuroleptic malignant syndrome. Some proposals for a new concept and classification

Planteamos el posible reconocimiento del síndrome neuroléptico maligno mediante un nuevo concepto de síndrome extrapiramidal maligno, que se ajustaría más a la sintomatología y a la respuesta fisiológica de la vía extrapiramidal. Se da importancia al valor diagnóstico de cada síntoma, que no se tiene en cuenta en el diagnóstico de los desórdenes mentales IV, y se hace una revisión del tema con la presentación de un nuevo caso (AU)

Rationales, values, and DSM-IV: the case of "medication-induced movement disorders".

The DSM-IV has improved psychiatric diagnostic classification through initiating, among other things, the open disclosure of rationales for nosologic changes. It will be argued that a consideration of values is necessary in justifying nosologic changes, considerations missing from the DSM-IV rationales. In illustration of this, I examine the reasons for including the medication-induced movement disorders (MIMDs) on axis I by using a literature review, then compare the published rationales for including the MIMDs with the DSM-IV Task Force's own guidelines for including categories. Discrepancies are found between the Task Force's guidelines for including categories and the published rationales for including MIMDs. Strict adherence to the Task Force guidelines more strongly supports placing MIMDs in axis III. Discussion emphasizes the importance of value commitments in nosology development.

A comparison of diagnostic criteria for neuroleptic malignant syndrome.

BACKGROUND: A variety of diagnostic criteria for neuroleptic malignant syndrome (NMS) have been used in clinical studies of this disorder, but it is not known if different criteria consistently identify NMS. This study examines agreement between three frequently used sets of diagnostic criteria in a series of possible NMS episodes. METHOD: All clinically suspected NMS episodes occurring at a large tertiary psychiatric facility during a 6-year period were evaluated by three different sets of diagnostic criteria. Agreement among these criteria was quantified statistically by means of the kappa and intraclass correlation coefficients. RESULTS: The NMS diagnostic criteria examined generally demonstrated only fair agreement with one another in the diagnosis of NMS. Agreement was best among these criteria when the "probable" category was employed. A complex interaction involving both definition and structure of individual diagnostic criteria and designation of criteria as major or minor appears to contribute to these findings. CONCLUSION: The published diagnostic criteria used in this study do not consistently identify NMS episodes and demonstrate different thresholds for assigning this diagnosis. These differences are not due solely to different definitions of individual criteria (e.g., fever). Possible implications of these findings for clinical practice and research are discussed.

Neuroleptic toxicity syndromes: a clinical spectrum.

The neuroleptic malignant syndrome (NMS) has undergone a number of changes since it was first described in the 1960s. This paper presents a review of these changes from the traditional approach of rigid categorization through the more flexible operational definitions to a spectrum of neuroleptic toxicity. This spectrum spans neuroleptic-induced extrapyramidal side effects, possible stages of neuroleptic toxicity, and the full blown neuroleptic malignant syndrome. Different theoretical concepts of the syndrome have contributed to diagnostic confusion among clinicians and thus to difficulties in management. The concept of a spectrum of neuroleptic toxicity provides a coherent theoretical base for understanding NMS and thus allows for more rapid identification of the potential threat of NMS. Three cases are presented and discussed to highlight the utility of the concept of a clinical spectrum.