By: SOPHIA F. DZIEGIELEWSKI
The
medication-related conditions listed in DSM-5 are not considered mental disorders. The information presented,
however, is important, as it may support the diagnostic assessment. Lacasse
(2014) warns that placing a diagnosis of a mental disorder can create a pathway
to treatment with psychiatric drugs.
Two important diagnostic
areas most often associated with these medications are in schizophrenia spectrum
disorders and use of neuroleptics and in the depressive disorders and
discontinuance syndromes related to stopping antidepressant medications. The
conditions listed here were previously covered in DSM-IV and DSM-IV-TR in a combined section, Other
Disorders That May Be a Focus of Clinical Attention. In addition, when used
with the previous multi-axial system, they were coded on Axis I.
These conditions were
reorganized and placed in their own place to emphasize the conditions’ prominence, and designating
a separate attention for them clearly highlights the importance of recognizing
medication effects and how the resulting presentation can affect and confuse
the mental health diagnosis. The medication-related conditions listed here can
lead to a temporary or permanent movement-based disorder or influence behavior because of
the adverse effects being experienced.
The APA (2013) gives two
primary reasons for including these in a separate article. The first is the helpful
information these categories can provide in management and subsequent treatment
of client problems. In these conditions, the medications are either the primary
or secondary effect and clearly influence any
subsequent diagnosis. The second reason is how helpful acknowledgment of these
medication-related conditions can be for making the diagnostic impression. Recognizing
these conditions can assist with the differential diagnosis and completing a
more comprehensive and accurate diagnostic impression.
For example, a client
suffering from an anxiety disorder may report feeling restless and fidgety. These types of
symptoms may be consistent with extreme anxiety. If the symptoms alone are
assessed without a good supporting history, the abnormal fidgety and rocking movements’ relationship to medication may
be missed.
The medication-related
condition most representative of these symptoms is neuroleptic-induced
akathisia. Therefore, recognizing the etiology of symptoms can clarify what is
medication related and what may be symptoms consistent with a mental disorder.
Several different
categories are all termed neuroleptic-induced; the conditions in this area are medication related, and the types of
medications are the neuroleptics. Because the term neuroleptic may be considered outdated
in some of the literature, the reader is cautioned that often this term is used
interchangeably with the term antipsychotics (APA, 2013).
Although explaining all the
differences between the types of antipsychotic medication is beyond the scope of
this article, it is important to distinguish between typical and atypical
types. The newer medications in this category, referred to as atypical
medications, may also have some serious side effects but fewer neuroleptic or
movement-related symptoms, which are the focus of this article. (See Quick
References 3.7 and 3.8).
Q Quick References 3.7 UICK
REFERENCE 3.7
|
Typical Antipsychotic Medications*
Chlorpromazine (Thorazine)
Thioridazine (Mellaril)
Trifluoperazine (Stelazine) |
QU Quick References 3.8 ICK REFERENCE
3.8
|
Selected Atypical Medications*
Clozapine (Clozaril) |
Medications often referred
to as traditional or neuroleptic antipsychotic medications are dopamine
inhibitors that
block other neurotransmitters, including acetylcholine, histamine, and norepinephrine.
For example, this article describes medication-induced acute dystonia and medication-induced acute akathisia; both conditions are related to
medications used to treat extrapyramidal symptoms. These problematic symptoms may develop a few
days after starting a medication or increasing or decreasing the dosage of a medication. The term extrapyramidal symptoms (EPS) describes a side effect profile that affects a client’s motor
movements and can accompany use of the neuroleptic medications.
Dystonia, which is characterized by
sudden and painful muscle stiffness, may present in clients as grimacing, difficulty with speech or
swallowing, oculogyric crisis (upward rotation of the eyeballs), muscle spasms of the neck and
throat, and extensor rigidity of the back muscles (Carpenter, Conley, &
Buchanan, 1998). Clients may also complain of a thick or stiff tongue that
impairs their ability to speak. These reactions often occur within the first few days of treatment.
Another symptom is akathisia, which is often considered
less obvious than dystonia, although it is the most common form of EPS.
Akathisia is an extreme form of motor restlessness that may be mistaken for
agitation (National Alliance on Mental Illness [NAMI], 2003). The individual
feels compelled to constantly move, and many times clients report an inner
restlessness evidenced by a shaking leg or constant pacing. During assessment,
these clients cannot sit still, and the restlessness in their legs can result in
uncontrollable foot tapping. Although akathisia
generally appears early in the course of treatment and can be related to other
EPS, it can also occur independently (Carpenter et al., 1998).
Another form of EPS which
results from long-term treatment with older antipsychotic medications, is tardive dyskinesia (TD). This condition
involves pronounced involuntary movements of any group of muscles, most
commonly the mouth and tongue (NIMH, 2009).This syndrome generally occurs with elderly
individuals, especially women. Prolonged use of these medications can also
result from movement-related symptoms characteristic of dystonia and akathisia
referred to as tardive dystonia and tardive akathisia.
A less frequent side effect
associated with the older or traditional antipsychotic medications is
neuroleptic malignant syndrome (NMS). Recognizing this syndrome can be difficult. It often includes serious medical complications and illness (pneumonia, etc.) and untreated or unrecognized symptoms related to the EPS mentioned earlier (PDR, 2013). Benzer (2007) reported that although NMS occurs in only 0.1% to 0.04% of cases, one of four cases of NMS can end in death. This condition is typically more common in males. Symptoms of NMS include severe rigidity of the muscles, high fever, confusion, pallor, sweating, and rapid heart rate. One early sign of the condition is high blood pressure. Once a client has been assessed with NMS, any further drug treatment must always be monitored closely by a medically trained professional.
neuroleptic malignant syndrome (NMS). Recognizing this syndrome can be difficult. It often includes serious medical complications and illness (pneumonia, etc.) and untreated or unrecognized symptoms related to the EPS mentioned earlier (PDR, 2013). Benzer (2007) reported that although NMS occurs in only 0.1% to 0.04% of cases, one of four cases of NMS can end in death. This condition is typically more common in males. Symptoms of NMS include severe rigidity of the muscles, high fever, confusion, pallor, sweating, and rapid heart rate. One early sign of the condition is high blood pressure. Once a client has been assessed with NMS, any further drug treatment must always be monitored closely by a medically trained professional.
The last conditions to be
coded are the other medication-induced movement disorders. In this classification, like the other groups,
the movement disorders are related to medications. These problematic medication-influenced movements, however, are
caused by medications other than the neuroleptics.
Another category in this
section is antidepressant discontinuation syndrome, the set of symptoms that
occur after an antidepressant medication has been taken for at least a month and then reduced or discontinued. In this condition, the discontinuation of
these medications can result in a multitude of symptoms that were not present before the
medication was taken initially, including a variety of somatic symptoms such as nausea and hypersensitivity
to noise and light. (See Quick Reference 3.9.)
QU Quick Reference 3.9.)ICK
REFERENCE 3.9
|
Medication-Induced Movement DisordersNeuroleptic-Induced ParkinsonismOther Medication-Induced Parkinsonism
Neuroleptic
Malignant Syndrome
Medication-Induced
Acute Dystonia
Medication-Induced
Acute Akathisia
Tardive Dystonia Tardive Akathisia Medication-Induced Postural Tremor Other Medication-Induced Movement Disorder Antidepressant Discontinuance Syndrome |
References
SOPHIA F.
DZIEGIELEWSK, 2015, DSM-5TM
in Action, by John Wiley & Sons, Inc.
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Other Conditions That May Be a Focus of Clinical Attention
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Coding Medical Conditions
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