High Potency Neuroleptics and Violence in Schizophrenics

Abstract

In a conti'olled stucly, inpatient violence was measured cluring placebo, high-potency (halopericlol) and lorv-potency (chlorpromazine or clozapine) neuroleptics. Some patients had a markecl increase in violent behavior rvith the mocleratelv high-dose haloperidol, but not u,ith lou,-potency neuroleptics. The authors cliscuss reasons for the inct'easecl vioience rvith halopericlol, inclucling al<athisia ancl clmg-induced behavioral toxicit.y. Until recently, it rvas u'iclely believecl that the nlentally ill were either less violent or no lnore violent than the general population. Recent findings, holl'ever, suggest that violence is cluite colnlnon in psychiatric hospitals (Yesavage, 1984), ancl consiclerable emphasis is now being placecl on the evaluation (Yesavzrge, 19BB), treatment (F elthous, 1984), and ltrecliction of violence (Mulvey and Liclz, 1984) ancl on the resultant legal ancl ethical issues. Although the potential clrug treatnients for violent behavior are many, neuroleptic drugs are often considered the treatment of choice when violence stems fi'om the psychotic cotrclition (Dubin, 1981; Gunn, 1979). However, there are fell'guicleliries by rvhich the clinician can choose an optitnal neut'oleptic. Accoi'cling to anecdotal reports, some clinicians prefer thioridazine (Itil and Wadacl, 1975), haloperidol (King, 1981), or elopenthixol (Yar-Khan, 1981); others prefer highpotency antipsychotics to low-potency antipsychotics because of a wicler margin of safety when usecl in high dosage (Csernatrskl, g;al., 1985). In one stucly of 33 aggressive mentaily retarcled people, an unmarketecl l:tenzazepine derivative was notecl to cause less violent behavior than treatrnent u'ith thioriclazine (trlie et al., 1980). However', we are ulta\vare of any sirnilar comparisons of controllecl stndies rvith neuroleptics in schizophrenic patients. We therefore unclertook systematic measurement of violence in patients rvho wel'e to receive both high and lorv-potencv neuroieptics in a controllecl stucly as-sessing the effectiveness of clozapine ancl chlorpromazine in schizophlenic patients who were prospectively cleterminecl to be treatrnent resistant by failure to respond to moclerately high-close haloperidol.Methods Inclusiott Includeci in the stuclv were 16 male patients rvho rnet DSM-III criteria for schizoplu'enia ancl rvere proven resistant to previous neu'oleptic tleatment efforts. The meari age of the patients u,as 33.3 year-s (range, 25 to 44 years) the mean age at the first hospitalization lvas 18.8 r,'ears (range, 72to 27 years), and the mean numbel of yeal's since the fir'st onset of p.sychosis u'a-s 15.4 (range, 7 to 24). The mean length of the current hospitalization was 83.9 u,eeks (range, 40 to 445), and the mean number of plior psychiatric hospitalizations rvas 10.5 (i'ange, 3 to 25). A retrospective chart, review revealerl that these patients did not have unusual histories of violence. T reqttrr ert,t R esistatrceTreatment resistance was cleterminecl on the basis of clocr.rnientecl failure to respond acleq...

Pitfalls in the Care of the Psychiatric Patient in the Emergency Department

“…Although there is no Emergency Medicine study to document this finding, Herrera et al found this situation on a psychiatric floor (37). They studied 16 male schizophrenic patients resistant to previous neuroleptic treatment.…”

“…It was uncertain whether this effect could be from akathisia or drug-induced behavioral toxicity. This idiosyncratic medication effect should be considered when additional doses of antipsychotics seem to make the agitation worse (37).…”

Drug Insight: from disturbed motility to disordered movement—a review of the clinical benefits and medicolegal risks of metoclopramide

“…The subjective component consists of a feeling of inner tension and restlessness that, on occasion, can be so distressing that it leads to violent behavior and suicide. 42,43 The objective component takes the form of stereotypic movements, such as shifting from one position to another, rocking, and repetitive touching (e.g. self-caressing mannerisms), 30 and in this regard can resemble restless legs syndrome, 44 but usually without the characteristic paresthesias of the latter.…”

Evidence-based treatment of psychiatric patient

“…There were 96 with transient hypotension, 40 with dystonia, three with seizures, two with respiratory arrests, and one with a cardiac arrest (level II) (72). It is interesting to note that one small study demonstrated a marked increase in violent behavior with high potency (haloperidol) vs. low potency neuroleptics (chlorpromazine) (level II) (74). Although many side effects of the anti-psychotics are problematic, problems with droperidol have resulted in FDA "black box" labeling.…”