Somebody talk to me about Tardive Dyskinesia and EPS

[gamecaco4]

Before I get into it, "C" is a 10 year old aspergers patient. Dx with anxiety disorder, sensory disorder, depression, OCD (phobias). I am going to call his med management team in the AM to see if they want him in before his scheduled April 2 appt.

 

C is on geodon, tenex, zoloft, and concerta. No new changes to his med regime aside from the addition of 3mg melatonin 2 weeks ago. Over the last 4 days, he can't sleep, has little focus, has been on/off super irritable, and has developed noticable tics aside from his usual stimming. His new symptoms include mouth/jaw movements, added hand/arm movements, ankle/lower leg movements, and full body "twitches" (like he got startled) several times a day. The first two days, he was incredibly irritable and barking demands and orders to his 7 year old sibling. Yesterday and today, he has been better, but defensive still. He hasn't slept more than 5 hours a night since last Thursday night. His phobias are of spiders and bees. Over the last week, with temps starting to warm up, he is more and more stressed by the impending arrival of those two things. Over the last two evenings, he's "seen" dots on the walls that he thought briefly (seconds) were spiders crawling all over his bedroom.

 

What say you? Added symptoms due to fatigue/lack of sleep or something more?

 

 

[jdenning]

Does any 10 year old kid, Asberger's or not, really need to be on 4 psychotropic meds???

[whoRyou]

Does ANY 10 year old kid, Asberger's or not, really need to be on 4 psychotropic meds???

Or for that matter an adult???

[jdenning]

Or for that matter an adult??? AGREE

 

Tardive dyskinesia, if that's what is going on with this kid, is almost always a medication effect and can be irreversible in some cases. Geodon is the most likely culprit but SSRIs can also cause. I would start with lowering the Geodon and SSRI and having a conversation with the psych prescriber

[whoRyou]

Are there effective treatments for TD?

There has never been a definitive, validated and widely accepted treatment for TD. Dozens of drugs have been tested over the past 30 years with mixed results at best. The atypical antipsychotic clozapine has been reported to reverse persistent TD after 6-12 months, possibly through gradual "down-regulation" of supersensitive dopamine D₂ receptors. Some preliminary reports suggest that other atypical antipsychotics may also help reverse TD.

 

However, given that a large majority of persons who need antipsychotic treatment are now receiving the new atypicals and given the drastically lower incidence of TD with atypical antipsychotics, the issue of developing a treatment for TD may have become a moot one. Preventing the occurrence of TD is much more preferable to treating TD.

 

Source: NAMI

[whoRyou]

What are the symptoms of TD and is TD reversible?

... the main symptoms of TD are continuous and random muscular movements in the tongue, mouth and face, but sometimes the limbs and trunks are affected as well. Rarely, the respiration muscles may be affected resulting in grunts and even breathing difficulties. Sometimes, the legs can be so severely affected that walking becomes difficult.

It must be noted that there are many other conditions that resemble TD and must be ruled out before a diagnosis of TD is made. For example, several neurodegenerative brain diseases may cause movement disorders. Very old persons may also develop mouth and facial movements with age that may be mistaken for TD. Blepharospasm is another condition that may be mistaken for TD. It should be emphasized that a history of several months or years of antipsychotic intake must be documented before TD is even considered.

TD is often mild and reversible. The percentage of patients who develop severe or irreversible TD is quite low as a proportion of those receiving long-term antipsychotic therapy.

 

Source: NAMI

 

Or for that matter an adult??? AGREE

Tardive dyskinesia, if that's what is going on with this kid, is almost always a medication effect and can be irreversible in some cases. Geodon is the most likely culprit but SSRIs can also cause. I would start with lowering the Geodon and SSRI and having a conversation with the psych prescriber

[myironlung]

what the hell is wrong with people prescribing so many meds...and for kids? How would you expect this kid to ever develop coping skills? I work in a prison so I'll probably see him in 8 years for addiction issues. I see this all day.

[jdenning]

I hope for this kid's sake that there is a psychologist involved somewhere. There are a lot of behavioral strategies that can be used for the types of problems he has.

 

Meds are NOT always the answer. For all the good they can do, they can also do harm

[ventana]

if this is a Med related case of TD you only have one choice

 

IMMEDIATE removal of the offending agent (s)

 

Anything less is malpractice and with all the lawyers around advertising for this exact issue..... well i would not want to be the one writting any atypicals (or some of the anti nausea meds too!)

 

You MUST talk to psych provider ASAP and document document document these conversations and your concerns.  If you are his psych provider - involve your SP now and do a full case review with him   -   Seriously this is no joke.  One of my SPs that I used to work with had this develop with a psych patient who had been getting Reglan (I think, or maybe it was compazine) and legal action was present

[cinntsp]

Did you check reflexes for possible serotonin syndrome?  

[winterallsummer]

^^^ Or even NMS.  Also concerta can worsen tics.  Also akinthesia (sp) is another consideration.  Geez this poor kid is on a tough regimen for a 10 year old.  Interested to hear an update to this case.  In reply to the OP, TD generally develops over years of antipsychotic use (more likely with first generation antipsychotics, possible with either).  Key word: years of use - there are exceptions but I'm not sure how common they are.  EPS can develop at any time with any antipsychotic (again more likely with 1st generation) and may respond well to cogentin or benadryl.  Clozapine, mentioned earlier, can treat TD but is in no way a realistic consideration in this case.

 

IMO the tx strategy here would be

 

1. rule on NMS and serotonin syndrome

2. tx with benadryl

3. first lower geodon and concerta and see how he responds (concerta - assuming it is worsening/bringing out tics), taper him off meds as appropriate and try to minimize polypharm in such a young pt.  

 

I'm not sure how quickly these meds were added.  I know antipsych's are being used to treat autism but if he is asberger's, not autism (albeit they got rid of the prior dx in dsm 5), does he really need this, or would it be possible to treat with behavior therapy and structured environment alone?  Tenex and Geodon also both could be for tics, again hard to say what drug is responsible for what here but I agree geodon is a likely culprit.  What is his dose?  Of his meds the other two are the most benign but as mentioned concerta can bring out or worsen tics which is a comorbidity with I believe both OCD and autism spectrim disorders. Please update us when you get more info on this.

[gamecaco4]

Thanks for the replies. No, I'm not his provider. I'm a student. And his parent. I've questioned why he continues to have meds added/changed instead of figuring out one or a treatment that works best. Hence the reason for our move 120 miles to a new city away from family and friends 5 months ago. We needed to get continuity of care for him and stop doing the Grand Rapids, Indiana border, Ann Arbor drives. Since late December, his dosage of zoloft and tenex has been decreased. Nothing has been added or increased. I hate that he's on so much and so do his new docs, so instead of messing with it, they wanted him to go to med management at a psych hospital to work it out. We're talking total med holiday now and starting from scratch.

 

I know I'll get flamed here, but his previous psych recommended that we teach him to get his own meds. We monitored closely for the first several weeks and after, we would stay near, but not hold the bottles, dispense to him, watch him swallow, etc. He is very aware of what can happen if he takes even one more than he should so taking them correctly is one of his obsessions. And he's proud of that. Anyway, he didn't realize we refilled his geodon and we didn't realize he wasn't getting that one out for a few days. Basically, he went cold turkey on 40mg of geodon. Back on it Tuesday evening, he slept 12 hours and tics were diminishing by Wednesday morning.

 

If anyone has any ideas as to other ways to help/parent/treat him, please do. Give me non-med ways to treat his phobias of bees and spiders, fear of public places, OCD, stimming, anxiety, depression (with no zoloft), SPD, and aggressive behavior (with no geodon). Let me know what we can do for him when he only sleeps 2-4 hours of sleep a night without any meds. He's in weekly OT, PT, behavioral therapy, and counseling, and monthly psych visits. I'm honestly open to any ideas. Oh, and we're also waiting for test results from a sleep study to confirm frontal lobe seizure activity.