Brain Research Bullerin, Vol. 11, pp. 171-174, 1983. 0 Ankho International Inc. Printed in the U.S.A

Tardive Dyskinesia and Treatment of Psychosis After Withdrawal

of Neuroleptics

SARAH J. BASKE’IT

Department of Psychiatry, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX 79430

BASKE’IT, S. J. Tardive dyskinesia and treatment of psychosis after withdrawal of neuroleptics. BRAIN RES BULL ll(2) 173-174, 1983.-A case of neuroleptic induced tardive dyskinesia is presented. The symptoms of tardive dyskinesia cleared when neuroleptics were withdrawn. The psychotic symptoms were then successfully treated by behavior modifica- tion .

Behavior modification Neuroleptics Psychosis Tardive dyskinesia

THE MOST important complication of long-term neurolep- tic use is the development of tardive dyskinesia. Although many drugs have been tested in the treatment of tardive dyskinesia, the only generally accepted treatment that has been reported has been the withdrawal of the neuroleptics [5]. The literature suggests that dyskinesia is reversible in somewhat more than one-third of the cases [41.

As the prevalence of dyskinesia among neuroleptic- treated patients continues to rise, psychiatrists are left with complicated treatment dilemmas. In order to reverse the symptoms, or at least stop the progression of the symptoms, the patient needs to be removed from neuroleptics. How then is the psychiatrist to treat the psychotic symptoms which led to the use of the neuroleptic in the first place?

Described here is one case in which the psychotic symp- toms were successfully treated by behavior modification after the withdrawal of neuroleptics.

CASE REPORT

Mr. B, a 56 year old male, presented with a three month history of early signs of tardive dyskinesia (abnormal in- voluntary movements of the mouth). He has a 20 year his- tory of severe depression with delusional features and audi- tory hallucinations. Twenty years ago he received 42 insulin coma treatments, followed by a ten year remission of his symptoms. Six years ago he was diagnosed as a paranoid schizophrenic and received electric convulsive treatments. He was also started on tricyclic anti-depressant and anti- psychotic drugs. Since that time he has taken various brands of these drugs in combination continuously. He has also taken an antiparkinsonian agent for one year. At the time he presented, he was taking trifluoperazine 40 mg per day, amitriptyline 150 mg per day, and trihexyphenidyl 2 mg per day. Each time the dosage of trifluoperazine was reduced,

the patient would begin experiencing auditory hallucination, telling him to kill himself. The auditory hallucinations caused him a great deal of anxiety and he was afraid to be alone for fear that he would carry out the instruction “to kill himself.”

After the oral dyskinesia was noted, the trihexyphenidyl was discontinued and the trifhtoperazine slowly withdrawn. The patient was very anxious about discontinuing the neuroleptic because of the auditory hallucination. He was referred to a psychologist for behavior modification in an attempt to control his hallucinations. He was placed on a program of self-monitored extinction. The patient was in- structed to record each time he experienced an hallucination. He was then asked to bring the record with him each time he came to the clinic. The frequency of hallucinations quickly dropped from three to four times a day to zero. He has remained completely free of hallucinations for six months on this program. His depression continues to be controlled on a regimen of amitriptyline and he no longer displays any symp- toms of the oral dyskinesia.

DISCUSSION

Over the past two decades many investigators have re- ported success in controlling hallucinations and other psychotic behavior by using various behavior modification techniques [l-3, 6-g]. Rutner and Bugle [7] describe the technique of a self-monitoring program in which a patient with auditory hallucinations was instructed to record the fre- quency of her hallucinations. The frequency dropped from 180 hallucinations the first day to 11 on the third day and zero on the 16th day. The patient had remained free of hal- lucinations for six months at the time the article was pub- lished. They feel that techniques which emphasize self- control would be the best and that one of the simplest appli- cations of learning self-control is self-monitoring. Other in- vestigators have used such behavior modification techniques

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as gargling at the time of hallucination [2], isolation (31, sys- patients with psychotic symptoms will respond to behavror- tematic desensitization [8], patient administered shock 111 modification, it may be a valuable treatment in some patients and verbal conditioning [6] to bring hallucinatory behavior and may resolve the treatment dilemma caused by the with- under control. Although it is not being suggested that all drawal of neuroleptics.

REFERENCES

1. Bucher, B. and J. Fabricatore. Use of patient-administered shock to suppress hallucinations. Behar Ther 1: 382-385, 1970.

2. Erickson, G. D. and G. J. Gustafson. Controlling auditory hal- lucinations. Hosp Community Psychialry 19: 327-329, 1968.

3. Haynes, S. N. and P. Geddy. Suppression of psychotic halluci- nations through time-out. Behav Ther 4: 123-127, 1973.

4. Jeste, D. V. and R. J. Wyatt. In search of treatment for tardive dyskinesia: Review of the literature. Schiz Bull 5: 251-293,1979.

Jeste, D. V. and R. J. Wyatt. Changing epidemiology of tardive dyskinesia: An overview. Am .I Psychiatry 138: 297-309, 1981. Nydegger, R. V. The elimination of hallucinatory and delusional behavior by verbal conditioning and assertive training: A case studv. J Behav Thrr Clin P.cvclticrtrv 3: 225-227. 1972. Rutner. I. T. and C. Bugle. ‘An experimental procedure for the modification of psychotic behavior. J Consul C/irl Ps.vc&~/ 33: 651-653, 1969. Slade, P. D. The effects of systematic desensitization on auditory hallucinations. Bchav Re.7 7%rr 10: 85-91, 1972.