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CASE: Paranoid and scared
Police bring Mr. C, age 42, to a local crisis center after he is found masturbating in public the same day he was released from jail after serving time for the same behavior. Previously, Mr. C was diagnosed with schizophrenia, paranoid type, and alcohol dependence. He is single, unemployed, and lives with his parents. He has had 3 previous admissions to a psychiatric hospital, but no preexisting medical illness. A judge involuntarily commits Mr. C to our psychiatric facility.
Mr. C looks older than his age and has poor hygiene. He appears bizarre, makes poor eye contact, and speaks slowly but with normal volume. His speech is not coherent, relevant, or goal-directed. He is not able to answer questions properly, chanting “it’s eternity, eternity, eternity.” He shows no tremors, repetitive motor behavior, or muscle rigidity. His affect is flat and he has no suicidal or homicidal ideations. Based on Mr. C’s history, we diagnose him with schizophrenia, paranoid type and alcohol dependence.
Over the next 9 days, Mr. C receives trials of haloperidol, lorazepam, diphenhydramine, ziprasidone, olanzapine, hydroxyzine, trazodone, and benztropine to treat his schizophrenia. From days 1 to 3, all medications are given on an as-needed basis. On day 1, Mr. C receives haloperidol, 20 mg, lorazepam, 9 mg, diphenhydramine, 150 mg, and ziprasidone, 20 mg. On day 2, he receives haloperidol, 15 mg, lorazepam, 10 mg, olanzapine, 20 mg, hydroxyzine, 100 mg, and trazodone, 50 mg. On day 3, he receives haloperidol, 20 mg, lorazepam, 6 mg, and trazodone, 100 mg. On days 4 to 8, in addition to scheduled haloperidol, 30 mg/d, benztropine, 1 mg/d, and trazodone, 100 mg/d, he receives haloperidol, 5 mg, and lorazepam, 2 mg, as needed. On day 9, he receives the scheduled haloperidol, 30 mg/d, benztropine, 1 mg/d, and trazodone, 100 mg/d.
During his stay, Mr. C is incoherent and disorganized. On day 9, he eats all of his lunch, none of his dinner, but sips milk and juice and eats snacks. He drinks 2 small cups of water with medication and 2 small cups of water during oral care. His mucosa and tongue are dry. At 11:30 pm, while lying in bed mumbling “scared, scared,” he experiences shortness of breath. His temperature is 99.6°F, blood pressure is 151/93 mm Hg, pulse is 125 beats per minute, respiratory rate is 40 breaths per minute, and oxygen saturation is 91% on ambient air. Twenty minutes later, his blood pressure increases to 180/120 mm Hg. On physical examination, he has “lead pipe” rigidity of both arms. He is awake, confused, and not able to communicate, still mumbling “scared, scared.” Changes in his blood pressure, pulse, and temperature during his stay in the psychiatric hospital are depicted in Figures 1 and 2, respectively.
Figure 1: Mr. C’s blood pressure and pulse changes from day 4 to day 9 in the psychiatric hospital
BP: blood pressure
Figure 2: Mr. C’s temperature changes from day 4 to day 9 in the psychiatric hospital
The authors’ observations
NMS is a life-threatening, iatrogenic neurologic emergency associated with antipsychotic use. Early incidence rate estimates ran as high as 3% of patients treated with antipsychotics; however, more recent data suggest an incidence of 0.01% to 0.02%.1 This decrease in frequency likely reflects increased awareness of the disorder, more conservative prescribing patterns, and a shift to using atypical antipsychotics.2 In the mid 1980s and early 1990s the mortality rate was 25% to 30% if NMS was not promptly recognized and treated3; however, progression to more fulminant, lethal NMS episodes now occurs less often and the mortality rate ranges from 10% to 20%.4
If NMS is suspected, immediate transfer to an emergency department (ED) is necessary. Even with early diagnosis, however, complications of NMS are still likely, including:
- rhabdomyolysis
- renal failure
- seizures
- respiratory failure
- aspiration pneumonia
- disseminated intravascular coagulation
- venous thromboembolism.5-9
Caroff et al reported observing a residual catatonic state after acute NMS symptoms subsided.10
Although the pathophysiology of NMS is complex—involving a cascade of dysregulation in multiple neurochemical and neuroendocrine systems—dopamine blockade likely plays a pivotal role in triggering the condition.2 In addition, evidence supports the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most NMS features.11
TREATMENT: Arrival in the ED
Based on his elevated blood pressure (151/93 mm Hg), “lead pipe” rigidity, and increased body temperature associated with Mr. C’s history of haloperidol use for 9 days, the treatment team suspects NMS. Labile blood pressure, which changed from 151/93 to 180/120 mm Hg in 20 minutes, reinforces the NMS diagnosis. Approximately 30 minutes after Mr. C shows signs of NMS, he is transferred to a local ED. He is awake, alert, and communicative after he arrives in the ED, but becomes confused and noncommunicative the next morning. When he arrives in the ED, he is found to have tachycardia (114 beats per minute), tachypnea (26 breaths per minute), blood pressure of 132/84 mm Hg, and temperature of 102°F. In the ED, he is given IV normal saline, diphenhydramine, 25 mg, and IV lorazepam, 1 mg. His rigidity slightly improves.