Abstract
This is a most timely book on the extrapyramidal side-effects (EPSE) of antipsychotic drugs, as we are in the transition between the newer atypical agents and the traditional agents which are still heavily relied on in Australia, particularly depot neuroleptics. In the past, extrapyramidal symptoms were accepted as part of the consequence of the effective treatment of positive symptoms, and the author dedicates a chapter to the golden age of neuroleptics and particularly the chlorpromazine story.
However, this viewpoint is well counter-balanced by the caution that EPSE are rapidly becoming a quality of care issue, that must be addressed within the context of management that is truly comprehensive. All those dealing with patients receiving antipsychotics and other implicated drugs must possess a constant vigilance and, as far as doctors are concerned, competent assessment skills.
Although the author gives a very good outline of the pathophysiology of dystonias, it is unfortunate that the treatment strategy which is recommended is that of procyclidine, since this drug has recently been withdrawn in the Australian market. Despite this, the description of the subjective experiences of acute dystonia and the well-enunciated clinical features of the prodromal phase of occulogyric crisis, the most acutely distressing set of symptoms, still makes this chapter worthwhile in terms of clinically relevant information.
The author is able to distinguish the differences between different drug-induced dystonias. This chapter delineates the differences in chronology between drug-induced parkinsonisms and Parkinson's disease with a very clear neurophysiological explanation of the interrelationship of the basal ganglia. The validity of the various models and the limitations of our knowledge are clearly exposed as each class of antipsychotics is appraised.
Akathisia has always been one of the more difficult areas to define, but the author explains the pathophysiology in a comprehensive manner and the effectiveness of beta-blockers on this symptom is explained. However, once again, the drug interventions in relation to combined akathisia and parkinsonia symptoms mainly focus on procyclidine. Nevertheless, I would still suggest that the outline of management of akathisia is highly clinically relevant. By combining his own clinical experiences, the author reduces the confusion considerably in his review of this subject. The author also goes on to expand the reader's knowledge of akathisia in neurological disorders. To quote page 146, ‘it is, perhaps, ironical that it should, in this one small area at least, be psychiatrists urging neurologists towards a more organic view point’, particularly the non-pathological Ekbom's syndrome (restless legs syndrome).
The chapter on tardive dyskinesia emphasises the importance of considering tardive dyskinesia beyond the bucco-linguo-masticatory triad, but goes on to an overinclusive discussion on various dyskinesias and other conditions associated with involuntary movements. However, the author presents quite well the literature analysing the different rates of tardive dyskinesia in treated and neuroleptic-naïve patients, and concludes with an up-to-date algorithm for the treatment of tardive dyskinesia. Although providing quite a comprehensive presentation on the pharmacological treatments of tardive dyskinesia, he unequivocally emphasises that the doses of antipsychotic during treatment must be kept to a minimum and that there is a huge need for every effort to be made to maintain compliance, especially in those patients who have a relapsing pattern of illness. The author dedicates a specific chapter to the limitations of the concept ‘tardive dyskinesia’ and the historical accounts of involuntary movements in the preneuroleptic era. This is a worthwhile reference for people undertaking research in this area.
The other pleasing aspect of this book is specific attention to ‘special populations’, particularly the evidence of EPSE in children and adolescents as well as some of the other areas where antipsychotics are used such as in the management of dementia, acquired immune deficiency syndromes and those patients with learning disability.
After taking the reader through a fairly systematic, standardised examination for EPSE, which would be well followed by any student or clinician being asked to demonstrate a psychiatrically appropriate neurological examination, the author introduces us to the common standardised recording instruments and outlines the evolution of the scales, their differences, the shortcomings of the rating scales, and the anthropological perspectives from both neurology and psychiatry, while maintaining the focus on the clinical relevance of multi-item scales versus global impression scales.
The author takes on the challenge of new drugs for old by agreeing that ‘a stout blow to the back of the head with a blunt object would flatten most people less than haloperidol. So, to those whose experience has for long been dominated by this compound and its ilk, anything must seem better!’ (p.313). He expresses scepticism about the overly optimistic statements by some commentators regarding the elimination of EPSE by the newer drugs. While acknowledging that the newer drugs are considerably more user-friendly, he adds the caution that ‘to assume that the modest advantages thus-far demonstrated represent a basis for liberating patients from risk, or for absolving clinicians of their responsibility of comprehensive patient care, is to fly in the face of good practice principles and over the rainbow to fantasy’.
The author concludes with a practical suggestion in relation to medico-legal and quality-of-care issues, namely the need for recording objective data both before and after the introduction of any drug treatment, and the exploration of issues around informed consent and patient education commensurate with the patient's ability to assimilate information.
The author's writing style is unashamedly British and full of anecdotes that maintain the reader's sense of humour as they develop awareness of the complexities and the need for obsession in the assessment and management of EPSE. As the author states, ‘ignorance must not be underestimated. At a NMRCP exam, the author recalls a cocky candidate being asked by a neurologist of international repute to examine infraspinatus. “Certainly,” replied the candidate, quite unphased. “Could you tell me precisely where it is, please?” ’. At completion of the book, the reader is left considerably more equipped than this candidate, for not only does he become acquainted with the nature of EPSE, but also its underlying pathophysiology, its assessment and a pragmatic approach to its management which draws heavily on a wealth of clinical experience. Although limited by some of the algorithms in terms of the withdrawal of procyclidine in Australia, I believe that the book still offers considerable practical information of benefit not only to practitioners prescribing antipsychotics, but for any person who is involved in the care of people who are being treated with antipsychotics. I also believe that the style of the author manages to shift what is normally a very dry topic into a format which is easily comprehensible and clinically relevant.