- Email: [email protected]
A case of schizophrenia with dysphagia successfully treated by a multidimensional approach
Available online at www.sciencedirect.com
General Hospital Psychiatry 32 (2010) 559.e11 – 559.e13
Case Report
A case of schizophrenia with dysphagia successfully treated by a multidimensional approach Kuo T. Tang, M.D.⁎, Ming H. Hsieh, M.D. Department of Psychiatry, National Taiwan University Hospital, Taipei 100, Taiwan Received 5 December 2009; accepted 26 January 2010
Abstract Dysphagia in patients with psychiatric illnesses contributes to morbidities and mortalities. It is, however, an overlooked problem in clinical practice. We report a patient of schizophrenia with dysphagia who was successfully treated using a multidimensional approach, which included medication adjustment, swallowing training and diet modification. © 2010 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Amantadine; Baclofen; Dysphagia; Psychiatric
1. Introduction Dysphagia is an easily overlooked problem in the medical setting. It has been shown that the prevalence of dysphagia is higher in those with mental health disorders [1]. Hospitalized older patients receiving higher doses of antipsychotic medications are associated with worse swallowing function [2]. Furthermore, use of antipsychotics in elderly people is correlated with greater risk of pneumonia, which may be partly explained by swallowing dysfunction [3] and potentially leads to morbidities and even mortalities.
2. Case report Mr. A is a 46-year-old male who had suffered from schizophrenia for 31 years and was admitted for dysphagia for 2 months. His psychotropic regimen included flupentixol 20 mg intramuscular injection every 2 weeks and sulpride 600 mg and valproate 500 mg orally per day for approximately 4 years. Two months before the admission, he presented with difficulty in swallowing liquid food initially, and then solid. Episodes of sudden asphyxia at
⁎ Corresponding author. Tel.: +886 2 23123456x66790, +886 928998019 (Mobile). E-mail address: [email protected] (K.T. Tang). 0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2010.01.012
eating occurred. Anticholinergic such as biperiden 2 mg three times a day was prescribed for a month but achieved no improvement. Therefore, he was admitted. On admission, general examination documented severe involuntary movement such as lateral jaw movement, tongue twisting and limbs tremor and athetoid movement, especially over upper limbs [Abnormal Involuntary Movement Score (AIMS) score: 23]. As for dysphagia, fast feeding was observed in clinical assessment. Videofluoroscopy showed abnormal bolus holding, piecemeal swallowing, abnormal epiglottic movement, delayed oral transit time in paste barium meal and delayed pharyngeal transit time in all kinds of barium meals, all of which resulted in frequent silent aspirations. Brain magnetic resonance imaging only revealed early brain atrophy, hypoplastic cerebellar vermis and focal attenuated change around left anterior limb of internal capsule. The first two findings might be attributed to chronic schizophrenia [4,5], and the last finding was possibly an old lacune. However, they could not explain current dysphagia. Therefore, drug-induced Parkinsonism was suspected and amantadine was gradually titrated to 100 mg three times a day. His dysphagia improved with solid food but psychotic symptoms exacerbated (AIMS score: 20). Hence, amantadine was tapered to 100 mg twice daily, and clozapine 150 mg daily was gradually substituted for flupentixol and sulpride. His psychotic symptoms subsided. Also, baclofen 5 mg per day was administered based on reports about its efficacy in dystonia [6] and also tardive dystonia [7].
559.e12
K.T. Tang, M.H. Hsieh / General Hospital Psychiatry 32 (2010) 559.e11–559.e13
Table 1 Dysphagia in psychiatric patients Type
Description
Examples
Bradykinetic Dyskinetic Dystonic Fast-feeding
Associated with drug-induced parkinsonism Associated with drug-induced dyskinesia Associated with drug-induced dystonia A feeding misbehavior characterized by poor chewing skills, restlessness and inattention to feeding Associated with drug-related adverse effect except for drug-induced movement disorder Associated with weakness of oropharyngeal musculature Associated with coexisting medical condition
Antipsychotic-induced parkinsonism Antipsychotic-induced tardive dyskinesia Antipsychotic-induced acute or tardive dystonia Large bites, rapid consumption of meals, etc.
Iatrogenic Paralytic Medical
Biperiden and valproate were discontinued due to poor efficacy and potential negative impact on dysphagia [13,14]. Nineteen days later, his dysphagia improved much in ingestion of solid foods, but was still present with fluid (AIMS score: 10). Follow-up videofluoroscopy revealed improved paste barium meal oral transit time and aspiration. Baclofen was increased to 5 mg twice daily, and both dysphagia and involuntary movement improved 8 days later (AIMS score: 3), despite persistent fast feeding which led to cough during liquid intake. Swallowing training and dietary modification were performed by the speech language pathologist and dietician and successfully prevented its occurrence. As a result, the patient was discharged with outpatient follow-up.
3. Discussion For dysphagia in the mentally ill, various mechanisms have been proposed (see Table 1). Five types were identified by Bazemore et al., namely, the bradykinetic, dyskinetic, fastfeeding, medical and paralytic type [8]. The first two are related to the extrapyramidal side effects of antipsychotics, while the last two imply the influence of underlying medical illnesses. In addition, there are some case reports indicating the association of antipsychotic-induced dystonia and dysphagia [9–12]. In view of the accumulating evidence of the differentiation of tardive dystonia from tardive dyskinesia and postulated treatment responsiveness of the former [7], it is reasonable to speculate that some reported cases of resolved dyskinetic type dysphagia might actually be manifestations of tardive dystonia. Iatrogenic dysphagia, on the other hand, originates from medication effect [13,14]. In clinical practice, however, these types may coexist in the patient, and the differential diagnosis becomes intricate for the reasons below. First, a psychiatric patient may take a variety of psychotropic medications and they all possibly impair normal swallowing. Second, these patients tend to suffer from medical comorbidities which may contribute. Third, to distinguish between bradykinetic-, dyskinetic- and dystonic-type dysphagia is troublesome. Standard imaging tools for swallowing help little as their findings are not specific. Additionally, dysphagia may be the only presentation of these movement disorders without other signs or
Lowered consciousness by benzodiszepine and anticonvulsant and xerostomia by anticholinergic Stroke-related dysphagia Tachypnea due to pulmonary disease interfering with feeding
symptoms. Furthermore, there is no consensus about the distinction of tardive dyskinesia and tardive dystonia. Fourth, fast-feeding is not uncommon among psychiatric patients based on our clinical experience. However, still some features could harbor clues. Imaging study can document whether swallowing dysfunction really exists. Fast-feeding may be revealed by bedside observation. Associated movement disorder of body and limbs also gives hints. In our case, a complex picture of a dysphagic psychiatric patient was shown. At least five types of dysphagia should be considered. It might be bradykinetic or dyskinetic in nature due to associated involuntary movement. Drug-induced dystonia, however, could not be excluded because dysphagia as an isolated presentation has been reported [9–12]. The patient had the fast-feeding habit, and some medications he took could negatively influence his feeding ability. As a result, we can see that, in addition to the adjustment of antipsychotic medications [9–12,15–18], a multidimensional and multidisciplinary team approach should be exercised in such cases, including avoidance of medications which may worsen dysphagia, dietary modification and long-term rehabilitation [13,19]. Beyond this, some role of amantadine and baclofen in the management of dysphagia related to antipsychotic-induced extrapyramidal syndrome might be implicated, although the true efficacy is hard to determine due to so many measures taken in the treatment course. Dysphagia leads to aspiration, malnutrition and further adverse consequences. Psychiatric patients may lack the ability to notice and even express their eating problems. Therefore, more studies are needed to elucidate the magnitude of the problem and its pathophysiology. Before these studies are done, a multidimensional approach may be required to better manage dysphagia in psychiatric patients in the clinical setting. References [1] Regan J, Sowman R, Walsh I. Prevalence of dysphagia in acute and community mental health settings. Dysphagia 2006:95–101. [2] Rudolph JL, Gardner KF, Gramigna GD, McGlinchey RE. Antipsychotics and oropharyngeal dysphagia in hospitalized older patients. J Clin Psychopharmacol 2008;28:532–5. [3] Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC. Antipsychotic drug use and risk of pneumonia in elderly people. J Am Geriatr Soc 2008;56:661–6.
K.T. Tang, M.H. Hsieh / General Hospital Psychiatry 32 (2010) 559.e11–559.e13 [4] Keshavan MS, Tandon R, Boutros NN, Nasrallah HA. Schizophrenia, “just the facts”: What we know in 2008 Part 3: Neurobiology. Schizophr Res 2008;106:89–107. [5] Picard H, Amado I, Mouchet-Mages S, Olie' JP, Krebs MO. The role of the cerebellum in schizophrenia: an update of clinical, cognitive, and functional evidences. Schizophr Bull 2008;34(1):155–72. [6] Bhidayasiri R. Dystonia: genetics and treatment update. Neurologist 2006;12:74–85. [7] Fernandez HH, Friedman JH. Classification and treatment of tardive syndromes. Neurologist 2003;9:16–27. [8] Bazemore PH, Tonkonogy J, Ananth R. Dysphagia in psychiatric patients: clinical and videofluoroscopic study. Dysphagia 1991;6: 2–5. [9] Stones M, Kennie DC, Fulton JD. Dystonic dysphagia associated with fluspirilene. BMJ 1990;301(6753):668–9. [10] Nair S, Saeed O, Shahab H, Sedky K, Garver D, Lippmann S. Sudden dysphagia with uvular enlargement following the initiation of risperidone which responded to benztropine: was this an extrapyramidal side effect? Gen Hosp Psychiatry 2001;23:230–4. [11] Aino I, Saigusa H, Nakamura T, Matsuoka C, Komachi T, Kokawa T. Progressive dysphagia with peculiar laryngeal movement induced by
[12]
[13] [14] [15]
[16] [17] [18]
[19]
559.e13
tardive dystonia. Nippon Jibiinkoka Gakkai Kaiho 2006;109(11): 785–8. Duggal HS, Mendhekar DN. Risperidone-induced tardive pharyngeal dystonia presenting with persistent dysphagia: a case report. Prim Care Companion. J Clin Psychiatry 2008;10(2):161–2. Bakheit AMO. Management of neurogenic dysphagia. Postgrad Med J 2001;77:694–9. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. Radiographics 2006;26(1):e22. Dziewas R, Warnecke T, Schnabel M, Ritter M, Nabavi DG, Schilling M, Ringelstein EB, Reker T. Neuroleptic-induced dysphagia: case report and literature review. Dysphagia 2007;22:63–7. Varghese ST, Balhara YPS, George SA, Sagar R. Risperidone and dysphagia. J Postgrad Med 2006;52(4):327–8. Kohen I, Lester P. Quetiapine-associated dysphagia. World J Biol Psychiatry 2008;10:1–3. Hayashi T, Nishikawa T, Koga I, Uchida Y, Yamawaki S. Lifethreatening dysphagia following prolonged neuroleptic therapy. Clin Neuropharmacol 1997;20(1):77–81. Lister R. Oropharyngeal dysphagia and nutritional management. Curr Opin Gastroenterol 2006;22:341–6.
General Hospital Psychiatry 32 (2010) 559.e11 – 559.e13
Case Report
A case of schizophrenia with dysphagia successfully treated by a multidimensional approach Kuo T. Tang, M.D.⁎, Ming H. Hsieh, M.D. Department of Psychiatry, National Taiwan University Hospital, Taipei 100, Taiwan Received 5 December 2009; accepted 26 January 2010
Abstract Dysphagia in patients with psychiatric illnesses contributes to morbidities and mortalities. It is, however, an overlooked problem in clinical practice. We report a patient of schizophrenia with dysphagia who was successfully treated using a multidimensional approach, which included medication adjustment, swallowing training and diet modification. © 2010 Elsevier Inc. All rights reserved. Keywords: Schizophrenia; Amantadine; Baclofen; Dysphagia; Psychiatric
1. Introduction Dysphagia is an easily overlooked problem in the medical setting. It has been shown that the prevalence of dysphagia is higher in those with mental health disorders [1]. Hospitalized older patients receiving higher doses of antipsychotic medications are associated with worse swallowing function [2]. Furthermore, use of antipsychotics in elderly people is correlated with greater risk of pneumonia, which may be partly explained by swallowing dysfunction [3] and potentially leads to morbidities and even mortalities.
2. Case report Mr. A is a 46-year-old male who had suffered from schizophrenia for 31 years and was admitted for dysphagia for 2 months. His psychotropic regimen included flupentixol 20 mg intramuscular injection every 2 weeks and sulpride 600 mg and valproate 500 mg orally per day for approximately 4 years. Two months before the admission, he presented with difficulty in swallowing liquid food initially, and then solid. Episodes of sudden asphyxia at
⁎ Corresponding author. Tel.: +886 2 23123456x66790, +886 928998019 (Mobile). E-mail address: [email protected] (K.T. Tang). 0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.genhosppsych.2010.01.012
eating occurred. Anticholinergic such as biperiden 2 mg three times a day was prescribed for a month but achieved no improvement. Therefore, he was admitted. On admission, general examination documented severe involuntary movement such as lateral jaw movement, tongue twisting and limbs tremor and athetoid movement, especially over upper limbs [Abnormal Involuntary Movement Score (AIMS) score: 23]. As for dysphagia, fast feeding was observed in clinical assessment. Videofluoroscopy showed abnormal bolus holding, piecemeal swallowing, abnormal epiglottic movement, delayed oral transit time in paste barium meal and delayed pharyngeal transit time in all kinds of barium meals, all of which resulted in frequent silent aspirations. Brain magnetic resonance imaging only revealed early brain atrophy, hypoplastic cerebellar vermis and focal attenuated change around left anterior limb of internal capsule. The first two findings might be attributed to chronic schizophrenia [4,5], and the last finding was possibly an old lacune. However, they could not explain current dysphagia. Therefore, drug-induced Parkinsonism was suspected and amantadine was gradually titrated to 100 mg three times a day. His dysphagia improved with solid food but psychotic symptoms exacerbated (AIMS score: 20). Hence, amantadine was tapered to 100 mg twice daily, and clozapine 150 mg daily was gradually substituted for flupentixol and sulpride. His psychotic symptoms subsided. Also, baclofen 5 mg per day was administered based on reports about its efficacy in dystonia [6] and also tardive dystonia [7].
559.e12
K.T. Tang, M.H. Hsieh / General Hospital Psychiatry 32 (2010) 559.e11–559.e13
Table 1 Dysphagia in psychiatric patients Type
Description
Examples
Bradykinetic Dyskinetic Dystonic Fast-feeding
Associated with drug-induced parkinsonism Associated with drug-induced dyskinesia Associated with drug-induced dystonia A feeding misbehavior characterized by poor chewing skills, restlessness and inattention to feeding Associated with drug-related adverse effect except for drug-induced movement disorder Associated with weakness of oropharyngeal musculature Associated with coexisting medical condition
Antipsychotic-induced parkinsonism Antipsychotic-induced tardive dyskinesia Antipsychotic-induced acute or tardive dystonia Large bites, rapid consumption of meals, etc.
Iatrogenic Paralytic Medical
Biperiden and valproate were discontinued due to poor efficacy and potential negative impact on dysphagia [13,14]. Nineteen days later, his dysphagia improved much in ingestion of solid foods, but was still present with fluid (AIMS score: 10). Follow-up videofluoroscopy revealed improved paste barium meal oral transit time and aspiration. Baclofen was increased to 5 mg twice daily, and both dysphagia and involuntary movement improved 8 days later (AIMS score: 3), despite persistent fast feeding which led to cough during liquid intake. Swallowing training and dietary modification were performed by the speech language pathologist and dietician and successfully prevented its occurrence. As a result, the patient was discharged with outpatient follow-up.
3. Discussion For dysphagia in the mentally ill, various mechanisms have been proposed (see Table 1). Five types were identified by Bazemore et al., namely, the bradykinetic, dyskinetic, fastfeeding, medical and paralytic type [8]. The first two are related to the extrapyramidal side effects of antipsychotics, while the last two imply the influence of underlying medical illnesses. In addition, there are some case reports indicating the association of antipsychotic-induced dystonia and dysphagia [9–12]. In view of the accumulating evidence of the differentiation of tardive dystonia from tardive dyskinesia and postulated treatment responsiveness of the former [7], it is reasonable to speculate that some reported cases of resolved dyskinetic type dysphagia might actually be manifestations of tardive dystonia. Iatrogenic dysphagia, on the other hand, originates from medication effect [13,14]. In clinical practice, however, these types may coexist in the patient, and the differential diagnosis becomes intricate for the reasons below. First, a psychiatric patient may take a variety of psychotropic medications and they all possibly impair normal swallowing. Second, these patients tend to suffer from medical comorbidities which may contribute. Third, to distinguish between bradykinetic-, dyskinetic- and dystonic-type dysphagia is troublesome. Standard imaging tools for swallowing help little as their findings are not specific. Additionally, dysphagia may be the only presentation of these movement disorders without other signs or
Lowered consciousness by benzodiszepine and anticonvulsant and xerostomia by anticholinergic Stroke-related dysphagia Tachypnea due to pulmonary disease interfering with feeding
symptoms. Furthermore, there is no consensus about the distinction of tardive dyskinesia and tardive dystonia. Fourth, fast-feeding is not uncommon among psychiatric patients based on our clinical experience. However, still some features could harbor clues. Imaging study can document whether swallowing dysfunction really exists. Fast-feeding may be revealed by bedside observation. Associated movement disorder of body and limbs also gives hints. In our case, a complex picture of a dysphagic psychiatric patient was shown. At least five types of dysphagia should be considered. It might be bradykinetic or dyskinetic in nature due to associated involuntary movement. Drug-induced dystonia, however, could not be excluded because dysphagia as an isolated presentation has been reported [9–12]. The patient had the fast-feeding habit, and some medications he took could negatively influence his feeding ability. As a result, we can see that, in addition to the adjustment of antipsychotic medications [9–12,15–18], a multidimensional and multidisciplinary team approach should be exercised in such cases, including avoidance of medications which may worsen dysphagia, dietary modification and long-term rehabilitation [13,19]. Beyond this, some role of amantadine and baclofen in the management of dysphagia related to antipsychotic-induced extrapyramidal syndrome might be implicated, although the true efficacy is hard to determine due to so many measures taken in the treatment course. Dysphagia leads to aspiration, malnutrition and further adverse consequences. Psychiatric patients may lack the ability to notice and even express their eating problems. Therefore, more studies are needed to elucidate the magnitude of the problem and its pathophysiology. Before these studies are done, a multidimensional approach may be required to better manage dysphagia in psychiatric patients in the clinical setting. References [1] Regan J, Sowman R, Walsh I. Prevalence of dysphagia in acute and community mental health settings. Dysphagia 2006:95–101. [2] Rudolph JL, Gardner KF, Gramigna GD, McGlinchey RE. Antipsychotics and oropharyngeal dysphagia in hospitalized older patients. J Clin Psychopharmacol 2008;28:532–5. [3] Knol W, van Marum RJ, Jansen PA, Souverein PC, Schobben AF, Egberts AC. Antipsychotic drug use and risk of pneumonia in elderly people. J Am Geriatr Soc 2008;56:661–6.
K.T. Tang, M.H. Hsieh / General Hospital Psychiatry 32 (2010) 559.e11–559.e13 [4] Keshavan MS, Tandon R, Boutros NN, Nasrallah HA. Schizophrenia, “just the facts”: What we know in 2008 Part 3: Neurobiology. Schizophr Res 2008;106:89–107. [5] Picard H, Amado I, Mouchet-Mages S, Olie' JP, Krebs MO. The role of the cerebellum in schizophrenia: an update of clinical, cognitive, and functional evidences. Schizophr Bull 2008;34(1):155–72. [6] Bhidayasiri R. Dystonia: genetics and treatment update. Neurologist 2006;12:74–85. [7] Fernandez HH, Friedman JH. Classification and treatment of tardive syndromes. Neurologist 2003;9:16–27. [8] Bazemore PH, Tonkonogy J, Ananth R. Dysphagia in psychiatric patients: clinical and videofluoroscopic study. Dysphagia 1991;6: 2–5. [9] Stones M, Kennie DC, Fulton JD. Dystonic dysphagia associated with fluspirilene. BMJ 1990;301(6753):668–9. [10] Nair S, Saeed O, Shahab H, Sedky K, Garver D, Lippmann S. Sudden dysphagia with uvular enlargement following the initiation of risperidone which responded to benztropine: was this an extrapyramidal side effect? Gen Hosp Psychiatry 2001;23:230–4. [11] Aino I, Saigusa H, Nakamura T, Matsuoka C, Komachi T, Kokawa T. Progressive dysphagia with peculiar laryngeal movement induced by
[12]
[13] [14] [15]
[16] [17] [18]
[19]
559.e13
tardive dystonia. Nippon Jibiinkoka Gakkai Kaiho 2006;109(11): 785–8. Duggal HS, Mendhekar DN. Risperidone-induced tardive pharyngeal dystonia presenting with persistent dysphagia: a case report. Prim Care Companion. J Clin Psychiatry 2008;10(2):161–2. Bakheit AMO. Management of neurogenic dysphagia. Postgrad Med J 2001;77:694–9. Gates J, Hartnell GG, Gramigna GD. Videofluoroscopy and swallowing studies for neurologic disease: a primer. Radiographics 2006;26(1):e22. Dziewas R, Warnecke T, Schnabel M, Ritter M, Nabavi DG, Schilling M, Ringelstein EB, Reker T. Neuroleptic-induced dysphagia: case report and literature review. Dysphagia 2007;22:63–7. Varghese ST, Balhara YPS, George SA, Sagar R. Risperidone and dysphagia. J Postgrad Med 2006;52(4):327–8. Kohen I, Lester P. Quetiapine-associated dysphagia. World J Biol Psychiatry 2008;10:1–3. Hayashi T, Nishikawa T, Koga I, Uchida Y, Yamawaki S. Lifethreatening dysphagia following prolonged neuroleptic therapy. Clin Neuropharmacol 1997;20(1):77–81. Lister R. Oropharyngeal dysphagia and nutritional management. Curr Opin Gastroenterol 2006;22:341–6.