Antipsychotics


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Antipsychotics

The use of antipsychotic medication has changed dramatically over the last five years with the introduction of atypical antipsychotics that have a lower risk of extrapyramidal symptoms (EPS) and tardive dyskinesias than classical antipsychotics (Findling et al. 1998). EPS include acute dystonic reactions, akathesia or involuntary motor restlessness, and a Parkinsonian syndrome of masklike facial expression, rigidity in the extremities, and tremor. EPS typically occur in the first few weeks of antipsychotic treatment, whereas tardive dyskinesias (which are rhythmic, repetitive, stereotypic movements, such as lip smacking) occur later in treatment and may be irreversible. Typical antipsychotics block both dopamine-D₂ receptors and serotonin 5HT₂ receptors, and it is the serotonin blockade that leads to protection from EPS, perhaps by increasing dopamine frontally and in the basal ganglia, most often when doses are kept low (Kapur and Remington 1996; Livingston 1994; Honey et al. 1999).

Antipsychotics: Risperidone (Risperidal)

The most commonly used atypical antipsychotic in pediatric practice is risperidone (Risperidal), which is not only helpful in treatment of schizophrenia (Quintana and Kesharan 1995; Honey et al. 1999) but also in treatment of tic disorder (Lombroso et al. 1995), bipolar disorder and aggression (Fras and Major 1995; Findling et al. 2000; Demb and Espiritu 1999), and treatment of behavior problems in children with mental retardation, autism, or PDD (Vanden Borre et al. 1993; Findling et al. 1997; Horrigan and Barnhill 1997; McDougle et al. 1997, 1998; Zuddas et al. 2000).

The wider utility of atypicals beyond schizophrenia, coupled with their superior safety profile, has led to their frequent use in the last few years. They should not be considered first-line treatments for aggression or mood stabilization, but they can be helpful when other medications previously described are not beneficial. In our experience, risperidone can be remarkably helpful in both children and adults with FXS who have significant aggression, mood instability, tantrums, or psychotic thinking, including paranoia (chap. 1). It is best to start at a low dose, 0.5 mg at bedtime, although increases to twice a day are often needed. Usually a dose of only 1 or 2 mg/day suffices (Demb and Espiritu 1999; Findling et al. 1998). Whenever possible, doses should be kept under 4 mg/day to avoid an increased risk of EPS (Kapur and Remington 1996).

Antipsychotics: Continued

This article is not intended to give medical advice for individual cases. Any change in medical treatment should be done in consultation with appropriate medical personnel. This article is written for medical professionals. Some of the terms will be unfamiliar to those who are not trained in medical fields.

*This article is from the chapter on treatment in the 3rd edition of Fragile X Syndrome: Diagnosis, Treatment, and Research edited by Randi Jenssen Hagerman, M.D. and Paul Hagerman, M.D., Ph.D., to be published May 2002. It is included with permission from The Johns Hopkins University Press. References to other chapters refer to chapters in the book which are not included as part of this website.

The complete 3rd edition of Fragile X Syndrome: Diagnosis, Treatment, and Research can be ordered from the National Fragile X Foundation by calling 1-800-688-8765 or from The Johns Hopkins University Press at 1-800-537-5487.

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