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Akathisia is a common adverse effect of antipsychotics and, less commonly, antidepressants. Akathisia can cause great discomfort and is often described by the patient as a most distressing sensation; however, the condition is often underdiagnosed or misdiagnosed. In oncological settings, neuroleptics and antidepressants that induce akathisia are also administered. However, reports of akathisia in oncology settings are few and a case of akathisia in a bedridden patient has not been reported as far as we know.
A 72-year-old man with esophageal cancer who could not sit down or stand up was administered 5 mg/day haloperidol to relieve agitation as a symptom of major depressive disorder. Three days after the administration of haloperidol, the agitation had become worse. Careful observation revealed that the patient sometimes showed slight rubbing movement of the lower extremities and slight twisting movements of the body, which were not observed before the administration of haloperidol. The patient moved his body and lower extremities to relieve restlessness, which had developed after the administration of haloperidol. Although symptoms were atypical, akathisia was suspected and discontinuation of haloperidol resolved the symptoms.
Results and significance of results:
In patients with poor performance status, clues leading to the correct diagnosis of akathisia might be absent, which would not be the case in patients who were able to walk, stand up, or sit down. Careful observations of patients before and after the administration of drugs that may cause akathisia may be required to ensure correct diagnosis.
There is substantial evidence that tricyclic antidepressants are effective in the management of chronic pain, including cancer pain. In oncological settings, these agents are used as adjuvant analgesic drugs. However, cases of akathisia due to tricyclic antidepressants used as adjuvant analgesic therapy have not previously been reported.
Two cancer patients experiencing chronic pain who were refractory to nonsteroidal anti-inflammatory drugs and opioids were prescribed amoxapine as an adjuvant analgesic therapy for neuropathic pain. These patients developed inner restlessness and restless physical movements after amoxapine was prescribed. Although symptoms were atypical, akathisia was suspected and discontinuation of amoxapine resolved the symptoms.
Results and significance of results:
Akathisia should be considered in patients receiving adjuvant analgesic therapy with tricyclic antidepressants. Early detection and appropriate treatment will relieve this distressing symptom. Restless movements involving parts of the body other than the legs may be the clue to the diagnosis.
Complications of neuropsychiatric disorders are often detected in cancer patients. Adjustment disorders, depression, or delirium are common psychiatric disorders in these patients, and drug-induced neuropsychiatric problems are sometimes referred for psychiatric consultation. Prochlorperazine and other antiemetic drugs that are phenothiazine derivates are also reported to cause akathisia due to the blockade of the dopamine receptor in the central nervous system, but the prevalence of akathisia in patients undergoing cancer treatment has not been reported. This study seeks to explore the prevalence of such drug-induced syndromes (e.g., akathisia) in this population.
This present study was a prospective study. The subjects of this study were 483 consecutive patients with cancer who had been referred to the Department of Psychiatry in Kanagawa Prefecture Cancer Center from February 1, 2004, to November 30, 2005. Trained psychiatrists conducted a nonstructured psychiatric interview and neurologic examination to establish psychiatric diagnoses according to DSM-IV and the presence or absence of drug-induced extra pyramidal symptoms. The past and current medications used in their cancer treatment were also examined in detail for an accurate evaluation.
A psychiatric diagnosis was made in 420 (87.0%) of the 483 cancer patients examined, and akathisia, a drug-induced movement disorder, was unexpectedly prevalent among the patients; 20 of 420 (4.8%) patients had developed akathisia from an antiemetic drug, prochlorperazine.
Significance of results:
Diagnosing such adverse drug reactions may be difficult due to complicating factors in cancer treatment, and the inner restlessness observed in akathisia is likely to be regarded as a symptom of a primary psychiatric disorder. The authors suggest that oncologists should optimize the use of antiemetic drugs and be aware of akathisia as a possible complication of cancer treatment.
Objective: We report here a terminally ill patient with
stomach cancer who developed a brief psychotic disorder mimicking
cerebrovascular attack after a short episode of nasal bleeding. Close
examination of the patient revealed that nasal bleeding was an event that
symbolized deterioration of the general condition leading to death for the
Methods: A 77-year-old male, who was diagnosed as having
stomach cancer and was receiving palliative care, presented with tremor
and insomnia just after a short episode of nasal bleeding and showed
reduced response to stimuli mimicking cerebrovascular attack. Laboratory
data were unremarkable. The next day, catatonic behavior developed. He had
no history of psychiatric illness or drug or alcohol abuse. After
receiving haloperidol, psychiatric symptoms disappeared and he returned to
the previous level of functioning within 3 days. The patient explained
that he had seen a patient whose general condition deteriorated after
nasal bleeding and regarded nasal bleeding as a symptom of deteriorating
general condition leading to death and thereafter became afraid of the
Results and Significance of results: Although, nasal bleeding
is common and usually not severe in medical settings, for the patient, it
was an event that symbolized deterioration of the general condition
leading to death. Brief psychotic disorder in cancer patients is rare in
the literature, although patients receiving terminal care share various
kinds of psychological burden. Medical staff in the palliative care unit
should be aware of the psychological distress experienced by each patient
and consider brief psychotic disorder as part of the differential
diagnosis when patients show unexplained neurological-like and/or
Malignancy-associated primary thiamine deficiency has been documented
in several experimental tumors, clinical case reports, and in patients
with fast growing malignancies. We report a terminally ill cancer patient
who developed delirium. Close examination of the patient demonstrated that
delirium was caused by thiamine deficiency, although she had been
consuming an average of 990 cal/day for the past 3 weeks.
Malabsorption or consumption by the tumor was considered the mechanism of
thiamine deficiency. Early recognition and subsequent treatment resulted
in successful palliation of delirium. In terminally ill cancer patients,
clinicians must remain aware of the possibility of Wernicke's
encephalopathy, when the patients develop unexplained delirium, even if
the patient has been consuming adequate amounts of food. Early
intervention may correct the symptoms and prevent irreversible brain
damage, and the quality of life for the patient may improve.
Objective: Although Wernicke encephalopathy has been reported
in the oncological literature, it has not previously been reported in
postoperative cancer patients.
Methods: In this communication, we report a patient of
hepatocellular carcinoma with liver cirrhosis who developed Wernicke
encephalopathy in the form of postoperative delirium. Preoperatively, the
patient had a very good appetite and had eaten all the food of an 1800
cal/day diet until 1 day before operation. The operation was done
without any complications. The patient developed delirium 2 days after the
lobectomy of the liver. The level of delirium remained unchanged until
administration of thiamine starting on day 7 postoperatively, which
resulted in palliation of delirium without brain damage. Laboratory data
demonstrated that the serum thiamine level at day 6 postoperatively was
below the lower limit of normal. As the mechanism of Wernicke
encephalopathy, we thought that decreased ability to store thiamine due to
liver cirrhosis led to depletion of thiamine faster than had been
Results and significance of the research: In cancer patients,
clinicians must always remain aware of the possibility of Wernicke
encephalopathy, especially in patients with liver dysfunction, which
decreases the ability to store thiamine in the liver. Early detection and
intervention may alleviate the symptoms of delirium and prevent
irreversible brain damage.
Objective: It is known that families of terminally-ill cancer
patients show levels of emotional and functional disruption and are called
“second order patients,” however, little is actually known
about the health problems of family members, especially in terms of
Methods: This study reviewed the family histories of
terminally-ill cancer patients in a palliative care unit and investigated
cancer related health problems of the spouses of terminally-ill cancer
Results: We investigated the past medical history of 125
spouses of terminally-ill cancer patients and found that five spouses had
a past medical history of cancer. In these five spouses, the duration of
illness, present status of treatment and physical condition were reviewed
from the database. Of these five spouses, three patients continued to
attend an outpatient clinic regularly for checkup and one patient was
hospitalized for nephrectomy. Two spouses did not have physical symptoms
that made them unable to provide direct care for the terminally-ill
spouses, while three could not provide care because of their own physical
symptoms derived from cancer.
Significance of results: Our findings indicated that some of
the spouses of terminally-ill cancer patients are not only “second
order patients” but also “cancer patients.” Our findings
also suggest that some spouses of terminally-ill cancer patients might
experience distress both as a cancer patient and as a spouse and may need
care both as a cancer patient and as a spouse.
Objective: Neuroleptic malignant syndrome (NMS) is a
life-threatening reaction to neuroleptics. Several prospective studies
have reported NMS occurrence rates ranging from 0.07% to 2.2% of patients
receiving neuroleptics. However, few occurrences of NMS have been reported
in cancer patients despite frequent complications of cancer and its
treatment by mental disorders managed with neuroleptic drugs. Exhaustion,
dehydration, and malnutrition are considered risk factors for NMS, and
cancer patients represent a high risk group for NMS.
Methods: We describe a patient with metastatic chondrosarcoma
who had received frequent neuroleptic injections prior to brain surgery
and developed NMS in the intensive care unit immediately after surgery.
The patient showed delirium, hyperpyrexia, tachycardia, diaphoresis, and
extrapyramidal symptoms. After a diagnosis of NMS was made, supportive
care and careful monitoring were carried out, and the patient recovered
over an interval of 11 days.
Results and significance of the research: Clinical NMS
studies have been conducted mainly in psychiatric units, but NMS can occur
wherever psychotropic drugs are administered. NMS can be difficult to
diagnose due to multiple complicating factors in cancer treatment, but the
diagnosis is highly important given the risk of death. Recognition of
prodromal NMS symptoms can facilitate actions to decrease morbidity and
mortality. It is suggested that special attention to cancer patients
undergoing psychopharmacologic treatment is required in clinical oncologic
Objective: Physical abuse is one of the most important public
health problems, but little is known about physical abuse of cancer
patients. The objects of this study are (1) to identify whether cancer
patients have sustained physical abuse; (2) to explore clinical
characteristics of the abused patients.
Methods: We reviewed 584 cancer patients referred to our
psychiatry clinic by a cancer center hospital and investigated whether
there were victims of physical abuse among these patients. We also
investigated psychiatric characteristics of the abused patients.
Results: Of these 584 patients, three patients were
recognized as victims of physical abuse at the time of referral. The
perpetrator of physical abuse was their husband (domestic violence) in all
three cases. All three patients had sustained physical abuse from their
husbands for years before being diagnosed with cancer. In addition to
physical abuse, all three patients had sustained emotional abuse (e.g.,
threat or intimidation) from their husbands. Psychiatric diagnoses of all
three patients fulfilled the DSM-IV criteria for post-traumatic stress
disorder (PTSD) and the traumatic event was mainly physical abuse by their
Significance of results: Oncologists and psychiatrists should
pay greater attention to the psychosocial and environmental problems of
cancer patients and inquire about the presence of physical abuse in
suspected cases. Medical staff should also know that early
multidisciplinary interventions in addition to cancer treatments are
needed for victims of physical abuse among cancer patients and that these
interventions are necessary to improve compliance with treatment and
proper decision making.
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