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Suggest Treatment For Dysarthria While On Anti-psychotic Drugs
Question: How to treat early-stage dysarthria for patient taking anti-psychotic drug like Qpine (Quetiapine) once 50 mg? Will proclydine hydrochloride (Perkinil) help improve while discontinuing Qpine? Will any particular medicine help while the treatment for psychosis is on? One doctor asked to stop all medication other one asked to provide Perkinil thrice ( currently administered twice 5mg x2). I am very confused. Patient, 27 years female, has slurred voice or mumbling for selective sound like L, T, D etc where the tongue requires a bit of strength. Patient is in better state excepting this voice problem. Other medications are Mrtazapine (anti-depressant) 1/2 of 7.5 mg once at night, Gabatine 300 twice daily as mood stabilizer. Some doctors also suggest trihexaphenadyl in lieu of Perkinil, why?Much appreciate your advice.
Brief Answer:
Pocyclidine and trihexyphenidyl both can be used
Detailed Answer:
Hi, XXXX.
I have read your query and understood your concerns.
Are you saying that the patient has taken Quetiapine single dose 50 mg and she developed Dysarthria? - Usually patient do not develop this kind of side effect after 50 mg of quetiapine, I am surprised. He must be on some other drugs.
Procyclidine is an anti-cholinergic drug which is commonly used for treatment of drug-induced parkinsonism, akathisia and acute dystonia; Parkinson disease and dystonia. It can help in improving this side effect and withdrawing quetiapine.
Usually even when the antipsychotic drug is on, the side effects of that drug will improve with anticholinergic drugs like procyclidine, Trihexyphenidyl and benztropine etc.
If the patient needs a mood stabilizer than I would never have prescribed gabatin for that. Better and strong mood stabilizers are available in the market like divalproex sodium.
What I feel that you need to visit a new psychiatrist because the patient is receiving a Antidepressant (mirtazapine), a mood stabilizer (so called, gabatin) and a antipsychotic (quetiapine), which is a cocktail of the drugs and patient usually may not need all of these together.
Hope I have answered your query. If you have any other query then feel free to ask.
Regards, Dr Ravi Soni
Pocyclidine and trihexyphenidyl both can be used
Detailed Answer:
Hi, XXXX.
I have read your query and understood your concerns.
Are you saying that the patient has taken Quetiapine single dose 50 mg and she developed Dysarthria? - Usually patient do not develop this kind of side effect after 50 mg of quetiapine, I am surprised. He must be on some other drugs.
Procyclidine is an anti-cholinergic drug which is commonly used for treatment of drug-induced parkinsonism, akathisia and acute dystonia; Parkinson disease and dystonia. It can help in improving this side effect and withdrawing quetiapine.
Usually even when the antipsychotic drug is on, the side effects of that drug will improve with anticholinergic drugs like procyclidine, Trihexyphenidyl and benztropine etc.
If the patient needs a mood stabilizer than I would never have prescribed gabatin for that. Better and strong mood stabilizers are available in the market like divalproex sodium.
What I feel that you need to visit a new psychiatrist because the patient is receiving a Antidepressant (mirtazapine), a mood stabilizer (so called, gabatin) and a antipsychotic (quetiapine), which is a cocktail of the drugs and patient usually may not need all of these together.
Hope I have answered your query. If you have any other query then feel free to ask.
Regards, Dr Ravi Soni
Above answer was peer-reviewed by :
Dr. Prasad
Dear Dr. XXXXXXX
Many thanks. The only other medicine she took was Otosil (promethixine) at night only. No medicine during day. In fact her medicine had tapered quite a bit. Her prolactin level is high 150 due to earlier intervention about 10 weeks back. She is on Bromergon for a week now to bring the prolactin level.
Will this side effect diminish if the medication is reduced. Can you suggest any medicine that can help, meanwhile, we will try to urge the doctor to cut down further- tapering,- the medication.
Thanks for your help.
Many thanks. The only other medicine she took was Otosil (promethixine) at night only. No medicine during day. In fact her medicine had tapered quite a bit. Her prolactin level is high 150 due to earlier intervention about 10 weeks back. She is on Bromergon for a week now to bring the prolactin level.
Will this side effect diminish if the medication is reduced. Can you suggest any medicine that can help, meanwhile, we will try to urge the doctor to cut down further- tapering,- the medication.
Thanks for your help.
Brief Answer:
Promethazine can also be a culprit
Detailed Answer:
Hi, XXXX, thanx for writing again.
Promethazine is the drug which can also cause similar side effects as antipsychotics. So, the dysarthria might have result from the combination of all these drugs taken together.
Increase in prolactin can also be because of the side effects of antipsychotics. Bromergon may be the brand name of the drug Bromocriptine, which can decrease the prolactin level. So, the continuation of bromergon is required until prolactin level is normal. The antipsychotics should be stopped along with promethazine.
Can you give me the list of the drugs she is currently on? Even the OTC drugs.
I am waiting for your reply.
Regards, Dr Ravi Soni.
Promethazine can also be a culprit
Detailed Answer:
Hi, XXXX, thanx for writing again.
Promethazine is the drug which can also cause similar side effects as antipsychotics. So, the dysarthria might have result from the combination of all these drugs taken together.
Increase in prolactin can also be because of the side effects of antipsychotics. Bromergon may be the brand name of the drug Bromocriptine, which can decrease the prolactin level. So, the continuation of bromergon is required until prolactin level is normal. The antipsychotics should be stopped along with promethazine.
Can you give me the list of the drugs she is currently on? Even the OTC drugs.
I am waiting for your reply.
Regards, Dr Ravi Soni.
Above answer was peer-reviewed by :
Dr. Nagamani Ng
Dear Dr. Soni:
Many thanks for your response, She is currently on the following drugs since September 3. But she has been suffering since mid-May and has been under various doctor and medication
Mirtaz (7.5 mg): 0+0+1/2
Gabatine (300 mg): 0+0+1
Hexinor (2mg): 1+1+1
Otosil (25mg): 0+0+1
Qpine (100 mg): 0+0+1/4 i.e. 25 mg
Bromargon (2.5 mg): 1+0+1 ( No other OTC medicines)
(1) Are the current doses at level that they can be stopped without affecting the patient's recovery; (2) which medication do you suggest be stopped and (3) if some medicines have to be continued then at what doses? (4) Do you suggest any replacement medicine? if so please provide the generic name or the renowned brand name with doses. (5) Will sudden withdrawal cause problems or symptoms that we may find difficult to handle without proper medical care?
I am indicating below her earlier conditions and medications following her attack in May 2016 for your review and recommendation:
Why treatment was sought:
1. Parents were away from country for about a month. Was left under care of aunt living in the floor above.
2. Felt frightened (Something bad could happen to her pr [pafrents)
3. Could not cope with stress of work and MBA studies. Depressed/ Mood swing/ Delusion/Restlessness and hallucination at times,
4. Violence at times
Date Doctor Visit # Medication Dose Observation/Comment `
24-May-16; Dr. Rabbani 1;
Tab Lithosun (400mg) ½ + ½ + ½ Tab Quipe (100 mg) 1 + 1 + 2
ab Indever (10 mg) ½ + ½ + ½
Tab Slipam (30 mg) 0 + 0 + 1
Medication could not be administered. Patient refused medication with various complains
31-May-16 Dr. Rabbani 2 nd visit All medicine above plus
Tab Rispolux (2mg) 1 + 1 + 1
Tab Perkinil (5mg) 1 + 1 + 1 Inj. Invega Sustenna (150 mg); 1st and 8 th then monthly once
Neither injection nor medication could be administered. Patient refused vehemently
9-Jun-16 Homeopath 3 4 doses (small bottles)
Not known-1st dose: Patient felt rejuvenated after first dose.
16-Jun-16: 2nd dose :Lack of sleep both during day and night. On Jun 19 walks all the way from home to abut 4.5 km under sun. Severe delusion on XXXXXXX 20. Insists this was Ramadan 27 Infact 13 th) . Administered Dr, Rabbani's medication. Agitated and got violent, Wanted to leave home for walk,
20-Jun-16: Admitted to Beacon Point (Clinic) under Dr, Rabbani. Reportedly refused medicine and at times food. Insisted she was okay. At times was fasting. Medication was apparently forced fed. Always spoke of wanting to take homeo medication. Remorseful about misbehaving with parents. First visit allowed-July 26. Physically looked well. Keen to return and resume homeo. Had to be kept at Beacon.
Dr. Rabbani Treatment at Beacon Point: Inj (i/M;I/V); Invega Sustenna (150mg-3); Halopid (5 mg), Opsonil (50 mg), Fenazin (25 mg) ; Clinsol-1(500 cc); Hartman Solution-1 (500 cc) TABLETS: All as during second visit plus Seroquet (100 mg) and Rispolux (4mg)- Doses not known
18-Aug-16 Released from Beacon
With following Medication Advice:
Tab Lithosun (400mg) 0 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
ab Rispolux (4mg) 0 + 0 + 1 Tab Parkiroll (0.25mg) 1 + 1 + 1
Tab. Seroquet (100 mg) 0 + 0 + 2 Tab Kemadrin (5 mg) 1 + 0 + 1
Tab Lozicum (1 mg) 1 + 1 + 2
nj.Fenazin (25 mg) fortnightly
Inj. Invega Sustenna (150 mg)-monthly
Above medication was not administered `
20-Aug-17 XXXXXXX XXXXXXX 1
Tab Mirez (15 mg) 0 + 0 + 1 ng/ml
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 0 + 1 + 1
Tab Gabatin (300 mg) 1 + 0 + 1
Tab Catapres (0.1 g) 0 + 0 + 1
ab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1
CaC 1000 1 + 0 + 0
27-Aug-17 XXXXXXX XXXXXXX 2 Tab Mirez (15 mg) 0 + 0 + 2 Refers patient to endocrinologist for immediate consultation/ hospitalization. Patient was very restless for the long drive to XXXXXXX and wait for the doctor. Doctor was very agitated with Beacon due to prolactin level was also displeased with me. He increased the doses of almost all the medicine but asked to stop the last three. I chose to stick to his Aug 20 prescription as I can see gradual imptovment. Yet to consult endocrinologist.
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 1 + 2 + 1
Tab Gabatin (300 mg) 1 + 1 + 1
Tab Catapres (0.1 g) 1 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1 Continued for sometime
CaC 1000 1 + 0 + 0
Medication by Dr. Golam Rabbani, XXXXXXX 20 to August 18 (Stay in Clinic)
Tab Lithosun (400mg) ½ + ½ + ½
Tab Quipe (100 mg) 1 + 1 + 2
Tab Indever (10 mg) ½ + ½ + ½
Tab Slipam (30 mg) 0 + 0 + 1
Tab Rispolux (2mg) 1 + 1 + 1
Tab Perkinil (5mg) 1 + 1 + 1
Tab Seroquet (100 mg)
Inj. Invega Sustenna (150 mg) 1st and 8 th then monthly
Inj. Fezanin (25 mg) Fortnightly
Others used: Halopid (5 mg), Opsonil (50 mg),
Medication by Dr. XXXXXXX XXXXXXX August 20
Tab Mirez (15 mg) 0 + 0 + 1
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 0 + 1 + 1
Tab Gabatin (300 mg) 1 + 0 + 1
Tab Catapres (0.1 g) 0 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1
CaC 1000 1 + 0 + 0
Medication by Dr. XXXXXXX Al-Mamun Date: 30 August 2015
Tab Gabatin (300 mg) 1 + 0 + 1 Continue
Tab Mirez (7.5 mg) 0 + 0 + 1 Continue
Tab Parkinil (5mg) 1 + 0 + 1 Continue
Tab Otosil (25 mg) 1 + 0 + 1 2 months
Tab Epnil (0.5 mg) 0 + 0 + 1 1 month Increase if restless
Tab Qpine (100 mg) 0 + 0 + ½ Continue
Medication by Dr Rezwana Qadri (current medication). Will continue with her.
She does not blame the medication though,
Can you pleach reach out to other doctors and seek their opinion if possible before you send a response. Will much appreciate. Also wanted to talk to you over viber, skype, messenger, whatsapp; Is this possible? Please copy your response to my email too if possible?
My daughter's voice is still same,. Looking forward to your valuable advice? You may refer to other specialist if deemed appropriate.
Regards
XXXX
Many thanks for your response, She is currently on the following drugs since September 3. But she has been suffering since mid-May and has been under various doctor and medication
Mirtaz (7.5 mg): 0+0+1/2
Gabatine (300 mg): 0+0+1
Hexinor (2mg): 1+1+1
Otosil (25mg): 0+0+1
Qpine (100 mg): 0+0+1/4 i.e. 25 mg
Bromargon (2.5 mg): 1+0+1 ( No other OTC medicines)
(1) Are the current doses at level that they can be stopped without affecting the patient's recovery; (2) which medication do you suggest be stopped and (3) if some medicines have to be continued then at what doses? (4) Do you suggest any replacement medicine? if so please provide the generic name or the renowned brand name with doses. (5) Will sudden withdrawal cause problems or symptoms that we may find difficult to handle without proper medical care?
I am indicating below her earlier conditions and medications following her attack in May 2016 for your review and recommendation:
Why treatment was sought:
1. Parents were away from country for about a month. Was left under care of aunt living in the floor above.
2. Felt frightened (Something bad could happen to her pr [pafrents)
3. Could not cope with stress of work and MBA studies. Depressed/ Mood swing/ Delusion/Restlessness and hallucination at times,
4. Violence at times
Date Doctor Visit # Medication Dose Observation/Comment `
24-May-16; Dr. Rabbani 1;
Tab Lithosun (400mg) ½ + ½ + ½ Tab Quipe (100 mg) 1 + 1 + 2
ab Indever (10 mg) ½ + ½ + ½
Tab Slipam (30 mg) 0 + 0 + 1
Medication could not be administered. Patient refused medication with various complains
31-May-16 Dr. Rabbani 2 nd visit All medicine above plus
Tab Rispolux (2mg) 1 + 1 + 1
Tab Perkinil (5mg) 1 + 1 + 1 Inj. Invega Sustenna (150 mg); 1st and 8 th then monthly once
Neither injection nor medication could be administered. Patient refused vehemently
9-Jun-16 Homeopath 3 4 doses (small bottles)
Not known-1st dose: Patient felt rejuvenated after first dose.
16-Jun-16: 2nd dose :Lack of sleep both during day and night. On Jun 19 walks all the way from home to abut 4.5 km under sun. Severe delusion on XXXXXXX 20. Insists this was Ramadan 27 Infact 13 th) . Administered Dr, Rabbani's medication. Agitated and got violent, Wanted to leave home for walk,
20-Jun-16: Admitted to Beacon Point (Clinic) under Dr, Rabbani. Reportedly refused medicine and at times food. Insisted she was okay. At times was fasting. Medication was apparently forced fed. Always spoke of wanting to take homeo medication. Remorseful about misbehaving with parents. First visit allowed-July 26. Physically looked well. Keen to return and resume homeo. Had to be kept at Beacon.
Dr. Rabbani Treatment at Beacon Point: Inj (i/M;I/V); Invega Sustenna (150mg-3); Halopid (5 mg), Opsonil (50 mg), Fenazin (25 mg) ; Clinsol-1(500 cc); Hartman Solution-1 (500 cc) TABLETS: All as during second visit plus Seroquet (100 mg) and Rispolux (4mg)- Doses not known
18-Aug-16 Released from Beacon
With following Medication Advice:
Tab Lithosun (400mg) 0 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
ab Rispolux (4mg) 0 + 0 + 1 Tab Parkiroll (0.25mg) 1 + 1 + 1
Tab. Seroquet (100 mg) 0 + 0 + 2 Tab Kemadrin (5 mg) 1 + 0 + 1
Tab Lozicum (1 mg) 1 + 1 + 2
nj.Fenazin (25 mg) fortnightly
Inj. Invega Sustenna (150 mg)-monthly
Above medication was not administered `
20-Aug-17 XXXXXXX XXXXXXX 1
Tab Mirez (15 mg) 0 + 0 + 1 ng/ml
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 0 + 1 + 1
Tab Gabatin (300 mg) 1 + 0 + 1
Tab Catapres (0.1 g) 0 + 0 + 1
ab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1
CaC 1000 1 + 0 + 0
27-Aug-17 XXXXXXX XXXXXXX 2 Tab Mirez (15 mg) 0 + 0 + 2 Refers patient to endocrinologist for immediate consultation/ hospitalization. Patient was very restless for the long drive to XXXXXXX and wait for the doctor. Doctor was very agitated with Beacon due to prolactin level was also displeased with me. He increased the doses of almost all the medicine but asked to stop the last three. I chose to stick to his Aug 20 prescription as I can see gradual imptovment. Yet to consult endocrinologist.
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 1 + 2 + 1
Tab Gabatin (300 mg) 1 + 1 + 1
Tab Catapres (0.1 g) 1 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1 Continued for sometime
CaC 1000 1 + 0 + 0
Medication by Dr. Golam Rabbani, XXXXXXX 20 to August 18 (Stay in Clinic)
Tab Lithosun (400mg) ½ + ½ + ½
Tab Quipe (100 mg) 1 + 1 + 2
Tab Indever (10 mg) ½ + ½ + ½
Tab Slipam (30 mg) 0 + 0 + 1
Tab Rispolux (2mg) 1 + 1 + 1
Tab Perkinil (5mg) 1 + 1 + 1
Tab Seroquet (100 mg)
Inj. Invega Sustenna (150 mg) 1st and 8 th then monthly
Inj. Fezanin (25 mg) Fortnightly
Others used: Halopid (5 mg), Opsonil (50 mg),
Medication by Dr. XXXXXXX XXXXXXX August 20
Tab Mirez (15 mg) 0 + 0 + 1
Tab Parkifen (5mg) 1 + 0 + 1
Tab Epnil (1mg) 0 + 1 + 1
Tab Gabatin (300 mg) 1 + 0 + 1
Tab Catapres (0.1 g) 0 + 0 + 1
Tab Indever (10 mg) ½ + ½ + ½
Vit E (200mg) 1 + 0 + 1
CaC 1000 1 + 0 + 0
Medication by Dr. XXXXXXX Al-Mamun Date: 30 August 2015
Tab Gabatin (300 mg) 1 + 0 + 1 Continue
Tab Mirez (7.5 mg) 0 + 0 + 1 Continue
Tab Parkinil (5mg) 1 + 0 + 1 Continue
Tab Otosil (25 mg) 1 + 0 + 1 2 months
Tab Epnil (0.5 mg) 0 + 0 + 1 1 month Increase if restless
Tab Qpine (100 mg) 0 + 0 + ½ Continue
Medication by Dr Rezwana Qadri (current medication). Will continue with her.
She does not blame the medication though,
Can you pleach reach out to other doctors and seek their opinion if possible before you send a response. Will much appreciate. Also wanted to talk to you over viber, skype, messenger, whatsapp; Is this possible? Please copy your response to my email too if possible?
My daughter's voice is still same,. Looking forward to your valuable advice? You may refer to other specialist if deemed appropriate.
Regards
XXXX
Brief Answer:
She will improve with this drugs
Detailed Answer:
Hi, XXXX.
Thanks for writing again.
I have read your query and understood your concerns regarding health of her.
You have asked many questions, So I shall answer accordingly.
1. Mirtaz (7.5 mg): 0+0+1/2: can be stopped, no alternatives needed
Gabatine (300 mg): 0+0+1: There is no need for this drugs, can be stopped
Hexinor (2mg): 1+1+1: necessary drug: increase 2-1-1
Otosil (25mg): 0+0+1: can be stopped, no alternatives needed
Qpine (100 mg): 0+0+1/4 i.e. 25 mg: can be continued
2. already mentioned
3. already mentioned
4. Usually stopping drugs like Otosil, Mirtaz and Gabatine can cause discontinuation symptoms but only when they are given in high doses. Here, they are running on small dose, so there wont be any problem. I also have suggested to increase the Hexinor 2mg, so it would cover it. (I consider Hexinor
as Trihexyphenidyl)
She was given high dose of antipsychotics and that is why she has developed these kinds of side effects. There is nothing to blame to doctor because she was not taking drugs orally, so Doctor had to be give drugs intramuscular that is invega sustenna and and fenazine.
Answer the following questions:
1. Does her body stiff? Difficult to flex her elbow by you?
2. Do her hands shake when kept outstretched in front of body?
3. Does she salivate?
4. How is she medically?
5. She was admitted to beacon point. She must have been investigated. Attach the blood investigation in next query.
Important investigations are: Complete blood count, Serum Creatinine, Blood urea, Serum elctrolytes, Liver function tests and most important is serum CPK.
I understand your concerns but you have said that she is improving, so it is better to wait and see the improvement.
If she is not sleeping properly then I would suggest to give her benzodiazepines like lorazepam in the dose of 2 to 4 mg at night.
Whatever changes I have suggested, must be implemented with your treating doctor's consultation because I am not there to see her in case of any urgency.
I am a specialist for the management of these kinds of side effects, so There is no need to take any further opinion from other doctors. Neurologist also refer these kinds of patients to us for management.
If you need to contact me directly then ask query directly to me. Find me in the psychiatrist panel in this website and ask directly.
Follow this URL: http://doctor.healthcaremagic.com/doctors/dr-ravi-soni/67402
Hope I have answered your query and tried my best to resolve your issues.
Regards, Dr Ravi Soni.
She will improve with this drugs
Detailed Answer:
Hi, XXXX.
Thanks for writing again.
I have read your query and understood your concerns regarding health of her.
You have asked many questions, So I shall answer accordingly.
1. Mirtaz (7.5 mg): 0+0+1/2: can be stopped, no alternatives needed
Gabatine (300 mg): 0+0+1: There is no need for this drugs, can be stopped
Hexinor (2mg): 1+1+1: necessary drug: increase 2-1-1
Otosil (25mg): 0+0+1: can be stopped, no alternatives needed
Qpine (100 mg): 0+0+1/4 i.e. 25 mg: can be continued
2. already mentioned
3. already mentioned
4. Usually stopping drugs like Otosil, Mirtaz and Gabatine can cause discontinuation symptoms but only when they are given in high doses. Here, they are running on small dose, so there wont be any problem. I also have suggested to increase the Hexinor 2mg, so it would cover it. (I consider Hexinor
as Trihexyphenidyl)
She was given high dose of antipsychotics and that is why she has developed these kinds of side effects. There is nothing to blame to doctor because she was not taking drugs orally, so Doctor had to be give drugs intramuscular that is invega sustenna and and fenazine.
Answer the following questions:
1. Does her body stiff? Difficult to flex her elbow by you?
2. Do her hands shake when kept outstretched in front of body?
3. Does she salivate?
4. How is she medically?
5. She was admitted to beacon point. She must have been investigated. Attach the blood investigation in next query.
Important investigations are: Complete blood count, Serum Creatinine, Blood urea, Serum elctrolytes, Liver function tests and most important is serum CPK.
I understand your concerns but you have said that she is improving, so it is better to wait and see the improvement.
If she is not sleeping properly then I would suggest to give her benzodiazepines like lorazepam in the dose of 2 to 4 mg at night.
Whatever changes I have suggested, must be implemented with your treating doctor's consultation because I am not there to see her in case of any urgency.
I am a specialist for the management of these kinds of side effects, so There is no need to take any further opinion from other doctors. Neurologist also refer these kinds of patients to us for management.
If you need to contact me directly then ask query directly to me. Find me in the psychiatrist panel in this website and ask directly.
Follow this URL: http://doctor.healthcaremagic.com/doctors/dr-ravi-soni/67402
Hope I have answered your query and tried my best to resolve your issues.
Regards, Dr Ravi Soni.
Above answer was peer-reviewed by :
Dr. Veerisetty Shyamkumar
Dear Dr. XXXXXXX
Many thanks for the elaborate and useful response. Firstly answers to your questions:
1. Body not stiff. Can flex elbow. Regularly skips.
2. Hands do not shake.
3, Normal saliva but complains about dry mouth.
4. Medically okay. Sugar slightly high. Not usual though,
5. Blood report-Beacon did immediately after admission. Recent one attached.
All available reports are being sent. Doctor appointment on Oct 15. Will let you know the results later. Meanwhile if you have any observations please let me know,
Many thanks for the elaborate and useful response. Firstly answers to your questions:
1. Body not stiff. Can flex elbow. Regularly skips.
2. Hands do not shake.
3, Normal saliva but complains about dry mouth.
4. Medically okay. Sugar slightly high. Not usual though,
5. Blood report-Beacon did immediately after admission. Recent one attached.
All available reports are being sent. Doctor appointment on Oct 15. Will let you know the results later. Meanwhile if you have any observations please let me know,
Brief Answer:
Reports are good
Detailed Answer:
Hi, Mr. XXXX, Thanks for writing again.
I have read your answers and according to it, she is better now and surely will improve within next few days with these medications.
You need not worry and take proper care of her. It may be possible that after recovering from these side effects, she might developed the same psychiatric symptoms. So, keep an eye on that.
I think that serum prolactin and other hormonal reports should be done again, so that we have better idea about the recovery.
Hope I have answered your query. If you have any other query then you can write me any time.
Regards,
Dr Ravi Soni.
Reports are good
Detailed Answer:
Hi, Mr. XXXX, Thanks for writing again.
I have read your answers and according to it, she is better now and surely will improve within next few days with these medications.
You need not worry and take proper care of her. It may be possible that after recovering from these side effects, she might developed the same psychiatric symptoms. So, keep an eye on that.
I think that serum prolactin and other hormonal reports should be done again, so that we have better idea about the recovery.
Hope I have answered your query. If you have any other query then you can write me any time.
Regards,
Dr Ravi Soni.
Above answer was peer-reviewed by :
Dr. Prasad
Dear Dr. XXXXXXX
Little confused. So I should keep the present doses of medicine going on and wait to see what the doctor says. If the medicine is further tapered the symptoms may itself go away? Will she have to be on some medication for the long-term to stop any relapse? Will psychotherapy help reliance on medication? Sorry to bother you. Different doctors have different opinions so it is frustrating. You may respond at your convenience.
Regards
XXXX
Little confused. So I should keep the present doses of medicine going on and wait to see what the doctor says. If the medicine is further tapered the symptoms may itself go away? Will she have to be on some medication for the long-term to stop any relapse? Will psychotherapy help reliance on medication? Sorry to bother you. Different doctors have different opinions so it is frustrating. You may respond at your convenience.
Regards
XXXX
Brief Answer:
I shall resolve your confusion
Detailed Answer:
Hi, Mr XXXX, thanks for writing again.
Just remember this:
1. Continue current medications.
2. Wait for next appointment to your doctor. Discuss with the treating doctor about her condition and repeat the hormonal assays.
3. Drugs are to be continued on the basis of improvement she has. E.g. Her prolactin level and other hormonal assays should be normalized before stopping the drugs. Her mental condition should be improved.
4. Drugs can be tapered if she is improving. Here, drugs are given to resolve the side effects and not to treat her basic psychiatric condition. So, if she is improving then the drugs should be reduced and gradually discontinued.
5. She needs to be on at least one antipsychotic to prevent relapse of psychiatric illness.
6. If the psychiatric symptoms are severe, she wont listen or respond to psychotherapy. Once her condition improves with antipsychotics, she can be exposed to psychotherapy.
Hope I have answered according to your questions. There is no need to hesitate in asking questions. If you have any further questions then ask at any time.
Regards, Dr Ravi Soni.
I shall resolve your confusion
Detailed Answer:
Hi, Mr XXXX, thanks for writing again.
Just remember this:
1. Continue current medications.
2. Wait for next appointment to your doctor. Discuss with the treating doctor about her condition and repeat the hormonal assays.
3. Drugs are to be continued on the basis of improvement she has. E.g. Her prolactin level and other hormonal assays should be normalized before stopping the drugs. Her mental condition should be improved.
4. Drugs can be tapered if she is improving. Here, drugs are given to resolve the side effects and not to treat her basic psychiatric condition. So, if she is improving then the drugs should be reduced and gradually discontinued.
5. She needs to be on at least one antipsychotic to prevent relapse of psychiatric illness.
6. If the psychiatric symptoms are severe, she wont listen or respond to psychotherapy. Once her condition improves with antipsychotics, she can be exposed to psychotherapy.
Hope I have answered according to your questions. There is no need to hesitate in asking questions. If you have any further questions then ask at any time.
Regards, Dr Ravi Soni.
Above answer was peer-reviewed by :
Dr. Yogesh D
Dear Dr. XXXXXXX
Her doctor assessed today and asked to continue the medicine with the following changes:
1. Increase the Mirtaz (Mirtazapine) to 7.5 from 3.75 this is a night time dose only.
2. Added Bromazepam 3 mg, Dose 0.75 mg 2 or 3 times daily when the voice quality deteriorates. We will try to go for twice.
3. Promethezine (Otosil) dropped.
She sounds better when she wakes up in the morning but the voice gets more slurred as the day progreeses and gets quite depressed. That's why Doctor chose to increase Mirtaz dose.
The problem is she doesn't want to take any medicine and feels that way things will be okay with her. This is a constant battle we parents are fighting with success till now. Don't know how long we can keep going. Any idea of how long she may take to recover her voice?
Regards
XXXX
Her doctor assessed today and asked to continue the medicine with the following changes:
1. Increase the Mirtaz (Mirtazapine) to 7.5 from 3.75 this is a night time dose only.
2. Added Bromazepam 3 mg, Dose 0.75 mg 2 or 3 times daily when the voice quality deteriorates. We will try to go for twice.
3. Promethezine (Otosil) dropped.
She sounds better when she wakes up in the morning but the voice gets more slurred as the day progreeses and gets quite depressed. That's why Doctor chose to increase Mirtaz dose.
The problem is she doesn't want to take any medicine and feels that way things will be okay with her. This is a constant battle we parents are fighting with success till now. Don't know how long we can keep going. Any idea of how long she may take to recover her voice?
Regards
XXXX
Brief Answer:
She will improve gradually
Detailed Answer:
Hi, Mr. XXXX.
Thanks for writing again.
I read your reply and I think doctor is going on right track, nothing more is needed now.
Her prolactin level must be assessed again.
Here, in my country, I usually give Electroconvulsive therapy (ECT) to such patient, who has severe symptoms, doesn't take drugs and has side effects with injectables. I don't know about Dhaka and How psychiatrist practice there? but ECT is very good, effective and safe option. It is not like what they depict in movies. It is completely safe and given under general anesthesia with proper emergency care. The duration of the procedure is only 10 to 15 minutes.
If possible, this option needs to be considered.
For dysarthria, I strongly believe that it is due to Side effects of the drugs and will gradually improve with time. It has improved recently, correct me if I am wrong.
If it doesn't improve for more than 3 to 4 months than we can go for CT scan Head or MRI Brain. Not needed if she is improving.
I want to ask few questions about the dysarthria:
1. Does the tongue start moving continuously?
2. Does the jaw move? Chewing movement?
3. Does she protrude the tongue repeatedly?
4. Does the tongue movement look like a worm or insect is crawling?
5. Does she have difficulty in opening the mouth?
6. Does she stutter?
You can watch a video of tardive dyskinesia affecting bucc-ofacial area over you tube and try to compare it with your daughters.
you can also see videos of dysarthria and sent me URL of the video which is matching with your daughter's movement.
I am waiting for your reply.
Regards,
Dr Ravi Soni.
She will improve gradually
Detailed Answer:
Hi, Mr. XXXX.
Thanks for writing again.
I read your reply and I think doctor is going on right track, nothing more is needed now.
Her prolactin level must be assessed again.
Here, in my country, I usually give Electroconvulsive therapy (ECT) to such patient, who has severe symptoms, doesn't take drugs and has side effects with injectables. I don't know about Dhaka and How psychiatrist practice there? but ECT is very good, effective and safe option. It is not like what they depict in movies. It is completely safe and given under general anesthesia with proper emergency care. The duration of the procedure is only 10 to 15 minutes.
If possible, this option needs to be considered.
For dysarthria, I strongly believe that it is due to Side effects of the drugs and will gradually improve with time. It has improved recently, correct me if I am wrong.
If it doesn't improve for more than 3 to 4 months than we can go for CT scan Head or MRI Brain. Not needed if she is improving.
I want to ask few questions about the dysarthria:
1. Does the tongue start moving continuously?
2. Does the jaw move? Chewing movement?
3. Does she protrude the tongue repeatedly?
4. Does the tongue movement look like a worm or insect is crawling?
5. Does she have difficulty in opening the mouth?
6. Does she stutter?
You can watch a video of tardive dyskinesia affecting bucc-ofacial area over you tube and try to compare it with your daughters.
you can also see videos of dysarthria and sent me URL of the video which is matching with your daughter's movement.
I am waiting for your reply.
Regards,
Dr Ravi Soni.
Above answer was peer-reviewed by :
Dr. Raju A.T
Dear Dr XXXXXXX
Here are the responses to your queries:
1. Tongue does not move continuously or involuntarily. Only when she speaks.
2-6. Not at all. It is only words that require the teeth to be closed or some force of the jaws the words are not pronounced properly.
She can pronounce all the words but like said above many don't come out clearly. I will send an audio clipping. She can pronounce words like Abba, Amma very clearly.
Do you think Bromapezam will help.
Excepting in hospitals and in severe cases ECT is not used I suppose.
She is very normal now only her mental framework may need a bit more strengthening to bear stress if she goes back to work. The voice issue is now a major concern for her and believes giving up all medication will help. Which is not correct and we constantly try to mentor her not to give up medicine without doctor's advice.
Please let me know if you have any additional advice. BTW as indicated above by God's grace she does not show any signs of TD.
Regards
XXXX
Here are the responses to your queries:
1. Tongue does not move continuously or involuntarily. Only when she speaks.
2-6. Not at all. It is only words that require the teeth to be closed or some force of the jaws the words are not pronounced properly.
She can pronounce all the words but like said above many don't come out clearly. I will send an audio clipping. She can pronounce words like Abba, Amma very clearly.
Do you think Bromapezam will help.
Excepting in hospitals and in severe cases ECT is not used I suppose.
She is very normal now only her mental framework may need a bit more strengthening to bear stress if she goes back to work. The voice issue is now a major concern for her and believes giving up all medication will help. Which is not correct and we constantly try to mentor her not to give up medicine without doctor's advice.
Please let me know if you have any additional advice. BTW as indicated above by God's grace she does not show any signs of TD.
Regards
XXXX
Brief Answer:
Her speech is not that bad
Detailed Answer:
Hi, Mr. XXXX.
Thanks for writing again.
I have listened to the Audio message you have attached in mail. I feel that she is pronouncing properly and has good flow in speech. I think she'll improve further.
It is good that she doesn't have TD. These movements of the tongue during speech usually resolve with time.
Usually in NMS (Neuroleptic malignant syndrome), which is a serious side effect and complication of the antipsychotics, we use benzodizepines and that is also like lorazepam. Bromazepam is a benzodiazepine and she does not have NMS as per my observation (I can not be sure because I was not managing her in person, Serum CPK?), So I feel that if she is feeling much sleepy throughout the day, Bromazepam can be shifted to night or the dose can be reduced or gradually stopped.
You have written that it was for improving voice quality. Does it benefit? What is your observation after starting bromazepam? I don't feel it will help, but in a patient of anxiety disorder who can not speak because of anxiety, will surely benefit from a benzodiazepine and that is not the issue in this case.
ECT is also a option, I also do not favor it but in a complicated case like this, it can be a option. If her psychotic illness is gone and all the symptoms resolved than it is very good but the illness can relapse and what can we do if it will happen? We can not give high dose drugs. So, in that case we have to go for ECT. That was the purpose of discussion.
A patient who has psychotic illness, lives in their own imagination and reality. They believe in their imagination. They do not feel that they are ill and therefore they have lost the touch of reality. They will always say that they are fine, but actually they are not, that is why they are called psychotic.
At present, nothing to be done, just take proper care of her. Voice will improve and she'll speak clearly within couple of weeks.
Hope I have answered your query. If you have any further query than feel free to ask.
Regards,
Dr Ravi Soni
Her speech is not that bad
Detailed Answer:
Hi, Mr. XXXX.
Thanks for writing again.
I have listened to the Audio message you have attached in mail. I feel that she is pronouncing properly and has good flow in speech. I think she'll improve further.
It is good that she doesn't have TD. These movements of the tongue during speech usually resolve with time.
Usually in NMS (Neuroleptic malignant syndrome), which is a serious side effect and complication of the antipsychotics, we use benzodizepines and that is also like lorazepam. Bromazepam is a benzodiazepine and she does not have NMS as per my observation (I can not be sure because I was not managing her in person, Serum CPK?), So I feel that if she is feeling much sleepy throughout the day, Bromazepam can be shifted to night or the dose can be reduced or gradually stopped.
You have written that it was for improving voice quality. Does it benefit? What is your observation after starting bromazepam? I don't feel it will help, but in a patient of anxiety disorder who can not speak because of anxiety, will surely benefit from a benzodiazepine and that is not the issue in this case.
ECT is also a option, I also do not favor it but in a complicated case like this, it can be a option. If her psychotic illness is gone and all the symptoms resolved than it is very good but the illness can relapse and what can we do if it will happen? We can not give high dose drugs. So, in that case we have to go for ECT. That was the purpose of discussion.
A patient who has psychotic illness, lives in their own imagination and reality. They believe in their imagination. They do not feel that they are ill and therefore they have lost the touch of reality. They will always say that they are fine, but actually they are not, that is why they are called psychotic.
At present, nothing to be done, just take proper care of her. Voice will improve and she'll speak clearly within couple of weeks.
Hope I have answered your query. If you have any further query than feel free to ask.
Regards,
Dr Ravi Soni
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Above answer was peer-reviewed by :
Dr. Prasad
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