Abstract
Neuroleptic malignant syndrome (NMS) continues to be an unpredictable and rare, but potentially fatal complication of antipsychotic medications. Presumptively linked to dopamine blockade, it nonetheless occurs in patients receiving newer atypical antipsychotics. The features of NMS, its pathophysiology, differential diagnosis, clinical course, risk factors, and morbidity and motality are reviewed. Nonpharmacologic management centers on aggressive supportive care including vigilant nursing, physical therapy, cooling, rehydration, anticoagulation. Pharmacologic interventions include immediate discontinuation of antipsychotics, judicious use of anticholinergics, and adjunctive benzodiazepines. The utility of specific agents in actively treating NMS is reviewed. Bromocriptine and other dopaminergic drugs and dantrolene sodium have alternatively been considered without merit or efficacious. Guidelines for using these agents are presented. Electroconvulsive therapy, also somewhat controversial, is identified as a second line of treatment. Finally, management of the post-NMS patient is also reviewed.
Similar content being viewed by others
REFERENCES
Caroff SN: The neuroleptic malignant syndrome. J Clin Psychiatry 41:79–83, 1980.
Keck PE Jr, Pope HG, McElroy SL: Frequency and presentation of neuroleptic malignant syndrome: A prospective study. Am J Psychiatry 144:1344–1346, 1987.
Friedman JH, David R, Wagner RL: Neuroleptic malignant syndrome: The results of a 6-month prospective of incidence in a state psychiatric hospital. Clin Neuropharmacol 11:373–377, 1988.
Gelenberg AJ, Bellinghausen B, Wojcik JD, et al: A prospective survey of neuroleptic malignant syndrome in a short-term psychiatric hospital. Am J Psychiatry 145:517–518, 1988.
Berardi D, Amore M, Keck P Jr, Troia M, Dell'Atti M: Clinical and pharmacologic risk factors for neuroleptic malignant syndrome: A Case-Control Study. Biol Psych 44:748–754, 1998.
Fawcett J: How do we keep our eyes open? Psychiatric Annals 30:304, 2000.
Hasan S, Buckley P: Novel antipsychotics and the neuroleptic malignant syndrome: A review and critique. Am J Psychiatry 155:1113–1116, 1998.
Wedzicha JA, Hoffbrand BI: Neuroleptic malignant syndrome and hyponatraemia. Lancet 1:963, 1984.
Gibb WRG, Wedzicha JA, Hoffbrand BI: Recurrent neuroleptic malignant syndrome and hyponatraemia. J Neurol Neurosurg Psychiatry 49:960–961, 1986.
Gurrera RJ: The role of calcium and peripheral catecholamines in the pathophysiology of neuroleptic malignant syndrome. Psychiatric Annals 30:356–362, 2000.
Rosebush PI, Mazurek MF: Serum iron and neuroleptic malignant syndrome. Lancet 338:149–151, 1991.
Friedman JH, Feinberg SS, Feldman RG: A neuroleptic malignant-like syndrome due to levodopa therapy withdrawal. JAMA 254:2792–2795, 1985.
Gibb WRG, Griffith DNW: Levodopa withdrawal syndrome identical to neuroleptic malignant syndrome. Postgrad Med J 62:59–60, 1986.
Simpson SM, Davis GC: Case report of neuroleptic malignant syndrome associated with withdrawal from amantadine. Am J Psychiatry 141:796–797, 1984.
Lazarus A: Neuroleptic malignant syndrome and amantadine withdrawal. Am J Psychiatry 142:142, 1985.
Toru M, Matsuda O, Makiguchi K, et al: Neuroleptic malignant syndrome-like state following a withdrawal of antiparkinsonian drugs. J Nerv Ment Dis 169:324–327, 1981.
Gurrera RJ: Sympathoadrenal hyperactivity and the etiology of neuroleptic malignant syndrome. Am J Psychiatry 156:169–180, 1999.
Demirkiran M, Jakovic J, Dean JM: Ecstasy intoxication: An overlap between serotonin syndrome and neuroleptic malignant syndrome. Clin Neuropharmacology 19:157–164, 1996.
Sternbach H: The serotonin syndrome. Am J Psychiatry 148:705–713, 1991.
Keck PE Jr, Arnold LM: The serotonin syndrome. Psychiatric Annals 30:333–343, 2000.
Addonizio G, Susman VL, Roth SD: Neuroleptic malignant syndrome: Review and analysis of 115 cases. Biol. Psychiatry 22:1004–1020, 1987.
Shalev A, Munitz H: The neuroleptic malignant syndrome: Agent and host interaction. Acta Psychiatr Scand 73:337–347, 1986.
Rosebush P, Stewart T: A prospective analysis of 24 episodes of neuroleptic malignant syndrome. Am J. Psychiatry 146:717–725, 1989.
Deuschl G, Oepen G, Hermle L, et al: Neuroleptic malignant syndrome: Observations on altered consciousness. Pharmacopsychiatry 20:168–170, 1987.
Dowling JJ, Patrick V: Delirium with dystonia: A variant of neuroleptic malignant syndrome? Am J Psychiatry 146:276–277, 1989.
Dursun SM, Oluboka OJ, Devarajan S, Kutcher SP: High-dose vitamin E plus vitamin B6 treatment of risperidone-related neuroleptic malignant syndrome.J of Psychopharmacology 12:220–221, 1998.
Rosebush PI, Stewart T, Mazurek MF: The treatment of neuroleptic malignant syndrome: Are dantrolene and bromocriptine useful adjuncts to supportive care? Brit J of Psych 159:709–712, 1991.
Rosenberg MR, Green M: Neuroleptic malignant syndrome: review of response to therapy. Arch Intern Med 149:1927–1931, 1989.
Sakkas P, Davis JM, Hua J, Wang Z: Pharmacotherapy of neuroleptic malignant syndrome. Psych Annals 21:157–164, 1991.
Kurlan R, Hamill R, Shoulson I: Neuroleptic malignant syndrome. Clin Neuropharmacol. 7:109–120, 1984.
Harris M, Nora L, Tanner CM: Neuroleptic malignant syndrome responsive to carbidopa/levodopa: Support for a dopaminergic pathogenesis. Clin Neuropharmacol 10:186–189, 1987.
Gelenberg AJ, Mandel MR: Catatonic reactions to high-potency neuroleptic drugs. Arch Gen Psychiatry 34:947–950, 1977.
McCarron MM, Boettger ML, Peck JJ: A case of neuroleptic malignant syndrome successfully treated with amantadine. J Clin Psychiatry 43:381–382, 1982.
Francis A, Chandragiri S, Rizvi S, Koch M, Petrides G. Is lorazepam a treatment for neuroleptic malignant syndrome? CNS Spectrum 5:54–57, 2000.
Davis JM, Janicak PG, Sakkas P, Gilmore C, Wang Z: Electroconvulsive therapy in the treatment of the neuroleptic malignant syndrome. Convulsive Therapy 7:111–120, 1991.
Nisijima K, Ishiguro T: Electroconvulsive therapy for the treatment of neuroleptic malignant syndrome with psychotic symptoms: A report of five cases. J of ECT 15:158–163, 1999.
Davis JM, Caroff SN, Mann SC: Treatment of neuroleptic malignant syndrome. Psychiatric Annals 30:325–331, 2000.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Susman, V.L. Clinical Management of Neuroleptic Malignant Syndrome. Psychiatr Q 72, 325–336 (2001). https://doi.org/10.1023/A:1010389215197
Issue Date:
DOI: https://doi.org/10.1023/A:1010389215197