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614-893-0910 or BTCarroll1@cs.com - 614-937-9427
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THE 4 TOWERS OF NMS
Delay, identified "Syndrome Malin Neuroleptique" and defined it in terms of exposure to neuroleptics.
Hyperthermia
Rigidity (EPS)
Autonomic Changes
Poor Outcome
In 1993 Sternbach described the Serotonin Syndrome.
Efforts to separate SS from NMS are based in orientation.
Suppose there is no difference as suggested by the Universal Field Hypothesis of Catatonia and NMS.
Can NMS and SS be differentiated?
Carroll, Graham & Thalassinos say NO!
There is no set of criteria that can differentiate these syndromes.
Perhaps it is possible on an individual basis, this may involve treatment response.
Carroll, Taylor, Northoff and Fink have stated that LC & NMS cannot be differentiated by clinical criteria?
Then there is the variability of NMS criteria:
1. Levenson
2. Guererra
3. Carroll, poster presentation
Then there is the variability of SS criteria
1. Sternbach
2. Look at NMS book, authors
Are there NMS Scales?
1. Yacoub-Francis NMS
2. Hines-Vickar NMS scale
Are there any SS scales? Yes, Hergl.
How do they differ? Not a lot.
1. SS - Diarrhea, diaphoresis, myoclonus
2. NMS – CPR, high level of hyperthermia
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In 2000, Dr. Lee came to the Chillicothe VAMC he presented a Tripartite model of NMS.
C-NMS NMSwC NMSw/oC
While the implications of this model are important, this has not been tested in a large database, (it was drawn from 12 of Dr. Lee’s cases)
While the number of specific medications that have been ascribed to either NMS or SS is voluminous, it suffices to say that the majority of cases is caused by multiple psychotropic medications. Very often, these medications have been implicated in either SS or NMS or both.
(NMS Chapter)
Of note is the fact that medications may share variable effects on the dopamine and serotonin. Most recently is the fact that novel antipsychotics have both dopamine blockade and serotonin increased activity.
I have previously argued that NMS and Catatonia are related to the same or similar neuro-chemical changes (Carroll, 2000- Northoff 2002)
We now argue that NMS and SS have the same, similar or overlapping mechanisims.
Of note is the finding of Meth-amphetamine - induced Hyperthermia related death in a retrospective study with Rhesus Monkeys, (Science 2002) while death was from a SS-like syndrome there were depletion of dopamine containing nerve terminals.
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There are four etiologies for NMS, these are shown above.
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In the past year, this result has been retracted, and this finding was for methamphetamine-induced hyperthermia. Nonetheless, dopamine depletion may have a role in these syndromes.
Some have argued about the role of these in Drug Induced Hyperthermia Catatonic syndrome (DIHC) (Additanjee, 2000)
Problem:
Our understanding of NMS is limited by:
1. The exclusion of SS
2. The exclusion of LC
3. The limitation of criteria that rely on the presence of neuroleptics (and related medications)
4. Over reliance on a pathophysiology of dopamine depletion.
5. Failure to appreciate the role of serotonin in the NMS continuum.
6. Failure to appreciate the role of GABA depletion. NMDA (glutamate) receptor function.
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Any one of these conditions or a combination of these conditions can precipitate an NMS-like syndrome.
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