Let's Twist Again

The other night at work a nurse brought me a prepackaged table that had been found lying unguarded on a counter near the new drug storage cabinet. “What’s this?” she asked, holding out a blister pack containing an oval, pale yellow tablet.

A bit of skillful detective work (we flipped the package over and read the label) found the tablet to be benztropine, otherwise known as Cogentin. The nurse can’t be blamed for not knowing what it was. It takes a wily and experienced (translated as “old”) clinician like me to fully tell its’ tale.

The story of Cogentin actually starts with the older antipsychotic medications like chlorpromazine (Thorazine) and thioridazine (Mellaril). The science suggests that schizophrenia and other psychotic states are caused, at least in pa art, by excess activity of a chemical called dopamine within the brain. Thorazine, Mellaril, and other older, “typical” antipsychotics work by blocking the action of dopamine within the frontal cortex and limbic system, portions of the brain involved in thought and feeling. But dopamine is a two-edged sword. Excess dopamine activity may lead to schizophrenia, but one of the hallmarks of Parkinson’s Disease, which is primarily a motion disorder, is a lack of dopamine within the deeper structures of the brain that control movement. As a result, even appropriate doses of antipsychotics can result in problems, which fall under a broad heading of “neuroleptic-induced movement disorders.” Cogentin is one of the medications used to control these side effects.

I learned about these problems for the first time on my med school psych rotation. At Western Missouri Mental Health Center (“Listening to the Voices in Your Head Since 1899”), the locked 4th floor was the hotbed of schizophrenic activity in Western Missouri. At the time, the preferred treatment for schizophrenia...or at least the only one I heard about…was to give as much Mellaril as you could find, followed by Cogentin for the inevitable side effects. This was the sole treatment plan authorized by our attending physician, who had an encyclopedic knowledge of Mellaril and a fully anencyclopedic knowledge of any other psychotherapeutic drug on the market. This is during an era when the number of effective drugs you had to know about was probably seven, and while it was known that brain chemistry probably had something to do with mental illness, most likely what really made you nuts was that your id had gotten into a fender bender with your superego and was contacting the Oedipal Law Firm to sue your mother or something like that. But once I had figured out the predominant treatment plan, it suddenly made sense why Father Marshall, who I thought was merely the Catholic Chaplain at the hospital, had a tongue that constantly darted in and out from between his lips like a garter snake and seemed to be talking to no one in particular at any given time.

(It was also one of the peculiarities of the time…and it still may be, I don’t know…that all the attending physicians and residents in psychiatry were foreign medical graduates. It always puzzled me why, in a specialty where communication and cultural sensitivity is probably more important than any other, the majority of doctors couldn’t speak the King’s English, let alone mine. But on occasion we were able to use this to our advantage. We’d tell patients who were destined to spend some time at Western Missouri…WoMo…that, “there are doctors there from all over the world that are here to take care of you.” That would hold ‘em long enough to get across the street.)

Most of time in the ED, these side effects are simply interesting things to note. On occasion, however, they present as a real live acute condition. People who have never been exposed to high-potency antipsychotics before may suffer from what’s known as a dystonic reaction. Dystonia results in contractions, twisting, and contortion of the facial muscles and the extremities, the same look you might find in Tea Partiers who inadvertently strolled into a showing of the Hustler Classic “Who’s Nailin’ Palin.”

The Golden Age of Emergent Dystonia in the 1990’s was a result of a marketing error. Haloperiodol (Haldol) is a potent antipsychotic that works by in a manner similar to Thorazine. Diazepam (Valium) is an anxiolytic and muscle relaxant that causes drowsiness. Both of them were small blue tablets. So when you were having trouble getting to sleep, your friend with the “thinking problems” gave you one of their small blue tablets that were “just like Valium.”

The folks who made Valium were understandably concerned that their tablets were getting mixed up with Haldol. So they decided that they would distinguish their product by cutting as small “V” into the tablet. At the same time, the makers of Haldol wanted to be sure that their tablets were not being mixed up with Valium, so they cut a small “H” into their tablets. Given that both tablets were the same color and about a third of an inch wide, this precaution had no effect at all.

Dystonia is actually really fun to treat. It’s one of those rare “instant cures’ in the ED that make you look like a total ace. The patient comes in all twisted and looking like The Elephant Man without the lumpiness. They are scared to death because they can’t control what their body does. But an intravenous injection of diphenhydramine (Benadryl) literally fixes then within about two minutes. One fun thing to do is to give the medication, wait fifteen seconds and then ask the patient to slowly recite the alphabet. You can actually see their bodies relax and hear their speech clear up as they go, and by the time they hit M they’re all better. When this occurs, they cannot be effusive enough in their praise of you. (These are the patients who go to Steak n’ Shake in the middle of the night and are so happy not to be deceased that they bring you a Double Steakburger and an Orange Freeze without you even asking.)

There are better medications out there now, antipsychotics that work through several different mechanisms at once and pose much less risk of harm to the patient. Still, it’s sometimes sad to see our quick fixes go by. There are so few opportunities for heroism in the ED, or at least heroism that the patient is aware of. It’s a truism of the ED that when you actually save a life, chances are the patient is too far out of it to have any memory of you. The doctor who gets the credit is the first one they see when they wake up. Especially if his tongue flicks in and out like a snake.