Abstract

This preliminary study done by abstracting relevant data from different testing material and using multiple rating scales, describes the sociodemographic variables, psychopathological correlates, and features of trihexyphenidyl (artane) abuse in a sample of 14 Saudi psychiatric patients and, as a result of this research, various relevant issues have been discussed.

Methods

The sample of this research consisted of 14 psychiatric patients. Based on certain features during a period of three years, these patients were identified abusing artane by a multidisciplinary team of workers from Buraidah Mental Health Hospital. In the past, these patients had on many occasions been interviewed by psychiatric specialists, psychologists, social workers, and mental health nurses, and a majority of the patients had been admitted to the hospital on more than one occasion. Therefore, for the purpose of data abstraction, their outpatient and inpatient files were reviewed. In addition, the author interviewed each patient in a structured manner with all relevant information regarding sociodemographic, clinical parameters, and artane-related features recorded on a specially designed proforma. In this study, the patient's total monthly income derived from different sources was the common denominator for arbitrary social stratification and joint or extended family was defined as a unit comprising of parents, children, and individuals united by kinship or marital ties. For the purpose of assessing the psychopathology and abnormal involuntary movements, the Brief Psychiatric Rating [26] and Abnormal Involuntary Movement [27] scales were administered to each patient. The DSM-111R [28] criteria was applied for personality and diagnostic evaluation. Finally, all patients gave their consent to participate in this research.

Observations

The sociodemographic description of artane abusers (N = 14) showed that the majority were male (92.86%), married (57.14%), adult (27.93 ± 6.55 years), smokers (85.72%) who had a low level of education (71.43%), high unemployment (57.14%), and belonged to a poor class (50%), and extended families (78.57%) with urban background (71.43%). In addition to some features displayed in Table 1, they were clinically characterized by chronic (9 ± 4.77 years) moderate psychopathology of a different nature, had multiple admissions (85.72%), initial diagnostic difficulties (57.14%), early personal history of polydrug abuse (57.14%), and were reported to have multiple stressors (71.42%) mainly related to family (49.98%), used antipsychotics and artane on a long-term basis (5.86 ± 3.1 years), and a few manifested tardive dyskinesia (14.28%).

In addition to the features of artane abuse as shown in Table 1, it was also demonstrated that all patients developed artane craving. Two patients developed artane craving after a mean duration of 50 days while 64.30% after 3.33 years. Symptoms of withdrawal included palpitations, restlessness, bodyaches, lethargy, irritability, aggression, discomfort, moderate to severe craving, low level of socialization, anxiety, and nausea. Vomiting and diarrhea was reported by one patient. Two patients (14.28%) showed extrapyramidal symptoms (EPS). Similarly, a substantial number of patients (85.72%), showed a tolerance, two patients used 8 mg/day, whereas 71.40% consumed mean doses of 42 mg/day. Artane reinstitution resulted in relieving the abstinent symptoms in all patients. Their distressing symptoms remained unaffected by drug modification (85.72%), and no immediate effect was noticed with benztropine (85.72%). A majority of patients (78.58%) were given artane on a prophylactic basis. In addition to different hospitals (100%), and private clinics (21.42%) being the main sources of artane, one patient shared it with his schizophrenic sibling, while two patients (14.28%) feigned EPS by protruding the tongue and rolling up eyeballs. Finally, 12 patients (85.72%) were successfully treated and two continued to have artane administered on a controlled basis with substantial improvement in negative symptoms.

Table 1. Some characteristics of artane abusers.

 (a) more than one disorder in first degree relatives; (b) more than one method by single patient;

(c) conveyed to physicians; (d) more than one drug by a single patient

Discussion

In addition to describing the demographic and clinical parameters of comorbidity disorders of artane abusers, this study also highlighted the features of artane abuse. Although there was limited information about the diagnostic criteria of artane abuse, this research revealed certain markers suggestive of artane dependence. Furthermore, an intriguing phenomenon found was that most of the patients with artane dependency continued to shift to its abuse for a considerable period of time. Similarly, another fascinating feature was that chronic artane abusers characterized by certain somatizations during abstinent period were liable to abuse other drugs such as benzodiazepines, phenergan, and spasmocibalgin. The possible implication of later findings was that artane abusers should not be prescribed drugs having a potentiality for abuse.

In relation to demographic parameters, it was found that artane abusers had more or less similar trends reported in other drug abuse researches [29]. However, the majority of artane abusers were married and came from joint families probably signifying the role of cultural factors. Interestingly, the high prevalence of smoking in artane abusers may reflect a sampling bias or a true dimension in mental patients which, in addition to demographic parameters, is in need of larger analytical studies.

The evaluation of comorbidity disorders of artane abusers found that the majority of patients had schizophrenic psychopatholgies which was not harmonious with other researchers [30]. The predominant liability of schizophrenics to abuse artane, as found, might be attributed to a number of possible factors including exorbitant exposure to artane, aberrant personality traits, negative symptomatology, personal and family history of polydrug abuse, especially stimulants and frequent admissions where they feigned EPS [22] to obtain artane. With regard to other clinical correlates, especially the low prevalence of tardive dyskinesia, was a fascinating finding which might be either due to drug variables, single AIM scale, sampling bias or some unknown factors. However, the high rates of initial diagnostic instability of comorbidity disorders may reflect either the initial confounding drug abuse factor, the perception of illness both by relatives and physicians, or the interviewing techniques and diagnostic criteria used.

The underlying neurobiological mechanisms of artane dependence/abuse are not well understood. However, according to some workers [2,25,31], the anxiolytic, antidepressant and mood elevating and hallucinogenic properties of artane are crucial determining factors for its abuse. Corollary to this study, it is of my opinion that early experiences with stimulant drugs, relief from somatopsychic pains, relatively easy and cheap availability, and indiscriminate prolonged prescriptions which provided patients with sufficient time to recognize the euphorogenic effects might be other possible contributory factors in the etiological formulation of artane abuse.

Despite its association with multiple complications, the controlled use of artane may benefit a group of patients (14.28%) whose lifestyles are characterized by multiple stresses and persistent. negative, disturbing psychopathology as they showed good improvement in functioning and in negative symptoms with minimal or no adverse anticholinergic effects [32]. In conclusion, the findings of this uncontrolled, preliminary study should be taken cautiously as they are tentative in nature and therefore a relatively large multicenter analytical study is warranted.

Acknowledgments

The author expresses his appreciation to all staff members for the permission to study their cases and also to staff of Online Search Division of King Abdulaziz City for Science and Technology for providing relevant literature, and Ms. M. B. Mejia for secretarial help.

References