58 year old known schizophrenic on medication since 18years slurred speech altered behaviour lack of speech shivering what could be the reason
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This is a clinically important scenario. Based on authoritative psychiatric and emergency medicine textbooks, here is a structured analysis:
58-Year-Old Schizophrenic on Long-Term Antipsychotics: Differential Diagnosis
Presenting features: Slurred speech (dysarthria), altered behaviour, reduced/lack of speech (mutism/poverty of speech), shivering/tremor
1. Neuroleptic Malignant Syndrome (NMS) — Most Urgent to Exclude
A potentially fatal complication of antipsychotic (neuroleptic) use that can occur at any time during treatment — even after years of stable therapy.
Cardinal features:
- Extreme hyperthermia
- Severe muscular rigidity and dystonia
- Akinesia and mutism
- Confusion, agitation
- Increased pulse rate and BP
- Dysarthria, tremor — present as listed symptoms
Lab findings: Elevated CK, WBC (10,000–40,000/mm³), elevated liver enzymes, myoglobinuria, possible renal failure.
Mortality: 20–30% if untreated. Symptoms evolve over 24–72 hours; untreated syndrome lasts 10–14 days.
"The diagnosis is often missed in the early stages, and the withdrawal or agitation may mistakenly be considered to reflect increased psychosis." — Kaplan and Sadock's Synopsis of Psychiatry
Action: STOP the neuroleptic immediately, cool the patient, monitor vitals/electrolytes/renal output, consider dantrolene (0.8–2.5 mg/kg q6h) + bromocriptine (20–30 mg/day).
2. Drug-Induced Parkinsonism / Extrapyramidal Side Effects (EPS)
Long-term antipsychotic use causes dopamine D2 blockade in the nigrostriatal pathway.
Features:
- Tremor (resting, shivering-like)
- Bradykinesia, rigidity
- Dysarthria (from motor rigidity of speech muscles)
- Akinesia, flat affect, reduced spontaneous speech
This is very common after 18 years of antipsychotic use and may worsen progressively.
3. Tardive Dyskinesia / Tardive Syndrome
After prolonged neuroleptic exposure (especially >years), tardive syndromes develop:
- Involuntary movements — can involve tongue, lips, jaw → dysarthria
- Tardive akathisia — restlessness, shivering-like movements
- Altered behaviour
4. Lithium Toxicity (if on lithium for augmentation)
If this patient is on lithium (commonly co-prescribed in schizophrenia), chronic toxicity presents with:
- Dysarthria
- Tremor (postural, coarse)
- Confusion, altered behaviour
- Ataxia, nystagmus
- In severe cases: stupor, seizures, coma
"Neurologic symptoms predominate in chronic [lithium] toxicity. Common symptoms include postural tremor, muscle fasciculation, dysarthria, nystagmus, agitation, and lethargy." — Tintinalli's Emergency Medicine
Chronic lithium toxicity can occur even at therapeutic serum levels in the context of dehydration, renal impairment, or drug interactions.
5. Central Anticholinergic Toxicity
From antipsychotics or anticholinergic co-medications (e.g., benztropine):
- Severe agitation, disorientation
- Hallucinations, seizures, high fever
- Altered consciousness → stupor and coma
6. Worsening/Relapse of Schizophrenia Itself
- Negative symptoms (poverty of speech, mutism, flat affect)
- Disorganised behaviour
- If medication compliance is poor
Priority Action Plan
| Step | Action |
|---|---|
| Immediate | Vital signs, temperature — fever + rigidity = NMS until proven otherwise |
| Labs | CK, CBC, LFTs, electrolytes, renal function, urine myoglobin, lithium level if applicable |
| Medication review | Current antipsychotic, dose, any recent dose changes, co-medications |
| Neurology assessment | For EPS, tardive syndromes |
| If NMS suspected | Stop antipsychotic, ICU-level care, dantrolene + bromocriptine |
| If lithium toxicity | Serum lithium level, hold lithium, IV fluids, consider dialysis if severe |
The most critical diagnosis to rule out first is NMS — it is life-threatening but treatable if caught early. The combination of altered behaviour, mutism, dysarthria, and shivering/rigidity in a patient on long-term neuroleptics is NMS until proven otherwise.
Sources: Kaplan and Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Tintinalli's Emergency Medicine
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