1. ACKNOWLEDGMENT
This study was partly supported by a
grant from Zikei Institute of Psychiatry.
AUTHOR DISCLOSURE
INFORMATION
The authors declare no conflicts of
interest.
Yutaka Mizuki, MD
Department of Neuropsychiatry
Okayama University Graduate
School of Medicine Dentistry, and
Pharmaceutical Sciences
Okayama, Japan
Manabu Takaki, MD, PhD
Department of Neuropsychiatry
Okayama University Graduate
School of Medicine Dentistry, and
Pharmaceutical Sciences
Okayama, Japan
manabuta@cc.okayama-u.ac.jp
REFERENCES
1. Reilly JG, Ayis SA, Ferrier IN, et al.
QTc-interval abnormalities and psychotropic
drug therapy in psychiatric patients. Lancet.
2000;355:1048Y1052.
2. Ray WA, Meredith S, Thapa PB, et al.
Antipsychotics and the risk of sudden cardiac
death. Arch Gen Psychiatry. 2001;58:
1161Y1167.
3. Deeks ED, Keating GM. Blonanserin: a review
of its use in the management of schizophrenia.
CNS Drugs. 2010;24:65Y84.
4. Noda Y, Kurumiya S, Miura Y, et al.
Comparative study of 2-(4-ethyl-1-piperazinyl)-
4-(fluorophenyl)-5,6,7,8,9,
10-hexahydrocycloocta[b]pyridine (AD-5423)
and haloperidol for their pharmacological
activities related to antipsychotic efficacy
and/or adverse side-effects. J Pharmacol Exp
Ther. 1993;265:745Y751.
5. Garcia E, Robert M, Peris F, et al. The efficacy
and safety of blonanserin compared with
haloperidol in acute-phase schizophrenia: a
randomized, double-blind, placebo-controlled,
multicentre study. CNS Drugs. 2009;23:
615Y625.
6. Yang J, Bahk WM, Cho HS, et al. Efficacy and
tolerability of blonanserin in the patients with
schizophrenia: a randomized, double-blind,
risperidone-compared trial. Clin
Neuropharmacol. 2010;33:169Y175.
7. Takaki M, Okahisa Y, Kodama M, et al.
Efficacy and tolerability of blonanserin in
48 patients with intractable schizophrenia.
Acta Neuropsychiatr. 2012;24:380Y383.
8. Vieweg WV, Hasnain M, Hancox JC, et al.
Risperidone, QTc interval prolongation, and
torsade de pointes: a systematic review of
case reports. Psychopharmacology (Berl).
2013;228:515Y524.
9. Kishi T, Matsuda Y, Iwata N. Cardiometabolic
risks of blonanserin and perospirone in the
management of schizophrenia: a systematic
review and meta-analysis of randomized
controlled trials. PLoS One. 2014;9:e88049.
10. US Food and Drug Administration Advisory
Committee. Zeldox Capsules (ziprasidone):
Summary of Efficacy and Safety and Overall
Benefit Risk Relationship. Bethesda, MD: US
Food and Drug Administration; 2000.
11. Harrigan EP, Miceli JJ, Anziano R, et al. A
randomized evaluation of the effects of six
antipsychotic agents on QTc, in the absence and
presence of metabolic inhibition. J Clin
Psychopharmacol. 2004;24:62Y69.
12. Crumb WJ Jr, Ekins S, Sarazan RD, et al.
Effects of antipsychotic drugs on I(to), I (Na), I
(sus), I (K1), and hERG: QT prolongation,
structure activity relationship, and network
analysis. Pharm Res. 2006;23:1133Y1143.
13. Vieweg WV. New generation antipsychotic
drugs and QTc interval prolongation. Prim
Care Companion J Clin Psychiatry. 2003;5:
205Y215.
14. Killeen MJ. Antipsychotic-induced sudden
cardiac death: examination of an atypical
reaction. Expert Opin Drug Saf. 2009;8:
249Y252.
Under Arrest
The Use of Amantadine for
Treatment-Refractory Mood
Lability and Aggression in a
Patient With Traumatic
Brain Injury
To the Editors:
Traumatic brain injury (TBI) is a com-
plex condition with high prevalence,
mortality, and morbidity. In the United
States alone, more than 50,000 people die
of TBI every year1
and more than 5 mil-
lion TBI survivors are living with perma-
nent disabilities.2
Patients with TBI often
struggle with myriad cognitive and psy-
chiatric symptoms. Rates of mood lability
and aggression in patients with TBI are
high,rangingfrom20%to73%.3Y6
Clinicians
prescribe a wide range of medications for the
treatment of mood lability and aggression
secondary to TBI, including anticonvulsants,
mood stabilizers, antidepressants, antipsy-
chotics, psychostimulants, and antihyperten-
sives,among other medication subtypes. In
clinical practice, patients presenting with
this TBI-associated symptom cluster often
report previous trials on multiple medica-
tions. We describe the case of a 52-year-old
man with treatment-refractory mood labil-
ity and aggression secondary to TBI and
treated with amantadine on 2 separate oc-
casions, both before and after being lost to
follow-up because of incarceration.
CASE REPORT
Mr A was a 52-year-old man
with a history of hepatitis C, hyperten-
sion, hypercholesterolemia, and TBI, who
presented to the psychiatric clinic for
evaluation of severe, daily emotional la-
bility, aggression, and insomnia. Eighteen
months before presentation, the patient
was attacked and sustained a severe TBI,
comprising a right temporofrontal skull
fracture, subdural hematoma, and subarach-
noid hemorrhage. His psychiatric history
included opioid use disorder, which was in
complete remission for 4 years at the time
of presentation. The patient had a history
of selling illicit substances for more than
5 years before presentation but had no
history of mood lability or violent behavior
before sustaining the TBI. Mr A seemed to
be of average intellectual ability, had a
ninth-grade education, and had most re-
cently worked as a logger before sustaining
the brain injury. At the time of presentation,
Mr A’s complete list of medications in-
cluded 250 mg of divalproex sodium by
mouth twice daily (for mood stabilization
because the patient had no known history
of seizures), 20 mg of ziprasidone by
mouth at night, and 1 mg of clonazepam by
mouth every 6 hours as needed for agita-
tion. The patient had previous trials of
quetiapine, lithium, risperidone, citalo-
pram, and paliperidone but had experi-
enced breakthrough aggression, lability,
and/or adverse effects on each. At this ini-
tial visit, the team increased the patient’s
divalproex sodium to 250 mg by mouth in
the morning and 500 mg by mouth at night
while continuing his other psychotropic
medications.
At week 4, divalproex sodium was
discontinued because of thrombocytope-
nia and leukopenia, both of which are
known adverse effects. The patient sub-
sequently underwent a trial on ziprasidone
(titrated to a dose of 40 mg by mouth in
the morning and 80 mg by mouth at
night), which was ineffective and caused
severe akathisia. Next, the patient was
tried on propranolol (up to a dose of
20 mg by mouth 3 times daily) but expe-
rienced severe breakthrough symptoms of
mood lability and aggression. The team
added olanzapine to the patient’s regimen
(2.5 mg by mouth in the morning and
5 mg by mouth at night), which resulted
in the patient’s admission to the inpa-
tient neurology service because of severe
hypotension.
Mr A was reassessed in the clinic at
week 13, and the treatment team consid-
ered various options. The team chose to
avoid carbamazepine because of the
patient’s risk for developing leukopenia
Letters to the Editors Journal of Clinical Psychopharmacology & Volume 35, Number 1, February 2015
102 www.psychopharmacology.com * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.

2. and thrombocytopenia. Because of the
patient’s history of failing citalopram and
the risk for possible aggravation of irrita-
bility, the team did not pursue treatment
with an antidepressant. Because the pa-
tient had experienced adverse effects with
multiple antipsychotics, the treatment team
steered away from this medication group.
Ultimately, the team initiated 100 mg of
amantadine by mouth twice daily (in the
morning and at night) and continued the
patient’s existing clonazepam dosage of
2 mg by mouth twice daily and 1 mg by
mouth every afternoon. The team chose to
divide the daily amantadine dosage with
the goal of optimizing medication tolera-
bility for this patient with a history of
susceptibility to adverse effects.
The patient presented for follow-up
at weeks 18 and 24 reporting remission of
mood lability and aggression during the
previous 11 weeks. Both Mr A and his
wife reported that he was much calmer,
without irritability or aggression, and tol-
erating amantadine well without adverse
effects. Because of persistent insomnia,
which had improved but not remitted on
amantadine, the team added 100 mg of
trazodone by mouth at night to the patient’s
standing regimen.
At week 26, after being off his psy-
chotropics for several days, the patient
reportedly cut his wife twice with a knife.
He was subsequently arrested and charged
with attempted murder.
Notably, Mr A presented to the clinic
more than a year later (week 80) after
serving time in jail for the aforementioned
act of violence. He was still experiencing
severe symptoms of irritability, mood la-
bility, and aggression. He also endorsed
symptoms of memory impairment, inat-
tention, insomnia, as well as mild inter-
mittent auditory and visual hallucinations.
Mr A could not recall a specific reason why
he had stopped taking his psychotropics
before his arrest. Shortly after his release
from incarceration and just before his re-
turn to the clinic, Mr A had been charged
with criminal domestic violence. The
patient’s medication regimen at this return
visit included 0.5 mg of alprazolam by
mouth 3 times a day and 100 mg of trazo-
done by mouth at night as needed for sleep.
Given his comorbid psychotic symp-
toms and at the patient’s request (due to his
own recollection of responding well to past
trials on risperidone and ziprasidone), Mr
A subsequently underwent repeated trials
on 2 mg of risperidone by mouth at night
(week 84) and 40 mg of ziprasidone by
mouth twice daily (week 89). Both trials
were ineffective and caused significant ad-
verse effects. In the case of risperidone, Mr
A experienced worsening agitation, poor
concentration, and sexual adverse effects.
While taking ziprasidone, the patient com-
plained of sedation, slurred speech, and
shuffling gait. Throughout these 2 trials, Mr
A was maintained on 100 mg of trazodone
by mouth at night, along with 0.5 mg of al-
prazolam by mouth 3 times daily.
At his week 106 visit, Mr A reported
that he had been charged with yet another
count of criminal domestic violence with
a girlfriend, stemming from an incident
that occurred several weeks prior. Given
his previous positive response, Mr A began
a second trial of 100 mg of amantadine by
mouth twice a day (in the morning and at
night), along with his aforementioned
schedule of trazodone and alprazolam.
At week 114, Mr A reported that his
mood had been stable, with no outbursts
of mood lability or aggression for the
prior 8 weeks. The patient had reconciled
with his girlfriend, who reported that Mr A
appeared much calmer and less agitated.
Because of complaints of mild feelings of
inner restlessness, the patient’s dose of
amantadine was titrated up to 200 mg by
mouth in the morning and 100 mg by mouth
at night. While Mr A continued to experi-
ence mild intermittent auditory hallucina-
tions, his overall level of functioning was
vastly improved compared with baseline.
DISCUSSION
Although there are reports in the lit-
erature describing the successful use of
amantadine for behavioral symptoms in
patients with TBI,3,7,8
this case report is
the first known to the authors describing a
patient who was previously refractory or
intolerant to multiple medications. Nota-
bly, the patient tolerated and responded
robustly to 2 separate trials on amanta-
dine, spaced nearly 2 years apart. As il-
lustrated in the case of Mr A, many first-
line medications used to treat TBI, espe-
cially antipsychotics but also anticonvul-
sants and other medication classes, have
significant risk for serious adverse effects.
In clinical practice, treatment-refractory
TBI-associated mood lability and aggres-
sion are not uncommon and evidence
suggests that patients with TBI are prone
to criminal violence.9
In the case of Mr A,
his target symptoms of mood lability, vi-
olence, and criminal behaviors were suc-
cessfully arrested during 2 distinct trials
on amantadine.
This patient’s rapid and robust re-
sponse to amantadine on both occasions
was interesting to the treatment team be-
cause amantadine is not typically high on
the armamentarium of medications used
by psychiatrists for any condition, espe-
cially for TBI. The proposed mechanisms
for this patient’s clinical improvement
include increased synaptic dopamine via
reuptake inhibition and increased dopa-
mine release. Some evidence suggests that
long-term amantadine use also causes post-
synaptic changes in receptor density and
function.10
This increased dopamine func-
tion in the frontal lobe is thought to improve
impulse control. In addition, amantadine is
an N-methyl-D-aspartate receptor antago-
nist, which potentially reduces agitation be-
cause of excessive glutamate levels that can
occur with brain injury.3
Amantadine has been reported to be
effective11
but is also more commonly
used by experts versus nonexperts in the
treatment of TBI-associated agitation.12
Given the efficacy and favorable side effect
profile demonstrated in this case, clinicians
and researchers of various disciplines may
wish to consider amantadine in treatment-
refractory mood lability and aggression
secondary to TBI. The authors are consid-
ering a possible case series on the use of
amantadine in this patient population.
AUTHOR DISCLOSURE
INFORMATION
McLeod F. Gwynette received travel
expenses from Vaya Pharma, Inc. for him-
self and his spouse (Gretchen W. Gwynette,
MD) to attend the 2012 Lipid Symposium
in Haifa, Israel.
Billy Beck declares no conflicts of
interest.
Amy VandenBerg received an hono-
rarium and travel expenses from the College
of Psychiatric and Neurologic Pharmacists
for April 2014 continuing education lecture
on drug shortages in the provision of elec-
troconvulsive therapy.
Nicole Stocking received a travel
grant from the American Association for
Geriatric Psychiatry as part of a scholar-
ship to attend the annual American Asso-
ciation for Geriatric Psychiatry meeting.
McLeod F. Gwynette, MD
Department of Psychiatry
and Behavioral Sciences
Medical University of South Carolina
Charleston, SC
gwynette@musc.edu
Billy Beck, MD
Amy VandenBerg, PharmD
Nicole Stocking, MD
Department of Psychiatry and
Behavioral Sciences
Medical University of South Carolina
Charleston, SC
REFERENCES
1. Centers for Disease Control and Prevention.
Surveillance for traumatic brain injury-related
deathsVUnited States, 1997Y2007. MMWR
Surveill Summ. 2011;60:1Y32.
Journal of Clinical Psychopharmacology & Volume 35, Number 1, February 2015 Letters to the Editors
* 2015 Wolters Kluwer Health, Inc. All rights reserved. www.psychopharmacology.com 103
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.

3. 2. Langlois JA, Rutland-Brown W, Wald MM.
The epidemiology and impact of traumatic
brain injury: a brief overview. J Head Trauma
Rehabil. 2006;21:375Y378.
3. Hammond FM, Bickett AK, Norton JH, et al.
Effectiveness of amantadine hydrochloride in
the reduction of chronic traumatic brain injury
irritability and aggression. J Head Trauma
Rehabil. 2014;29:391Y399.
4. Rao V, Rosenberg P, Bertrand M, et al.
Aggression after traumatic brain injury:
prevalence and correlates. J Neuropsychiatry
Clin Neurosci. 2009;21:420Y429.
5. Brooke MM, Questad KA, Patterson DR, et al.
Agitation and restlessness after closed head
injury: a prospective study of 100 consecutive
admissions. Arch Phys Med Rehabil.
1992;73:320Y323.
6. Tateno A, Jorge RE, Robinson RG. Clinical
correlates of aggressive behavior after traumatic
brain injury. J Neuropsychiatry Clin Neurosci.
2003;15:155Y160.
7. Nickels JL, Schneider WN, Dombovy ML,
et al. Clinical use of amantadine in brain
injury rehabilitation. Brain Inj. 1994;8:709Y718.
8. Gualtieri T, Chandler M, Coons TB, et al.
Amantadine: a new clinical profile for traumatic
brain injury. Clin Neuropharmacol.
1989;12:258Y270.
9. To MJ, O’brien K, Palepu A, et al. Healthcare
utilization, legal incidents, and victimization
following traumatic brain injury in homeless
and vulnerably housed individuals: a
prospective cohort study. J Head Trauma
Rehabil. 2014. [Epub ahead of print].
10. Gianutsos G, Chute S, Dunn JP.
Pharmacological changes in dopaminergic
systems induced by long-term administration
of amantadine. Eur J Pharmacol. 1985;110:
357Y361.
11. Chew E, Zafonte RD. Pharmacological
management of neurobehavioral disorders
following traumatic brain injuryVa
state-of-the-art review. J Rehabil Res Dev.
2009;46:851Y878.
12. Fugate LP, Spacek LA, Kresty LA, et al.
Measurement and treatment of agitation
following traumatic brain injury: II. A survey of
the Brain Injury Special Interest Group of the
American Academy of Physical Medicine
and Rehabilitation. Arch Phys Med Rehabil.
1997;78(9):924Y928.
Memory Reconsolidation
for Treatment-Resistant
Aggression and
Self-Injurious Behaviors
To the Editors:
Aggression and self-injurious behav-
iors (SIBs) that cannot be effectively
managed by available pharmacologic and
behavioral interventions are an important
and difficult clinical challenge. Presented
below is a case (the first to our knowledge)
where a memory reconsolidation para-
digm was successfully used to lower the
frequency of these episodes.
CASE
A 47-year-old man diagnosed with
intermittent explosive disorder, polysub-
stance dependence (in a controlled set-
ting), significant childhood neglect and
abuse, and mild mental retardation (IQ of
56 per Wechsler Adult Intelligence Scale-
Fourth Edition) was hospitalized in a state
inpatient hospital with a long history of
aggression and SIB. Aggressive behaviors
included spitting, punching, and kicking
staff and peers along with SIB of scratch-
ing arms, swallowing items, and banging,
punching, or breaking glass windows.
There were no consistent predisposing
factors to these behaviors, but he would
sometimes state he did these behaviors
when he felt lonely, wanted soda or money
and had none, or when he was bored and
wanted to be placed on constant observa-
tion. The patient developed and acquired
these reinforcing properties over a long
period, and clinical observation and inter-
pretation suggested that this became a part
of his pattern of interacting with others,
serving to both modulate internal distress
(as he had limited verbal capacity to express
his feelings directly) as well as establish
socioenvironmentalcontroloverotherstoget
his desires met on the unit. These behaviors
had kept him from being placed with com-
munity providers, and as a consequence, he
had been hospitalized for over 7 years.
All previous attempts to mitigate these
behaviors through medication (adequate tri-
als of risperidone, haloperidol, olanzapine,
quetiapine, topiramate, bupropion, paroxe-
tine, trazodone, clonazepam, and naltrexone
had been tried in combination and/or as
necessary) and behavioral interventions (in-
cluding weekly individual therapy, peer-
based groups, transition care counseling,
substance abuse counseling [including al-
coholic anonymous meetings], multiple in-
dividualized coping skills treatments, and a
differential reinforcement of other behavior
schedule) did not have lasting results of de-
creasing the targeted behaviors.
Given the failure of these specialized
pharmacologic and behavior treatments
and after a through review of the patient’s
history, we began a trial of modafinil. This
was chosen because of his addiction histo-
ry, the habitual nature of these behaviors
(which seemed to be rewarding and there-
fore could be perceived as a behavioral
addiction), the novel mechanism of the
drug,1
and clinical research suggesting a
modulating effect on addiction and pro-
cesses requiring cognitive control.1,2
He
had a good initial response at 100 mg with
a decrease in self-harm and had the dose
increased to 200 mg after some of the
problem behaviors returned after 6 weeks.
He was maintained on this dose with good
effect, and after the second month of treat-
ment, he had no SIB and was recommended
for a possible discharge to an appropriate
outpatient facility.
Atthattime,hehadaburstofaggression/
SIB (which accumulated in 32 restraints in
2 months), and modafinil was tapered and
discontinued by a treating psychiatrist be-
cause it was thought that this was possibly
activating the patient given the potential
stimulating propertiesof the drug.Noother
treatments (including multiple doses of
different antipsychotics and behavioral
techniques) could effectively manage these
behaviors at this time.
Given the lack of efficacy of previous
and current treatments and the seriousness
of these behaviors, we discussed trying a
new (and somewhat controversial) tech-
nique based on memory reconsolidation.
Briefly, memory reconsolidation focuses
on when memories are retrieved and are
briefly open to a more physiologically mal-
leable state where they can be either
strengthened or weakened based on tech-
nique (please see Schwabe et al,3
Lee,4
and
Nader and Hardt5
for reviews). Importantly
for this case, these methods have been found
to effectively reduce addiction and emotion-
allyladenmemoriesinhumanpopulations.3,6
Propranolol, an adrenergic receptor
antagonist, was chosen as the preferred
method because it has been previously
studied, cited widely in the literature,3
and
safe in this clinical context. The patient
consented, and then the procedure was
started on the unit (Fig. 1). A 1-time dose
of 40 mg propranolol was given approxi-
mately 5 hours after an SIB episode in
which he was restrained. After waiting
90 minutes (when peak levels of propran-
olol can be expected in humans after oral
administration), we had him remember in
as much detail as possible the things that
led up to the episode, the actual incident,
and his emotional response to the situation.
After that session (30 minutes), we
led him to the window and asked him if he
wanted to hit it. He declined and stated he
was tired. The rest of the week showed a
dramatic reduction in SIB with only 1
short episode of hitting the window in
which he was redirected without a re-
straint. We tried the propanolol session
again the next week (with the same perim-
eters) after he was triggered in a trauma
group by a peer and escalated with another
restraint. He maintained a marked reduction
in SIB incidents afterwards (a total of
Letters to the Editors Journal of Clinical Psychopharmacology & Volume 35, Number 1, February 2015
104 www.psychopharmacology.com * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved.