Tardive dyskinesia and dystonia – Clinical case review and grand rounds

Tardive dyskinesia (TD) syndromes are clinical conditions characterized by abnormal involuntary movements of the body and can range from occasional annoying involuntary movements to debilitating dystonia and are associated with increased mortality rates in schizophrenia. The annual incidence of TDs 5.5% for first-generation antipsychotics and 3.9% for second-generation antipsychotics. The prevalence of TD in long-term use of antipsychotics ranges from 15% to 30%. Tardive syndromes include TD, dystonia, akathisia, tremor, and variants of other movement disorders. Tardive syndromes are poorly understood and often inadequately treated. Although there are diverse groups of drugs that are helpful in this condition, no single agent is proven to be consistently effective. The incidence of tardive syndromes has not significantly decreased with the increased use of second-generation antipsychotics. Conventionally, olanzapine, quetiapine, and clozapine are considered safe alternatives as they are most atypical among antipsychotics. There is reasonable evidence to suggest that adjunct quetiapine and clozapine are associated with a decrease in the severity of TDs. In this case, we report a patient with schizophrenia who has had long-standing tardive dystonia and dyskinesia, which did not improve with baclofen, tetrabenazine, benzodiazepines, diphenhydramine, and Vitamin E. He was given a trial of quetiapine as an inpatient, with subsequent worsening of dystonia and dyskinesia. The administration of clozapine was associated with significant improvement in symptoms. Through this case, we highlight the presence of long-term TD in a person suffering from bipolar affective disorder, examine the role of antipsychotics in its exacerbation of TD, and discuss treatment strategies. Subsequently, we highlight the essential facts about TD through clinical grand rounds discussion.