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Resident and Fellow in Psychiatry Department of Psychiatry (Wang ACC-812) Massachusetts General/McLean Hospitals 15 Parkman Street Boston, Massachusetts 02114-2622 FAX 617/726-7541 mjgrant{at}partners.org
Professor of Psychiatry and Neuroscience Harvard Medical School Boston Director Neuropharmacology Laboratory & Psychopharmacology Program McLean Division of Massachusetts General Hospital Belmont, Massachusetts
Published Online, October 11, 2005. www.theannals.com, DOI 10.1345/aph.1G255
Case Report. A 54-year-old woman had persistent persecutory delusions, recurrent major depression, and post-traumatic stress symptoms following abusive relationships, with homelessness, estrangement from her children, and one psychiatric hospitalization for a suicidal overdose. She was socially isolated and living in public housing on disability income. For several years, the patient had been preoccupied with persecutory delusions, ideas of reference, and occasional auditory hallucinations of her ex-husband's voice.
Psychiatric treatment at our center in the previous 2 years followed complaints of depressive symptoms, persecutory delusions, and ideas of reference, including concerns of being considered a prostitute by policemen in her neighborhood. Treatment with sertraline (to 200 mg) and risperidone (to 6 mg) daily, plus bi-weekly supportive psychotherapy led to improved mood, but psychotic symptoms persisted. After 3 months, risperidone was changed to olanzapine, with an initial dose of 5 mg/day, with little change in psychotic symptoms. The woman became suicidal, planned to drink a caustic drain cleaner, and was hospitalized, where assessments including brain magnetic resonance imaging and electroencephalographic tests were noncontributory. With increased daily doses of olanzapine (to 25 mg/day) and sertraline (to 250 mg/day), she improved temporarily.
One month after discharge, the patient presented to the emergency department complaining of acute persecutory delusions and suicidal preoccupations. Olanzapine was discontinued, and haloperidol 7.5 mg with benztropine 1 mg daily was initiated to control new-onset hand tremor. Her delusional fears continued, and she reported nightmares and flashbacks to past physical abuse. After 6 months, she developed dyskinetic oral movements, with lip-puckering, jaw stiffness, and ear pain that had not occurred during treatment with risperidone or olanzapine. Haloperidol was discontinued over one week, aripiprazole 10 mg/day was substituted, and sertraline was increased to 300 mg daily. Dyskinetic signs gradually disappeared over the following 2 months and re-emerged only occasionally, with increased agitation. Her delusions remained unchanged.
Discussion. This case presents oromandibular dyskinesia arising rapidly during treatment with a moderate dose of the potent typical neuroleptic haloperidol in a woman who had previously tolerated substantial and sustained doses of both risperidone and olanzapine. After changing to aripiprazole, her dyskinetic signs virtually disappeared. Removal of haloperidol, and perhaps use of aripiprazole, may have contributed to improvement of the dyskinesia.
Two other cases of improvement in neuroleptic-induced tardive dyskinesia during treatment with aripiprazole have been reported,3,4 as well as one case involving new-onset dyskinesia in association with aripiprazole.5 These few inconsistent observations indicate that systematic studies are needed to quantify risks of tardive dyskinesia during treatment with specific modern antipsychotic agents and that a broad lack of risk with modern antipsychotics should not be assumed.1,5
Footnotes
Dr. Baldessarini currently serves as a consultant to Auritec, Eli Lilly, IFI SpA, Novartis, Janssen, and JDS, with no relationship to the manufacturers of aripiprazole.
References
This article has been cited by other articles:
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  D. D. Miller, S. N. Caroff, S. M. Davis, R. A. Rosenheck, J. P. McEvoy, B. L. Saltz, S. Riggio, M. H. Chakos, M. S. Swartz, R. S. E. Keefe, et al. Extrapyramidal side-effects of antipsychotics in a randomised trial The British Journal of Psychiatry, October 1, 2008; 193(4): 279 - 288. [Abstract] [Full Text] [PDF]
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 C. Kenney, C. Hunter, A. Davidson, and J. Jankovic Metoclopramide, an Increasingly Recognized Cause of Tardive Dyskinesia J. Clin. Pharmacol., March 1, 2008; 48(3): 379 - 384. [Full Text] [PDF]
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