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Objective: To present brief idea about a suitable and safe antipsychotic usage in patient with schizophrenia and tardive dystonia.
Method: Results will be discussed.
Results:
Case: A 42-year-old woman with diagnose of first episode and drug naïve schizophrenia presented with involuntary movements in her orobuccal region, including tongue and lips. At first administration, routine biochemical and hematological assessments were normal, and patient had positive and negative features of schizophrenia. According to the information received her relatives, although she has not taken any antipsychotic medication, her involuntary movements has been risen 18 month earlier her antipsychotic treatment. These movements were consulted with neurology clinic. Her brain MRI, EEG, and further assessments including detailed neurological examination, jaw MRI was normal, and specialist of neurology suggested that the clozapine usage may be helpful because of the possible idiopathic tardive dystonia. Clozapine medication was started with gradually, although there was not enough proof about prior antipsychotic usage and anatomical or functional deficit. During her hospitalization, all of the involuntary movements were recovered with 200 mg/day clozapine, and more than 35% percent decrease was observed at her positive (SAPS) and negative (SANS) scale assessments with 600 mg /day clozapine. In this period, there was no side effect except moderate sialorrhea. Etiology of the idiopathic tardive dystonia is still remaining unclear, and data for treatments is receiving from the case reports. There is some evidence about efficacy of clozapine treatment (1,2). In addition, there is a consensus about that clozapine can cause extrapyramidal side effects rarely and effective treatment option for schizophrenia as well (3). On the other hand, tendency of the general psychiatry practice would prefer to this molecule in the resistant schizophrenia which is describe as show no remission despite of two different kinds of antipsychotic usage for minimum six weeks (4). In this case, clozapine usage in the first line seems to be necessary because of the idiopathic tardive dystonia. It may be clarified with further studies whether this case was remitted incidentally or this remission was related with antagonistic effects of clozapine on the receptors of D1.
Conclusion: Clozapine may be a first line treatment option for the drug naïve patients with first episode schizophrenia and tardive dystonia. However, we need further studies performed with wide case series to achieve this kind of opinion.
References:
1. Kwan Y, Sim K. Resolution of tardive dystonia in a patient with bipolar disorder treated with clozapine: a case report. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34(1):238-239.
2. Aukst-Margetic B, Margetic B. Treatment of generalized tardive dystonia with clozapine. Psychiatr Danub 2008; 20(3):329-331.
3. Asenjo Lobos C, Komossa K, Rummel-Kluge C, Hunger H, Schmid F, Schwarz S, et al. Clozapine versus other atypical antipsychotics for schizophrenia.
Cochrane Database Syst Rev 2010; (11):CD006633.
4. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry 1988; 45(9):789-796. Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S201