Olanzapine-Induced Tardive Dystonia

Ms. A was a 40-year-old African American woman with psychosis. She was diagnosed with schizophrenia and treated with loxapine, 35 mg/day, and her symptoms completely remitted. Her dyskinesia was first noted as bruxism. Ms. A’s loxapine dose was decreased to 5 mg/day, yet the bruxism persisted. Then blepharospasm developed, prompting the diagnosis of tardive dyskinesia. Her loxa­pine treatment was discontinued, and trazodone treatment, 50 mg at bedtime, was initiated. Over the following months, Ms. A experienced increased blepharospasm, lip tremor, difficulty swallowing, and aphonia. Treatment with reserpine, haloperidol, and botulinum toxin was unsuccessful. Eventually, her condition was successfully treated with vitamin E, 1600 IU/day. Ms. A then experienced a manic episode with psychosis and was rediagnosed with bipolar disorder. She received divalproex, 1250 mg at bedtime, and partially responded. Later, olanzapine, 10 mg at bedtime, was added, and her symptoms fully remitted. Seven months later, Ms. A’s neck started intermittently turning to the right. Soon thereafter, she was in marked distress, with severe, frequent torticollis. She also displayed severe dysphonia, blepharospasm, and grimacing; moderate lateral and opening jaw movements; and mild upper extremity choreiform movements, lip pouting, back arching, and head bobbing. Her total Abnormal Involuntary Movement Scale (AIMS) score was 15. Clozapine treatment was initiated, and her dose was titrated to 200 mg/day, while her olanzapine treatment was discontinued. At her 4-month follow-up examination, her dystonia had decreased by 50%, and she felt significantly less distressed. Her AIMS total score was 8; she had minimal blepharo­spasm and grimacing, mild lip and jaw movements, and moderate torticollis.