To the Editor: Tardive dystonia is usually considered a variant of tardive dyskinesia. However, the type of onset and the response to treatment clearly differentiate the two conditions with the notion that dystonias begin earlier and are more difficult to treat (1–3).
Mr. A was a 43-year-old man with a diagnosis of schizophrenia and polysubstance dependence who was in outpatient treatment. He spent 5 years in prison and was then in a state hospital for 1 year after an episode in which he stabbed his mother. He began taking neuroleptic medications at age 25, mainly chlorpromazine up to 1000 mg/day, for about 14 years. According to his records, Mr. A first noticed the presence of involuntary movements at age 35. These movements consisted of excessive blinking, which caused difficulty seeing, facial grimacing, jerky movements of the jaw resembling a yawn, and neck twisting accompanied by a gasping or barking sound that occasionally caused some respiratory distress.
Mr. A was evaluated by neurologists, who made a diagnosis of tardive dyskinesia and added that he might have late-onset Tourette’s syndrome. Results of a magnetic resonance imaging of the brain were normal. Risperidone treatment was started, which he said seemed to help his movements; however, he remained markedly affected by his involuntary movements at the end of 2 years of risperidone therapy at 6 mg/day. When seen by one of us (M.E.J.), a diagnosis of tardive dystonia was made. His risperidone therapy was tapered, and he was started on olanzapine therapy, which was increased to 15 mg at bedtime. After being at this dose for 6 weeks, Mr. A experienced a marked decrease in his involuntary grunting, and his blepharospasms almost completely disappeared. After taking olanzapine for 7 months, his tardive dystonia improved further. He did not have any involuntary grunting or neck twisting, but he still had mild involuntary jaw movements.
While it is impossible to be definitive about the beneficial effects of olanzapine on this patient’s movement disorder, the length of time it was present and the course of its improvement certainly suggest that olanzapine played a role in his improvement. Similar claims have been made for clozapine.