Risperidone-Induced Tardive Dyskinesia

We present a case of risperidone-induced tardive dyskinesia (TD) and tardive dystonia in a young patient who had never taken any other psychotropic medications. There are risperidone-induced TD reports but patients had also received typical antipsychotic [1] [2] [7] [9] or fluoxetine, associated or not with risperidone ([6], Carroll et al., 1999 [not in references]). There is only one report of unequivocal tardive dyskinesia related to risperidone [3].

W.F.C., a white male, now 25 years old, presented persecutory delusions, auditory hallucinations and social withdrawal for 6 months in 11/1994. Physical and neurological examination, laboratory screening and EEG results were normal. Computed tomography scan of the head showed atrophic lesions in temporoparietal and frontal lobes due to a cranio-encephalic trauma without neurological consequences when he was 15 years old. He was diagnosed as having paranoid schizophrenia according to DSM-IV criteria, and was given risperidone 6 mg/day. In 1/1995, as all symptoms remitted and the patient presented parkinsonism, risperidone dose was reduced to 3 mg/day and biperiden at 4 mg/day was added. There was an improvement of parkinsonism and in 7/1995 biperiden was withdrawn. Risperidone dose was gradually reduced and completely withdrawn in 12/1997.

In 2/1998, the patient presented moderate diskinetic movements on the mouth, on the left hand and on the neck and severe blepharoespasm. Biperiden at 6 mg/day was reintroduced, and distonic movements improved partially but diskinetic movements persisted. Without medical consent, the patient took risperidone 1 mg/day for 3 weeks, with temporary improvement of diskinetic movements. Since all the movements were still present in 10/1998, although less intense, treatment by a local injection of botulinus toxin in the eyelids was started and clonazepan 2 mg/day was given to improve diskinetic movements. There was a great reduction of blepharoespasm, and the biperiden dose was reduced to 2 mg/day. In 3/1999, blepharoespasm was almost absent but mild diskinetic movements on the left hand, neck and mouth were still present, fulfilling Schooler and Kane diagnostic criteria for TD.

Risperidone blocks D2 and 5-HT2 receptors, causing less extra-pyramidal symptoms (EPS) than other antipsychotics when given in low doses, but in sensitive patients, even low doses can cause acute EPS. TD is almost certainly associated with use of risperidone in this patient, since he had had no neurological abnormalities before use of risperidone and had never taken other antipsychotics or other drugs that can cause tardive dyskinesia. In spite of receiving low doses of risperidone and being young and male, he presented a cerebral lesion, which is a risk factor for developing TD [4], although other authors [8] do not replicate this finding. In addition, lesions usually found on patients with TD are either diffuse or located in the basal ganglia [5].

We conclude that risperidone seems to have potential to induce TD and should be used with caution on patients with possible greater risk to develop it.

References

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