Cacap-may 2011.vp

LETTER TO THE PSYCHOPHARMACOLOGY SECTION EDITOR
Reversible Oral Dyskinesia Associated with Quetiapine in an
Adolescent: A Case-Report
mg in the evening) and methotrimeprazine was temporarilyincreased to 70 mg daily (as 15 mg morning, noon and evening There are published reports (Mehler-Wex, Roamnos, and 25 mg at bedtime). One week after these dose increases he Kircheiner & Schulze, 2008; Court et al., 2010) of promising reported abnormal tongue movements which hindered speech.
results using quetiapine for treatment of anorexia nervosa.
Tongue fasciculations were verified and quetiapine was gradu- Quetiapine-related movement disorders are rare compared to ally tapered and discontinued over a two week period. No other other neuroleptic agents. We report the case of a young male abnormal movements were noticed or reported, and no abnor- who developed orolingual dyskinesia after long-term malities in laboratory data were identified. Based on a Medline quetiapine treatment, with complete remission of symptoms search and published literature recommendations (Gupta, et al.
following quetiapine discontinuation.
1999), the patient received single doses of medications includ- A 17-year old male being treated for aggressive and self-dam- ing diazepam 5 mg, biperiden 8 mg, tetrazepam 50 mg and aging behaviours, anorexia nervosa (restricting type) with clonazepam 1 mg. None of these treatments showed any effect Body Mass Index (BMI) of 19.9, chronic anxiety, panic attacks on his symptoms. Tocopherol (vitamin E) 800 international and depression was receiving fluoxetine 40 mg and immedi- units daily was recommended because of its reported promis- ate-release quetiapine 100 mg daily upon entry to day hospital.
ing effect in dyskinesia treatment and prevention (Gupta, et al.
He is the elder of two brothers. His father had previously been 1999). Abnormal movements improved one week after stop- diagnosed with alcohol abuse and aggressive behaviour. His ping quetiapine and prior to the patient starting tocopherol.
mother, with whom he has a difficult relationship, receives Five weeks later only slight involuntary movements of the treatment for anxiety and depressive symptoms. He was first tongue tip remained, and after another month they remitted.
referred to a psychiatrist at age 13 for treatment of depression Although anxiety and emotional outbursts persisted, at six and anxiety after his parents separated. He was started on treat- months follow-up he remained stable on sertraline 150 mg ment with paroxetine, quetiapine and diazepam. At age 14 daily, methotrimeprazine 62.5 mg daily (as 12.5 mg in the increasing food restriction and weight loss added to his depres- morning, 25 mg at noon and 25 mg in the evening) and sion. His usual introspective mood changed and he became overtly aggressive at home and developed self-harming This patient presented with an eating disorder, conduct disor- der, panic attacks and a dysthymic-like mood disorder. Treat- When the patient entered the Eating Disorders day hospital ment of chronic anxiety is a common pharmacological program he was restricting intake and exercising excessively, challenge for psychiatrists. Comorbidity is common and con- but was not purging. He reported insomnia and nightmares, duct disorders often reflect difficult family environments.
sad, touchy and unstable mood and loss of interest in daily Although antidepressants are a good choice for the chronic activities. He kept injuring himself by repeatedly cutting his anxious patient, they may be insufficient to control high levels wrist, had frequent panic attacks and had more frequent aggres- of maintained anxiety, and sedative agents may be required.
sive outbursts at home. At day hospital, pharmacotherapy was Potential risk for benzodiazepine dependence may lead clini- progressively adjusted. Fluoxetine was changed to sertraline cians to consider use of antipsychotics as alternative agents for 150 mg daily (50 mg in the morning and 100 mg in the eve- treatment of anxiety. Amongst them, quetiapine has both seda- ning), quetiapine was increased to 200 mg daily in three tive and mood stabilising effects and is rarely associated with divided doses (50 mg morning and noon and 100 mg in the eve- movement disorders because of limited dopamine2-receptor ning), and methotrimeprazine (known elsewhere as blockade. Quetiapine may even be recommended when levomepromazine) 20 mg daily (5 mg morning and noon and dyskinetic effects appear with other antipsychotics 10 mg in the evening) was introduced to control anxiety. He (Peritogiannis & Tsouli, 2009). Sertraline is a moderate was prescribed lorazepam 1 mg at bedtime for insomnia. In CYP3A4 inhibitor and quetiapine is metabolized via CYP3A4.
addition, he was treated with psychotherapy and environmental It is possible that sertraline may have contributed to increased control measures. Depressive symptoms improved and quetiapine levels and the appearance of dyskinesia symptoms.
self-harm became less frequent, while restricting behaviours Use of first-generation antipsychotics, long-term treatment, and anxiety persisted. Eight months later, BMI was 21. While higher dosages and sudden antipsychotic withdrawal are facing stressful adaptive events he reported an increase in related to development of tardive dyskinesia, and second gen- impulsive thoughts of self-harm, so quetiapine was temporarily eration antipsychotics are not excluded from an association increased to 400 mg daily (as 50 mg morning and noon and 200 with this condition (Michaelides, Thakore-James & Durso, J Can Acad Child Adolesc Psychiatry, 20:2, May 2011 2005). Use of benzodiazepines is associated with risk for References
dependence, and must be balanced against known adverseeffects of antipsychotic agents, especially in younger patients 1. Court, A., Mulder, C., Kerr, M., Yuen, H. P., Boasman, M., Goldstone, S., et al. (2010). Investigating the effectiveness, safety and tolerability of or in those with increased risk of dependence. GABA-ergic quetiapine in the treatment of anorexia nervosa in young people: A pilot medications like pregabalin may be helpful, although in our study. Journal of Psychiatric Research, 44(15), 1027-1034.
experience their effect is only moderate. Risks and benefits of 2. Gupta, S., Mosnik, D., Black, D.W., Berry, S., & Masand, P. S. (1999).
treatment must be carefully considered. Judicious use of Tardive dyskinesia: Review of treatments past, present and future. Annals pharmacotherapy is encouraged. Methods such as relaxation, of Clinical Psychiatry, 11 (4), 257-266.
family therapy, physical and anger management techniques are 3. Mehler-Wex, C., Romanos, M., Kircheiner, J., & Schulze, U. M. (2008).
approaches that may help avoid drug abuse/dependence and Atypical antipsychotics in severe anorexia nervosa in children and adolescents: review and case reports. European Eating Disorders Review,16(2), 100-108.
Conflicts of Interest: None declared. Informed consent for pub-lication of this report was obtained from both the patient and his 4. Michaelides, C., Thakore-James, M., & Durso, R. (2005). Reversible withdrawal dyskinesia associated with quetiapine. Movement Disorders Sonia Sarró, MD
5. Peritogiannis, V., & Tsouli, S. (2009). Can atypical antipsychotics Psychiatrist, ABB Eating Disorders Centre, improve tardive dyskinesia associated with other atypical antipsychotics? Case-report and brief review of the literature. Journal of Psychopharmacology, 24(7), 1121-1125.
J Can Acad Child Adolesc Psychiatry, 20:2, May 2011

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