1. Cervical Dystonia following Olanzapine Treatment
Cini E., Coleiro R., Vella Baldacchino J.
Introduction
Cervical dystonia, also known as spasmodic torticollis, is a relatively rare disorder occurring due to uncontrollable and often painful muscular contractions of the neck muscles causing the head to turn into abnormal postures. It can occur due to neck or head injuries, medication, neuro-degenerative diseases or it may be an idiopathic or primary dystonias. The diagnosis of tardive dystonia is based on sustained muscle contractions that develop following at least one month of anti-psychotic treatment (Goetz et al, 2004).
Case Report
Mr. J., a 58-year-old man, chronically abused alcohol over a span of 33 years. He used to drink, on average, 24 units alcohol/day. For his alcohol dependence problem he was treated, on different occasions, with disulfiram and naltrexone. He developed a monothematic delusion about his wife’s infidelity (Othello’s Syndrome) and various antipsychotic were used to try treating this delusion, as follows:
Mr. J., has no history of perinatal distress, cranial or peripheral nerve injury or electroconvulsive therapy and he had no relevant family history of dystonia or other movement disorders. He was also seen by an orthopaedic surgeon and no physical cause for the cervical dystonia was found. A neurologist was consulted who started him on 15 mg/day baclofen tablets, then 75 mg/day tetrabenazine and finally he was given a trial of 4 botulinum toxin injections, which caused a slight improvement. However, to date, the cervical dystonia still persists and he remains attending follow up reviews with the neurologist.
Discussion
Tardive dystonia is an uncommon complication of anti-psychotic treatment. Its diagnosis is made on the basis of exposure to dopamine receptor blocking agents and a negative family history for dystonia. Olanzapine is a 5HT2-D2 receptor antagonist, with anticholinergic and histamine H1 receptor-blocking activity. There is no satisfactory treatment for this condition. Anticholinergic drugs are ineffective and the condition often persists even after withdrawal of the antipsychotic drug. The remission rate is considered to be only 10% (Havaki-Kontaxaki et al, 2003).
References
1. Charfi, F., Cohen, D., Houeto, J.L., et al (2004) Tardive dystonia induced by atypical neuroleptics: a case report with olanzapine. Journal of Child and Adolescent Psychopharmacology, 14,
2. Goetz C.G., Horn S. (2004) Tardive dyskinesia. In Movement Disorders: Neurologic Principles and Practice (eds R.L. Watts, W.C. Koller), pp New York: McGraw-Hill Medical Publishing.
3. Gunal, D.I., Onultan, O., Afsar, N., et al (2001) Tardive dystonia associated with olanzapine therapy. Journal of Neurological Sciences, 22,
4. Havaki-Kontaxaki, B.J., Kontaxakis, V.P., Margariti, M.M., et al (2003) Treatment of severe neuroleptic-induced tardive torticollis. Annals of General Hospital Psychiatry, 2: 9, doi: /
5. Velickovic, M., Benabou, R., Brin, M.F. (2001) Cervical dystonia pathophysiology and treatment options. Drugs, 61,
Year
Medication
Comments
1986
15mg trifluoperazine OD & 6mg benzhexol
For 2 years; symptoms still present
1991
4mg pimozide
No improvement
1996
100mg fluphenazine decanoate 4-weekly depot & 6mg benzhexol
Improvement in his delusions; developed orofacial dyskinesia
2000
20mg flupentixol decanoate depot & 10my procyclidine 4-weekly + 10mg oral olanzapine OD
The flupentixol was gradually tailed off & stopped once Mr J was stabilized on olanzapine
2001
10mg olanzapine OD
Doing well
2002
Rotational-type of cervical dystonia developed. Olanzapine was gradually tailed off and changed to quetiapine.