Case history
Case history
A 65-year-old African-American woman presents to the clinic with a 4-month history of involuntary movements of her mouth and face. Her past medical history is significant for bipolar disorder, and a year ago she had an episode of severe mania, for which she was hospitalized and given haloperidol. She was discharged home with olanzapine. She had an acute dystonic reaction after receiving an intramuscular injection of haloperidol during the hospitalization, which subsided with the administration of intravenous diphenhydramine. Her current involuntary movements started 3-4 months after taking olanzapine and have been persistent since then. She has not had any trauma to the face or neck and no history of tooth extraction. Examination reveals continuous oro-buccal-lingual (OBL) stereotypies (lip smacking, lip puckering, and tongue writhing) along with increased blinking and intermittent involuntary closure of the eyes. Her neurologic exam is otherwise unremarkable.
Other presentations
While TD classically manifests with OBL stereotypies, clinicians should be familiar with other phenomenologies of tardive syndrome. These include tardive dystonia, tardive akathisia, tardive tremor, tardive tics (tourettism), tardive myoclonus, tardive chorea, and tardive parkinsonism. It is possible that patients with TD have additional phenomenologies as listed above. Some patients also develop chronic painful oral and genital sensations, which are termed as tardive pain.[4] The presence of such symptoms should not prompt extensive investigations as those are part of the tardive syndrome. There can be substantial variations in the duration of exposure to dopamine receptor-blocking agents that lead to TD. While in the majority of patients TD develops 1-2 years after a continuous exposure of dopamine receptor-blocking agent, in some patients TD may appear within 3 months to 1 year.[5][6] In people over 65 years, a diagnosis of TD can be considered after only 1 month's use of dopamine receptor-blocking agents.[2] The rates of remission reported are variable, but have been summarized as below 25%.[7] In some patients, TD may persist for more than 2-3 decades after discontinuing a dopamine receptor-blocking agent.[5]
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