Letters to the Editor
Improvement of Torticollis With Quetiapine in a Schizophrenia Patient
Dear Editor:
In patients with schizophrenia, extra- pyramidal symptoms (EPS) and tardive syndromes are commonly associated with exposure to conventional antipsychotics such as haloperidol and can lead to noncompliance. Atypical antipsychotics are much less likely to cause such side effects and often reduce these problems (1), though there are differences among drugs within this class (2). Here I report the history of a patient with schizophrenia who suffered distressing, involuntary contractures of the neck muscles (torticollis).
Case Report
Miss C, aged 35 years, was diagnosed with paranoid schizophrenia at age 24 years, while attending university. She received intramuscular, short-acting haloperidol (1 dose of 10 mg) and developed torticollis. Torticollis persisted for 1 year, despite treatment with a reduced dosage of haloperidol, a dosage of chlorpromazine (maximum 400 mg daily) and several side effect medications (specifically, benztropine, procy- clidine, amantadine, and lorazepam). A neurological consultant believed the muscle contractures were secondary to the antipsychotic medication. Following the failure of tetrabenazine (maximum 75 mg daily) to reduce the contractures, the patient and her family refused antipsychotic medication, believing the cure was worse than the illness. Over the next 5 years, Miss C attended the emergency department 18 times, with agitated or aggressive behaviour and was treated with various antipsychotics, with moderate response and little improvement in neck dystonia. Outside of hospital, she refused medication and was largely housebound.
In May 1998, the family brought her to hospital because she had threatened her father with a knife. She was experiencing auditory hallucinations and believed an outside force was controlling her thoughts. She had a marked twisting of the neck, which she found very distressing. Her total score on the Positive and Negative Syndrome Scale (PANSS) was 108 and the neck dystonia was considered severe on the Clinical Global Impression of severity of dystonia scale (the Extrapyramidal Symptom Rating Scale).
A trial of clozapine was undertaken, but despite moderate improvement in neck dystonia, clozapine was discontinued after 4 weeks because of neutropenia. The patient then received an increasing dosage of quetiapine (50 to 800 mg daily over 3 weeks) and demonstrated a moderate initial response. Over 6 weeks, after a dosage of 800 mg daily was achieved, her delusions abated, her agitation ceased, and she stopped responding to auditory hallucinations. The dystonic neck posture normalized, with neck muscle spasms causing only occasional concern. Her PANSS total score was 67, and severity of dystonia was mild.
This case demonstrates that switching to second-generation antipsychotics may improve tardive dystonia. Both cloza- pine and quetiapine have demonstrated placebo-level EPS across the dosage range (3,4). However, clozapine is associated with agranulocytosis and requires regular blood monitoring (5), which may decrease its acceptability to patients. Further, quetiapine has demonstrated efficacy in patients who have switched from other antipsychotics following an inadequate response or intolerance (6,7). In the treatment of schizophrenia appropriate side effect management is important in ensuring that poor compliance, and subsequently poor outcome, are avoided. The patient and her family were very pleased with the resolution of the neck dystonia with quetiapine, and as a result, she continues on her medication, has returned to part-time education, and remains in good health.
References
1. Raja M. Managing antipsychotic-induced acute and tardive dystonia. Drug Saf 1998;19:57–72.
2. Tarsy D, Baldessarini RJ, Tarazi FI. Effects of newer antipsychotics on extrapyramidal function. CNS Drugs 2002;16:23–45.
3. Arvanitis LA, Miller BG, and the Seroquel Trial 13 study group. Multiple fixed doses of “Seroquel” (quetiapine) in patients with acute exacerbation of schizophrenia: a comparison with haloperidol and placebo. Biol Psychiatry 1997;42:233–246.
4. Gerlach J. Improving outcome in schizophrenia: the potential importance of EPS and neuroleptic dysphoria. Ann Clin Psychiatry 2002;14:47–57.
5. Alvir JMJ, Lieberman JA, Safferman AZ, Schwimmer JL, Schaaf JA. Clozapine-induced agranulocytosis. Incidence and risk factors in the United States. N Engl J Med 1993;329:162–7.
6. Emsley RA, Raniwalla J, Bailey PJ, Jones AM. A comparison of the effects of quetiapine (‘Seroquel’) and haloperidol in schizophrenic patients with a history of and a demonstrated, partial response to conventional antipsychotic treatment. Int Clin Psychopharmacol 2000;15:121–31.
7. De Nayer A, Windhager E, Irmansyah, Larmo I, Lindenbauer B, Rittmannsberger H, and others.
Efficacy and tolerability of quetiapine in patients with schizophrenia switched from other antipsychotics. Int J Psych Clin Pract 2003;7:59–66.
Sean W Flynn MD, FRCPC
Port Coquitlam, British Columbia
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