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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
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
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
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
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
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
J Can Acad Child Adolesc Psychiatry
, 20:2, May 2011
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D. Interference testing REFERENCES AccuTest™ THC Test Cassette The AccuTest™ THC test strip performance at cut1. Urine testing for drugs of abuse, NIDA Research not affected when pH and Specific Gravity ranges of urine 2. Steven B. Karch, Drugs of abuse hand book, CRC specimen are at 4.5 to 9.0 and 1.005 to 1.035. FOR THE QUALITATIVE ASSESSMENT OFTHCL AND The follow