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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 57, Num. 1, 2009, pp. 94-95

Neurology India, Vol. 57, No. 1, January-February, 2009, pp. 94-95

Letter To Editor

Tardive dyskinesia following risperidone treatment in Tourette's syndrome

Department of Child and Adolescent Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu, India

Correspondence Address:Department of Child and Adolescent Psychiatry, Christian Medical College, Vellore - 632 002, Tamil Nadu, India

Date of Acceptance: 05-Feb-2009

Code Number: ni09028


Tics are involuntary, sudden, repetitive, stereotyped motor movements or phonic productions. Tourette's syndrome (TS) is diagnosed when multiple motor tics and at least one phonic tic is present during the course of the illness. Obsessive-compulsive disorder/symptoms (OCD/OCS) typically manifest as own, egodystonic and involuntary intrusive thoughts, ideas or images accompanied by ritualized, overt, or covert behaviors. The frequent association of TS with obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorder (OCD) is widely recognized. [1] The neurobiology of TS involves frontal subcortical circuits and neurotransmitter systems. [2] The usefulness of antipsychotics in the treatment of TS has been documented, but is often associated with incapacitating side-effects. There are a few case reports of Tardive dyskinesia (TD) in TS after treatment with typical antipsychotics unlike with atypical antipsychotics. We discuss the case of a 24-year-old male who first exhibited repetitive head and neck twisting movements that started at 15 years of age. Nine years after the onset of symptoms when a definitive diagnosis of TS was made, his symptoms included motor and phonic tics [Yale Global Tic Severity Scale (YGTSS) = severe] as well as obsessional thoughts [Yale-Brown Obsessive Compulsive Scale (Y-BOCS) = mild). There was no movement other than tics. His biochemical and neuromaging tests were normal. Initially he was treated with oral sertraline 50mg and haloperidol 0.5mg daily, but was lost to follow-up and reported for treatment after a year with identical symptoms. Oral risperidone was started as well as maintained at 1mg with dinner and fluoxetine was increased to 40mg with breakfast. Although his tics were minimal at this dose (YGTSS = mild), he developed severe TD of the lower jaw (oro-mandibular dyskinetic movements) after four months of treatment [Abnormal Involuntary Movement Scale (AIMS) rating = severe]. This movement was entirely different from the initial symptoms both anatomically and phenomenologically. Following this, risperidone was stopped and patient was started on vitamin E and clonazepam. In about 45 days there was significant improvement in the dyskinetic movements (AIMS score = mild) but the TS worsened significantly causing severe distress (YGTSS = severe). Risperidone has a higher affinity for 5-hydroxytryptamine 2A receptors and lower dopamine D2 receptor binding than haloperidol. [3] As the 5-HT2A receptor has been implicated in the pathophysiology of TS, risperidone may be of theoretical benefit in TS, especially if the patient has OCD/OCS where 5-HT has been implicated. Several reports illustrate efficacy [4] and lack of extrapyramidal side-effects in TS patients treated with risperidone. [5] To our knowledge, this is the first report of TD complicating the use of risperidone in the treatment of TS. We wish to highlight the need for awareness among clinicians and patients about the potential risk of getting new movement disorders during the course of treatment with risperidone for tic disorders.


1.Eapen V, Fox-Hiley P, Banerjee S, Robertson M. Clinical features and associated psychopathology in a Tourette syndrome cohort. Acta Neurol Scand 2004;109:255-60.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Robertson MM, Stern JS. Tic disorders: New developments in Tourette syndrome and related disorders. Curr Opin Neurol 1998;11:373-80.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Leysen JE, Janssen PM, Gommeren W, Wynants J, Pauwels PJ, Janssen PA. In vitro and in vivo receptor binding and effects on monoamine turnover in rat brain regions of the novel antipsychotics risperidone and ocaperidone. Mol Pharmacol 1992;41:494-508.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bruun RD, Budman CL. Risperidone as a treatment for Tourette's syndrome. J Clin Psychiatry 1996;57:29-31.  Back to cited text no. 4    
5.Robertson MM, Scull DA, Eapen V, Trimble MR. Risperidone in the treatment of Tourette syndrome: A retrospective case note study. J Psychopharmacol 1996;10:317-20.  Back to cited text no. 5    

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