Tardive dyskinesia with low dose amisulpride
A 56-year-old female presented to the Schizophrenia Foundation Hospital (SCARF) outpatient services with a seven-year on and off history of sub syndromal anxiety and depressive symptoms related to marital stressors and a one-month exacerbation of symptoms following her son's marriage. Patient was diagnosed as a case of mixed anxiety and depression as per International Classification of Diseases (ICD)-10 criteria. Treatment was initiated with escitalopram 10 mg for a week and discontinued due to gastritis. Subsequently patient was started on amisulpride 50 mg/day and hiked to 100 mg when she gradually reported improvement in mood in 6 weeks. During the next follow up at week 12 of 100 mg amisulpride therapy, she was first noticed to have orofacial dyskinetic movements and amisulpride was discontinued. However, patient was prescribed fluvoxamine 25-50 mg for 8 weeks because of worsening of anxiety and depressive symptoms. During her subsequent hospital visits, patient reported progressively severe dyskinetic movements of the face, neck, right forearm, wrist, and fingers and opisthotonic posturing of the chest. She was evaluated in detail and diagnosed with dyskinesia (drug induced) as per ICD-10. Her Abnormal Involuntary Movement Scale (AIMS) score was 15. A score of 4 on the Naranjo adverse drug reaction probability scale indicates a possible cause of dyskinesia related to amisulpride. Her medical co morbidity also included diabetes mellitus, which was not well controlled. There was no past or current history of substance use or neurological disorder, or any family history of movement disorders or any previous antipsychotic use. Magnetic resonance imaging (MRI) done did not reveal any abnormal finding. To treat drug-induced dyskinesia, fluvoxamine was stopped and patient was started on tetrabenazine. Two months later, tardive dyskinesia persisted and there was no improvement in dyskinetic movement. Patient has recently been started on clozapine for dyskinesia.