Treatment of severe neuroleptic-induced tardive torticollis

The patient, a 30-year old man with a seven-year history of delusional disorder experienced severe right torticollis with painful tightness of the neck and elevation of the shoulder. At this time he was receiving haloperidol 20 mg, trifluoperazine 5 mg, zuclopenthixol 20 mg and biperidine 4 mg daily. The combination therapy with clozapine and clonazepam and the long-term use of botulinum toxin-A resulted in a complete remission of dystonic movements.The present observations provide evidence indicating that this combination therapy may be of benefit in patients with severe neuroleptic-induced tardive torticollis.Tardive dystonia (TDt) is an uncommon complication of antipsychotic treatment characterized by twisting and sustained muscle spasms that cause repetitive movements or abnormal postures. It is a persistent and painful disorder with no satisfactory treatment. The remission rate is considered to be only 10%. TDt can affect any body area. The muscles of the head and the neck are usually affected producing retro-, latero, - ante- or torti-collis [1-3].We here describe a patient with severe tardive torticollis successfully treated with clozapine, clonazepam and botulinum toxin A (BTX) who remains well after four years while on clozapine monotherapy.Mr A, a 30-year-old man with a seven year history of delusional disorder was treated with a variety of neuroleptics including haloperidol, trifluoperazine, perfenazine, pipamperone, thioproperazine, zuclopenthixol, in high doses and various combinations. He experienced severe extrapyramidal symptoms and received therapy with anticholinegrics for many years. Abnormal involuntary movements of his neck and head were first noticed in July 1996. At this time he was receiving haloperidol 20 mg/day, trifluoperazine 5 mg/day, zuclopenthixol 20 mg/day, biperiden 4 mg/day.His condition progressively deteriorated. Three months later he experienced right torticollis with painful tightness of the neck and elevation of the shoulder. H