Objective: To report a case of tardive dystonia induced by risperidone and discuss the therapeutic approach, including the use of botulinum toxin.

Background: Risperidone, a second-generation antipsychotic (SGAs), is generally associated with a lower risk of causing extrapyramidal syndromes (EPS) and tardive dyskinesia (TD) compared to first-generation antipsychotics (FGAs). However, risperidone can still induce tardive dystonia, a rare but serious condition, through its potent antagonism of dopamine D2 receptors, disrupting the balance of neurotransmitters in the basal ganglia, a region critical for motor control [1].

Method: A case report

Results: A 27-year-old man with a history of schizophrenia, who had been receiving a low dose SGAs, specifically risperidone (4 mg/day), slowly developed neck pain and rigidity along with sustained involuntary spasmodic leftward head-turning movement consistent with cervical dystonia, one year after starting his psychiatric medication. The patient was subsequently diagnosed with tardive dyskinesia as per the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V).

In response to these symptoms, risperidone was reduced to 2 mg at night, and sertraline 25mg, diazepam 2.5 mg, trihexyphenidyl 4 mg were added. Despite these adjustments, his condition showed no significant change. 

In an effort to alleviate his symptoms, the patient received  botulinum toxin injections with 20 units administered to the right sternocleidomastoid muscle and 20 units to the left trapezius muscle. Two weeks following the treatment, the patient reported significant improvement in neck mobility dan reduction in pain. Consequently, risperidone was discontinued and replaced with quetiapine (200mg). At the six-month follow-up, the symptoms didn’t recurred.

Conclusion: This case highlights the importance of recognizing SGAs like risperidone, as a systemic contributor of the development of focal dystonia, particularly tardive dystonia, due to its impact on the dopamine system. Early detection and appropriate management, including the use of botulinum toxin therapy and antipsychotic modifications, can lead to significant improvement in patient outcomes.

References: [1] Rokon AE, Alsomali FA, Alrasheed MA, et al. Tardive Dyskinesia Following Low-Dose Risperidone. Cureus. 2022;14(12):e32319. Published 2022 Dec 8. doi:10.7759/cureus.32319

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MDS Abstracts - https://www.mdsabstracts.org/abstract/tardive-dystonia-following-risperidone-treatment-a-case-report-and-therapeutic-approach/