LETTERS

bipeniden, increased

3 mg/day. The dose of haloperidol to 27 mg/day and propeniciazine

over

the next

trunk

gradually

ion

of the

4 weeks.

Within

developed

body

and

the following

a peculiar

backward

week,

position,

axial

rotation.

rarely reported in treatment,

was gradually to 225 mg/day with The

Mr.

A’s

side flex-

patient

was

considered to be suffering from the Pisa syndrome, since he fulfilled the criteria for tardive dystonia developed by Burke et al. (2) and showed the typical posture of this syndrome (1) without any other dystonic reactions.

The

propeniciazine

was

first

discontinued,

and

then

halopenidol was decreased to I 8 mg/day over 4 weeks, but without any noticeable improvement. We then tried agents reported to improve tardive dystonia, such as prometha-

zinc,

amantadine,

tiapnide,

carbamazepine,

lene sodium. 2 weeks with antipsychotic

Each of these was no benefit. Finally, from haloperidol,

I 8 mg/ day.

From

that

gradually improved within I week. The several months.

We changed son. ing

There the

Pisa

time

on,

agent

no report

syndrome.

of selective

The

affinity

non-D2 receptor sites For example, blockade idol exhibits in dystonia

with

for

rcarecep-

in in vitro radioreceptor activity of habopenidol

at

may be responsible for the syndrome. of the sigma receptor, which haboper-

a high

affinity,

is considered

to play

a role

(5).

REFERENCES 1. Ekbom K, Lindholm H, Ljungberg L: New dystonic syndrome associated with butyrophenon therapy. Z Neurol 1972; 202:94-

I03

caused

by antipsychotic

3. Yassa R, Nastase pleurothotonus): Psychiatry

I 990;

J, Marsden late-onset

drugs.

C, Cvejic prevalence

Neurology

CD, Lang AE, Gollomp and persistent dystonia 1982;

32:1335-1

J, Laberge G: The Pisa syndrome in a psychogeriatic population.

346

(or Biol

29:942-945

4.

Richelson E, Nelson A: Antagonism by neuroleptics of neurotransmitter receptors of normal human brain in vitro. Eur J Pharmacol 1984; 103:197-205 S. Walker JM, Matsumoto RR, Bowen WD, Gans DL, Jones KD, Walker FO: Evidence for a role of haboperidol-sensitive sigma‘opiate’ receptors in the motor effects of antipsychotic drugs. Neurology 1988; 38:961-965 EIJI SUZUKI, SHIGENOBU KANBA, MASASHI NIBUYA, FUTOSHI SHINTANI, NORIHISA KINOSHITA, GOHEI YAGI, MASAHIRO ASAI, Tokyo,

Rare

Presentation

of Tardive

SIR: Severe presentations quently disabling because movements, severe tardive

movements. ing irregular

Am

J

Respiratory respiratory

Psychiatry

Ms.

1 49:8,

M.D. M.D. M.D. M.D. M.D. M.D. M.D. Japan

Dyskinesia of tardive dyskinesia ( 1 ) are freof difficulties in masticatory akathisia, or limb and finger

or swallowing dyskinesias rates or grunting noises

August

1992

A had

been

treated

severe

presentation

woman with personality

for several

years

of

a diagnosis disorder ac-

with

tency neuroleptics, probably to contain agitation ety unresponsive to benzodiazepines. Persistent kinesia was diagnosed according to Schooler criteria (3) using the Rockland Simpson scale dyskinesia (4). Ms. A’s total score was 48.

high and

tardive

poanxi-

dys-

and Kane for tardive

of gait.

These

signs

were

associated

with

a continu-

typical tardive dyskinesia patterns, disappearing only during sleep and worsening with anxiety, and its continuous occurrence affected severely the patient’s speech and ability

to fall asleep. Awareness of this symptom was higher than for the other symptoms, maybe because of the auditory feedback. During 2 years of illness, severity was reported to decrease if neuroleptic doses were increased and to worsen upon decrease or withdrawal. The severity also increased if anticholinergics

stable drawal

2. Burke RE, Fahn S, Jankovic S, Ilson J: Tardive dystonia:

and

rhythmical, clearly involuntary vocal emission, like a cry, the origin of which seemed to be laryngeal, defined by the patient as “illness of the cry.” The vocal emission (together with other signs) followed

causD2

of rare

often irrelevant in these cases

ous,

disappeared over the next

D2 antagonists

a case

tardive dyskinesia in a 57-year-old of dysthymic disorder and histrionic cording to DSM-III-R.

malities

symptoms

for the following

(1). We observed

strategies, and ineffective

EDITOR

Upon admission Ms. A showed chewing movements, choreoathetoid movements of the tongue, blepharospasmus, finger movements, akathisia, and bordosis with abnor-

more than the patient’s to pimozide,

of pimozide

tors is higher than that of haloperidol assay (4). This suggested that the

dantro-

for

the dystonic

and almost completely symptoms did not recur

the antipsychotic

has been

and

prescribed we changed 18 mg/day,

(2). Therapeutic are more difficult

TO THE

produchave been

were

used.

In the last 6 months

severity

was

with Ms. A taking cbothiapine, 40 mg/day. Withfrom medication induced a significant worsening of

vocal emission and other symptoms. Neurological examination and nuclear magnetic resonance imaging excluded an olivopontocerebellar syndrome, which was considered in differential diagnosis, as well as other neurological conditions possibly related to the vocal emission and other involuntary movements. After 1 week of treatment with clonazepam. 8 mg/day,

most bances,

symptoms and

the

decreased, vocal

38), which remained 1 -month observation

except

emission

(total

unchanged period.

lordosis,

gait

distur-

Simpson

scale

score=

throughout

the following

The similarity of our patient’s symptoms with Tourettes’s disorder is worth noting. Our observations seem to be quite similar to cases of tardive Tourette’s disorder reported in the literature (5).

REFERENCES 1. Gardos G, Cole OJ, Salomon M, Schniebolk 5: Clinical forms of severe tardive dyskinesia. Am J Psychiatry 1987; 144:895-902 2. Casey DE: Tardive dyskinesia, in Psychopharmacology: The Third Generation of Progress. Edited by Meltzer HY. New York, Raven Press, 1987 3. Schooler NR, Kane JM: Research diagnosis for tardive dyskinesia. Arch Gen Psychiatry 1982; 39:486-487 4. Simpson GM, Lee JH, Zoubok B, Gardos G: A rating scale for tardive dyskinesia. Psychopharmacology I 979; 64:171-179 S. Shapiro AK, Shapiro E: Tic disorders, in Comprehensive Textbook of Psychiatry, vol V. Edited by Kaplan HI, Sadock BJ. Baltimore,

Williams

& Wilkins,

1989

R. CAVALLARO, E. SMERALDI, Milan,

M.D. M.D. Italy

1115