Involuntary Facial Twitching in a Patient with Schizophrenia on Treatment with Long Acting Injectable Olanzapine

Dear Editor

We report a case of a 49 year old Caucasian male with chronic schizophrenia and a history of non-compliance with treatment, due to lack of insight, resulting in multiple acute psychotic relapses that required compulsory admissions to hospital during which he was treated orally with olanzapine, risperidone and aripiprazole monotherapies. Subsequently, the patient was switched to long acting injectable (LAI) risperidone [initially 25 mg and later on increased to 50 mg, once every two weeks] and placed on a community treatment order that led to substantial improvement in his treatment compliance and reduction in hospitalisation.¹,² Although the patient’s positive symptoms remitted, 6 years after commencement of LAI risperidone he continued to lack insight into his mental disorder and his apathy, asociability, and lack of emotional responsiveness progressively dominated his clinical picture and were particularly troublesome to his carers who were concerned that his negative symptoms may be, at least partly, secondary to his risperidone treatment. Thus, in an attempt to address those concerns, LAI risperidone was switched to LAI olanzapine as follows: LAI olanzapine 300 mg [instead of LAI risperidone] was administered on the day the latter was due, and was subsequently maintained at the aforementioned dose once every two weeks.

Eight months later there was no notable change in the patient’s mental state, albeit his carers reported that switching to LAI olanzapine was associated with the insidious development of facial twitching which gradually increased in frequency, and was then observed several times per day. Examination revealed the presence of involuntary, ultra-rapid [but not athetotic or choreiformic] recurrent contractions of the lower facial muscles resulting in unilateral retraction of the angle of the mouth, which the patient was unaware of, suggesting tardive dyskinesia;³ a troublesome and potentially irreversible antipsychotic-induced movement disorder that is probably mediated by dopamine D2 receptor supersensitivity.⁴,⁵ Thus, LAI olanzapine was discontinued, which was associated with the attenuation of the facial twitching. Four weeks after the last LAI olanzapine injection [when plasma olanzapine was likely to still be present at clinically relevant levels], the involuntary movements were no longer observable, which may suggest a dose-related effect. At this stage, and in order to prevent a psychotic relapse, the patient was commenced and maintained on LAI aripiprazole [400 mg once monthly], which is a partial D2 agonist with low propensity for causing dopamine supersensitivity.⁴ Twelve months later the patient’s condition remained stable with no recurrence of the involuntary movements.

This case emphasises the importance of early recognition, and potential reversibility, of probable dose-related tardive phenomena that may emerge in patients with schizophrenia receiving treatment with LAI olanzapine.

Disclosure Statement

The authors have no conflicts of interest to declare.