A 60-year-old woman comes to the office due to uncontrollable movements that have worsened. Medical history is significant for hypertension, hyperlipidemia, osteoarthritis, and schizophrenia, and she has been on a stable medication regimen for years. Throughout the interview, she exhibits facial grimacing, lip smacking, and twisting movements of her hands and feet. The patient has lived in a group home for many years and worries that her housemates are avoiding her because her symptoms make her look "strange." On mental status examination, the patient makes poor eye contact and is generally distrustful but has no specific delusions or hallucinations. Which of the following is the most likely diagnosis?

Question

A 60-year-old woman comes to the office due to uncontrollable movements that have worsened.  Medical history is significant for hypertension, hyperlipidemia, osteoarthritis, and schizophrenia, and she has been on a stable medication regimen for years.  Throughout the interview, she exhibits facial grimacing, lip smacking, and twisting movements of her hands and feet.  The patient has lived in a group home for many years and worries that her housemates are avoiding her because her symptoms make her look "strange."  On mental status examination, the patient makes poor eye contact and is generally distrustful but has no specific delusions or hallucinations.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3601_02d1_9249_9f83bd5720fd_MD0001_00 This patient has a diagnosis of schizophrenia and has likely been treated with antipsychotic medications for many years. Her abnormal movements are characteristic of tardive dyskinesia (TD), a movement disorder associated with long-term treatment with dopamine antagonist medications (eg, antipsychotics, metoclopramide). Possible mechanisms of TD include development of hypersensitive post-synaptic D2 receptors following prolonged D2 blockade and an imbalance between D1 and D2 receptor-mediated effects. TD typically consists of repetitive, rhythmic, involuntary movements of the tongue, lips, face, trunk, and extremities. Orofacial dyskinesias (eg, facial grimacing, tongue movements, lip smacking and puckering) are most common, but choreoathetoid movements of the trunk and limbs can also occur. Older age and exposure to first-generation antipsychotics increase the risk of developing TD. Treatment typically includes discontinuing the offending agent when feasible. (Choices A, C, and D) TD can be differentiated from acute extrapyramidal syndromes that also result from exposure to dopamine antagonists. Acute dystonia involves a distressing, sustained, involuntary contraction of the neck, mouth, tongue, or eye muscles that typically occurs within the first few days of receiving a dopamine antagonist. Akathisia is characterized by physical restlessness, difficulty sitting still, and a compelling need to move. Drug-induced parkinsonism manifests with tremor, bradykinesia, and cogwheel rigidity. (Choice B) Poor eye contact and general distrust are symptoms that frequently persist in patients treated with antipsychotics during the maintenance phase of schizophrenia. Signs and symptoms of an acute psychotic episode include delusions, hallucinations, and disorganized speech and behavior. (Choice E) Neuroleptic malignant syndrome, which is also an adverse reaction related to antipsychotic treatment, is a rare and potentially fatal syndrome characterized by delirium, high fever, severe muscle rigidity, and autonomic instability. (Choice G) The characteristic feature of all tic disorders involves brief, recurrent, nonrhythmic motor movements (eg, eye blinking) and/or vocalizations (eg, grunting), beginning in childhood. Educational objective: Tardive dyskinesia consists of abnormal involuntary movements of the mouth, tongue, face, extremities, or trunk associated with prolonged exposure to antipsychotics. Characteristic movements include lip smacking, facial grimacing, tongue protrusions, and choreoathetoid movements of the head, limbs, and trunk. __________ References: Tardive dyskinesia: recognition, patient assessment, and differential diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/29570969) Tardive dyskinesia (syndrome): current concept and modern approaches to its management. (http://www.ncbi.nlm.nih.gov/pubmed/25556809)

A 60-Year-Old Woman Comes to the Office Due to Uncontrollable