This is a hypothetical patient case developed for educational purposes by Desiree M. Matthews, PMHNP-BC, based on characteristics of patients with tardive dyskinesia as seen in clinical practice. The hypothetical case was sponsored and co-developed by Neurocrine Biosciences.

Silvia G. is a 41-year-old woman who works at a daycare and lives at home with her husband and teenage daughter. She is currently being treated for bipolar I disorder and generalized anxiety disorder (GAD). At a recent telemedicine video visit for routine follow-up, her psychiatric nurse practitioner (NP) noted abnormal facial movements during their conversation.

Silvia was being seen via telemedicine by her psychiatric NP for routine follow-up and to schedule a long-acting injectable appointment. During their conversation, her NP made note of abnormal facial movements, including frequent lip pursing, increased blink rate, and tongue darting.1-3 Upon discussion, Silvia mentioned that her coworkers thought she should see an eye doctor, commenting that she blinks and squints a lot.2,3 She said she had an eye exam about a year ago and noted, “Everything was fine.”

Patient Information
  • Name: Silvia G.
  • Age: 41 y
  • Sex: Female
  • Race/Ethnicity: Hispanic
  • BMI: 29
  • BP: 138/87 mm Hg
  • Current problems:
    • Bipolar I disorder
    • Generalized anxiety disorder
    • Hypertension
    • Vitamin D insufficiency
  • Current medications:
    • Aripiprazole extended-release injectable
    • 400 mg IM every 28 days
    • Lamotrigine 100 mg QHS
    • Sertraline 150 mg QHS
    • Amlodipine 5 mg QD
    • Vitamin D3 2000 IU QD
BMI, body mass index; BP, blood pressure; IM, intramuscular; QD, every day; QHS, every night at bedtime.
  1. Fahn S, et al. In: Fahn S, et al, eds. Principles and Practice of Movement Disorders. 2nd ed. Saunders; 2011:415-446.
  2. Tarsy D. Curr Treat Options Neurol. 2000;2(3):205-214.
  3. Savitt D, et al. J Neurol Sci. 2018;389:35-42.

Silvia was diagnosed with bipolar I disorder after hospitalization for a manic episode at age 20. She spent several years without treatment and was subsequently hospitalized at age 25 for a suicide attempt and diagnosed with acute bipolar I depression. Since then, she has been treated with several antipsychotic, anxiolytic, and antidepressant medications. She experienced drug-induced parkinsonism and elevated prolactin levels with previous antipsychotic treatments, but has been healthy and stable on her current medication regimen for the past few years. Based on her history, the goals of the case are to maintain control of her psychiatric symptoms and evaluate the whole body for movements that may be consistent with drug-induced movement disorders from long-standing antipsychotic use.

Psychiatric History 
  • Current diagnosis: Bipolar I disorder, generalized anxiety disorder
  • Previous psychiatric diagnoses: PTSD
  • Current psychiatric medication:
    • Aripiprazole extended-release injectable, 400 mg IM every 28 days
    • Lamotrigine 100 mg QHS
    • Sertraline 150 mg QHS
  • Psychiatric medication history:
    • Haloperidol, sodium valproate, lithium, risperidone, quetiapine, oral aripiprazole, clonazepam, alprazolam, paroxetine, citalopram
  • Safety concerns: History of medication nonadherence and nonadherence to lab monitoring requirements
  • Previous psychiatric hospitalizations: 2 hospitalizations 16 and 25 years ago
  • Substance use: None reported
IM, intramuscular; PTSD, post-traumatic stress disorder; QHS, daily at bedtime.

Upon discussion, Silvia says that her husband had noticed “strange movements” in her face for the past several months. She is concerned about the movements and bothered when her husband or coworkers mention them. She was regularly avoiding interactions with her coworkers and felt self-conscious meeting new people. Her psychiatric NP conducted an AIMS exam during the video visit and reviewed her past treatment history and diagnoses. Based on the clinical interview, the type of movements observed,1-3> and her long-standing treatment with antipsychotics,1 a diagnosis of tardive dyskinesia (TD) was made.

Motor Evaluation
  • Frequent lip pursing, increased blink rate, tongue darting1-3
  • Normal gait4
  • No tremor observed4
  • AIMS exam
    • Total dyskinesia score: 8
  • Previous AIMS exam (1 year ago)
    • Total dyskinesia score: 0
AIMS, Abnormal Involuntary Movement Scale.
  1. Fahn S, et al. In: Fahn S, et al, eds. Principles and Practice of Movement Disorders. 2nd ed. Saunders; 2011:415-446.
  2. Tarsy D. Curr Treat Options Neurol. 2000;2(3):205-214.
  3. Savitt D, et al. J Neurol Sci. 2018;389:35-42.
  4. Ward K, et al. Neurol Ther. 2018;7(2):23.

Silvia and her psychiatric NP discussed her diagnosis, prognosis, and treatment options together and made the decision to treat with a VMAT2 inhibitor. After 4 months of treatment, the movements were reduced and the subsequent AIMS score had decreased from an 8 to a 4. Silvia remained psychiatrically stable on her medication regimen to control bipolar I disorder and GAD.

Notes From Today's Visit
  • Provided patient education on TD
  • Discussed use of VMAT2 inhibitors to treat abnormal movements associated with TD
  • Reviewed the treatment plan and discussed what to expect at the next visit
VMAT2, vesicular monoamine transporter type 2.

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MED-MSL-TD-US-0217 v2 CP-TD-US-0679 v3 10/2022