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

Jennifer S. is a 47-year-old telecom worker and mother of 3. She is currently in a day program due to a depressive episode with mixed features. She recently blew up at her boss on a stressful day. She is currently anxious, not sleeping, and concerned about losing her job. She is also distressed by what she describes as a “tremor” in her lips and hands, especially during work meetings, which adds to her overall anxious mood.

Based on her current presentation, the primary treatment goal is to stabilize her mood and address her abnormal movements.

Patient Information
  • Name: Jennifer S.
  • Age: 47 y
  • Sex: Female
  • Race/Ethnicity: African American, White
  • Occupation: Telecom worker
  • BMI: 34
  • BP: 145/95 mm Hg
  • Current problems:
    • Bipolar disorder
    • Hypertension
    • Prediabetes
  • Current medications:
    • Metformin 500 mg BID
    • Lamotrigine 100 mg BID
    • Escitalopram 20 mg qam
    • Olanzapine 10 mg qhs
    • Benztropine 2 mg BID
    • Lorazepam 1 mg qam and 2 mg qhs
BID, twice daily; BMI, body mass index; BP, blood pressure; qam, every morning; qhs, every night at bedtime.

Jennifer was diagnosed with bipolar disorder in her mid-20s and has been treated with a variety of psychiatric medications since, including typical and atypical antipsychotics on and off. Her current depressive episode with mixed features has been ongoing for 4 months.

Psychiatric History 
  • Current diagnosis: Bipolar disorder
  • Previous psychiatric diagnoses: Current depressive episode with mixed features (4 months)
  • Current psychiatric medication:
    • Lamotrigine 100 mg BID
    • Escitalopram 20 mg qam
    • Olanzapine 10 mg qhs
    • Benztropine 2 mg BID
    • Lorazepam 1 mg qam and 2 mg qhs
  • Past psychiatric medications:
    • Lithium 300 mg 1 qam and 2 qhs
    • Risperidone 2 mg qhs
    • Sertraline 100 mg qam
    • Quetiapine 200 mg qhs
    • Haloperidol 5 mg IM prn while in hospital
IM, intramuscular; prn, as needed.

In her early 20s, Jennifer was hospitalized for an episode of mania and treated with quetiapine and haloperidol IM. During this hospitalization, she developed drug-induced parkinsonism. She was prescribed benztropine for these movements, which helped. Years later, she began to develop involuntary movements in her lips and hands that she described as “tremor,” a term she remembered from her experience with acute drug-induced parkinsonism. She was again prescribed benztropine, but the movements did not change. Despite this, her benztropine prescription has continued for 2 years.

History of Movement Disorders 
  • History of tremor/rigidity after treatment with haloperidol IM during psychiatric hospitalization, diagnosis of drug-induced parkinsonism
  • Benztropine prescribed while in hospital
Recently, in an effort to address her abnormal movements, her antipsychotic dose was decreased. However, her movements worsened.1 Jennifer’s children noticed the movements and became worried. Jennifer is unsure why the benztropine is not helping and reports that she feels “embarrassed when she looks in the mirror.” Though her abnormal movements are relatively mild, she says they make her anxious and self-conscious, especially in meetings at work. She has been losing sleep and is worried about how her “tremor” might be perceived at work.

Impact of Movements
  • Movements in her lips, tongue, and fingers
  • Patient reports embarrassment and increase in anxiety due to movements at home and at work
1. Treatment of tardive syndromes. American Academy of Neurology. Published 2013. Accessed September 9, 2020. https://www.aan.com/Guidelines/Home/GetGuidelineContent/613

Based on these symptoms and history, a thorough motor evaluation was conducted.1 The evaluation revealed abnormal movements of the lips and hands, including irregular, arrhythmic lip pursing and finger tapping.2 A diagnosis of tardive dyskinesia (TD) was made based on the type of movement, medication history, worsening of symptoms upon antipsychotic dose decrease,3 nonresponse to benztropine,4 and ongoing abnormal movements.5

Motor Evaluation
  • Abnormal, involuntary movements of lips and hands
    • Lip pursing, finger tapping
    • Movements are irregular in rhythm
  • Patient’s gait is not disrupted and arm movements are normal
  • When antipsychotic dose was decreased, movements worsened
  • Duration of movements: ~2 years
  • No improvement with benztropine
1. Treatment of tardive syndromes. American Academy of Neurology. Published 2013. Accessed September 9, 2020. https://www.aan.com/Guidelines/Home/GetGuidelineContent/613 2. Rush JA. Handbook of Psychiatric Measures. 2000:166-168. 3. Treatment of tardive syndromes. American Academy of Neurology. Published 2013. Accessed September 9, 2020. https://www.aan.com/Guidelines/Home/GetGuidelineContent /613 4. Benztropine mesylate [package insert]. Lake Forest, IL: Akorn; 2017. 5. APA. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. APA; 2013.

After helping Jennifer better understand her TD diagnosis, the treating clinician reviewed available therapeutic options and together they made the decision to begin treatment of TD with a VMAT2 inhibitor.

Notes From Today's Visit
  • Provided education about TD and available treatment options
  • Shared decision to initiate treatment with a VMAT2 inhibitor
  • Follow-up in 1 month
VMAT2, vesicular monoamine transporter 2.

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