CLOZAPINE WITHDRAWAL EMERGENT DYSTONIAS AND DYSKINESIAS - A CASE SERIES

Background: Severe psychotic decompensation during clozapine withdrawa l has been reported previously. Less attention has been paid to moveme nt disorders following abrupt clozapine withdrawal. This report descri bes 4 subjects who experienced severe dystonias and dyskinesias upon a brupt clozapine withdrawal. Method: Current and past medical records o f 4 subjects with DSM-IV schizophrenia or schizoaffective disorder wer e reviewed. Results: All subjects had a history of neuroleptic-induced extrapyramidal symptoms, 1 had a history of severe dystonias, and 1 h ad neuroleptic malignant syndrome. All had mild orolingual tar dive dy skinesia prior to clozapine treatment. All subjects had received cloza pine for several months, and 3 of the 4 subjects stopped clozapine abr uptly. Two subjects experienced cholinergic rebound symptoms within ho urs, which resolved quickly. These subjects had severe limb-axial and neck dystonias and dyskinesias 5 to 14 days after clozapine withdrawal . Two subjects were unable to ambulate, and 1 had a lurching gait. Two gagged while eating or drinking. Two subjects were returned to clozap ine, 1 was started on low-dose risperidone treatment, and 1 was starte d on olanzapine treatment. All experienced significant improvements in their mental state and movement disorders. Conclusion: Severe movemen t disorders, which may be worse than the movements prior to clozapine treatment, and cholinergic rebound symptoms may occur upon abrupt cloz apine withdrawal and must be recognized in addition to the severe psyc hotic decompensation noted in some patients. Patients, families, and c aregivers must be alerted to this possibility. Where possible, a slow clozapine taper, the use of anticholinergic agents, and symptomatic tr eatment may help minimize these withdrawal symptoms, and reintroductio n of clozapine or treatment with the newer atypical agents can help in the clinical management of these symptoms.