Resolution of complex tardive syndrome and psychotic symptoms with clozapine and electroconvulsive therapy in a patient with schizophrenia: A case report

Although treatment guidelines for tardive dyskinesia (TDk) exist, comprehensive data for other tardive syndrome (TS) types are scarce, and no treatment guideline for the combined form of TS are available. Patients sometimes present with different types of TS combined (e.g., TDk and tardive dystonia (TDt)). The priority of candidate treatment options is unclear, resulting in difficult treatment decisions. Our patient, a 25-year-old male with schizophrenia, had been taking non-clozapine antipsychotic medications for one year, and severe involuntary movements had emerged mainly in his right shoulder (TDk) and face and abdomen (TDt). Several types of medication did not control his psychotic symptoms, leaving him withdrawn at home. At his presentation, he was unable to eat due to complicated body movements, which caused him serious distress. He was admitted to our hospital, and treatment with clozapine was immediately initiated. On the 30th treatment day, electroconvulsive therapy (ECT) was added; nine ECT sessions greatly improved the TS. A subsequent slow increase of clozapine completely disappeared the remaining psychotic symptoms. Since TS sometimes exhibits heterogeneous presentation among patients, physicians should take not only motor symptoms but also psychiatric symptoms into account, requiring a highly individualized approach. Evidence regarding the treatment of the mixed type of TS is scarce. The present patient's case indicates that a combination approach (e.g., clozapine and ECT) could be a promising option in similar cases.