Tardive dyskinesia associated with olanzapine in a neuroleptic-naive patient with schizophrenia.

The patient commenced olanzapine 20 mg daily, along with participation in an outpatient dual-diagnosis program. Three months later, paroxetine 20 mg daily was added for major depression, together with maintenance diazepam for withdrawal symptoms. The frequency of polysubstance use decreased gradually over the following year. At annual follow-up, parkinsonism (that is, postural rigidity, left upper extremity tremor, and rigidity without TD occurrence) was observed and recorded according to the Extrapyramidal Symptom Rating Scale (ESRS) (5). During the subsequent year, diazepam was tapered, and topiramate 300 mg daily was added for mood stabilization. Olanzapine was gradually increased to 40 mg daily to decrease residual psychotic symptoms. The polysubstance use became sporadic. At second-year follow-up, the ESRS elicited new jaw TD with previously stable parkinsonism. Owing to ongoing psychotic symptoms, we did not attempt any pharmacotherapy changes. Currently, the patient is not bothered by TD and continues pharmacotherapy. Illicit substance use remains a concern.