E-ISSN: 1309-5749 | ISSN: 1018-8681 | Join E-mail List | Contact | Twitter
A Case of Aripiprazole- Related Acute Dystonia in an Adolescent Patient
1Assist. Prof. Dr
2Resident, Gaziantep University, Faculty of Medicine, Department of Child and Adolescent Psychiatry, Gaziantep - Turkey
3Assist. Prof. Dr., Gaziantep University, Faculty of Medicine, Department of Psychiatry, Gaziantep - Turkey
Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2014; 2(27): 160-163 DOI: 10.5350/DAJPN2014270209
Full Text PDF


Acute dystonic reaction (ADR) is an extrapyramidal side effect, which is more commonly seen with the use of typical antipsychotics and more rarely seen with the use of atypical antipsychotics. This reaction is a movement disorder characterized by involuntary, sustained, twisting and rotating muscle contractions, which leads to temporary postural abnormalities. Here, we will present a 15-years-old subject with aripiprazol-related ADR. This case was presented since aripiprazole-related ADR in adolescents is very rare in literature.


Acute dystonic reaction (ADR) is an extrapyramidal side effect, which is defined as involuntary muscle spasms and contractions typically involving the muscles of the neck, jaw, eye, mouth, and/or tongue. ADRs are rarely seen with the use of atypical antipsychotics. Atypical antipsychotics are used to treat conduct disorders, pervasive developmental disorder, self-mutilative behaviours along with mental retardation during the childhood, stereotypical behaviours, irritability, agitation, hyperactivity and aggression (1-3). Aripiprazole, a new antipsychotic agent, is a chinolinon derivative with high affinity for 5-HT1A, 5-HT2A ve 5-HT2B serotonin receptors as well as dopamine D2 and D3 receptors. Pharmacologically, it acts as a partial agonist for D2 ve 5-HT1A receptors and as an antagonist for 5-HT2A receptors (4). Because of these properties, it causes less EPS, movement disorders such as dystonia, and metabolic disorders such as lipid or glucose metabolism disorders than the other antipsychotics cause (5,6). There are some publications for the efficacy of aripiprazole in the pediatric and adolescent patients with schizophrenia, bipolar disorder, attention deficit hyperactivity disorder (ADHD), pervasive development disorder, Tourette disorder, tic disorder, obsessive compulsive disorder and behavioral disorder (7-13). This paper presents aripiprazole-related ADR in a subject with borderline mental capacity with inappropriate sexual behaviors. This case is important because it is one of of the rare aripiprazole-related dystonia cases in adolescents reported in the literature.


A 15-years-old, male 8th year student was presented to our clinic by his parents because of his sexually explicit impulsive behaviors at an extent to impair his social relations in his school and home environment. His anamnesis revealed that these behaviours have increased especially for the last year, along with the onset of his adolescence. The parents of the patient declared that he had tried to open the trousers of his friends, to touch their bottoms and to open their shirts in the classroom. Due to these behaviors, his teacher has not allowed him to share his school desk with another student. His sexually explicit behaviors firstly began at the age of eight, as trying to open the shirts of his friends. The child was followed-up with the diagnosis of nocturnal enuresis, encopresis, behavioral disorder and ADHD in the Department of Pediatric Psychiatry of another university between 2003 and 2012. In WISC-R test performed in 2005, verbal point was 68, performance point was 79 and total point was 72. According to his medical history, he was delivered by normal spontaneous vaginal delivery on term after a healthy gestational period. His development steps were retarded for his age. In addition, he was diagnosed with diabetes mellitus (DM) type I when he was 2 years old. There was major depression in his father’s medical history. Risperidon is a modality which is commonly used to ensure the impulse control in this kind of cases (14). However, due to negative effects of risperidon on blood glucose regulation in DM (15), he initiated to receive aripiprazole, which is a safer agent in terms of metabolic side effects (16). Aripiprazole was started at a dose of 5 mg/day, which was increased to 10 mg/day at the end of one week. The parents discontinued the medicine and consulted to our out-patient clinic upon onset of contractions in arm, neck and back region and a fixed stare 3 days after the dose increased to 10 mg/day. In physical examination, torticollis, oculogyric crisis, contractions in arms and legs-tonus increase were present in the case. However, in neurological and systemic examinations, no positive finding was detected. The patient was administered 5 mg intramuscular (IM) biperiden injection followed by biperiden oral 2 mg/day for one week upon improvement of dystonia findings and aripiprazole was discontinued. Afterwards, dystonia symptoms did not relapse and additional anticholinergic treatment was not required. It was decided that child was going to be followed with interviews since the parent did not accept any other psychotropic drug.


Aripiprazole is an agent associated with less EPS due to its partial agonist characteristics, so much so that, in the literature, some studies suggest it may be potentially useful in treating tardive dyskinesia and dystonia at low doses (17). However, it should be noted that there are also aripiprazole-related ADR, acathisia and parkinsonism case reports in the literature (18-21). The majority of these case reports relate to adult patients. Our case is one of a limited number of aripiprazole-related ADR in adolescents cited in the literature.

Risk factors for the development of antipsychotic-related dystonia include smaller age, male gender, previous history of acute dystonia, the first episode of the mental disorder, first encounter with the antipsychotic drug, high potency of the antipsychotic drug and the initiation of the therapy at a high dose (22). In our case, among these risk factors, first encounter with the antipsychotic drug, smaller age and male gender were present. In our case, ADR was evaluated according to the side effect probability scale of Naranjo et al. (23). In this scale, a score ≥9 is considered as definite; a score between 5 and 8 is considered as probable; a score between 1 and 4 is considered as possible and a score of 0 is considered as doubtful. When we evaluated our case according to this scale, our case had a total of 7 points, with the pre-existence of aripiprazole-related dystonia case in the literature (1 point), the absence of a causal factor that could lead to ADR other than the drug (2 points), the resolution of the side effect after the administration of a specific antagonist (1 point), the occurrence of the dystonia after the administration of the suspected drug (2 points) and the confirmation of the side effect with objective evidences (1 point) (in our case, dystonia was confirmed by neurological examination). These information suggest that ADR most probably resulted from the use of aripiprazole. In addition to this, absence of history of antipsychotic use that may cause a dopaminergic hypersensitivity state in our case supports this idea.

We planned to use a drug with safe metabolic side effect profile to establish impulse control as the patient had DM. Although risperidone is a good choice for treatment patient’s impulsive behavior, the metabolic side effects of risperidone are higher than those of aripiprazole (15). Thus, aripiprazole was considered to be more appropriate.

In our case that developed ADR with aripiprazole, we used biperiden 5 mg IM. Along with the treatment, patient’s contractions were recovered within half an hour. Intramuscular agents are the agents of choice for the treatment of acute dystonia. In addition to biperiden, diphenhydramine and benzotropine are also among the anticholinergic agents which can be used to treat ADR (24).

Consequently, it should be noted that although aripiprazole is a good antipsychotic agent with its safety profile, it may lead to extrapyramidal side effects. We think that new studies about the risk for extrapyramidal side effects observed with the use of aripiprazole are needed to guide the clinicians.


1. Aman MG, DeSmedt G, Derivan A, Lyons B, Findling RL. Risperidone disruptive behavior study group: double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence. Am J Psychiatry 2002; 159:1337-1346.

2. McDougle CJ, Stigler KA, Posey DJ. Treatment of aggression in children and adolescents with autism and conduct disorder. J Clin Psychiatry 2003; 64(Suppl.4):16-25.

3. Stigler KA, Posey DJ, McDougle CJ. Advances in the pharmacotherapy of pervasive developmental disorder (PDD). Child Adolesc Psychopharmacol News 2003; 8:6-11.

4. Kuroki T, Nagao N, Nakahara T. Neuropharmacology of second-generation antipsychotic drugs: a validity of the serotonin-dopamine hypothesis. Prog Brain Res 2008; 172:199-212.

5. Saha AR, Carson WH, Ali MW, Dunbar GC, Ingenito G. Efficacy and safety of aripiprazole and risperidone vs. placebo in patients with schizophrenia and schizoaffective disorder. World J Biol Psychiatry 2001; 2(Suppl.1):305.

6. Yeung PP, Carson WH, Saha AR, McQuade RD, Ali MW, Stringfellow JC, Ingenito G. Efficacy of aripiprazole, a novel antipsychotic, in schizophrenia and schizoaffective disorder: results of a placebo-controlled trial with risperidone. Eur. Neuropsychopharmacol 2001; 11(Suppl.3):241.

7. Findling RL, Robb A, Nyilas M, Forbes RA, Jin N, Ivanova S, Marcus R, McQuade RD, Iwamoto T, Carson WH. A multiple-center, randomized, double-blind, placebo-controlled study of oral aripiprazole for treatment of adolescents with schizophrenia. Am J Psychiatry 2008; 165:1432-1441.

8. Biederman J, Mick E, Spencer T, Doyle R, Joshi G, Hammerness P, Kotarski M, Aleardi M, Wozniak J. An open-label trial of aripiprazole monotherapy in children and adolescents with bipolar disorder. CNS Spectr 2007; 12:683-689.

9. Masi G, Cosenza A, Millepiedi S, Muratori F, Pari C, Salvadori F. Aripiprazole monotherapy in children and young adolescents with pervasive developmental disorders: a retrospective study. CNS Drugs 2009; 23:511-521.

10. Seo WS, Sung HM, Sea HS, Bai DS. Aripiprazole treatment of children and adolescents with Tourette disorder or chronic tic disorder. J Child Adolesc Psychopharmacol 2008; 18:197-205.

11. Curtis AR, Richards RW. The treatment of psychogenic excoriation and obsessive compulsive disorder using aripiprazole and fluoxetine. Ann Clin Psychiatry 2007; 19:199-200.

12. Findling RL, Short EJ, Leskovec T, Townsend LD, Demeter CA, McNamara MK, Stansbrey RJ. Aripiprazole in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol 2008; 18:347-354.

13. Ercan ES, Uysal T, Ercan E, Ardic UA. Aripiprazole in children and adolescents with conduct disorder: a single-center, open-label study. Pharmacopsychiatry 2012; 45:13-19.

14. Snyder R, Turgay A, Aman M, Binder C, Fisman S, Carroll A. Risperidone Conduct Study Group. Effects of risperidone on conduct and disruptive behavior disorders in children with subaverage IQs. J Am Acad Child Adolesc Psychiatry 2002; 41:1026-1036.

15. American Diabetes Association. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care 2004; 27:596-601.

16. Cohen D, Bonnot O, Bodeau N, Consoli A, Laurent C. Adverse effects of second-generation antipsychotics in children and adolescents: a bayesian meta-analysis. J Clin Psychopharmacol 2012; 32:309-316.

17. Imai N, Ikawa M. Efficacy of Aripiprazole in sulpiride-induced tardive oromandibular dystonia. Intern Med 2011; 50:635-637.

18. Saddichha S, Kumar R, Babu GN, Chandra P. Aripiprazole associated with acute dystonia, akathisia, and parkinsonism in a single patient. J Clin Pharmacol 2012; 52:1448-1449.

19. Varkula M, Dale R. Acute dystonic reaction after initiating aripiprazole monotherapy in a 20-year-old man. J Clin Psychopharmacol 2008; 28:245-247.

20. Sharma A, Sorrell JH. Aripiprazole-induced parkinsonism. Int Clin Psychopharmacol 2006; 21:127-129.

21. Singh MK, Delbello MP, Adler CM. Acute dystonia associated with aripiprazole in a child. J Am Acad Child Adolesc Psychiatry 2007; 46:306-307.

22. Keepers GA, Casey DE. Use of neuroleptic-induced extrapyramidal symptoms to predict future vulnerability to side effects. Am J Psychiatry 1991; 148:85-89.

23. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, Janecek E, Domecq C, Greenblatt DJ. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981; 30:239-245.

24. Annagur BB, Tamam L. Bilateral Temporomandibular joint dislocation associated with use of anti-psychotic drug. Archives of Neuropsychiatry 2010; 47:351-353. (Turkish)

Ergen bir hastada aripiprazol kullanımına bağlı gelişen akut distoni olgusu
2Asistan, Gaziantep Üniversitesi Tıp Fakültesi Çocuk ve Ergen Psikiyatrisi Anabilim Dalı, Gaziantep - Türkiye
3Asistan. Dr., Gaziantep Üniversitesi, Tıp Fakültesi, Psikiyatri Anabilim Dalı, Gaziantep - Türkiye
Dusunen Adam The Journal of Psychiatry and Neurological Sciences 2014; 2(27): 160-163 DOI: 10.5350/DAJPN2014270209

Akut distonik reaksiyon (ADR) tipik antipsikotiklerle daha sık, atipik antipsikotiklerle nadir görülen ekstrapramidal bir yan etkidir. Bu reaksiyon; istemsiz, süreğen, bükücü ve döndürücü tarzda kas kasılmalarıyla karakterize, geçici anormal postürlere yol açan bir hareket bozukluğudur. Biz bu olguda 15 yaşında aripiprazol kullanımına bağlı bir ADR olgusunu paylaşacağız. Bu olgu literatürde çocuk ve ergenlerde aripiprazol kullanımına bağlı çok az ADR vakası olması nedeniyle sunulmuştur.