Quetiapine-Related Tic in a Pediatric Bipolar Patient

Case Report

L, a 16-year-old boy without any other past psychiatric history, was overactive for ∼5 weeks, and his mother thought him, “mad.” She said that he “spent all his money to buy lots of unnecessary things.” His teachers thought that he appeared restless all day without getting tired. He frequently felt more self-confident than usual and always said he could be in charge of a country. He talked rapidly with abrupt changes from topic to topic, and was difficult to interrupt during the outpatient clinical examination. No abnormality was detected on a brain MRI scan or electroencephalogram (EEG), or during laboratory examination. No childhood or family history of tic disorder was found. Because L's history also revealed a depression episode 2 years earlier, he was diagnosed with bipolar disorder type I according to the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children—Present and Lifetime Version (K-SADS-PL). His score on the Young Mania Rating Scale was 44.

Quetiapine was started at 50mg/day for the first 2 days. The dose of quetiapine was increased progressively by 50 mg every 4 days. The patient's symptoms resolved completely when quetiapine was titrated up to 600 mg/day. His father told us afterwards that he occasionally blinked his eyes once the quetiapine dose was titrated to 150 mg/day. Recurrent episodes of ‘‘tightening’’ of his eyes, nose, and the corner of his mouth increased in frequency, ultimately occurring thousands of times per day when quetiapine was titrated up to 600 mg/day. When the patient came to our clinic again, we used the Yale Global Tic Severity Scale to measure the severity of tic symptoms, and the score was 40.

Therefore, the dose of quetiapine was quickly decreased to 50 mg/day. After ∼2 weeks, the tic symptoms greatly resolved. However, with a dose of quetiapine 50 mg/day, the patient's mother felt that he was hyperactive. Therefore, quetiapine was titrated to 600 mg/day again. Two weeks later, the mania symptom resolved, but the tic symptom occurred again. For that reason, we added haloperidol 4 mg/day to resolve the tic symptoms, and they soon subsided. At his follow-up visit 6 months later, he appeared to have no symptoms of bipolar disorder and no tics in response to the treatment, which consisted of quetiapine at 600 mg/day and haloperidol at 4 mg/day.

Discussion

Our literature search identified only one case report describing quetiapine-related tic (Huang et al. 2002), which reported an adult schizophrenia patient with tics induced during quetiapine therapy. As the pediatric bipolar patient described here had no previous tics, this suggests that tics can occur de novo during quetiapine treatment.

Together with previously reported cases, our case suggests that tic-like symptoms might occur in certain vulnerable individuals during treatment with atypical antipsychotics such as clozapine or amisulpride (Kinon and Lieberman 1996; Lin et al. 2006). Compelling evidence suggests that increased central dopaminergic activity may exacerbate tics. Quetiapine, clozapine, and amisulpride are all dopamine-2 (D2) antagonists (Kinon and Lieberman 1996) resulting in an enhancement of dopamine release. Further, quetiapine has relatively low dopamine D2 receptor blocking and rapid dissociation from the dopamine D2 receptor, thus increasing dopaminergic function. Clinicians should be aware of this side effect, as it can detrimental to treatment adherence.