TARDIVE DYSKINESIA AS A SIDE EFFECT OF COMBINATION ADMINISTRATION OF HALOPERIDOL AND RISPERIDONE IN SCHIZOPHRENIC PATIENT WITH PASUNG: A CASE REPORT
Authors: Yusnita *Ervana Ikha , Prananjaya Bintang Arroyantri 
Published: February 2025

Abstract

Introduction
Pasung is an act of restraint and seclution carried out by the family or local community against schizophrenia patients.1 Based on data in Muara Enim on 2022, there were 45 cases of pasung. Pasung can occur due behavioral problems, lack of knowledge, poor socio-economic factors and public stigma towards patients with schizophrenia.2,3 The available drugs in primary care facilities are limited to haloperidol and risperidone. Tardive dyskinesia (TD) can arise as a side effect of long-term administration of antipsychotics, both first and second generation antipsychotics.

Objective
This case report discusses the side effects of TD arising from the combination of risperidone and haloperidol in schizophrenia patients with pasung.

Method
A man, Mr. TM, 32 years old, Sumatran, presented with complaints of restlessness, and involuntary movements..The patient had previously been treated with pasung using chains and wooden blocks for about 3 years because of his aggressive behaviour. The family did not take the patient to be treated at a mental hospital due to financial problems. The closest access to treatment is a primary care facility. He was given combination therapy with risperidone 2x2 mg, haloperidol 2x5 mg and trihexyfenidil 2x2 mg for around 5 years. In the fifth year of treatment, the family noticed the patient became more restless, showing uncontrolled chewing movements, and uncontrolled right hand movements and twitching for no reason. The patient was diagnosed with comorbid schizophrenia with TD.

Result and Discussion
TD is a hyperkinetic movement disorder that occurs due to long-term administration of conventional antipsychotics and is thought to be mediated by the emergence of possibly irreversible changes in D2 receptors in the nigrostriatal D2 pathway.4,5 However, there are a number of case reports state that risperidone as a second generation antipsychotic also has a risk of causing TD.6 This patient was given a combination of haloperidol and risperidone. Significant improvements occurred immediately after administering the medication. Symptoms of TD such as restless, uncontrollable chewing movements and involuntary hand movements appeared after 5 years of treatment. Other risk factors such as high doses of antipsychotics, and concomitant administration with anticholinergic agents increase the risk of TD in this patient.7 Treatment was carried out by stopping the administration of risperidone and haloperidol and switching to quetiapine XR 1x100 mg and alprazolam 2x0.5 mg. The main guideline in TD therapy is to switch antipsychotics from the first generation to the second generation with lower affinity for D2 receptors.8,9,10 The choice of quetiapine was based on the theory that quetiapine is a second generation antipsychotic that has low affinity for D2 receptors, making it possible to reduce TD symptoms by reducing dopaminergic transmission without worsening D2 upregulation at the post synapse.11

Conclusion
Primary care facilities that have direct contact with schizophrenic patients with pasung, have many limitation in administering antipsychotic. This can cause serious side effects related to the medication especially in long term. Therefore, regulations are needed that can simplify treatment for schizophrenic patients with pasung to get better medication at advanced health facilities.

References
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