Rare Form of Dyskinetic Movements Associated with Alcohol Withdrawal.

Movement disorders are known to occur during alcohol withdrawal. Tremor, choreoathetosis, transient parkinsonism, myoclonus and dystonia have been previously described. The present report describes involuntary 'fluttering' movements of fingers developing during alcohol withdrawal reminiscent of a rare form of tardive dyskinesia. Such a presentation has not been described earlier.

INTRODUCTION

Movement disorders are known to occur in association with alcohol use.[1] Of those that occur during alcohol withdrawal tremor is the best known.[1] However, other movement abnormalities such as transient parkinsonism,[2] choreoathetosis,[3] myoclonus,[4] and dystonia[5] have also been described. The dyskinesias that have been described during alcohol withdrawal are mostly those involving the orofacial musculature[6] and trunk although a report of choreiform dyskinesia involving all four limbs[7] has also been published. The present report describes a patient who developed “fluttering” (as if playing an imaginary piano) movements of fingers during alcohol withdrawal, reminiscent of a less common type of tardive dyskinesia affecting the fingers. Such a presentation has not been described so far to the best of our knowledge.

CASE REPORT

The patient is a 54-year-old married male who presented for the treatment of alcohol dependence (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [DSM-IV-TR]). Patient had been consuming alcohol in the form of spirits for the past 38 years. Patient was admitted in the ward and was detoxified with diazepam. By the end of the 1st day of abstinence, the patient started developing involuntary movements of fingers of both hands. The movements involved dyskinetic movements of fingers as if playing an imaginary piano. There were no other involuntary movements in other parts of the body. The abnormal involuntary movement scale severity score was 3 with awareness and moderate distress. Patient's past history was carefully reviewed. The patient had been admitted for the treatment of alcohol dependence 4 times in the past 6 years. During each of these admissions, patient reports that similar involuntary movements of the fingers had occurred starting from the 1st day of abstinence. The movements would spontaneously subside after about 10-14 days of abstinence. The patient's past psychiatric history was also explored into. Patient had three episodes suggestive of alcohol-induced psychotic disorder (DSM-IV-TR) respectively 35, 33, and 22 years ago. The duration of each episode varied between 3 and 6 months and was prescribed chlorpromazine 100-300 mg for the same. The medication was taken irregularly for a period of 2-3 years after the onset of the first episode and for a period of 6 months after the third episode. The patient has been free of all antipsychotic medications for approximately last 21 years. The patient was observed in the ward and detoxification was completed over a period of 10 days. He was started on acamprosate 1998 mg as an anticraving agent. Aspartate transaminase and alanine transaminase levels were 105 and 95 International Units respectively with serum bilirubin being in the normal range. The involuntary movements continued until the 12th day of abstinence before subsiding completely. The patient was followed up in the outpatient services of the hospital on a fortnightly basis for a period of 3 months. During this period, he was abstinent to alcohol and no involuntary movements were noticed.

DISCUSSION

The above case demonstrates a rare presentation of dyskinesia during alcohol withdrawal. Although the patient had been exposed to typical antipsychotics, the last dose was more than two decades ago and would clearly not fulfill DSM-IV-TR criteria for tardive dyskinesia due to antipsychotic treatment. Abnormal involuntary movements are known to occur in antipsychotic naοve patients diagnosed with schizophrenia. However, the case described here was diagnosed with an alcohol-induced psychotic disorder rather than an independent psychiatric disorder. Thus, alcohol withdrawal represents the most likely cause of the involuntary movements. This view is further strengthened by the fact that similar observations were made in the preceding four instances of withdrawal and the movements disappeared once the withdrawal phase was over. Changes in dopamine receptor sensitivity[89] associated with alcohol use may account for such involuntary movements.