Tardive dyskinesia as a consequence of long term treatment with antipsychotic drugs has an average prevalence of 15%–20%1 and may coexist with tardive dystonia which occurs in 1%–4% of patients.2 The medical treatment of both is notoriously difficult and it is often impossible to withdraw the provoking medications. We report a patient with early onset severe and refractory tardive dyskinesia and dystonia which was significantly improved by bilateral simultaneous posteroventral pallidotomies.

A 31 year old man had a seven year history of a schizophrenic illness presenting with auditory hallucinations, persecutory delusions, delusions of reference, thought insertion, withdrawal, and broadcasting. There was no history of family psychiatric or neurological disorder and no relevant personal medical or psychiatric history. After initially responding well to treatment with trifluoperazine he discontinued this after a few months and relapsed requiring admission to hospital two years after his first illness. His illness again responded to oral antipsychotic drugs and then depot flupenthixol decanoate (maximum dose of 40 mg monthly). One year later he was first noted to have dyskinetic movements of his mouth and tongue and his depot flupenthixol decanoate was reduced and then discontinued but he quickly relapsed and has required treatment with antipsychotic medication since. His tardive dyskinesia rapidly progressed to involve his limbs and trunk with severe choreiform and hemiballistic movements. Severe dystonia developed involving his neck, larynx, upper limb girdle, and chest. …