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Tardive Dyskinesia Management — MRCPsych Paper B MCQ

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HardSchizophrenia & PsychosisTardive Dyskinesia ManagementMRCPsych Paper B

A 50-year-old man with schizophrenia has received haloperidol decanoate 200 mg intramuscularly every 4 weeks for 10 years. His psychosis is stable, but previous antipsychotic discontinuation led to relapse. For 4 months he has had persistent choreiform orobuccolingual and truncal movements without rigidity or resting tremor. His AIMS score is 14, and the movements impair everyday activities. Assessment supports antipsychotic-induced tardive dyskinesia. No attempt has yet been made to reduce the haloperidol dose or change antipsychotic treatment. What is the most appropriate initial management strategy?

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Correct answer: D — Undertake a planned switch from haloperidol decanoate to clozapine with the required monitoring

The correct answer is D. This is established, functionally impairing tardive dyskinesia after prolonged exposure to a potent D2 antagonist. Because ongoing antipsychotic treatment is required, the causative drug should be replaced with an antipsychotic carrying a lower propensity for tardive dyskinesia. Clozapine is licensed for schizophrenia complicated by severe, otherwise untreatable neurological adverse reactions and may improve existing tardive dyskinesia. Increasing haloperidol can temporarily mask movements but maintains the causative exposure. Observation alone is inappropriate for persistent impairment. Procyclidine treats parkinsonism and acute dystonia, not tardive dyskinesia, and may worsen it. Tetrabenazine is a potential specialist treatment when clinically significant symptoms persist despite withdrawal, dose reduction or switching, or when modification of antipsychotic therapy is unsuitable; it should not replace an appropriate first attempt to remove haloperidol exposure here.

Reference: Clozapine Viatris 100 mg Tablets, Summary of Product Characteristics, sections 4.1 and 4.8, updated 13 March 2026. https://www.medicines.org.uk/emc/product/15498/smpc