# Persistent Tremor in Bipolar Disorder: A Case Report of Idiopathic Parkinson’s Disease Superimposed on Lithium and Antipsychotic Effects

## TL;DR

A woman with bipolar disorder developed persistent tremors linked to Parkinson's disease, not just medication side effects, showing the need for careful diagnosis and teamwork between psychiatrists and neurologists.

## Contribution

Highlights the importance of considering idiopathic Parkinson's disease in bipolar patients with persistent parkinsonian symptoms, not just drug-induced effects.

## Key findings

- Parkinsonian symptoms persisted after stopping lithium and aripiprazole, suggesting idiopathic Parkinson's disease.
- Dopamine transporter imaging confirmed reduced uptake in the left putamen, supporting a Parkinson's diagnosis.
- Collaborative care between psychiatry and neurology improved motor symptoms while managing mood instability.

## Abstract

We report a 58‐year‐old woman with bipolar I disorder on long‐term lithium and aripiprazole who developed a progressive asymmetric resting tremor and rigidity. Despite stopping both agents, the tremor persisted for more than a year. Dopamine transporter imaging showed reduced uptake in the left putamen, confirming idiopathic Parkinson’s disease (PD) with superimposed drug‐induced parkinsonism (DIP). Management included discontinuing lithium, switching aripiprazole to quetiapine to limit motor worsening, and starting carbidopa–levodopa. Motor symptoms improved, but hypomanic symptoms emerged and required psychiatric dose adjustments, while apathy remained prominent. The case illustrates diagnostic overshadowing in bipolar disorder (BD) and highlights two practical lessons. When parkinsonian signs are atypical or persist after medication changes, consider idiopathic PD rather than attributing symptoms to side effects. Care is best delivered through close collaboration between psychiatry and neurology to balance dopaminergic therapy with mood stabilization.