Tardive Dyskinesia

Tardive dyskinesia symptoms include involuntary movements of the face and extremities.

Dyskinesias are involuntary movements of the face (including lips, tongue, eyes), trunk, and extremities, which are identified in patients who have been treated with certain (dopamine-antagonist) medications.

Dyskinesias are difficult to control. Many different conditions can lead to dyskinetic movements, including rheumatic fever, genetic disorders, or unusual disorders such as motor tics and paroxysmal nonkinesigenic dyskinesia. Dyskinetic movements can include eye blinking or closure, mouth opening or lip pursing, involuntary tongue movements, or more pronounced movements of the extremities or trunk. Sometimes, dyskinetic movements can include sustained abnormal postures; in these cases, the movements are called dystonia.

Tardive dyskinesias are a subgroup of dyskinesias that occur after exposure to certain types of medication. The most common medications that can lead to tardive dyskinesia include antipsychotic medications and medications used to treat chronic nausea. This class of medications is often used to treat psychiatric conditions such as schizophrenia, severe depression or anxiety, or bipolar disorder. Often stereotyped, these drug-induced movement disorders include orofacial dyskinesias, or involuntary movements of the mouth, eyes, and tongue. The movements can range from intermittent and infrequent to almost constant.

The number of people who develop tardive dyskinesia is unknown, but estimates suggest that about 5%-6% of those who take neuroleptic or anti-nausea medications may develop symptoms; this number rises to about 25% of the elderly population. Sometimes tardive dyskinesia isn’t seen until the medication is stopped (this is called withdrawal dyskinesia); others find that their symptoms resolve after restarting the medication or adjusting the dose (this is known as “masked tardive dyskinesia”).

Although medications can trigger tardive dyskinesia, the underlying reason or cause of tardive dyskinesia remains unknown. Scientists speculate that medication-induced changes to a specific region in the brain (dopamine-2 or D-2 receptors) may lead to the movements, but this theory has not been proven yet.

While antipsychotic medications -- including first- and second-generation antipsychotics -- metoclopramide, and antiemetics have been implicated in the onset of tardive dyskinesia, the underlying cause remains unclear.

Risk factors for tardive dyskinesia include:

• Age
• Gender (older females are more likely to develop tardive dyskinesia, whereas younger males seem more likely to develop tardive dystonia)
• Duration of exposure to antipsychotic medications
• A dose of antipsychotic medications
• Cigarette smoking.

There are many different symptoms associated with tardive dyskinesia, including:

• Twisting movements of the tongue or tongue protrusion
• Lip pursing or smacking
• Grimacing
• Cheek bulging or “puffing out”
• Chewing actions
• Eye closure

The facial movements may interfere with speaking or eating.

Other symptoms or signs include:

• Involuntary actions of the hands or feet, including persistent finger movements or toe extension
• Shoulder shrugging
• Neck movements (including pulling the head back or pushing it forward)
• Rocking activity
• Hip movements
• In rare cases, irregular breathing

Common symptoms of tardive dyskinesia

• Involuntary facial movements, especially tongue protrusion. In some cases, the tongue movements are so pronounced that the person’s tongue begins to grow, exacerbating the problems with protrusion.
• Lip pursing and grunting also are frequently identified in cases of tardive dyskinesia.
• Sometimes a person with tardive dyskinesia will appear to be chewing on something.

When the person is distracted, the movements are often worse; however, if the affected person becomes aware of the movements, he or she is often able to stop or decrease the activity.

When patients develop sustained twisting or abnormal postures related to medication use, a diagnosis of tardive dystonia may be made.

Akathisia is a sense of pronounced restlessness and an inability to sit still. People with akathisia will often pace, fidget, or march for hours on end. Unlike tardive dyskinesia, which occurs after several months or years of treatment, akathisia may arise after a single dose of a medication. Akathisia may be described as acute, occurring shortly after starting a medication, or tardive, occurring many months or years after starting the medication.

Psychiatrists and neurologists, especially those who specialize in treating movement disorders, are most experienced in treating tardive dyskinesia.

Tardive dyskinesia is diagnosed after careful clinical examination and assessment of a patient’s history. Healthcare professionals consider and exclude other movement disorders, including drug-induced movement disorders, before making a diagnosis of tardive dyskinesia.

Tardive dyskinesia is a clinical diagnosis, meaning that there are no blood tests, X-rays, or other objective assessments which can confirm this condition. Physicians often use the Abnormal Involuntary Movement Scale (AIMS) to quantify movements, which appear to be tardive dyskinesia. This scale is a numeric score that grades involuntary movements from 0-4 in 10 different areas, including muscles of facial expression, lips/perioral area, jaw, tongue, upper extremities, lower extremities, neck, shoulders, hips, severity of overall movements, and patient awareness of the movements. Many sources suggest that patients who are treated with antipsychotic medications be rated before initiating treatment and every 3 months thereafter.

Healthcare professionals consider conditions such as thyroid disorders, parathyroid conditions, Sydenham chorea, syphilis, Wilson disease, and Meige syndrome (idiopathic orofacial dystonia) before making a diagnosis of tardive dyskinesia, as treatment is much different in those conditions.

Treatment of tardive dyskinesia is often difficult; in some cases, symptoms may escalate if a medication is stopped abruptly. Although discontinuation of the drug thought to be the cause of tardive dyskinesia is suggested followed by a trial of an alternate antipsychotic agent, this is not always a feasible solution for patients, and sometimes stopping the current antipsychotic medication may exacerbate the symptoms.

• Dopamine-depleting medications -- including tetrabenazine, deutetrabenazine, valbenazine, and reserpine -- can all be beneficial to help alleviate symptoms of tardive dyskinesia. Although tetrabenazine has been used for many years to treat tardive dyskinesia, it has not received FDA approval for this application. Deutetrabenazine and valbenazine are FDA-approved medications to treat tardive dyskinesia.
• Benzodiazepines may be of benefit to some patients.
• Botulinum toxin injections can be helpful for certain symptoms such as blepharospasm or isolated dystonia.

Some patients have successfully used Ginkgo biloba for control of their tardive dyskinesia. Researchers evaluated vitamin E but found it to be ineffective.

Tardive dyskinesia can be treated or even reversed in many patients. Early identification and treatment of this condition are often the most successful in controlling the symptoms.

The most effective strategy in controlling tardive dyskinesia is prevention; this includes short-term use of antipsychotic medications and regular assessment of whether patients need to remain on the medication. Experts recommend that the use of metoclopramide be limited to less than 3 months.

Studies looking at the potential benefit of pyridoxine, as well as attempting to quantify the incidence of tardive dyskinesia are underway. Further information can be found at clinicaltrials.gov.