Tardive Dyskinesia

Key Features

• A syndrome of involuntary stereotyped movements of the face, mouth, tongue, trunk, limbs

• Occurs after months or (typically) years of antipsychotic treatment in 20–35% of patients

• Predisposing factors

  • Older age

  • Cigarette smoking

  • Diabetes mellitus

• Atypical antipsychotics appear to incur a lower risk

• Symptoms do not necessarily worsen and in rare cases may improve even when antipsychotics are continued

• Symptoms do not occur during sleep and can be voluntarily suppressed for short periods

• Stress and movements in other parts of the body aggravate the condition

Clinical Findings

• Early signs

  • Fine worm-like tongue movements

  • Difficulty sticking out the tongue

  • Facial tics

  • Increased blink frequency

  • Jaw movements

• Late signs

  • Lip smacking

  • Chewing motions

  • Mouth opening and closing

  • Disturbed gag reflex

  • Puffing of the cheeks

  • Respiratory distress

  • Disrupted speech

  • Choreoathetoid movements

Diagnosis

• Differentiate early signs of tardive dyskinesia from reversible side effects of medications (eg, tricyclic antidepressants and antiparkinsonism agents)

• Other neurologic conditions such as Huntington chorea can be differentiated by history and examination

Treatment

• Emphasis should be on prevention by using lowest effective dose of the antipsychotic medication

• Gradually discontinue antipsychotic medication, if clinical feasible

• Clozapine and vesicular monoamine transporter 2 (VMAT2) inhibitors, such as valbenazine and deutetetrabenazine, have some usefulness in treating antipsychotic-induced tardive dyskinesia

• Adjunctive agents such as benzodiazepines or lithium may allow control of psychotic symptoms with a low dosage of antipsychotics