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For further information, see CMDT Part 27-11: Schizophrenia Spectrum Disorders

KEY FEATURES

  • A syndrome of abnormal 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

    • Years of treatment

    • Cigarette smoking

    • Diabetes mellitus

  • Atypical antipsychotics appear to incur a lower risk than typical or first-generation antipsychotic therapy; clozapine is unique in that it can treat antipsychotic-induced tardive dyskinesia.

  • 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 at rest

    • Difficulty sticking out the tongue

    • Facial tics

    • Increased blink frequency

    • Jaw movements

  • Later signs

    • Bucco-linguo-masticatory movements

    • Lip smacking

    • Chewing motions

    • Mouth opening and closing

    • Disturbed gag reflex

    • Puffing of the cheeks

    • Respiratory distress

    • Disrupted speech

    • Choreoathetoid movements (more prevalent in younger patients)

    • Dyskinesias do not occur during sleep; can be voluntarily suppressed for short periods

DIAGNOSIS

  • Differentiate early signs of tardive dyskinesia from similar symptoms produced by ill-fitting dentures or reversible side effects of nonantipsychotic 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 of side effects by using lowest effective dose of the antipsychotic medication

  • Gradually discontinue antipsychotic medication, if clinical feasible

  • Keep patient off the medications until reemergent psychotic symptoms dictate their resumption; restart in low doses and gradually increase until there is clinical improvement

  • Clozapine and olanzapine appear to offer less risk of recurrence

  • 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

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