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Tardive dyskinesia

Tardive dyskinesia

Definition

Tardive dyskinesia is a neurological disorder consisting of abnormal, involuntary body movements caused by certain medicines. It is usually associated with long-term use of medicines for treating schizophrenia and other psychotic disorders.

Description

Tardive means "late" and dyskinesia means "abnormal movements." It refers to abnormal body movements that occur after a person has been taking a certain medicine for a long period of time. It sometimes starts after the medicine has been discontinued. In the early stages, the movements may be so subtle that neither the person nor the people around him or her notice them. For instance, the person may blink rapidly or lick their lips often. In later stages, the movements become noticeable and may affect the person's physical abilities.

Other types of tardive dyskinesia can occur. In tardive dystonia, there are abnormal contractions of the neck and shoulder muscles. In tardive akathisia, the person feels restless all the time.

Causes and symptoms

Causes

It is not altogether certain what causes tardive dyskinesia. The medicines that cause it affect how nerve impulses are transmitted across gaps between nerve cells (synapses). They do this in part by blocking a chemical made by the body called dopamine. After a while, the nerves seem to become hypersensitive to dopamine. Stimulation by even a little bit of dopamine may cause the abnormal movements.

The medicines most commonly associated with tardive dyskinesia include:

  • Antipsychotic medicines used to treat schizophrenia and other psychoses. These are also known as neuroleptic medicines.
  • Levodopa or L-dopa, which is used to treat Parkinson's disease (although high doses of L-dopa may actually help control tardive dyskinesia).
  • Antiemetic medicines used to control nausea and vomiting.
  • Tricyclic antidepressants used to treat depression and other mood disorders.
  • Other medicines that block dopamine.

Symptoms

Symptoms of tardive dyskinesia include:

  • involuntary movements of the face, including frowning, blinking, smiling, lip licking, mouth puckering, biting or chewing, clenching the jaw, sticking out the tongue, or rolling the tongue around in the mouth
  • involuntary movements of the hands, arms, feet, or legs, such as twitching the hands or tapping the feet
  • trunk movements, such as rocking, twisting, or squirming
  • grunting or trouble speaking because of involuntary movements of the diaphragm

Movements may be rapid or slow and complicated. They are usually irregular and do not follow a pattern.

Demographics

Tardive dyskinesia develops in about a third of all people who take antipsychotic medicines for several years. The risk is higher in older patients. Approximately 5% of young adults taking antipsychotic medicines will develop tardive dyskinesia after a year of treatment, compared with a rate of 30% in elderly patients.

Treatments

Each case is treated differently. In some cases, the medicine causing the problem can be stopped. However, most people taking antipsychotic medicine cannot stop taking the medicine because of the high risk that their psychosis will return. Some newer antipsychotic medicines such as clozapine (Clozaril) do not seem to cause tardive dyskinesia. It may be possible to switch to a newer antipsychotic medication. If not, it may be possible to lower the dose to a level that does not cause the movements. There is controversy about whether or not "drug holidays" reduce the likelihood of developing tardive dyskinesia. "Drug holidays" are planned periods of time in which the person goes off the medicine, then resumes it.

Vitamin E has been shown to be helpful in patients, especially those who have had the problem for less than five years. L-dopa and some other medicines are sometimes helpful.

Prognosis

The earlier the problem is noticed and treatment begun, the better chance there is that the abnormal movements will go away. Most patients have a noticeable improvement in their symptoms within a year and a half. However, some abnormal movements may remain. People who are over 60 have a greater chance of having the problem go away on its own.

See also Medication-induced movement disorders

Resources

BOOKS

Hales Robert E., Yudofsky Stuart C., Talbott John A., eds. The American Psychiatric Press Textbook of Psychiatry. 3rd ed. Washington DC: American Psychiatric Press, 1999.

ORGANIZATIONS

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201. Telephone: (703) 524-7600. NAMI HelpLine: (800) 950-NAMI. <www.nami.org>.

National Institute of Neurological Disorders and Stroke. Part of the National Institutes of Health (NIH), Bethesda, Maryland 20892.<www.ninds.nih.gov>.

Jody Bower, M.S.W

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Tardive Dyskinesia

Tardive Dyskinesia

Definition

Tardive dyskinesia is a mostly irreversible neurological disorder of involuntary movements caused by long-term use of antipsychotic or neuroleptic drugs.

Description

Antipsychotic or neuroleptic drugs are powerful tranquilizers generally prescribed for serious psychiatric disorders, as well as neurological and gastrointestinal disorders. Some common antipsychotics are: chlorpromazine HCl (Thorazine), thioridazine HCl (Mellaril), haloperidol (Haldol), perphenazine (Trilafon), thiothixene (Navane), trifluoperazine HCl (Stelazine), and fluphenazine HCl (Permitil, Prolixin).

When these drugs are used long term, tardive dyskinesia (TD) can result. About 20 percent of people taking antipsychotic drugs for more then one year become affected by TD. The prevalence of TD tends to be highest among elderly patients and among women.

Causes and symptoms

TD usually appears after years of antipsychotic drug use, and seems to be related to the total lifetime dose of medication. The symptoms include the following:

  • tongue protrusion
  • grimacing
  • rapid eye blinking
  • lip smacking, pursing, or puckering
  • rapid movement of the arms or legs
  • other involuntary movements of the head, face, neck and tongue muscles

Diagnosis

The diagnosis of TD is suspected upon observation of involuntary movements of the head, neck, face, and tongue in individuals who have a history of antipsychotic drug prescription.

Treatment

There is no standard treatment for TD. The primary approach is to discontinue or minimize the use of antipsychotic drugs while attempting to treat some of the symptoms. The treatment must be individualized to the patient, because discontinuation of the antipsychotic drug(s) may not be advisable, depending on the patient's condition. In some cases, substituting another drug for the antipsychotic drug may be beneficial.

Prognosis

Once TD appears in fullblown form, it can be permanent. With careful management, some symptoms may improve and even disappear with time. In less severe cases, some patients may recover from TD within three months of discontinuing the use of antipsychotic medication. Studies report that at least half of patients experience remission of major symptoms within 12 to 18 months following discontinuation of antipsychotic drugs. In some patients, however, decreasing the dose of the antipsychotic drug actually increases the symptoms of TD, while increasing the dose sometimes offers a temporary remission of the symptoms.

Prevention

TD can be prevented by early recognition and discontinuation of the antipsychotic medication if this is clinically possible. The use of antipsychotic drugs should in any case be kept to a minimum in all patients. Patients should be followed carefully to determine when the dose of the drug can be tapered off as the psychiatric condition improves. In all cases, the benefits of taking the antipsychotic medication should outweigh the risk of developing TD.

A study has shown that elderly institutionalized patients with dementia that were treated with risperidone had a low incidence of TD. Although further study is needed, this study shows that non-conventional neuroleptic drugs should be considered to avoid the risk of tardive dyskinesia, particularly in elderly patients.

Resources

BOOKS

Tierney, Lawrence, et al. Current Medical Diagnosis and Treatment. Los Altos: Lange Medical Publications, 2001.

PERIODICALS

"Risperidone May Lower Incidence of TD." Brown University geroPsych Report August 2000: 2.

ORGANIZATIONS

National Institute for Mental Health. 6001 Executive Blvd., Room 8184, MSC 9663, Bethesda, MD 20892-9663. http://www.nimh.nih.gov.

Tardive Dyskinesia/Tardive Dystonia National Association. P.O. Box 45732, Seattle, WA 98145-0732. (206) 522-3166.

KEY TERMS

Antipsychotics Drugs used to treat psychotic conditions such as schizophrenia or psychosis. These medications are powerful tranquilizers that all have sedating and calming effects, but their major effect is to reduce psychotic thinking and behavior.

Neuroleptics Any of a class of drugs used to treat psychotic conditions.

Psychosis A condition where a person's ability to recognize reality and cope with everyday life is severely affected.

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tardive dyskinesia

tardive dyskinesia (tard-iv) n. see dyskinesia.

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Tardive Dyskinesia

Tardive Dyskinesia

Definition

Description

Causes and symptoms

Demographics

Treatments

Prognosis

Resources

Definition

Tardive dyskinesia is a neurological disorder consisting of abnormal, involuntary body movements, usually associated with taking antipsychotics (medication used to treat the symptoms of schizophrenia or other psychotic disorders), although it can occur in the absence of drug administration.

Description

Tardive means “late” and dyskinesia means “abnormal movements.” The term refers to abnormal body movements that occur, usually after a person has been taking an antipsychotic medication for a long period of time. The symptoms can sometimes arise even after the medication has been discontinued. In the early stages, the movements may be so subtle that neither the person nor others notice them. For instance, the person may blink rapidly or lick their lips often. In later stages, the movements become noticeable and may affect the person’s physical abilities.

Other subtypes of tardive dyskinesia can occur. In tardive dystonia, there are abnormal contractions of the neck and shoulder muscles. In tardive akathisia, the person feels restless all the time.

Causes and symptoms

Causes

Because antipsychotics block the proteins that recognize and transmit the signals from dopamine, a neu-rotransmitter (nerve-signaling molecule), the current hypotheses about the causes of tardive dyskinesia center on these dopamine pathways in the brain. The leading hypothesis is that after an extended period of blocked dopamine signaling, the nerves become hypersensitive to dopamine, and stimulation by even a little bit of dopamine results in abnormal movements. The parts of the brain that send signals to the muscles and use dopamine signaling may be affected.

The medicines most commonly associated with tardive dyskinesia include:

  • antipsychotic medicines used to treat schizophrenia and other psychoses. These are also known as neuro-leptic medicines. First-generation or older versions of these drugs were strongly linked to tardive dyskinesia and other movement disorders. With the advent of new, “second-generation” or “atypical” antipsychotics, which generally block dopamine receptors more weakly and briefly, clinicians had expected to see a reduction in the incidence of tardive dyskinesia. Although a reduction in other motor symptoms related to antipsychotics has been observed, it has not been clearly established that tardive dyskinesia rates have fallen. It appears, however, that the atypical neuroleptics do carry a lower risk.
  • L-dopa, which is used to treat Parkinson’s disease (although high doses of L-dopa may actually help control tardive dyskinesia)
  • antiemetic medicines, used to control nausea and vomiting
  • tricyclic antidepressants used to treat depression and other mood disorders
  • other medicines that block dopamine signaling

Symptoms

Symptoms of tardive dyskinesia include:

  • involuntary movements of the face (orofacial dyskinesia), including frowning, blinking, smiling, lip licking, mouth puckering, biting or chewing, clenching the jaw, sticking out the tongue, or rolling the tongue around in the mouth
  • involuntary movements of the hands, arms, feet, or legs, such as twitching the hands or tapping the feet
  • trunk movements, such as rocking, twisting, or squirming
  • grunting or trouble speaking because of involuntary movements of the diaphragm

Movements may be rapid or slow and complicated. They are usually irregular and do not follow a pattern.

Demographics

The prevalence of tardive dyskinesia in clinical populations is between 16% and 43%. Risk is greater in older patients, who exhibit a prevalence rate that is five or six times higher than that of people under the age of 50 years.

Reported rates of tardive dyskinesia among people who have not taken and are not taking antipsychotics vary widely, from 3.7% to 77% in clinical populations, with an average of 5.5%. Rates are higher among the elderly.

Treatments

Each case is treated differently. In some cases, the medicine causing the problem can be stopped. However, most people taking antipsychotic medicine cannot stop taking the medicine because of the high risk that their psychosis will return. The atypical antipsychotic

KEY TERMS

Akisthesia —An uncontrollable feeling of restlessness.

Dystonia —A neurological disorder characterized by involuntary muscle spasms. The spasms can cause a painful twisting of the body and difficulty walking or moving.

that is associated with the lowest incidence of tardive dyskinesia is clozapine. The atypicals that have been more associated with tardive dyskinesia are risperidone and olanzapine; in the case of risperidone, its longer history of clinical use may be an explanation. It may be possible to lower the dose to a level that does not cause the movements. One study has found that low-potency “first-generation” antipsychotics taken at moderate doses may carry no increased risk of eliciting tardive dyskinesia compared to second-generation drugs. There is controversy about whether or not “drug holidays” reduce the likelihood of developing tardive dyskinesia. “Drug holidays” are planned periods of time in which the person goes off the medicine, then resumes it.

Vitamin E has been shown to be helpful in patients, especially those who have had the problem for less than five years. L-dopa and some other medicines are sometimes helpful.

Prognosis

The earlier the problem is noticed and treatment is begun, the better of eliminating abnormal movements. Reports indicate that in most cases, tardive dyskinesia is not necessarily progressive and can be reversed. Most patients have a noticeable improvement in their symptoms within 18 months; however, some abnormal movements may remain. People who are over 60 have a greater chance of having the problem go away on its own.

See alsoSchizophrenia.

Resources

BOOKS

Hales Robert E., Stuart C. Yudofsky, and John A. Talbott, eds. The American Psychiatric Press Textbook of Psychiatry. 3rd ed. Washington D.C.: American Psychiatric Press, 1999.

ORGANIZATIONS

National Alliance for the Mentally Ill. Colonial Place Three, 2107 Wilson Boulevard, Suite 300, Arlington, VA 22201. Telephone: (703) 524-7600. NAMI HelpLine: (800) 950-NAMI.www.nami.org

National Institute of Neurological Disorders and Stroke. Part of the National Institutes of Health (NIH), Bethesda, MD 20892. www.ninds.nih.gov

PERIODICALS

Marchand, William R., and Valentina Dilda. “New Models of Frontal-Subcortical Skeletomotor Circuit Pathology in Tardive Dyskinesia.” The Neuroscientist 12 (2006):186–98.

Tarsy, Daniel, and Ross J. Baldessarini. “Epidemiology of Tardive Dyskinesia: Is Risk Declining with Modern Antipsychotics?” Movement Disorders 21 (2006): 589–98.

Jody Bower, M.S.W

Emily Jane Willingham, PhD

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