tardive dyskinesia

tardive dyskinesia, drug-induced condition characterized by repetitive involuntary movements, particularly in the face. Tardive dyskinesia results from long-term use of certain medications—the word tardive refers to the condition’s delayed onset. Typically, the condition is associated with drugs that interfere with signaling by the neurotransmitter dopamine; although tardive dyskinesia is thought to result from the inhibition of dopamine signaling, the causal mechanism is incompletely understood. The condition is often chronic, with symptoms lasting years or even decades after their onset.

The first description of a patient with symptoms characteristic of tardive dyskinesia was published in 1957. In 1964 the term tardive dyskinesia was coined by Danish researchers to describe the atypical movements associated with the use of some medications. Since then, defining the condition has been a matter of debate. Although it is often based on a diagnosis that encompasses any tardive movement—generally involuntary movements—some researchers define the condition as being limited to oral-buccal-lingual (face, mouth, and jaw) symptoms and recommend that the diagnosis be considered as a part of an overarching tardive syndrome, thereby distinguishing tardive dyskinesia from a broader syndrome characterized by involuntary movements in other parts of the body. Because of the lack of clarity in definition, some experts use the terms tardive dyskinesia and tardive syndrome interchangeably.

Causes and risk factors

Tardive dyskinesia is thought to arise from chronic blockage of dopamine receptors in the brain, particularly so-called D2 receptors and, potentially, D3 receptors. Antipsychotic drugs, also known as neuroleptics, are strongly associated with tardive dyskinesia, especially first-generation antipsychotics, which work by blocking primarily dopamine receptors (second-generation antipsychotics partially block dopamine, while also affecting other neurotransmitters). An estimated 20 percent of patients who are treated with antipsychotic drugs develop tardive dyskinesia, though rates vary. Tricyclic antidepressants, certain gastrointestinal drugs, and mood disorder medications—including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and lithium—are also linked to tardive dyskinesia.

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Certain factors increase the risk of developing tardive dyskinesia, including age, sex, race, and the presence of other disorders. In particular, patients who are female or Black are at a greater risk of developing the condition. An increase in risk also applies to persons with diabetes, brain damage, and substance use disorder. Genetic factors are theorized to play an important role, since patients taking the exact same medication regimens may exhibit significant differences in symptom presentation and severity.

Symptoms

Symptoms of tardive dyskinesia can range from almost the unnoticeable to the fully disabling. The condition is most commonly characterized by repetitive movements in the face, mouth, and jaw, which is classified as tardive stereotypy. These uncontrollable movements may manifest in the form of lip smacking, chewing motions, facial grimacing, and other atypical facial mannerisms. Analogous movements in the limbs, trunk, or pelvis are sometimes also included as a part of the diagnosis. On the wider spectrum of tardive syndrome, additional movement and sensory symptoms may include twisting posture, painful oral or genital sensations, and atypical gait.

Prognosis and treatment

Symptoms usually first appear one to two years after continued use of the offending medication. Onset begins with mild symptoms before evolving into significant and noticeable involuntary movements, which ultimately stabilize after a couple of days or weeks. Tardive dyskinesia tends to persist, however, even when the patient stops taking the medication. Partial or full remission may occur after some time; however, researchers have found a wide range of remission rates, anywhere from 12 to 33 percent.

Treatment of tardive dyskinesia generally begins with lowering the offending drug’s dosage or, when possible, taking the patient off the medication entirely. Research suggests, in fact, that symptoms are more likely to resolve sooner when the medication linked to symptoms is immediately discontinued. For patients on antipsychotic drugs, switching from a first-generation to a second-generation antipsychotic may be effective in reducing symptoms. In some instances, movement symptoms may be treated with vesicular monoamine transporter 2 (VMAT2) inhibitors, such as tetrabenazine and valbenazine, which may be used concurrently with antipsychotic medication. In severe cases, such as when symptoms are resistant to other forms of treatment, botulinum toxin (Botox) injections or deep brain stimulation may be used to block nerve signals that trigger dyskinesia.

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