What Is Tardive Dyskinesia (TD)?

Tardive dyskinesia (TD) is a medication-induced neurological condition, meaning it affects the brain and nervous system. It causes abnormal and uncontrollable movements in the face, torso, and across the whole body. TD is caused by the use of medications that block dopamine receptors (which affect movement and emotion) in the brain, like antipsychotics. Antipsychotics are used for mental health conditions like bipolar disorder, schizophrenia, and depression. The majority of tardive dyskinesia cases are irreversible.

Every year, tardive dyskinesia occurs in 5 to 7% of people who use antipsychotic drugs. That percentage increases with the long-term use of antipsychotic medications. Additionally, rates of TD are higher in older adults (55 years and older).

Symptoms of tardive dyskinesia can appear anywhere from one to six months after beginning antipsychotic drug treatments. Fortunately, there are a number of treatment options to treat TD to help minimize symptoms, improve quality of life, and allow for continued use of antipsychotic medication.

Tardive Dyskinesia Symptoms

The main symptoms of tardive dyskinesia are involuntary movements of the jaw, face, and tongue. Approximately three-quarters of patients with TD will experience these types of involuntary facial movements. Examples of facial TD symptoms are:

• Twisting movements of the tongue
• Retraction of the corners of the mouth
• Chewing movements
• Bulging of cheeks
• Smacking of lips 
• Rapid eye blinking
• Jaw swinging (characterized by the jaw moving from side to side, sometimes accompanied by teeth grinding)

These involuntary movements vary in severity and sometimes can interfere with speech, eating, and swallowing.

Involuntary movements caused by tardive dyskinesia can also involve your arms, legs, and other parts of the body. Some examples of these are:

• Piano-playing finger movements
• Shoulder shrugging
• Rocking and swaying
• Hip thrusting
• Irregular breathing rhythms
• Restlessness
• Dystonia (muscle contractions that result in repetitive twisting or fixed postures)

Involuntary limb movements are usually more severe in younger people. Additionally, these movements can have a severe effect on posture and balance, which can increase your risk of falls.

What Causes Tardive Dyskinesia? 

The primary cause of tardive dyskinesia is the prolonged and consistent use of antipsychotic drugs. Other factors may be involved, including genetic predisposition, age, biological sex, alcohol and drug use, and pre-existing conditions.

Antipsychotic drugs are used for the treatment of a variety of mental health conditions, including schizophrenia, depression, and bipolar disorder, among others. These drugs treat mental health conditions by blocking dopamine receptors in the brain. The symptoms of TD are the result of antipsychotic drugs blocking dopamine receptors.

Antipsychotic drugs can be described as first- or second-generation and both types can cause tardive dyskinesia symptoms. First-generation antipsychotics are considered "typical" and their purpose is to block dopamine receptors. Second-generation antipsychotics are considered "atypical" and partially block dopamine receptors, but may also affect other hormones such as serotonin. Each year, TD occurs in 5 to 6% of people who take first-generation antipsychotics and 4% of people who take second-generation antipsychotics.

Examples of commonly prescribed first- and second-generation antipsychotics are:

• First generation: Thorazine (chlorpromazine), Modecate (fluphenazine), Haldol (haloperidol), and Serentil (mesoridazine besylate)
• Second generation: Invega (paliperidone), Risperdal (risperidone), Abilify (aripiprazole), Latuda (lurasidone), (Zyprexa) olanzapine

Additionally, Reglan (metoclopramide) and Stemetil (prochlorperazine), two dopamine-blocking medications that are used to treat nausea and vomiting, have been shown to cause tardive dyskinesia.

Risk Factors

Some scientists hypothesize that people that develop TD have a genetic predisposition that makes dopamine receptors in their brains more sensitive to these dopamine-blocking medications.

Additionally to this potential genetic predisposition, there are some risk factors that make some individuals more susceptible to developing tardive dyskinesia. 

The two major risk factors for developing TD symptoms are older age (over 55) and prolonged use of antipsychotics. Adults over 55 are five times more likely to develop in adults over 55 than younger adults. Long-term use of antipsychotic drugs (five to 10 years) can increase the risk of developing tardive dyskinesia by up to almost 50%. 

Some studies suggest that tardive dyskinesia is more likely to affect women than men. About 30% of post-menopausal women experience TD after a year of using antipsychotics. Also, other studies indicate that Black Americans are more likely to develop symptoms of TD than white Americans. 

Some additional risk factors include:

• Having diabetes
• History of electroconvulsive therapy
• Excessive alcohol or drug use
• Pre-existing mood disorders
• Schizophrenia diagnosis
  

Diagnosis

Tardive dyskinesia is diagnosed by a doctor (likely a psychiatrist, or a medical doctor who specializes in the care and treatment of mental health conditions) who directly observes someone who is undergoing antipsychotic treatment.

To properly evaluate their observations and reach a diagnosis, they use the Abnormal Involuntary Movement Scale (AIMS). This scale was developed by the National Institute of Mental Health in the 1970s to assess abnormal movements in patients that were undergoing antipsychotic treatment.

Using the AIMS scale, doctors evaluate 12 categories of movements, including facial, oral, extremity, and trunk movements, and classify movements as mild, moderate, or severe.

Doctors who prescribe antipsychotic drugs should be regularly checking for the development of tardive dyskinesia symptoms during routine checkups with the people they are treating.

Treatments for Tardive Dyskinesia

Once a patient is diagnosed with tardive dyskinesia the goal of treatment is to find ways to reduce the severity of involuntary movements. Healthcare providers have various treatment options at their disposal.

Managing Your Antipsychotic Medication

One of the first treatment approaches healthcare providers use to treat tardive dyskinesia symptoms is stopping or slowly switching you off the antipsychotic that you are currently taking.

During this process, your healthcare provider will evaluate your antipsychotic treatment and identify a plan to reduce your current antipsychotic treatment safely. It is important to follow their directions carefully. Stopping antipsychotics abruptly can cause withdrawal symptoms that can make involuntary movement symptoms worse.

Prescribing Movement Disorder Medications

Your doctor can prescribe a movement disorder medication to treat your symptoms. In 2017 the Food and Drug Administration (FDA) approved Ingrezza (valbenazine) and Austedo (deutetrabenazine) to treat tardive dyskinesia and reduce involuntary movements. They are currently the only two medications approved to treat TD symptoms.

Ingrezza and Austedo work by decreasing the release of dopamine in areas of the brain that control motor control, helping to reduce involuntary movements. These drugs have proven to be effective in reducing tardive dyskinesia symptoms in clinical trials. Both Ingrezza and Austedo proved to significatively reduce TD symptoms via the AIMS symptom scale.

Deep Brain Stimulation

Deep brain stimulation is an elective surgical procedure in which electrodes are implanted into the brain in order to control abnormal brain activity.

There is some emerging evidence that suggests that deep brain stimulation can be used to treat tardive dyskinesia. A 2016 study published in the scientific journal Neurology reported that deep brain stimulation reduced TD symptoms by 40% after six months, and this improvement continued after 12 months.

Prevention

The primary way to prevent tardive dyskinesia from developing due to prescription antipsychotics is by using the lowest effective dose possible for a short period of time.

After beginning antipsychotic treatment it is important for your healthcare provider to regularly screen you for tardive dyskinesia symptoms. People on long-term antipsychotic treatment should be screened for symptoms every three months.

Finally, being aware of potential risk factors is essential. Discussing risk factors prior to beginning antipsychotic treatment can be helpful in preventing TD symptoms from developing.

Related Conditions 

Because tardive dyskinesia is a condition that is caused by medications that treat mental health disorders, it is common to expect people with TD to be affected by these conditions. The most common conditions that co-occur with TD are schizophrenia and bipolar disorder.

In addition to mental health conditions, people with TD have a higher likelihood of having cardio-metabolic conditions, including hypertension, diabetes, and obesity. They also are 1.5 times more like to have a substance use disorder compared to the general population.

Living With Tardive Dyskinesia

While not deadly, tardive dyskinesia symptoms can have a large impact on your quality of life. Involuntary movement symptoms can be severe enough to interfere with everyday activities like speaking, eating/swallowing, walking, climbing stairs, balancing, and driving, among others.

Additionally, TD symptoms can take an emotional toll on you. Stigma related to the condition can result in social isolation. People with TD, on average, experience a higher rate of social withdrawal versus people without TD. The rates of social withdrawal increased with the severity of tardive dyskinesia symptoms.

Luckily, tardive dyskinesia treatments discussed above can help manage and reduce symptoms which can significantly improve your quality of life. Regular exercise can help manage some of the symptoms related to involuntary movements that affect balance and gait.

If you or a loved one is undergoing antipsychotic treatment, talk to your healthcare provider about screening for TD symptoms.