About Tardive Dyskinesia

“Tardive” meaning late and “dyskinesia” meaning involuntary movement, is the result of treatment with dopamine receptor-blocking agents (DRBAs). Classic tardive dyskinesia (TD) involves involuntary, repetitive movements of the face, limbs, torso and/or other body parts. The term “tardive dyskinesia” refers to movement disorders resulting from use of these medications for longer than a few months according to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The most common group of medications that can cause tardive syndromes (an umbrella term encompassing a number of abnormal, involuntary movement disorders including classic TD) are antipsychotics and anti-emetics (anti-nausea drugs), though many other drugs have caused TD and other tardive syndromes. In many cases these syndromes are permanent. TD and other tardive syndromes can range from mild to life-threatening. Some form of TD affects at least 500,000 people in the U.S. and does not discriminate with regard to age, race, or gender.

Other Tardive Syndromes

Tardive akathisia: A state of mental agitation that causes an inner sense of restlessness with an inability to sit still, typically in the trunk or legs. It presents as body rocking movements, shifting weight from one foot to another, marching in place, and/or continual crossing and uncrossing of the legs. Sometimes it is associated with moaning or repetitive touching movements. It is one of the most disabling and difficult to treat tardive syndromes.

Tardive chorea: Random, jerking movements that flow from one body region to the next, in an unpredictable manner.

Tardive dystonia: Usually presents as eye twitching, oral and jaw muscle contractions, repetitive muscle contractions that cause neck extension, trunk hyperextension, arm hyperextension and wrist flexion. It can sometimes be severe enough to cause life-threatening swallowing difficulties.

Tardive gait: Tripping and shuffling movements of the feet with difficulty standing and moving from one place to the other.

Tardive ocular deviations: Spasmodic movements of the eyes with deviation in the upward direction that last for several seconds or minutes.

Tardive myoclonus: Often presents as a brief, jerk-like muscle contraction in the upper extremities, usually in the arms and shoulders.

Tardive sensory syndrome (tardive pain): A chronic burning sensation usually limited to the mouth and/or genitalia.

Tardive parkinsonism: Parkinsonism that persists after discontinuation from dopamine receptor blocking agents (DRBAs), with a normal SPECT scan. Other than the history of DRBAs use and the presence of other tardive syndromes, there are no other features that separate it from other causes of parkinsonism. Considered very rare.

Tardive tics (tardive Tourette’s): Sudden, brief, sporadic involuntary movements or sounds.

Tardive tremor: A tremor that occurs while at complete rest or with voluntary action. It may affect any part of the body, but most often affects the arms and hands.

Copulatory dyskinesia: Thrusting movements of the trunk and pelvis.

Esophageal dyskinesia: It can lead to asphyxiation of food and is potentially life-threatening.

Rabbit syndrome: Fine, rhythmic actions at rest, that mimic the chewing actions of a rabbit. The tongue is usually not involved.

Respiratory dyskinesia: The respiratory pattern is affected. It causes irregular inhalation and exhalation during breathing. This leads to hyperventilation and hypoventilation, at different times. It can also lead to aspiration pneumonia.

Stereotypy: Seeming purposeful, repetitive (rather than random) and coordinated movements that can appear like rituals. Though they seem purposeful, they are involuntary. Examples include the “piano-playing fingers” and “hand clasping” sometimes seen in TD.

Withdrawal emergent syndrome: Occurs in patients rapidly withdrawn from DRBAs. The movements usually mainly involve the neck, trunk and limbs. The oral-buccal-lingual muscles are rarely involved. It is usually self-limited, but when it persists beyond four weeks it is considered a tardive syndrome. The slow tapering of DRBAs reduces the risk of this syndrome.

Fahn, S., Jankovic, J., & Hallett, M. (2011). The tardive syndromes. In Principles and Practice of Movement Disorders (2nd ed., pp. 415–446). Elsevier Saunders.

Frei, K. D., Truong, D. A., Fahn, S., Jankovic, J., & Hauser, R. A. (2018). The Nosology of Tardive Syndromes. Journal of the Neurological Sciences, 389(1), 10–16.

Savitt, D. & Jankovic, J. (2018) Tardive Syndromes. Journal of the Neurological Sciences, 389(1), 35-42.

 

Causes of TD and Other Tardive Syndromes

The following medications have been shown to cause tardive dyskinesia and other tardive syndromes in some people:

Asendin
Compazine (Both an antipsychotic and an anti-emetic; the brand name is no longer approved in the U.S. It is sold as the generic prochlorperazine.)
Compro
Daxolin
Etrafon
Haldol
Inapsine (Both an antipsychotic and an anti-emetic.)
Loxitane
Mellaril
Moban
Navane
Orap
Permitil
Phenadoz
Phenergan (Both an anti-emetic and an antihistamine.)
Prolixin
Serentil
Sparine
Stelazine
Taractan
Thorazine
Tindal
Torecan
Trilafon
Vesprin

Abilify (aripiprazole)

Abilify Maintena (aripiprazole extended release injectable suspension)

Abilfy Mycite (aripiprazole tablets with sensor)

Clozaril (clozapine)

Fanapt (iloperidone)

Geodon (ziprasidone HCl)

Invega (paliperidone)

Invega Sustenna (paliperidone)

Invega Trinza (paliperidone palmitate)

Latuda (lurasidone HCl)

Rexulti (brexpiprazole)

Risperdal (risperidone)

Risperdal Consta (risperidone long-acting injectable suspension)

Saphris (asenapine sublingual tablets)

Seroquel (quetiapine fumarate)

Seroquel XR (quetiapine fumarate extended-release tablets)

Symbyax (olanzapine plus fluoxetine)

Vraylar (cariprazine)

Zyprexa Relprevv (olanzapine extended-release injectable suspension)

The brand name atypical antipsychotic, Zyprexa, and Zyprexa Zydis, are no longer being produced, but are still available as olanzapine and olanzapine orally disintegrating tablets.

The following generic atypical antipsychotic is available in the U.S. for research purposes only in the U.S.: amisulpride, which carries a risk of tardive dyskinesia. N-methyl amisulpride (LB-102) is in clinical trials in the U.S. and is expected to carry the same risk of tardive dyskinesia as amisulpride.

Barbituates
Benzodiazepines (When stopped rapidly, especially Klonopin, can lead to withdrawal-emergent dyskinesia, a reversible form of TD.)
Equinil
Miltown

Akineton
Artane
Kemadrin
Norgesic
Parsidol

Dilantin
Lamictal
Tegretol

Tricyclic antidepressants (especially Anafranil, Elavil, and Silenor)
MAOIs (especially Nardil, Selegiline, Rasagiline, and Phenelzine)
SSRIs (especially Prozac and Zoloft)
Trazodone

Compazine (Both an antipsychotic and an anti-emetic; the brand name is no longer approved in the U.S. It is sold as the generic prochlorperazine.)
Inapsine (Both an antipsychotic and an anti-emetic.)
Maxolon
Phenergan (Both an anti-emetic and an antihistamine.)
Reglan

Phenergan (Both an anti-emetic and an antihistamine.)
Vistaril

Atamet
Parlodel
L-Dopa
Sinemet

Aralen
Camoquin

Phenylpropanolamine (tardive dystonia)

(as found in oral contraceptives and hormone replacement therapy; rare)

Lithium (Especially when used in combination or with a history of antipsychotics.)

Adderall
Ritalin

Cornett, E. M., Novitch, M., Kaye, A. D., Kata, V., & Kaye, A. M. (2017). Medication-Induced Tardive Dyskinesia: A Review and Update. The Ochsner Journal, 17(2), 162–174.

Tardive Dyskinesia Resources Center: Psychiatric Drug Facts. (n.d.). Retrieved December 1, 2019, from https://breggin.com/antipsychotic-drugs-and-tardive-dyskinesia-resources-center/.

Medications that cause Tardive Dyskinesia. (n.d.). Retrieved December 1, 2019, from https://www.brainandspinalcord.org/medications-cause-tardive-dyskinesia/.