About Tardive Dyskinesia
“Tardive” meaning late and “dyskinesia” meaning involuntary movement, is the result of treatment with medications called 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. Experts believe that some form of TD now affects an estimated 750,000 people in the U.S. alone.
Tardive Dyskinesia Symptoms
Tardive Dyskinesia can cause involuntary movements throughout your body from your tongue to your toes. The most common symptoms experienced by those with TD include:
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Head/Face
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Eyes
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Blinking Squinting
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Lips |
Puckering Rubbing Together Smacking Pursing
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Tongue |
Sticking out Darting in & out Twisting
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Jaws |
Chewing motions Clenching Side-to-side movements
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Mouth |
Puffing of cheeks Grimacing Difficulty speaking Difficulty swallowing |
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Upper Limbs |
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Swaying Jerking Movements |
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Lower Limbs |
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Difficulty walking Jerking Twitching |
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Torso |
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Shifting Rocking Leaning back |
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Hands |
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Twisting Finger Dancing Opening & closing |
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Feet |
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Toes stretching Toes dancing Ankle twisting |
The Predominant Theory of TD Development
A brief, excellent explanation of the leading theory of how prescription medications may cause tardive dyskinesia. We thank the Depression and Bipolar Support Alliance for producing this easy-to-understand, animated tutorial of the development of TD.
Risk Factors for TD
In addition to taking antipsychotics or any of the other drugs listed on this page, there are certain characteristics that can put you at a greater risk for TD:
- Being an older adult (50+)
- Female (especially post-menopausal)
- White or African descent
- A member of your immediate family has TD
- Having a behavioral health condition such as bipolar, schizophrenia, schizoaffective disorder, or having experienced traumatic brain injury
- Having diabetes or HIV
- Having a history of alcohol or substance use, especially stimulants
- Being a smoker
- Having experienced early onset extrapyramidal symptoms (EPS) such as dystonia, pseudo-parkinsonism and akathisia
- Having taken lithium or an anti-parkinsonian agent
- Metabolizing antipsychotic medications either extremely slowly or ultra-rapidly as indicated by genetic testing of your CYP2D6 enzyme.
TD Triggers
If you have been diagnosed with TD, you’ll want to avoid some common lifestyle factors and nutrients that could trigger an episode or exacerbate your movements, including:
- Stress
- Anxiety
- Lack of sleep. Sleep is crucial for proper functioning of your body and for reducing stress and anxiety.
- Stimulants such as caffeine (e.g., coffee, soda)
- The artificial sweetener Aspartame, commonly found in “sugar free” foods. Aspartame is also marketed under the brand names NutraSweet® and Equal®. Aspartame is made from two amino acids — aspartic acid and phenylalanine. Ingesting phenylalanine may increase dopamine; in those with TD, this often produces involuntary muscle movements.
- The amino acid Tyrosine. Tyrosine is a non-essential amino acid (it is produced by the body and is not necessary to get from your diet). It is a building block of phenylalanine, a precursor of dopamine. Tyrosine is also found in many brands of energy drinks where it is usually accompanied by caffeine and phenylalanine as well. If you have TD, you should avoid such artificial energy drinks that often cause a boost of dopamine.
Taking an Antipsychotic? What You Need to Know About Tardive Dyskinesia
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. (Founder’s comment: Akathisia can also cause a debilitating inner terror and a feeling as if the person is on fire or their blood is boiling, with or without visible outer symptoms. Visit the Akathisia Alliance for Education and Research for more information.)
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 time-limited to four to eight weeks, but when it persists more than eight weeks it is considered tardive dyskinesia. 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
If a drug blocks the D2 dopamine receptor, it can cause TD. The following medications have been shown to cause tardive dyskinesia and other tardive syndromes in some people. (Warning: Never stop taking a prescription medication without consulting your doctor. Proper withdrawal from the causation medication should only be attempted under the direction of your healthcare provider.)
First generation antipsychotics have the highest incidence rate for TD. An estimated 30% of those taking drugs of this class will develop TD.
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
The second generation of antipsychotics listed below have a much lower incidence rate of TD than the first generation antipsychotics. An average of 1 in 14 people taking these medications develop TD. However, this varies by risk level. High-risk patients, such as seniors, have been found to have risk rates around 11% with consistent use. Low-risk patients, such as younger people with few risk factors, may experience risks of TD as low as 3% or less.
Abilify (aripiprazole)
Abilify Asimtufii (aripiprazole once-every-two-months injectable)
Abilify Maintena (aripiprazole once-a-month injectable suspension)
Abilify Mycite (aripiprazole tablets with sensor)
Caplyta (lumateperone)
Clozaril (clozapine)
Fanapt (iloperidone)
Geodon (ziprasidone HCl)
Invega (paliperidone)
Invega Sustenna (paliperidone)
Invega Trinza (paliperidone palmitate)
Latuda (lurasidone HCl)
Lybalvi (olanzapine and samidorphan)
Rexulti (brexpiprazole)
Risperdal (risperidone)
Risperdal Consta (risperidone long-acting injectable suspension)
Rykindo (extended-release injectable risperidone)
Saphris (asenapine sublingual tablets)
Secuado (asenapine) transdermal system
Seroquel (quetiapine fumarate)
Seroquel XR (quetiapine fumarate extended-release tablets)
Symbyax (olanzapine plus fluoxetine)
Uzedy (risperidone)
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.
Anti-emetic drugs help reduce nausea. This class of drugs may be used in palliative care for a variety of patients, such as those undergoing chemotherapy.
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
Antidepressants can carry some risk for TD, especially in older patients; however, they cause TD much less frequently than use of antipsychotics.
Tricyclic antidepressants (especially Anafranil, Elavil, and Silenor)
MAOIs (especially Nardil, Selegiline, Rasagiline, and Phenelzine)
SSRIs (especially Prozac and Zoloft)
Trazodone
Barbituates
Benzodiazepines (When stopped rapidly, especially Klonopin, can lead to withdrawal-emergent dyskinesia, a reversible form of TD.)
Equinil
Miltown
Some studies on animals suggest that chronic use of anti-cholinergic drugs may cause TD, such as the following:
Akineton
Artane
Kemadrin
Norgesic
Parsidol
While considered a rare side effect of anti-seizure medications, there have been cases of TD in patients taking the following medications:
Dilantin
Lamictal
Trileptal (oxcarbazepine)
Tegretol (carbamazepine)
Phenergan (Both an anti-emetic and an antihistamine.)
Vistaril
Long-term use of anti-cholinergic medications to treat Parkinson’s disease has been shown to worsen cases of TD.
orphenadrine
trihexyphenidyl
L-Dopa
Sinemet
Aralen
Camoquin
Phenylpropanolamine (tardive dystonia)
(as found in oral contraceptives and hormone replacement therapy; this is considered 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/.