eMedicine Specialties > Neurology > Movement and Neurodegenerative Diseases

Tardive Dyskinesia: Treatment & Medication

Author: James Robert Brasic, MD, MPH, Research Associate, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
Coauthor(s): Brian Bronson, MD, Staff Physician, Department of Psychiatry, New York University Medical Center; Tristen T Chun, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
Contributor Information and Disclosures

Updated: Oct 2, 2008

Treatment

Medical Care

  • Primary prevention of TD by using the lowest effective dose of neuroleptic for the shortest period of time is recommended. When TD is diagnosed, reduce or discontinue the causative agent if possible. The risk of a permanent movement disorder must be weighed against the risks of exacerbating psychosis. In addition, TD may initially worsen after discontinuing neuroleptics.
  • Atypical neuroleptics may control psychosis while reducing the risk of TD. While traditional neuroleptics primarily block D2 receptors, atypical neuroleptics bind variably to dopaminergic, serotonergic, alpha-adrenergic, histaminic, and muscarinic receptors.
    • In particular, clozapine has been recommended as treatment for patients with TD who require antipsychotics. Clozapine is one of the most effective atypical neuroleptics for treatment-refractory schizophrenia. Although clozapine has been associated with TD,16 the incidence of TD with this and other atypical agents appears markedly less than that of traditional neuroleptics. The benefits of clozapine may result from its affinity for the D4 receptor. However, risperidone and clozapine may be ineffective in treating negative and positive symptoms in some patients. Treatment with clozapine requires regular hematologic evaluation to avoid fatal agranulocytosis.
    • Administration of branched-chain amino acids has been reported to markedly reduce the movements of TD in a group of adult men with TD. This intervention in contraindicated in pregnant women. This promising treatment requires investigation in other locations to confirm its safety and efficacy.
  • Other anecdotal treatments include vitamin E, levodopa, benzodiazepines, botulinum toxin, reserpine, tetrabenazine, and dopamine-depleting agents. Ondansetron, a selective 5-hydroxytryptamine-3 antagonist, has helped some individuals with TD. Discontinuation of treatment with anticholinergics may relieve TD. A controversial strategy to treat TD is continuing and/or increasing the dose of the dopamine antagonist.
  • Tardive blepharospasm can respond favorably to reduction or cessation of dopamine antagonists. Individuals who must be treated with neuroleptics often respond favorably to atypical neuroleptics. Additional treatments to consider include anticholinergics, dopamine-depleting agents, benzodiazepines, clozapine, and botulinum toxin.
  • For tardive tics, remove the causative neuroleptic if possible. If the patient cannot tolerate absence of the neuroleptic, substitute an atypical neuroleptic. Pimozide, clonidine, and haloperidol can be helpful in some patients with tardive tics.
  • Clozapine has treated tardive tremor successfully. Propanolol is useful for tardive akathisia. In 2005, Ertugrul and Demir reported the occurrence of TD in a man treated with clozapine for a year; the man had previously received other dopamine antagonists. Previous exposure to dopamine antagonists may have contributed to the development of TD in the man.16
  • Lin and colleagues have reported beneficial effects of zotepine on clozapine-induced tardive dyskinesia.17
  • Clonazepam has been reported to successfully alleviate the symptoms of TD and spontaneous oral dyskinesia.
  • Miyaoka and colleagues have reported that yi-gan san, a traditional Japanese herbal medicine, alleviated psychosis and tardive dyskinesia in an open label trial with 22 people with schizophrenia.18 These promising findings await confirmation by controlled clinical trials.
  • Aripirazole has been reported to relieve the dyskinetic movements of tardive dyskinesia in a 65-year-old man with schizophrenia.  
  • Slotema and colleagues report nonsignificant improvement in orofacial tardive dyskinesia after the administration of botulinum toxin.19
  • van Harten and colleagues report that lithium may have a protective effect in some patients, preventing the development of tardive dyskinesia.20

Consultations

Consultation with an ophthalmologist is indicated to evaluate tardive blepharospasm and/or to exclude Wilson disease with slit lamp examination.

For information about a neurologist in your area, please contact the American Academy of Neurology as follows:

American Academy of Neurology
1080 Montreal Avenue
St Paul, MN 55116
Telephone (651) 695-2717
Fax (651) 695-2791

Consultation with a movement-disorders specialist may help to clarify the diagnosis and treatment. For information about movement disorder experts in your area, please contact the Movement Disorder Society as follows:

The Movement Disorder Society
611 East Wells Street
Milwaukee, WI 53202
Telephone (414) 276-2145
Fax (414) 276-3349

Psychiatric consultation is indicated for people with possible psychogenic movement disorders (see slides 35 and 38 of Media file 1 of Catatonia).

Psychogenic movement disorders are some of the most bizarre and florid movement disorders. Typically, psychogenic movement disorders do not demonstrate the usual phenomenology and topology of TD (see slides 35 and 38 of Media file 1 of Catatonia).

Patients may have both psychogenic movement disorders and TD. The primary clinician tactfully and diplomatically must suggest to the patient that consultation to investigate psychological aspects may be helpful.

The patient should agree to psychiatric consultation before the specialist is asked to visit. If uncertain about the possible existence of a psychological component to a movement disorder, a prudent clinician requests psychiatric consultation.

A course of psychotherapy may have less morbidity than pharmacologic interventions.

Medication

Reduction and cessation of the causative agents may relieve tardive symptoms. Anecdotal reports have suggested that various agents have helped individuals. No established medications exist to treat TD.

More on Tardive Dyskinesia

Overview: Tardive Dyskinesia
Differential Diagnoses & Workup: Tardive Dyskinesia
Treatment & Medication: Tardive Dyskinesia
Follow-up: Tardive Dyskinesia
Multimedia: Tardive Dyskinesia
References
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Further Reading

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Keywords

TD, buccolingual dyskinesia, orofacial dyskinesia, masticatory dyskinesia, extrapyramidal syndromes, EPS, antipsychotic medication, acute movement disorder, exposure to dopamine antagonists, long-term dopaminergic antagonist therapy, involuntary movement of the tongue, involuntary movement of the lips, involuntary movement of the face, involuntary movement of the trunk, involuntary movement of the extremities, schizophrenia, schizoaffective disorder, bipolar disorder, long-term treatment with neuroleptics, acute tremor, acute akathisia

acute Parkinsonism, tardive blepharospasm, tardive dystonia, neuroleptic-induced TD, choreiform movements, athetoid movements, rhythmic movements of tongue, rhythmic movements of jaw, rhythmic movements of trunk, rhythmic movements of extremities, cerebrovascular disease, encephalitis, head trauma, hereditary dyskinesias, Huntington disease, Wilson disease, torsion dystonia, orofacial dyskinesia, tardive akathisia, tardive myoclonus, tardive tics, Meige syndrome, anterocollis, retrocollis, torticollis, tardive tourettism 

echolalia, echopraxia, coprolalia, copropraxia, multiple motor and vocal tics, tardive tremor, facial grimacing, protrusion of tongue, involuntary athetoid movements of extremities, snakelike writhing of extremities, lip smacking, chewing, sucking, puckering, tongue writhing, jaw opening, jaw closing, grimacing, excessive blinking and brow wrinkling, brow wrinkling, guitar playing movements, piano playing movements, Hillside Akathisia Scale, dyskinetic blinking, scoliosis, tortipelvis, spasmodic torticollis, involuntary rhythmic sinusoidal movements of limbs, involuntary rhythmic sinusoidal movements of head, involuntary rhythmic sinusoidal movements of neck, Movement Disorders Checklist, stereotypy, Timed Stereotypies Rating Scale, Munchausen syndrome, bradykinesias, hyperkinesias, chorea

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Contributor Information and Disclosures

Author

James Robert Brasic, MD, MPH, Research Associate, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
James Robert Brasic, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Neurology, and Movement Disorders Society
Disclosure: Taylor and Francis Royalty Independent contractor; Wolters Kluver/Lippincott Williams & Wilkins Royalty Independent contractor

Coauthor(s)

Brian Bronson, MD, Staff Physician, Department of Psychiatry, New York University Medical Center
Disclosure: Nothing to disclose.

Tristen T Chun, Division of Nuclear Medicine, Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Daniel H Jacobs, MD, Associate Professor of Neurology, University of Central Florida College of Medicine
Daniel H Jacobs, MD is a member of the following medical societies: American Academy of Neurology, American Society of Neurorehabilitation, and Society for Neuroscience
Disclosure: Teva Pharmaceutical Grant/research funds Consulting; Biogen Idex Grant/research funds Independent contractor; Serono EMD Royalty Speaking and teaching; Pfizer Royalty Speaking and teaching; Berlex Royalty Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Nestor Galvez-Jimenez, MD, MSc, MHA, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida
Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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