Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Tardive Dystonia Treatment & Management

  • Author: Daniel Schneider, MD, MA; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Aug 12, 2015
 

Medical Care

The treatment of patients with tardive dystonia is difficult. Refractoriness to treatment is a substantial clinical concern. Several pharmacologic and other somatic interventions have been tried with variable results.

The first step after the diagnosis of tardive dystonia induced by neuroleptics or other drugs is to taper and then discontinue the causative drugs. Many times, a severe psychiatric illness makes this impossible, but carefully reconsidering the indications for dopamine antagonists in a given patient and considering alternate therapy are imperative. Unfortunately, it is not uncommon for the symptoms to worsen for a time after the offending medication is discontinued or reduced.

If the dystonia is focal and amenable to botulinum toxin therapy, this should be considered.[23, 24]

The primary pharmacological treatment for tardive dystonia is dopamine-depleting agents. Another option would be dopamine receptor blockers (ie, neuroleptics).[2, 3, 4] A common observation for all tardive syndromes is that the symptoms improve with an increase of dopamine blockade and worsen with a decrease. Thus, the goal is to add a medication that will provide dopamine blockade while minimizing the risk of worsening the tardive syndrome or creating new tardive syndromes. The treatments of choice are dopamine depleters such as tetrabenazine or reserpine, since these do not appear to cause tardive symptoms. However, their side effects can make these difficult to tolerate and they are not as effective at treating psychiatric illness as dopamine receptor blockers.

Another strategy, particularly for those with severe psychiatric illnesses or who are intolerant to the side effects of dopamine depleters, is to start a neuroleptic such as clozapine, which has minimal risk for creating tardive syndromes. Clozapine is frequently chosen because it has the least number of credible reports of inducing tardive symptoms and the most data for alleviating those symptoms. Other neuroleptics could also be considered; however, given that there are case reports of all neuroleptics causing tardive dystonia, other choices should be made with caution.

If starting a dopamine-depleting or a dopamine receptor blocking agent is only partially successful, treatment can be supplemented with alpha-methyl-para-tyrosine (AMPT) for additional dopamine blockade.

If dopamine blockade is not successful or only partially successful, anticholinergic medications such as artane can be tried.[2, 3, 4]

There are case reports of clonazepam being added to clozapine for additional benefit, and this could be considered if a single medication is only partially successful.[25, 26]

There is also limited evidence of the effectiveness of electroconvulsive therapy in this condition, and this may be considered if pharmacological treatments have failed and there is reason not to consider deep brain stimulation (DBS).[3]

A comprehensive approach to patients with tardive dystonia includes patient education and supportive care. Physical therapy and well-fitted braces are designed primarily to improve posture and to prevent contractures. Although braces are tolerated poorly, particularly by children, they may be used in some cases as a substitute for sensory input. For example, in some patients with cervical dystonia, neck and head braces seem to provide sensory input by touching certain portions of the head or neck in a fashion similar to the patient's own sensory trick, thus enabling the patient to maintain a desirable head position. Some patients find various muscle relaxation techniques and sensory feedback therapy useful adjuncts to medical or surgical management.

Next

Surgical Care

Deep brain stimulation is probably the surgical treatment of choice at this time for those with severely disabling dystonia who have not responded to medical therapy.

Small studies by Trottenberg et al and Zhang et al initially showed some success in deep brain stimulation of the globus pallidus interna and bilateral subthalamic nuclei.[27, 28]

Thobois et al were able to show improvement by 63% in 5 patients with bilateral GPi stimulation compared to 8 controls[29] . Gruber et al were able to show improvement in 9 patients by nearly 75% on the Burke-Fahn-Marsden Dystonia Rating Scale after 3-6 months.[30]

Gruber et al assessed the long-term effects, including motor function, quality of life, and mood, of bilateral globus pallidus internus DBS on patients with tardive dystonia and concluded it is a safe and effective long-term treatment. Patients were assessed 3 times using established movement disorder and neuropsychological scales. Results showed significant improvement in quality of life regarding physical components and affective state. They also noted that cognitive functions remained unchanged, and no permanent adverse effects occurred.[30]

Other treatments, such as thalamotomy and pallidotomy, have also been investigated, but as there is no evidence that these provide benefits beyond DBS (and certainly carry greater risk due to their irreversibility), these would be considered second-line.[3]

Previous
Next

Activity

Physical activity depends on the grade of disability caused by the dystonic movements. In most patients, physical and occupational therapy encourage activity and help make life more comfortable and actions more effective.

Previous
Next

Deterrence/Prevention

According to conventional wisdom, the new atypical antipsychotic medications, which appear to have less adverse extrapyramidal and tardive dystonic effects, have decreased the incidence of this syndrome. To this point, no rigorous studies support this belief.

BTTA injections appear to be a good development in the treatment of tardive dyskinesia, especially the tardive cranial and cervical forms.

Unless necessary, avoid use of all drugs that may be offending agents. Before beginning treatment, consider carefully the risks and benefits of using medications such as neuroleptics for nonindicated uses (eg, sedation) or at doses higher then clinically necessary.

Previous
 
 
Contributor Information and Disclosures
Author

Daniel Schneider, MD, MA Assistant Professor of Neurology, Division of Movement Disorders and Behavioral Neurology, Medical Director for Neurologic and Psychiatric Deep Brain Stimulation, Rutgers Robert Wood Johnson Medical School

Disclosure: Nothing to disclose.

Coauthor(s)

Paula D Ravin, MD Associate Professor of Clinical Neurology, University of Massachusetts Memorial Health Care

Paula D Ravin, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, Massachusetts Medical Society, American Headache Society, National Headache Foundation

Disclosure: Received grant/research funds from Chelsea Pharmaceuticals for independent contractor; Received grant/research funds from Kyowa Pharma for independent contractor; Received consulting fee from Best Doctors Inc for consulting; Received grant/research funds from Beth Israel IRB for independent contractor.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Additional Contributors

Alan D Schmetzer, MD Professor Emeritus, Department of Psychiatry, Indiana University School of Medicine

Alan D Schmetzer, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Clinical Psychiatrists, American Academy of Psychiatry and the Law, American Association for Physician Leadership, American Medical Association, American Psychiatric Association, International Society for ECT and Neurostimulation, American Neuropsychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Nestor Galvez-Jimenez, MD, and Perla Periut, MD, to the development and writing of this article.

References
  1. Bhidayasiri R, Fahn S, Weiner WJ, Gronseth GS, Sullivan KL, Zesiewicz TA. Evidence-based guideline: treatment of tardive syndromes: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 Jul 30. 81(5):463-9. [Medline].

  2. Burke RE, Fahn S, Jankovic J, et al. Tardive dystonia: late-onset and persistent dystonia caused by antipsychotic drugs. Neurology. 1982 Dec. 32(12):1335-46. [Medline].

  3. Adityanjee, Aderibigbe YA, Jampala VC, Mathews T. The current status of tardive dystonia. Biol Psychiatry. 1999 Mar 15. 45(6):715-30. [Medline].

  4. Kiriakakis V, Bhatia KP, Quinn NP, Marsden CD. The natural history of tardive dystonia. A long-term follow-up study of 107 cases. Brain. 1998 Nov. 121 (Pt 11):2053-66. [Medline].

  5. Fahn S, Marsden, CD, Calne DB. Classification and Investigation of Dystonia. Marsden CD, Fahn S. Movement Disorders, Vol. 2. London: Butterworths; 1987. 332-358.

  6. Fahn, Stanley and Jankovic, Joseph. Principles and Practice of Movement Disorders. Philadelphia, PA: Churchill Livingston Elveiser; 2007.

  7. Stacy, Mark A. Handbook of Dystonia. New York, NY: Informa Healthcare; 2007.

  8. Keegan DL, Rajput AH. Drug induced dystonia tarda: treatment with L-dopa. Dis Nerv Syst. 1973 Mar. 34(3):167-9. [Medline].

  9. Kang UJ, Burke RE, Fahn S. Tardive dystonia. Adv Neurol. 1988. 50:415-29. [Medline].

  10. Sachdev P. Risk factors for tardive dystonia: a case-control comparison with tardive dyskinesia. Acta Psychiatr Scand. 1993 Aug. 88(2):98-103. [Medline].

  11. Mihara K, Kondo T, Higuchi H, Takahashi H, Yoshida K, Shimizu T. Tardive dystonia and genetic polymorphisms of cytochrome P4502D6 and dopamine D2 and D3 receptors: a preliminary finding. Am J Med Genet. 2002 Aug 8. 114(6):693-5. [Medline].

  12. Trugman JM, Leadbetter R, Zalis ME, Burgdorf RO, Wooten GF. Treatment of severe axial tardive dystonia with clozapine: case report and hypothesis. Mov Disord. 1994 Jul. 9(4):441-6. [Medline].

  13. Yassa R, Nair V, Iskandar H. A comparison of severe tardive dystonia and severe tardive dyskinesia. Acta Psychiatr Scand. 1989 Aug. 80(2):155-9. [Medline].

  14. Friedman JH, Kucharski LT, Wagner RL. Tardive dystonia in a psychiatric hospital. J Neurol Neurosurg Psychiatry. 1987 Jun. 50(6):801-3. [Medline].

  15. Sethi KD, Hess DC, Harp RJ. Prevalence of dystonia in veterans on chronic antipsychotic therapy. Mov Disord. 1990. 5(4):319-21. [Medline].

  16. Gimenez-Roldan S, Mateo D, Bartolome P. Tardive dystonia and severe tardive dyskinesia. A comparison of risk factors and prognosis. Acta Psychiatr Scand. 1985 May. 71(5):488-94. [Medline].

  17. Burke RE. Neuroleptic-induced tardive dyskinesia variants. Lang AE, Weiner WJ, eds. Drug-Induced Movement Disorders. New York, NY: Futu; 1992. 168-98.

  18. Vandel P, Bonin B, Leveque E, et al. Tricyclic antidepressant-induced extrapyramidal side effects. Eur Neuropsychopharmacol. 1997 Aug. 7(3):207-12. [Medline].

  19. Gabellini AS, Pezzoli A, De Massis P, Sacquegna T. Veralipride-induced tardive dystonia in a patient with bipolar psychosis. Ital J Neurol Sci. 1992 Oct. 13(7):621-3. [Medline].

  20. Chakrabarti S, Chand PK. Lithium - induced tardive dystonia. Neurol India. 2002 Dec. 50(4):473-5. [Medline].

  21. Chase TN, Tamminga CA, Burrows H. Positron emission tomographic studies of regional cerebral glucose metabolism in idiopathic dystonia. Adv Neurol. 1988. 50:237-41. [Medline].

  22. Arai N, Amano N, Iseki E, et al. Tardive dyskinesia with inflated neurons of the cerebellar dentate nucleus. Case reports and morphometric study. Acta Neuropathol (Berl). 1987. 73(1):38-42. [Medline].

  23. Kaufman DM. Use of botulinum toxin injections for spasmodic torticollis of tardive dystonia. J Neuropsychiatry Clin Neurosci. 1994 Winter. 6(1):50-3. [Medline].

  24. Hennings JM, Krause E, Bötzel K, Wetter TC. Successful treatment of tardive lingual dystonia with botulinum toxin: case report and review of the literature. Prog Neuropsychopharmacol Biol Psychiatry. 2008 Jul 1. 32(5):1167-71. [Medline].

  25. Shapleske J, Mickay AP, Mckenna PJ. Successful treatment of tardive dystonia with clozapine and clonazepam. Br J Psychiatry. 1996 Apr. 168(4):516-8. [Medline].

  26. Blake LM, Marks RC, Nierman P, Luchins DJ. Clozapine and clonazepam in tardive dystonia. J Clin Psychopharmacol. 1991 Aug. 11(4):268-9. [Medline].

  27. Trottenberg T, Volkmann J, Deuschl G, Kühn AA, Schneider GH, Müller J. Treatment of severe tardive dystonia with pallidal deep brain stimulation. Neurology. 2005 Jan 25. 64(2):344-6. [Medline].

  28. Zhang JG, Zhang K, Wang ZC. Deep brain stimulation in the treatment of tardive dystonia. Chin Med J (Engl). 2006 May 5. 119(9):789-92. [Medline].

  29. Thobois S, Ballanger B, Xie-Brustolin J, Damier P, Durif F, Azulay JP, et al. Globus pallidus stimulation reduces frontal hyperactivity in tardive dystonia. J Cereb Blood Flow Metab. 2008 Jun. 28(6):1127-38. [Medline].

  30. Gruber D, Trottenberg T, Kivi A, Schoenecker T, Kopp UA, Hoffmann KT, et al. Long-term effects of pallidal deep brain stimulation in tardive dystonia. Neurology. 2009 Jul 7. 73(1):53-8. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.