What Is Tardive Dyskinesia (TD)? Symptoms, Causes And Treatments (2024)

“TD is a disorder of involuntary, abnormal, hyperkinetic [unwanted or excessive] movements that occurs after treatment with drugs that block certain dopamine receptors in the brain,” explains Stanley N. Caroff, M.D., professor of psychiatry at the University of Pennsylvania Perelman School of Medicine.

As opposed to other movement disorders, TD is strictly caused by the use dopamine-blocking drugs and is not tied to an underlying condition according to Dr. Caroff. The reason why these medications cause TD are complex, but have to do with the fact that dopamine is a neurotransmitter that plays an important role in the body’s movement systems and motor control functions.

Notably, TD is a chronic condition whose symptoms can remain long after an individual has stopped taking the medication responsible for causing them.

TD is a hyperkinetic movement disorder, which refers to overactive, extra or unnecessary movements such as excessive eye blinking, lip smacking or jerking of the hands or limbs. This is distinct from hypokinetic movement disorders such as Parkinson’s disease, which is characterized by the slowing, reduction or loss of intentional movements.

“TD can present with several types of abnormal movements or postures, but most often TD consists of persistent, patterned or stereotyped movements,” says Dr. Caroff. These movements often include:

• Excessive and persistent movements including:
  • Chewing
  • Puckering of or distorting the mouth
  • Lip-licking
• Jerking or writhing movements (also known as choreiform movements) including:
  • Fidgeting of fingers or toes
  • Frequent eye blinking
  • Tongue-darting

The movements can be so mild that they may not be immediately noticeable by the individual or those around them. Conversely, they can be so severe that they inhibit a person’s ability to perform certain vocational or household duties. Due to the stigma associated with the visible movements, the condition may also have a negative impact on one’s social life and psychological well-being.

When assessing for and treating TD, one should not just consider the severity of the movements present, according to Richard Jackson, M.D., a psychiatrist and associate clinical professor at Wayne State School of Medicine and assistant clinical professor at the University of Michigan. “We should also look at the impact those movements are causing, and use that to guide treatment.”

The use of medications that block dopamine receptors in the brain, including antipsychotics and drugs aimed at treating certain gastrointestinal issues, can cause TD.

The main risk factors that can increase the possibility of TD developing are the type of dopamine antagonists used to treat an individual, and how long they use that treatment. Studies also show that older age is associated with a higher risk of developing TD. Additionally, some evidence indicates the female sex and African and caucasian ethnicity may also be potential risk factors^[2]Frei K. Tardive dyskinesia: Who gets it and why. Parkinsonism Relat Disord. 2019;59:151-154. .

Fortunately, newer antipsychotics show a lower prevalence of TD development. Second-generation, or atypical, antipsychotics have a cumulative incidence rate of 20.7%, or about 4% annually, whereas first-generation antipsychotics have a cumulative TD incidence rate of 30% , according to a meta-analysis in the Journal of Clinical Psychology^[3]Carbon M, Hsieh CH, Kane JM, Correll CU. Tardive Dyskinesia Prevalence in the Period of Second-Generation Antipsychotic Use: A Meta-Analysis. J Clin Psychiatry. 2017;78(3):e264-e278. .

While the risk of developing TD from second generation antipsychotics is lower than earlier versions of dopamine blockers, the number of indications for which they have been approved has also increased. In other words, doctors are now prescribing these medications not only for schizophrenia and bipolar disorder with psychosis, but also for bipolar disorder without psychosis and major depressive disorder, according to Dr. Jackson.

While there are newer antipsychotic drugs being developed that do not bind to dopamine receptors and may not cause TD in the future, in the meantime, people should discuss TD with their doctors to make sure that low-risk antipsychotics are prescribed and only for approved indications.” notes Dr. Caroff.

TD is diagnosed by performing a physical examination on an individual who has received or is receiving a dopamine-blocking medication to determine if abnormal and involuntary movements are present. Various rating scales are used to evaluate the presence and severity of these movements. The most commonly used is the Abnormal Involuntary Movement Scale, or AIMS.

Movements can be particularly subtle during early stage TD, which “gets picked up more when it’s moderate, severe,” says Dr. Jackson. ” It’s therefore important for physicians to perform a thorough examination before prescribing a dopamine receptor antagonist, so they have a baseline specific to the individual, Dr. Jackson continues. Since TD can develop in as little as one month from beginning treatment with a dopamine blocker, a subsequent assessment should be performed within three months from the start of the treatment.

Symptoms of TD may be similar in appearance to abnormal movements present in other movement disorders. “There are no tests to confirm the diagnosis,but tests may be considered to rule out other disorders that may cause abnormal movements in some cases,” says Dr. Caroff

The Impact-TD Scale: A Novel Diagnosis Tool

“What is really important is not so much how much movement [a patient] has, but how much those movements impact [their] daily life,” explains Dr. Jackson. Mild to moderate movements in one’s face may greatly impact someone who regularly has to speak in front of groups of people, whereas even mild movements in the hands could be severely detrimental to a mechanic, for instance.

Dr. Jackson and others have worked to develop a new clinical tool for evaluating the impact of TD on a person’s life, according to a 2022 report in the Journal of Clinical Psychology. Known as the TD-Impact Scale, this tool guides clinicians to assess the consequences of TD within four domains of a patient’s life: Social, psychological/psychiatric, physical and vocational/educational/recreational^[4]Jackson R, Brams MN, Carlozzi NE, Citrome L, Fritz NE, Hoberg AR, Isaacson SH, Kane JM, Kumar R. Impact-Tardive Dyskinesia (Impact-TD) Scale: A Clinical Tool to Assess the Impact of Tardive Dyskinesia. J Clin Psychiatry. 2022;84(1). .

The TD-Impact Scale highlights the impact of TD on an individual’s life even if the severity of their movements is low according to their AIMS scores, notes Dr. Jackson. “If you have impact, you should have treatment,” he says. “Any movement is enough for TD. Any impact is enough for treatment.”

Given the risk of developing TD, utilizing treatment options other than dopamine blockers whenever possible may be ideal for some individuals. Fortunately, the FDA approved valbenazine, a vesicular monoamine transporter-2 (VMAT-2) in 2017 for the treatment of TD.

In addition to valbenazine, another VMAT-2 inhibitor, deutetrabenazine, is effective in treating TD, according to a review in the Drug Design, Development and Therapy Journal^[5]Solmi M, Pigato G, Kane JM, Correll CU. Treatment of tardive dyskinesia with VMAT-2 inhibitors: a systematic review and meta-analysis of randomized controlled trials. Drug Des Devel Ther. 2018;12:1215-1238. . Moreover, these VMAT-2 inhibitors can be taken alongside dopamine blockers if needed, so treatment for the initial condition need not be interrupted.

Beyond medication, Dr. Caroff highlights the following features of a strong TD treatment plan:

• Regular screenings utilizing available rating scales
• Continued discussion of the latest medications available with patients and caregivers
• Possible modification of the original dopamine-blocking medication

When discussing any new drug with your doctor, considerations should include both potential short- and long-term side effects, as well as an understanding about how these side effects might impact you and your lifestyle.

Many individuals with TD may feel self-conscious about their involuntary movements. Advances in medicine and customized plans of care can be of great service in this regard, but fighting the social stigma associated with the movements is important too, notes Dr. Jackson.

Staying vigilant and educated on the signs of TD can also help caregivers and family members support an individual, notes Dr. Caroff. “People and caregivers should be informed as to what TD looks like, how to self-examine and the need to contact their clinician to report any unusual or abnormal movements that develop so that effective treatment can be started.”