Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas Hospital, Portrane

Tardive dyskinesia
Definition
Involuntary, repetitive purposeless movements, occurring with long-term
antipsychotic treatment (although also ahs been reported in untreated
schizophrenic patients)
Also associated with lithium, phenytoin, clomipramine, bupropion and buspirone

Symptoms/signs
Lip smacking or chewing
Tongue protrusion
Choreiform hand movements (pill rolling or piano playing)
Pelvic thrusting

Symptoms can be consciously suppressed, worsen with distraction, are

exacerbated by stress and antiparkinsonian agents and disappear during sleep

Pathophysiology
Not yet fully understood
Theories include:
o dopaminergic/cholinergic imbalance
o upregulation/supersensitivity of postsynaptic DA receptors in the basal ganglia
following chronic blockade,
o GABA hypofunction leading to enhanced DA transmission

Rating scale
Abnormal Involuntary Movement Scale (AIMS)

Prevalence
5% of patients per year of antipsychotic exposure

Risk factors
Elderly women
Presence of organic brain illness, alcoholism, affective illness, diabetes and
learning disability
Those who had acute EPSEs early on in treatment
Chronic use of antipsychotics (particularly in high dose)
Concomitant anticholinergic treatment

Time taken to develop symptoms

Months to years. Approx 50% of cases are reversible

Differential diagnosis
Stereotypies
Tic disorders
Other causes of dyskinesia (e.g. Parkinsons disease or use of antiparkinsonian
agents).
Other causes of chorea/athetoid movements (e.g. Syndenhams/Huntingtons
chorea, Wilsons disease)

1
Dr Diane Mullins, RCSI Tutor in Psychiatry, St Itas Hospital, Portrane

Treatment
Stop anticholinergics
antipsychotic dose
Change to an atypical antipsychotic
Clozapine

Course/prognosis
Symptoms may not progress and remission rates are ~30%/year with 50% of
suffers clinically improved after 5 years, even without treatment
Most cases will respond to treatment although a balance may need to be struck
between reduction in dyskinesia Vs control of psychotic symptoms

Follow-up
Residual symptoms should be closely monitored
The need for continued antipsychotic treatment should also be regularly reviewed
Ensure that occurrence of TD and treatment strategy clearly recorded in case notes