Differentiating tardive dyskinesia: a video-based review of antipsychotic-induced movement disorders in clinical practice

Abstract

Accurate diagnosis and appropriate treatment of tardive dyskinesia (TD) are imperative, as its symptoms can be highly disruptive to both patients and their caregivers. Misdiagnosis can lead to incorrect interventions with suboptimal or even deleterious results. To aid in the identification and differentiation of TD in the psychiatric practice setting, we review its clinical features and movement phenomenology, as well as those of other antipsychotic-induced movement disorders, with accompanying links to illustrative videos. Exposure to dopamine receptor blocking agents (DRBAs) such as antipsychotics or antiemetics is associated with a spectrum of movement disorders including TD. The differential diagnosis of TD is based on history of DRBA exposure, recent discontinuation or dose reduction of a DRBA, and movement phenomenology. Common diagnostic challenges are the abnormal behaviors and dyskinesias associated with advanced age or chronic mental illness, and other movement disorders associated with DRBA therapy, such as akathisia, parkinsonian tremor, and tremor related to use of mood stabilizing agents (eg, lithium, divalproex). Duration of exposure may help rule out acute drug-induced syndromes such as acute dystonia or acute/subacute akathisia. Another important consideration is the potential for TD to present together with other drug-induced movement disorders (eg, parkinsonism, parkinsonian tremor, and postural tremor from mood stabilizers) in the same patient, which can complicate both diagnosis and management. After documentation of the phenomenology, severity, and distribution of TD movements, treatment options should be reviewed with the patient and caregivers.

Assessment of the Impact of Tardive Dyskinesia in Clinical Practice: Consensus Panel Recommendations

“…An accurate TD diagnosis is crucial for all aspects of disease management for both patients and caregivers. 19 , 20 An accurate diagnosis is also the foundation upon which all recommendations about assessing the impact of TD are based.…”

VMAT2 Inhibitors for the Treatment of Tardive Dyskinesia

“…TD is characterized by persistent, abnormal, involuntary movements of the mouth, tongue, jaw, face, trunk, and/or extremities that are usually described as choreoathetoic: irregular, dancelike (choreic), and/or slow, writhing (athetoic). Repetitive, chewing movements of the mouth/jaw, often with tongue protrusion and lip pursing or smacking, are considered to be the "classic" manifestations of TD and are often referred to as "oral-buccal-lingual" or "OBL" movements (Factor et al, 2019;Hauser et al, 2020;Savitt & Jankovic, 2018). Involuntary movements in the OBL region account for many TD cases (with some estimates reaching 60% to 80%) and can lead to difficulty speaking, swallowing, and eating, as well as biting of the lips and tongue, and cracking/grinding of the teeth (Hauser et al, 2020).…”

“…Repetitive, chewing movements of the mouth/jaw, often with tongue protrusion and lip pursing or smacking, are considered to be the "classic" manifestations of TD and are often referred to as "oral-buccal-lingual" or "OBL" movements (Factor et al, 2019;Hauser et al, 2020;Savitt & Jankovic, 2018). Involuntary movements in the OBL region account for many TD cases (with some estimates reaching 60% to 80%) and can lead to difficulty speaking, swallowing, and eating, as well as biting of the lips and tongue, and cracking/grinding of the teeth (Hauser et al, 2020). Abnormal facial movements (e.g., grimacing) and/or frequent eye blinking may also occur.…”

“…TD can be highly disruptive and cause embarrassment, social isolation, and reduced functioning and quality of life (Ascher-Svanum et al, 2008;Hauser et al, 2020). In a recent study which documented the presence and impact of possible TD in a real-world cohort of 739 patients who were taking antipsychotics, 27.6% had clinician-confirmed TD and had significantly reduced functioning and quality of life compared to those without TD (Caroff et al, 2020b).…”

“…Tardive dyskinesia (TD) is an iatrogenic, persistent, and potentially debilitating hyperkinetic movement disorder associated with prolonged exposure to dopamine receptor blocking agents such as antipsychotics and antiemetics (e.g., metoclopramide) (Hauser et al, 2020;Savitt & Jankovic, 2018;Waln & Jankovic, 2013). In patients with TD, prolonged use of these treatments is thought to result in irregular dopamine signaling in a region of the brain that controls movement (Teo et al, 2012;Waln & Jankovic, 2013).…”