Motor › Movement Disorders Associated with Antipsychotic Medication

Tardive Dyskinesia

Tardive dyskinesia consists of repetitive, purposeless involuntary movements, usually affecting the mouth, tongue, and facial muscles, that develop later in the course of illness or treatment rather than acutely. It is strongly associated with long-term antipsychotic exposure, but is also recognised to occur in a proportion of people with schizophrenia who have never been exposed to antipsychotic medication at all, indicating that the illness itself, and not only its treatment, can give rise to this pattern.

This has traditionally been highlighted as clinically important beyond its physical features, because the visible, repetitive facial and oral movements can lead to significant additional stigmatisation and social disability for the person affected, on top of whatever difficulties their underlying psychiatric illness already presents.

Recognition features

• Repetitive, purposeless involuntary movements, most often affecting the mouth, tongue, and facial muscles
• A later, more gradual ('tardive') onset, in contrast to the acute presentations of dystonia and akathisia
• Strongly associated with long-term antipsychotic exposure, though also documented in a meaningful proportion of neuroleptic-naïve patients with first-episode schizophrenia
• Can lead to significant additional social stigmatisation and disability, given its visible, involuntary, and often persistent nature

Eliciting it at interview

• Examine specifically for repetitive movements of the mouth, tongue, and face, such as lip-smacking, tongue protrusion, or chewing-like movements, using a systematic approach and, where available, a validated rating scale
• Take a careful history of antipsychotic exposure over time, while also bearing in mind that these movements can occur even without any prior medication exposure, particularly in first-episode schizophrenia
• Ask about the person's own experience of stigma or social difficulty related to the visible movements, since this can be a significant, under-recognised source of distress

Distinguishing features

• Differs from acute dystonia and akathisia by its later, more gradual onset and its characteristic repetitive, purposeless oral and facial movement quality, rather than sustained spasm or generalised restlessness
• Differs from a catatonic stereotypy in its specific oral and facial distribution and its documented occurrence independent of antipsychotic exposure in some patients with schizophrenia
• Its potential occurrence even without prior medication exposure is an important distinguishing feature, showing that this pattern is not purely a drug effect

Common misconceptions

• That tardive dyskinesia is always caused by antipsychotic medication; it has also been documented in patients with first-episode schizophrenia who have never taken such medication
• That the movements of tardive dyskinesia are purely a physical inconvenience; the visible, involuntary nature of the movements can cause significant additional social stigma and distress

Related phenomena

Movement Disorders Associated with Antipsychotic Medication · Involuntary Neurological Movement Signs

Practice this

After several years of antipsychotic treatment, a patient develops repetitive, purposeless movements of the mouth, tongue, and face, with a gradual onset that developed slowly over time rather than suddenly. What is this? · Two days after starting an antipsychotic medication, a patient suddenly develops a sustained, uncomfortable twisting of the neck to one side. Before revealing the answer: is this tardive dyskinesia? · A patient on long-term antipsychotic treatment has developed abnormal movements. Before revealing the answer, decide what distinguishes akathisia from tardive dyskinesia. · A patient shows an involuntary movement pattern with a possible medication history. Before revealing the answer, decide what distinguishes the broader family of involuntary neurological movement signs from tardive dyskinesia specifically. · A patient on antipsychotic medication develops an abnormal involuntary movement. Before revealing the answer, decide what distinguishes tardive dyskinesia from acute dystonia. · You are assessing a long-term antipsychotic user for tardive dyskinesia. Before revealing the answer, decide how you would assess for this on examination. · Explain why the occurrence of tardive dyskinesia in some patients who have never been exposed to antipsychotic medication is clinically significant.

Illustration

A 60-year-old woman with a long history of antipsychotic treatment develops persistent, repetitive lip-smacking and tongue-protruding movements that she cannot voluntarily suppress for more than a few seconds at a time, and confides that she has started avoiding social gatherings because she is embarrassed by how the movements make her look to others.

References

• Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 8, 'Motor Disorders'.