What Is Tardive Dyskinesia
Tardive dyskinesia is a drug-induced movement disorder. Taking specific medications, often for a mental health disorder, can cause it.
Tardive dyskinesia causes involuntary facial tics . It can also cause uncontrollable movements like lip-smacking.
Tardive means delayed or late. Dyskinesia refers to involuntary muscle movements. With this condition, theres a delay between when you start a medicine and when you develop dyskinesia. Most people take a medicine for years before developing the disorder.
Are There Ways To Manage Dyskinesia
Once dyskinesia has started it is difficult to treat. However, there are several ways to delay it from starting or reduce it once it has begun.
Supplemental or alternative treatment options
Things you can do on your own
- Keep a diary that logs the time and frequency of dyskinesia, which will help your doctor assess if your medications are working and help you schedule daily activities when mobility is better.
- Physical activity, including mild aerobic exercise such as walking, dancing, and swimming, will help keep the body strong and prevent muscle weakening.
- Stress can make dyskinesia symptoms worse, so find ways to reduce stress and try to keep a positive attitude.
- Poor sleep at night is associated with dyskinesia. Aim for good sleep quality and try to experiment with different positions in bed that will help you relax and sleep better.
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Uncontrolled Movements In Parkinson’s Disease
Parkinson’s disease is a disorder that can involve several different kinds of uncontrolled movements. Some are caused by the disease, such as tremor and gait freezing, while dyskinesia uncontrolled jerking or twisting movement is caused by long-term levodopa use. We unpack how dyskinesia affects movement in Parkinsons disease and how its usually treated.
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Approach To Psychogenic Movement Disorders
Patients with psychogenic movement disorders, somatoform disorder, somatization disorder, hypochondriasis, hysteria, conversion disorder, malingering, Munchausen syndrome, and factitious disorders usually have manifestations that rule out TD. Nevertheless, clinicians may be tempted to consider treatment for possible TD in people who have psychiatric and psychological problems. The desire of the clinician to offer a therapeutic intervention may be intensified by the requests and demands of patients for surgery and other help.
Prudent clinicians must exercise extreme caution to avoid providing pharmacologic and surgical treatments to patients with psychogenic movement disorders. These patients are likely to experience extreme adverse effects and no beneficial effects from such treatments. In particular, surgery, including psychosurgery, is contraindicated for psychogenic movement disorders.
A tactful suggestion that stress may be contributing to the symptoms is appropriate. Typically, people who manifest psychogenic movement disorders have recently had life experiences that are stressful. The life stresses can be both positive, such as a promotion, and negative, such as the death of a loved one. Psychotherapy may then provide a more effective means of expressing the psychological distress often associated with psychogenic movement disorders. Referral to mental health professionals should always be considered.
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What Causes Dyskinesia In Parkinsons Disease
Unlike off time, patients typically experience dyskinesia in Parkinsons when medications are working and other symptoms are under control. Researchers arent exactly sure what causes dyskinesia, but it is believed to be a side effect of long-term levodopa use, not a symptom itself. Levodopa-induced dyskinesia can look like fidgeting, writhing, wriggling, head bobbing, or body swaying. LID can sometimes be confused with Parkinsons tremor, which is a back and forth shaking caused by the disease.
Because levodopa is taken throughout the day, dopamine levels in the brain rise and fall. These fluctuating levels of dopamine combined with the continued loss of dopamine in the brain make it difficult to maintain regular dopamine levels, and lead to dyskinesia.
Individuals diagnosed with Parkinsons at a younger age are more likely to experience dyskinesia. Its also more common in later stages of Parkinsons or in those who have taken levodopa for several years.
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How Common Is Tardive Dyskinesia With Antipsychotic Use
Tardive dyskinesia develops within the first year in 6% to 12% of people who take even low-dose antipsychotics. Age can impact the likelihood of developing TD, with 25% to 45% of people over age 45 developing TD after a year of treatment.
Beyond antipsychotics, several other medications have also been linked to tardive dyskinesia. These include:
- Antidepressants, such as Prozac and Desyrel
- Anti-epileptic drugs , such as Dilantin and Tegretol
- Anticholinergics, such as Cogentin
Extrapyramidal symptoms like tardive dyskinesia are caused by certain medications like antipsychotics.
Acknowledgements And Conflict Of Interest Disclosure
RM acknowledges grants from the Spanish Ministries de Economía y Competitividad and of Sanidad Política Social e Igualdad, ISCIII: BFU2010-20664, PNSD, CIBERNED ref. CB06/05/0055 and Comunidad de Madrid ref. S2011/BMD-2336, JRGM is supported by ICyTDF México MTH acknowledges the support by CIBERNED CB05/05/505, SAF2007-062262 and FIS PI10-02827. RH and KC were supported by the German Bundesministerium für Bildung und Forschung, Grant 01GN1006B. NS gratefully acknowledges Sardinia Regional Government for financial support . The authors have no conflicts of interest to declare.
All experiments were conducted in compliance with the ARRIVE guidelines.
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Is Tardive Dyskinesia A Symptom Of Parkinson’s Disease
Tardive dyskinesia is not a symptom of Parkinson’s disease. It’s a separate movement disorder caused by long-term use of anti-psychotic medications.
In addition to being a side effect of different medications, tardive dyskinesia also has its own set of symptoms. The movements associated with tardive dyskinesia tend to be more fluid in appearance compared with Parkinson’s dyskinesia.
What Is Dyskinesia In Parkinsons Disease
Dyskinesia is predominately a side effect of a medication called levodopa thats used to treat Parkinsons disease.
To the trained eye, dyskinesias look quite different , says Herrington. Dyskinesias are not rhythmic they have a more writhing quality.
Herrington points out that you can see an example of dyskinesia if you look at videos of Michael J. Fox. Usually, he says, when is on camera, he has some dyskinesia, or extra movements that are involuntary.
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Whats The Main Difference Between Tremor And Dyskinesia
Tremor seen in Parkinsons disease is one of the hallmark features of the condition. Its one of the motor symptoms of Parkinsons that shows improvement with medication.
On the other hand, dyskinesia tends to show up later in the course of the disease as a long-term side effect of medications used to treat Parkinsons. Sometimes it can be a bit hard to tell whether the abnormal movements are tremor or dyskinesia.
How Can I Manage Or Stop Drug
Managing drug-induced dyskinesia can be challenging. One effective method is to reduce the dose of medication, particularly levodopa. However, this may cause some of the motor symptoms related to Parkinsons to return.
Newer formulations and methods of delivering medications provide a more sustained release of the drug and help reduce the symptoms of dyskinesia. Sustained release formulations and direct intestinal infusions are examples of such methods.
Newer generations of non-levodopa medications, such as safinamide , a monoamine oxidase B inhibitor, and opicapone , a catechol-O-methyltransferase inhibitor, have also shown promise in reducing dyskinesia.
Surgery for Parkinsons, such as deep brain stimulation , also results in a reduction of dyskinesia symptoms. This may be because DBS frequently helps to lessen the amount of medication needed for Parkinsons.
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How Is Parkinsons Disease Dyskinesia Diagnosed
Contrary to many disorders in modern medicine, where sophisticated medical tests are required, in most instances, diagnosis of this is almost purely based on the clinical history and most importantly a physical examination. It can best be made by the well-trained eye of a movement disorder specialist.
The movements can include chorea , athetosis or dystonia . They are typically random in occurrence rather than rhythmically repetitive and can range from very mild to severe. In milder cases, they can be mistaken for normal restlessness, and its not unusual for a person with Parkinsons to be totally unaware of them.
At the other end of the spectrum, Parkinsons Disease Dyskinesia can be quite severe and can significantly interfere with activities of daily living, even affecting gait and balance. The critical point is that these dyskinesias can occur when a person with Parkinsons needs more, not less, levodopa.
Acute Dystonia/acute Dystonic Reactions
Onset of acute dystonia often occurs within hours of the first dose of a DRBA, presumably due to an acute low postsynaptic dopamine state, with 95% of cases appearing within the first 5 days of initiating or increasing dosage.Reference Caroff and Campbell2 Phenomenologically, acute dystonia is similar to the presentation of tardive dystonia described above, characterized by sustained muscle contractions causing twisting or pulling movements or abnormal postures of the head, neck, jaw, mouth, face, and eyes .Reference Caroff and Campbell2,Reference Tarsy41,Reference van Harten, Hoek and Kahn42 If pharyngeal or laryngeal muscles are involved, this can pose a life-threatening emergency. Less frequently, dystonia of the trunk or extremities can present. Dystonic reactions can last a few seconds or several hours and may be sustained, fluctuating, or episodic.Reference Owens47 Symptoms of acute dystonia usually resolve within 24 to 48 hours of discontinuation of oral DRBAs.
The movement phenomenologies of the acute and tardive forms of dystonia are difficult to distinguish thus, acute dystonia is primarily distinguished from tardive dystonia by a rapid onset after DRBA administration and rapid resolution after cessation of DRBAs or rescue treatment with anticholinergics such as benztropine or intravenous diphenhydramine .Reference Caroff and Campbell2
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How Are Akathisia And Tardive Dyskinesia Diagnosed
If you are taking medications that can cause tardive dyskinesia or akathisia, your healthcare provider will ask you about these symptoms when you go for your regular medical visits or therapy sessions. They will also observe you for signs of the movements during your visit.
There are no laboratory or imaging tests that can verify these conditions. Your healthcare provider will rely on your medical history and physical examination to diagnose your condition.
Your healthcare provider will use your medical history and physical examination to differentiate between these movement disorders, which is important because they respond differently to treatment.
For example, anticholinergic treatment can worsen tardive dyskinesia, may have a moderately beneficial effect on akathisia, and may help improve symptoms of Parkinsonism.
If you have akathisia or tardive dyskinesia, your healthcare provider will usually document your symptom frequency, which areas of the body are affected, and how severe the symptoms are. Some providers may use a rating scale to quantify your symptoms and to be able to objectively follow the progression or improvement over time.
Examples of rating scales:
Make A Difference By Distinguishing Td From Drug
It is not enough to be acquainted with TD, according to Dr Kremens. It is crucial to distinguish TD from drug-induced parkinsonism because there can be serious implications for treatment, he says. Treatments for parkinsonism, such as benztropine, can actually worsen TD in some instances and is not recommended. Failure to distinguish between these 2 conditions may lead to poor outcomes for patients.
A difference that may aid in an accurate diagnosis is noting the timing of symptom onset. Symptoms of drug-induced parkinsonism can surface within days or weeks after initiation of an antipsychotic. In contrast, symptoms of TD may not manifest for months or years.1 As such, symptoms of TD can be masked by ongoing treatment or by increasing the DRBA dose.11 Furthermore, TD may become permanent, regardless of whether the causative agent is discontinued.11,12
Table 1 provides a side-by-side overview of TD and drug-induced parkinsonism, highlighting some key differences between these movement disorders.
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Take Additional Medication For Your Parkinsons Disease
Taking a medication called a dopamine agonist can allow your doctor to reduce your levodopa dosage, which may help ease the symptoms of dyskinesia. However, according to the 2016 review, these drugs can cause similar side effects as those of levodopa for some people and may require you to adjust your dose of levodopa.
Adding amantadine to your treatment regimen may also provide relief of dyskinesia symptoms.
Ataxia / Dysmetria / Asynergia
Ataxia is an unsteady and swaying walk, often with feet planted widely apart. People have difficulty walking a straight line with their heel touching the toe of the shoe in front . Ataxia can occur in a number of neurologic conditions.
Dysmetria is misjudging the distance to a target. A person with dysmetria will have problems reaching out and accurately touching a targeted object.
Asynergia is a breakdown of movement, so that movements of the arms and legs become irregular and clumsy.
For more information, visit the National Ataxia Foundation website at www.ataxia.org.
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Talk To Your Doctor About Continuous Drug Infusion
One way to potentially avoid fluctuations in medication delivery and dopamine levels is through a continuous drug delivery system such as duodenal infusion, in which the medication travels through a tube directly into the intestine. Another option is continuous subcutaneous apomorphine infusion, in which a small device similar to an insulin pump is clipped to the clothing, according to the Parkinsons Foundation. A wire then enters the skin to deliver a steady dose of the medication apomorphine , a dopamine agonist, which may reduce the off periods, when levodopa stops working, and may minimize dyskinesia symptoms.
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Other Causes Of Dyskinesia And Dystonia
There are many types of dystonia unrelated to Parkinsons disease. Many forms of dystonia occur with no known cause. Some causes of dystonia are hereditary, while brain injury can also cause dystonia.
Huntingtons disease is a rare, genetic condition in which nerve cells in the brain degenerate over time. This disease causes movement disorders similar to Parkinsons, including chorea and dystonia.
Multiple system atrophy and progressive supranuclear palsy are other rare, degenerative disorders that affect muscle movements. Dyskinesia can occur when people with MSA or PSP are treated with levodopa, and untreated MSA or PSP can lead to the development of dystonia.
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What Are The Complications Of Tardive Dyskinesia
Tardive dyskinesia can make you self-conscious. You may withdraw from people. Isolation may bring on or worsen depression or anxiety, though. The condition can affect your ability to work. It may strain relationships with loved ones, as well.
A small number of people develop severe symptoms that can affect quality of life. Rarely, these problems are life-threatening. They include:
- Breathing issues.
- Irreversible facial changes, such as drooping eyelids or mouth.
- Speech difficulties.
Drugs Acting On Serotonergic Systems
The basal ganglia have dense serotonergic innervation. It is suggested that serotonergic transmission has an inhibitory effect on dopaminergic transmission. There are reports of successful use of 5HT agents in treating LIDs., However, these studies included very small numbers and were mostly uncontrolled.
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Knowing The Difference Can Make A Difference
TD and drug-induced parkinsonism are 2 entirely different movement disorders in terms of time of onset after exposure to DRBAs, the pattern and type of movements, the body distribution of the movements, the reversibility of the movements, and the pathophysiology underlying each disorder. It is vital that clinicians recognize what type of movement the patient is manifesting because the goal of treatment of drug-induced parkinsonism is to increase dopamine activity, whereas the goal of treatment of TD is to dopamine activity.
Each condition requires its own unique management. Drug-induced parkinsonism is a hypodopaminergic state, while TD is a hyperdopaminergic state. Anticholinergic agents are used for drug-induced parkinsonism because they may increase dopaminergic activity and help reverse the hypodopaminergic state o drug-induced parkinsonism. However, if anticholinergic agents are used in TD, they may further exacerbate the hyperdopaminergic staterather than help it.
Henry Nasrallah, MD
How Are Tremors And Dyskinesia Treated
We treat these two kinds of movements very differently, says Herrington. Dyskinesias are usually a problem of too much dopamine medication , and tremors are sometimes a problem of not quite enough.
Its therefore important for a neurologist to be able to tell the difference between the two symptoms, he says, and to adjust the medications accordingly.
Herrington points out that not all people are similarly bothered by tremors or dyskinesia. Take tremors, for example. There are some people who have a very small tremor and it bothers them immensely, he says. Other people have quite a substantial tremor and really dont seem to care about it very much.
When it comes to treating Parkinsons-related tremors, doctors may start out by asking people how much the symptom bothers them. As a physician, you can categorize which symptoms people have or the level of severity, says Herrington, but its always really important to ask the person what bothers them. The most objectively severe symptom may not be the one that bothers them the most.
As for dyskinesia, some people dont notice it at all, he says. there is often a divergence between how much they notice and are bothered by it and how much their loved ones notice and are bothered by it.
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What Symptoms Occur With Akathisia And Tardive Dyskinesia
Akathisia and tardive dyskinesia can develop within days of starting a causative medication, or the symptoms can begin after you have been taking the medication for months or years.
The symptoms of akathisia and tardive dyskinesia can resemble those of other movement disorders or psychological conditions.
Most people who have akathisia are aware of the symptoms. Sometimes people who have tardive dyskinesia are aware of the symptoms, but they are not as distressing as the symptoms of akathisia.