Tardive Dyskinesia

TD is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, tongue movements within the mouth. The more classic TD symptoms are lip smacking, puckering and pursing and rapid eye blinking. Less commonly abnormal lower and upper extremity movements may also occur. TD is a serious complication of most drugs used to treat schizophrenia.

The typical antipsychotics refer to the older drugs such as Thorazine released in 1956 as a tranquilizer and as an adjunct during general anesthesia. Others are Haldol and Stelazine.

Haldol and Thorazine are still given intramuscularly for patients who are out of control in psychotic crisis.  The oral tablets are used on a daily basis for maintenance. The problems with these typicals is excessive sedation that I call the zombie effect. Later complications include tardive dyskinesia and pseudo-Parkinson symptoms. TD occurs in 30% of patients usually after months or years of use if stopped immediately.

The atypical antipsychotics began clinical use in the 90s. Seroquel seems to me the most used. Its primary use for is for schizophrenia but gradually they were observed to be good add on drugs for bipolar mania in bipolar I disease with psychosis and in some cases for bipolar I. A major problem is significant weight gain. TD can occur in 20% of patients after months or years of treatment.

I should mention that dopamine receptor antagonists such as Wellbutrin and Reglan can cause TD as all these drugs are phenothiazines. In the case of Reglan the onset can be shortly after initiation for bowel motility.

Get ready for the list of the atypicals. They include by brand name:  Zyprexa, Invega, Seroquel, Risperdal, Saphris, Latuda, Nuplazid, Rexulti, Abilify, Vraylar, Fanapt, Geodon, Aristada, Caplyta, Secuado, and Versacloz. Clozaril another atypical antipsychotic is used when many of the others have not been effective. The reason is its ability to cause agranulocytosis or reduction of circulating white blood cells due to bone marrow failure. Frequent blood tests are required.

I have a personal bias. I don’t believe we need such a vast number of atypical antipsychotics. They are chemically closely related and have the same mechanism of action. A good article about mechanism of action can be found in Can. J Psychiatry. Feb; 47(1)27-38 2002 Feb; 47(1)27—38. The mechanism of action of the typical antipsychotics versus the newer atypical antipsychotics is how tight and long the drugs bind to the dopamine 2 receptors blocking dopamine itself.

There are two FDA approved to treat TD. The two are Austedo (deutetrabenazine) and Valbenazine (Ingrezza). However, the drug trials were on thirty patients for six weeks. 

I am a clinical nephrologist who has struggled with bipolar II for the last 45 years and have had a very satisfying 39 years taking care of some very complicated people. My new avocation after retirement has been to help the public at large and peers better understand mental illness. One day two folks are talking and one has diabetes and the listener asks type I or II? I want to see the day where I can say I have bipolar disease and instead of a strange or embarrassed look the listener asks bipolar I or 2 and are you on lithium?

Lastly for those who want to read a block buster book The Hidden Valley Road: Inside the Mind of an American Family. (2020: Robert Kolker in 2 parts) is non-fiction about a couple with twelve children, six of whom have schizophrenia.

Written by paul