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Tardive Dyskinesia

Tardive dyskinesia is a movement disorder that can develop if you take an antipsychotic medication and/or other types of medications. It’s typically not reversible, but treatment may help manage the symptoms.

Overview

What is tardive dyskinesia?

Tardive dyskinesia (TD) is a neurological syndrome that involves involuntary (out of your control) movements. Taking antipsychotic (neuroleptic) medications is the main cause of this condition. But other medications can cause it as well.

“Tardive” means delayed or late. “Dyskinesia” refers to involuntary muscle movements. With this condition, there’s typically a delay between when you start a medication and when you develop dyskinesia. Many people take a medication for years before developing the condition. But you can also develop TD after short-term medication use. TD after short-term medication use is more likely to happen to people over 65.

How common is tardive dyskinesia?

Researchers estimate that at least 20% of all people who take first-generation antipsychotic medications develop tardive dyskinesia. There aren’t as many studies on the other medications that can cause the condition, so it’s difficult to estimate how frequently they result in tardive dyskinesia.

Symptoms and Causes

What are the symptoms of tardive dyskinesia?

Tardive dyskinesia causes involuntary movements of your:

Facial muscles.

Tongue.

Neck.

Trunk muscles.

Limbs.

Facial involuntary movements may include:

Lip-smacking or making sucking motions with your mouth.

Grimacing or frowning.

Sticking your tongue out or against the inside of your cheek.

Chewing movements.

Puffing your cheeks.

Rapid eye blinking (blepharospasm).

Other involuntary movements may include:

Making repetitive finger movements like you’re playing the piano.

Thrusting or rocking your pelvis.

Walking with a duck-like gait.

Inability to remain physically still (akathisia).

These symptoms can range from mild and barely noticeable to severe.

Healthcare providers may describe these symptoms as:

Dystonia (uncontrollable muscle contractions).

Myoclonus (brief, sudden muscle movement).

Buccolingual stereotypy (repetitive movements of your mouth).

Tics (habitual contractions of your muscles, often in your face).

What causes tardive dyskinesia?

Researchers don’t know the exact cause of tardive dyskinesia. But the main theory is that it can develop due to the use of dopamine receptor-blocking medications (dopamine antagonists). This includes short-term and long-term use of the medications, though it’s more likely to develop after long-term use. TD can also happen after discontinuation of, a change in or reduction in medications.

Dopamine antagonists block dopamine for a long time. This may make the dopamine receptors in your brain extra sensitive, especially in your basal ganglia (a part of your brain that helps control movement). Excess dopamine (a neurotransmitter) — or extra sensitive receptors — leads to involuntary movements.

In addition to dopamine, other neurotransmitter receptors may be involved in the condition, including serotonin, acetylcholine and GABA. This may explain why medications other than antipsychotics can occasionally lead to tardive dyskinesia.

What drugs cause tardive dyskinesia?

Tardive dyskinesia can develop due to exposure to the following medications:

Antipsychotic medications (neuroleptics).

Metoclopramide or other anti-nausea medications.

Certain antidepressants.

In rare cases, TD may also develop due to other medications:

Lithium.

Antiseizure medications.

Antihistamines, specifically hydroxyzine.

Antimalarials.

Antipsychotic medications and TD

Antipsychotic medications (neuroleptics) mainly treat psychosis-related conditions, like schizophrenia. These medications are the most common cause of tardive dyskinesia.

First-generation (“typical”) antipsychotics are considered more likely to cause tardive dyskinesia than second-generation (“atypical”) antipsychotics.

Examples of first-generation antipsychotics include:

Chlorpromazine.

Fluphenazine.

Haloperidol.

Perphenazine.

Prochlorperazine.

Thioridazine.

Trifluoperazine.

Metoclopramide and tardive dyskinesia

Metoclopramide is a medication that can relieve GERD (chronic acid reflux). It can also help treat diabetes-related gastroparesis.

Metoclopramide is strongly linked to TD. Risk factors for developing metoclopramide-induced TD include:

Being 65 or older.

Being female.

Having diabetes.

Taking metoclopramide for 12 or more weeks.

Antidepressants and TD

Antidepressants help treat depression and other conditions like anxiety and obsessive-compulsive disorder. Antidepressant-induced TD is more likely to affect people over 65 due to age-related brain changes. In general, this is much more rare than TD due to antipsychotic medications. The following antidepressants are associated with TD:

Trazodone, which is a serotonin modulator.

Amitriptyline, clomipramine and doxepin, which are tricyclic antidepressants.

Fluoxetine and sertraline, which are SSRIs.

Phenelzine and rasagiline, which are MAOIs.

Selegiline (an MAOI) is associated with TD when you use it in combination with levodopa.

Lithium and TD

Lithium, a medication that helps treat bipolar disorder, is linked to TD. But your risk of developing TD is much higher if you take lithium in combination with an antipsychotic medication.

Antiseizure medications and TD

Antiseizure medications help treat and prevent seizures. Carbamazepine and lamotrigine are associated with TD, but it’s rare for them to cause it. Phenytoin is also associated with TD.

Antihistamines and TD

Antihistamines help treat allergy symptoms. Hydroxyzine in particular is associated with TD after prolonged use.

People over the age of 65 with previous exposure to phenothiazines (typical antipsychotics) have a higher likelihood of developing TD after taking hydroxyzine.

Antimalarials and TD

Antimalarials treat or prevent malaria. Chloroquine and amodiaquine are associated with TD.

What are the risk factors for tardive dyskinesia?

Certain factors may increase your risk of developing tardive dyskinesia, including:

Age: People over 40 are more likely to develop TD. Those over 65 are especially at risk due to age-related neurological changes.

Sex: Females are more likely to develop TD. Those in post-menopause have rates of TD as high as 30% after almost a year of exposure to antipsychotic medications.

Race: Studies show that Black Americans are more likely to develop TD than white Americans. And people of Filipino and Asian descent have a lower risk of developing TD than people of Caucasian descent.

Bipolar disorder: People with bipolar disorder who take antipsychotic medications are more sensitive to developing TD compared to other people taking the same medications.

Researchers are currently studying genetic factors that may increase or decrease your chance of developing TD.

What are the complications of tardive dyskinesia?

The uncontrollable movements of tardive dyskinesia can be uncomfortable and affect your social and emotional well-being. This can significantly impact your mental health. It can also make it difficult to do everyday tasks.

TD generally isn’t fatal. But severe TD that affects your larynx (laryngospasm) and diaphragm can very rarely cause breathing issues that can be life-threatening.

Diagnosis and Tests

How is tardive dyskinesia diagnosed?

Your healthcare provider will ask about your symptoms, medical history and medication history. If you take a medication that’s known to cause tardive dyskinesia, your provider will likely suspect TD. They’ll also do a physical exam and a neurological exam. They may refer you to a specialist, like a neurologist, movement disorder specialist or psychiatrist.

Healthcare providers refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose tardive dyskinesia. It states that symptoms of TD must last for at least one month after stopping the medication to get a diagnosis of the condition. You must have been on the medication for at least three months if you’re 40 or younger or one month if you’re over 40.

Your provider may recommend other tests to confirm TD or rule out other conditions with similar symptoms, like Huntington’s disease. These may include laboratory tests and imaging tests, like a brain CT scan and/or MRI. But TD is typically a clinical diagnosis. This means that providers make the diagnosis after obtaining an accurate medical history and detailed physical exam without any additional testing.

Management and Treatment

What is the treatment for tardive dyskinesia?

Studies on the management of tardive dyskinesia are inconsistent. Some studies show an improvement when you decrease the dose or stop taking the antipsychotic medication. Other studies show no change.

Your provider may recommend stopping the medication causing TD, if possible. Unfortunately, this approach isn’t always feasible, as it can worsen the underlying condition it’s meant to treat.

If you develop TD while taking a first-generation antipsychotic medication, your provider may switch you to a second-generation antipsychotic medication.

Other than stopping or switching antipsychotic medication, the strongest current evidence for TD treatment is the use of the VMAT inhibitors, deutetrabenazine and valbenazine. These medications have now been proven to be safe and effective. Your provider may recommend these medications if you have moderate to severe TD that’s affecting your quality of life.

Is tardive dyskinesia reversible?

Unfortunately, most cases of tardive dyskinesia are chronic (long-term). While medication may help manage the condition, it can’t cure or reverse it.

Outlook

What can I expect if I have tardive dyskinesia?

Tardive dyskinesia affects everyone differently. The symptoms can range from mild to severe. In addition, treatment helps manage the symptoms for some but not for others. Your healthcare provider will work with you to find the best treatment plan. They’ll be able to give you a better idea of what to expect.

Does Tardive Dyskinesia Go Away?

Usually, tardive dyskinesia is a long-term medical condition. But your TD symptoms can go into remission, meaning your symptoms can go away. If you're taking an antipsychotic or antiemetic medication, watch for TD signs.

Tell your doctor right away if you notice any uncontrolled movements. Early diagnosis gives you the best chance for treatment and remission. Your doctor can help you decide on the best treatment option.

Prevention

Is tardive dyskinesia preventable?

Tardive dyskinesia is unpredictable. Not everyone who takes certain medications develops it.

If you have risk factors that make you more prone to this condition, talk to your healthcare provider. You may be able to prevent tardive dyskinesia by taking a different medication. To lower your risk of developing TD, your provider will prescribe the lowest effective dose of an antipsychotic medication for the shortest period possible.

If you have to take a medication known to cause TD, talk to your provider about routine screenings of movement symptoms. Recognizing the symptoms of TD early can help lessen their severity. It’s best to get these screenings every three to six months after starting a medication that can cause TD.

Living With TD

How can I take care of myself if I have tardive dyskinesia?

Your healthcare provider will work with you to adjust your treatment plan as needed. Other steps you can take to manage TD include:

Making sure you have a routine symptom assessment by your provider every three to six months.

Keeping track of your symptoms and letting your provider know if you develop new ones.

Practicing self-care that includes physical activity. Exercise can help relieve some movement symptoms.

Talking to your provider about your daily functioning and quality of life

Seeking help from a mental health professional if TD is affecting your mental and social health.

When should I go to the ER?

If tardive dyskinesia is making it difficult to breathe, call 911 or go to the nearest emergency room as soon as possible.

Tardive Dyskinesia FAQ's

How to reverse tardive dyskinesia

Although potentially permanent, you can do some things to help prevent or lower your chances for tardive dyskinesia. Monitor your symptoms for early diagnosis. Watch out for any uncontrollable movements and tell your doctor right away. Your doctor can help identify the cause of your TD symptoms. With treatment, TD symptoms can go into remission (a period without symptoms).

Is tardive dyskinesia permanent?

Tardive dyskinesia is potentially a permanent condition. But early diagnosis and treatment can mean remission. Remission is when your TD symptoms go away or lessen. Your doctor can help you decide on the best treatment for your TD.

What kind of doctor treats tardive dyskinesia?

Most movement disorder specialists are doctors who treat brain problems. This can include a neurologist (a doctor who treats your brain, spinal cord, and nerves) or a psychiatrist (who specializes in mental health).

One Final Note..

Tardive dyskinesia (TD) affects everyone differently. For some, it can significantly affect their quality of life. Know that your healthcare provider will be by your side to monitor and manage TD. They can recommend and adapt treatment plans to fit your needs and suggest self-care strategies that can help.

Other Tardive Syndromes

Tardive akathisia: A state of mental agitation that causes an inner sense of restlessness with an inability to sit still, typically in the trunk or legs. It presents as body rocking movements, shifting weight from one foot to another, marching in place, and/or continual crossing and uncrossing of the legs. Sometimes it is associated with moaning or repetitive touching movements. It is one of the most disabling and difficult to treat tardive syndromes. (Founder’s comment: Akathisia can also cause a debilitating inner terror and a feeling as if the person is on fire or their blood is boiling, with or without visible outer symptoms.

Tardive chorea: Random, jerking movements that flow from one body region to the next, in an unpredictable manner.

Tardive dystonia: Usually presents as eye twitching, oral and jaw muscle contractions, repetitive muscle contractions that cause neck extension, trunk hyperextension, arm hyperextension and wrist flexion. It can sometimes be severe enough to cause life-threatening swallowing difficulties.

Tardive gait: Tripping and shuffling movements of the feet with difficulty standing and moving from one place to the other.

Tardive ocular deviations: Spasmodic movements of the eyes with deviation in the upward direction that last for several seconds or minutes.

Tardive myoclonus: Often presents as a brief, jerk-like muscle contraction in the upper extremities, usually in the arms and shoulders.

Tardive sensory syndrome (tardive pain): A chronic burning sensation usually limited to the mouth and/or genitalia.

Tardive parkinsonism: Parkinsonism that persists after discontinuation from dopamine receptor blocking agents (DRBAs), with a normal SPECT scan. Other than the history of DRBAs use and the presence of other tardive syndromes, there are no other features that separate it from other causes of parkinsonism. Considered very rare.

Tardive tics (tardive Tourette’s): Sudden, brief, sporadic involuntary movements or sounds.

Tardive tremor: A tremor that occurs while at complete rest or with voluntary action. It may affect any part of the body, but most often affects the arms and hands.

Copulatory dyskinesia: Thrusting movements of the trunk and pelvis.

Esophageal dyskinesia: It can lead to asphyxiation of food and is potentially life-threatening.

Rabbit syndrome: Fine, rhythmic actions at rest, that mimic the chewing actions of a rabbit. The tongue is usually not involved.

Respiratory dyskinesia: The respiratory pattern is affected. It causes irregular inhalation and exhalation during breathing. This leads to hyperventilation and hypoventilation, at different times. It can also lead to aspiration pneumonia.

Stereotypy: Seeming purposeful, repetitive (rather than random) and coordinated movements that can appear like rituals. Though they seem purposeful, they are involuntary. Examples include the “piano-playing fingers” and “hand clasping” sometimes seen in TD.

Withdrawal emergent syndrome: Occurs in patients rapidly withdrawn from DRBAs. The movements usually mainly involve the neck, trunk and limbs. The oral-buccal-lingual muscles are rarely involved. It is usually time-limited to four to eight weeks, but when it persists more than eight weeks it is considered tardive dyskinesia. The slow tapering of DRBAs reduces the risk of this syndrome.

A look at the big picture

Tardive dyskinesia affects an estimated 500,000 persons in the United States. About 60% to 70% of cases are mild, and about 3% are extremely severe. Particularly at risk are patients who have been treated for schizophrenia, schizoaffective disorder, or bipolar disorder. Persistent and irreversible tardive dyskinesia is most likely to develop in older persons.

Significance questioned

Tardive dyskinesia’s relative significance as a clinical problem and the need for treatment have been questioned since the disorder was first recognized, according to Stanley N. Caroff, MD, Perelman School of Medicine, University of Pennsylvania, in a recent article in Neuropsychiatric Disease and Treatment. Tardive dyskinesia had been thought to be uncommon and restricted to patients with chronic mental illness, but recent evidence has shown that anyone exposed to dopamine-receptor blocking drugs, not just persons with chronic mental illness, may be at risk.

Some key statistics:

The cumulative incidence is about 4% to 5% annually; the prevalence rate is 20% to 30%.

Younger patients are at risk and may be particularly susceptible to more generalized and dystonic movements, but older age is a major risk factor.

The annual incidence in patients older than 45 years is 15% to 30% after 1 year of treatment; the prevalence rate is about 50% to 60%.

Tardive dyskinesia has been linked with female gender, race, higher ratings of negative symptoms and thought disorder, greater cognitive impairments, acute drug-induced movement disorders, substance abuse, and diabetes.

Older adults and patients with schizophrenia may be at greatest risk, but patients with mood disorders are at risk and have been considered to be at high risk.

Regardless of diagnosis, tardive dyskinesia is not rare and anyone exposed to treatment with antipsychotics is at risk.

First- vs second-generation antipsychotics

A 6- to 12-fold reduction in tardive dyskinesia risk was found with newer second-generation antipsychotics (SGAs) compared with haloperidol.

The relative risk of tardive dyskinesia with SGAs is significantly less on average than that with older first-generation antipsychotics. The risk associated with clozapine is probably least.

The SGAs retain some risk. No currently available antipsychotic is risk-free.

Additional risk factors for the development and persistence of tardive dyskinesia are longer duration of antipsychotic treatment and greater cumulative drug doses.

Objective severity and functional impact

The conventional wisdom that tardive dyskinesia is unimportant may be the result of patient selection bias or the lack of rigorous investigations, Dr Caroff noted. In the early reports of older patients with chronic illnesses showing indifference, up to two-thirds seemed unaware of tardive dyskinesia movements. However, in a recent survey of outpatients with possible tardive dyskinesia, 70% to 80% were aware of their movements and 50% to 60% felt self-conscious or embarrassed by them.

As clinicians assess the seriousness of tardive dyskinesia and the need for treatment, they should consider the objective severity of the movements and the functional impact on patients, Dr Caroff suggested.

He added that correlations between tardive dyskinesia and impaired cognition, poor response to treatment, risk of relapse, and other factors are confounded by the effect of the underlying psychiatric illness-patients with severe psychoses and poor prognoses receive higher doses of antipsychotics for longer periods with poor adherence, resulting secondarily in a greater incidence of tardive dyskinesia.

Adverse effects on quality of life

RealâWorld Evaluation Screening Study and Registry of Dyskinesia in Patients Taking Antipsychotic Agents (RE-KINECT) study data showed the following effects of involuntary movements on patient health-related quality of life (HRQoL):

Close to 30% of patients who had possible tardive dyskinesia reported moderate-to-extreme problems in performing their usual activities (eg, work, housework, and leisure activities) compared with just under 20% of patients who did not.

Almost half of patients who had possible tardive dyskinesia experienced moderate-to-extreme anxiety or depression compared with just under 40% of patients who did not.

Just more than 20% of patients who had possible tardive dyskinesia reported moderate-to-extreme mobility problems compared with about 12% of patients who did not.

Utility scores in a regression model showed poorer perceived QoL in patients who had possible tardive dyskinesia and reported “a lot” of severity or “a lot” of impact on daily activities compared with patients who did not.

“The RE-KINECT study provides valuable insights into the real-world and personal impact the involuntary movements from possible tardive dyskinesia may have on the everyday life of a patient,” said Dr Caroff. “The findings from RE-KINECT are valuable for informing treatment decisions in clinical practice and demonstrate the importance of including assessments from patients and caregivers on the severity and social impact of the stigmatizing movements of tardive dyskinesia.”

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Most recent revision July 12, 2025 08:38:14 AM

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