Tardive disorders

Tardive dyskinesia is a disorder characterized by involuntary choreo-athetoid movements of the face, trunk, or extremities. The syn- 

TD is a complex disorder with mental and emotional effects that are often overlooked by health care providers. In my professional capacity 

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Fatigue to the point of exhaustion almost always accompanies tardive disorders of any severity. Patients often become exhausted by the movements, by the effort to hide them, and by increased difficulty associated with carrying out daily activities. The primary impact on the brain itself may also produce fatigue. Although the disorders tend to disappear in sleep, they can make it difficult to fall asleep, adding to the exhaustion. Having to contend with the physical pain associated with tardive akathisia (inner torment) and with tardive dystonia (muscle spasms) can also wear a person down. 

Chapter 5 will look at impairments to mental functioning that are almost always found in patients with drug-induced tardive disorders. Overall, even a slight or minimal degree of tardive disorder can end up seriously impairing an individual s quality of life. 

The 2003 edition of The American Psychiatric Publishing Textbook of Clinical Psychiatry makes no mention of tardive psychosis or supersensitivity psychosis in the discussion of adverse neuroleptic effects, including in the section Tardive Disorders (Hales et al., 2003). Nor is there any discussion of the many studies on cognitive deficits associated with neuroleptics and in particular with TD. The only mention of tardive psychosis occurs within a discussion of mood disorders with citations to three studies spanning 1991-1993. The 1993 study points to a possible biological mechanism in the death of striatal cholinergic neurons, caused by prolonged exposure to neuroleptics (Miller et al., 1993). 

Olivera AA, Kiefer MW, Manley NK Tardive dyskinesia in psychiarric parienrs with substance abuse disorders. Am J Drug Alcohol Abuse 16 57-66, 1990 Palatini P, Tedeschi L, Prison G, er al Dose-dependent absorption and eliminarion of gamma-hydroxybutyric acid in healthy volunteers. Eur J Clin Pharmacol 45 3 53— 356, 1993... 

Tardive dyskinesia A chronic disorder of the nervous system characterized by involuntary jerky or writhing movements of the face, tongue, jaws, trunk, and limbs, usually developing as a late side effect of prolonged treatment with antipsychotic drugs. 

Patients who have received neuroleptics for long periods of time may develop a hyperkinetic disorder of the extrapyramidal system characterized by involuntary, purposeless movements affecting many parts of the body. This is known as tardive dyskinesia. Most commonly, these are manifested in a syndrome involving abnormal movements of the tongue, mouth and masticatory muscles. There are also choreoathetoid movements of the extremities. The mechanism by which these symptoms develop remains unknown. 

The major adverse effects of first-generation drugs for schizophrenia are involuntary movement disorders. Symptoms include tremor, rigidity, restlessness, and slowness of movement, strongly reminiscent of the movement disorders in parkinsonism, about which more follows later. The worst of these movement disorders is tardive dyskinesia, an irreversible movement disorder. 

Atypical Antipsychotics. The so-called atypical antipsychotics have revolutionized the treatment of schizophrenia and other psychotic disorders since their introduction in the 1990s. Similarly, they are replacing the older antipsychotics in the treatment of BPAD as well. They offer a similar degree of antimanic efficacy without a lessened long-term risk of tardive dyskinesia. For more information regarding the atypical antipsychotics, please refer to Chapter 4 Schizophrenia. 

The occurrence of tardive dyskinesia after treatment with conventional antipsychotics for a long term raises some interesting questions. Remember, dyskinesias are a symptom of HD and other neurological disorders in which there is too much dopamine flowing through the nigrostriatal pathway. How can a dopamine-blocking medication produce symptoms similar to HD ... 

Antipsychotics also have a troublesome side effect burden that includes an often-irreversible movement disorder known as tardive dyskinesia (TD). Other side effects include so-called parkinsonism, dystonic reactions (i.e., abrupt onset of muscle spasms), akathisia (an uncomfortable sense of motoric restlessness), sedation, weight gain, dizziness, dry mouth, and constipation among others. These side effects, in particular the risk for TD, limit the usefulness of antipsychotics in the treatment of ADHD, and at this time the typical antipsychotics cannot be considered a reasonable monotherapy in uncomplicated ADHD. 

There are, of course, risks with long-term use of conventional antipsychotics. The most concerning is an irreversible movement disorder known as tardive dyskinesia. Nevertheless, some particularly fragile patients with BPD may require long-term antipsychotic treatment. If so, atypical antipsychotics are recommended. 

Q80 Tardive dyskinesia is a chronic movement disorder characterised by uncontrolled facial movements. Tardive dyskinesia is associated with the use of trifluoperazine. 

Danysz W, Parsons CG, Mobius HJ, et al (2000) Neuroprotective and symptomatological action of memantine relevant for Alzheimer s disease—an unified glutamatergic hypothesis on the mechanism of action. Neurotox Res 2 85-97 Davis SM, Lees KR, Albers GW, et al (2000) Selfotel in acute ischemic stroke possible neurotoxic effects of an NMDA antagonist. Stroke 31 347-354 DeKeyser J (1991) Excitotoxic mechanisms may be involved in the pathophysiology of tardive dyskinesia. Clin Neuropharmacol 14 562-565 Del Dotto P, Pavese N, Gambaccini G, et al (2001) Intravenous amantadine improves levodopa-induced dyskinesias an acute double-blind placebo-controlled study. Mov Disord 16 515-520... 

Unlabeled Uses Prevention of migraine treatment of behavior disorders in Alzheimer s disease bipolar disorder chorea, myoclonic, simple partial, and tonic-clonic seizures organic brain syndrome schizophrenia status epilepticus tardive dyskinesia... 

Tardive dyskinesia is a potentially irreversible movement disorder characterized by choreoathetoid movements. The possibility of a primary neurological disorder should be considered when a patient being treated with an antipsychotic develops involuntary movements. It should also be noted that patients might develop transient withdrawal dyskinesias as the dosage of neuroleptics is lowered or discontinued (Campbell et ah, 1999). It appears that withdrawal dyskinesias are more common in children than adults. 

The main indications for atypical antipsychotics are the acute and maintenance treatment of schizophrenic disorders, with an emphasis on the treatment of refractory and chronic disorders. However, because of the lower risk of EPS and in particular of tardive dyskinesia, there is a tendency toward a wider range of indications for some of the atypical neuroleptics. Favorable effects in drug-induced psychoses have been demonstrated for olanzapine. Clozapine seems effective in the treatment and relapse prevention of manic episodes and bipolar disorders, and risperidone has been shown to have good efficacy in conduct disorders and in the pervasive developmental disorders. 

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