Does tardive dyskinesia exist?

Historical perspectives on tardive dyskinesia

Tardive dyskinesia (TD) is a persistent hyperkinetic movement disorder associated with dopamine receptor blocking agents including antipsychotic medications. Although uncertainty and concern about this drug side effect have vacillated since its initial recognition 60 years ago, recent commercial interest in developing effective treatments has rekindled scientific and clinical interest after a protracted period of neglect. Although substantial research has advanced knowledge of the clinical features and epidemiology of TD, many fundamental questions raised by early investigators remain unresolved. In this paper, we review the early clinical reports that led to the acceptance of TD as an iatrogenic disorder and the lingering controversies that emerged thereafter. Continued research on TD as a serious adverse reaction to treatment may not only enhance patient outcomes and recovery efforts but may also provide insights into both the mechanism of action of antipsychotic drugs and the nosology and pathophysiology of idiopathic psychomotor disorders.

Structural brain changes associated with tardive dyskinesia in schizophrenia

BACKGROUND

The pathological basis of tardive dyskinesia is unknown. Although its clinical features implicate the basal ganglia, imaging studies have not found clear evidence that it is associated with volume changes in these or other brain structures.

AIMS

To determine, using voxel-based structural imaging, whether there are regions of grey matter volume change in people with schizophrenia who also have tardive dyskinesia compared with those without tardive dyskinesia.

METHOD

A total of 81 people with chronic schizophrenia, 32 with tardive dyskinesia and 49 without, were examined using magnetic resonance imaging (MRI) and whole-brain, optimised voxel-based morphometry. A comparison group of 61 healthy controls was also examined.

RESULTS

Compared with those without tardive dyskinesia, patients with tardive dyskinesia showed a pattern of volume reductions in predominantly subcortical regions, including the basal ganglia and the thalamus. Within the basal ganglia, volume reductions were seen in the caudate nucleus, to a lesser extent in the putamen, and only marginally in the globus pallidus. The patients with tardive dyskinesia, but not those without, showed significant volume reductions in the basal ganglia compared with the healthy controls but both groups had smaller volumes than controls in other affected areas.

CONCLUSIONS

The pathological process or processes that underlie the development of tardive dyskinesia are not just neurochemical in nature, but affect brain structure.

Benzodiazepines for neuroleptic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a disfiguring movement disorder, often of the orofacial region, frequently caused by the use of neuroleptic drugs. A wide range of strategies have been used to help manage tardive dyskinesia, and for those who are unable to have their antipsychotic medication stopped or substantially changed, the benzodiazepine group of drugs have been suggested as a useful adjunctive treatment.

OBJECTIVES

To determine the effects of benzodiazepines for neuroleptic-induced tardive dyskinesia in people with schizophrenia or other chronic mental illnesses.

SEARCH STRATEGY

1. Electronic searches. For the update of 2006, we searched The Cochrane Schizophrenia Group Trials Register (November 2005). For the previous two updates (1996, 2002) the review authors searched Biological Abstracts (1982-2002), the Cochrane Schizophrenia Group's Register of trials (February 2002), EMBASE (1980-2002), LILACS (1982-2002), MEDLINE (1966-2002), PsycLIT (1974-2002), SCISEARCH (2002), hand searched references of all included/excluded studies and contacted the first author of each included trial.

SELECTION CRITERIA

We included all randomised clinical studies focusing on people with schizophrenia (or other chronic mental illnesses) and neuroleptic-induced tardive dyskinesia that compared benzodiazepines with placebo or no intervention.

DATA COLLECTION AND ANALYSIS

We independently extracted data from the studies and ensured that they were reliably selected, and quality assessed. For homogenous dichotomous data we calculated random effects, relative risk (RR), 95% confidence intervals (CI) and, where appropriate, numbers needed to treat (NNT) on an intention-to-treat basis. We synthesised continuous data from valid scales by using a weighted mean difference (WMD). For continuous outcomes we preferred endpoint data to change data.

MAIN RESULTS

We identified three trials (total N=56, one additional trial since 2002, n=24). Using benzodiazepines as an adjunctive treatment did not result in any clear changes for a series of tardive dyskinesia medium-term outcomes (n=30, 2 RCTs, RR not improved to clinically important extent 1.08 CI 0.57 to 2.05). One trial (n=24) found end point abnormal movement scores to be better for those receiving adjunct benzodiazepines(WMD AIMS -3.22 CI -4.63 to -1.81 ). Less than 10% in both groups left these studies before completion and none of the studies reported clear adverse effects.

AUTHORS' CONCLUSIONS

One small study reports some preliminary evidence that benzodiazepines may have some effect in neuroleptic induced tardive dyskinesia. Inconclusive results from other studies means routine clinical use is not indicated and these treatments remain experimental.

Clinical correlates of tardive dyskinesia in schizophrenia: baseline data from the CATIE schizophrenia trial

OBJECTIVE

To examine the clinical characteristics of individuals with schizophrenia that develop tardive dyskinesia (TD) associated with antipsychotic treatment.

METHODS

Baseline data on 1460 patients with schizophrenia were collected as part of the Clinical Antipsychotic Trials of Intervention Effectiveness schizophrenia study. Subjects who met Schooler-Kane criteria for probable TD were compared to those without TD. Multiple regression analyses were used to examine the relationship between TD and clinical variables.

RESULTS

212 subjects met the Schooler-Kane criteria for probable TD and 1098 had no history or current evidence of TD. Subjects with TD were older, had a longer duration of receiving antipsychotic medication, and were more likely to have been receiving a conventional antipsychotic and an anticholinergic agent. After controlling for important baseline covariates, diabetes mellitus (DM) and hypertension did not predict TD, whereas substance abuse significantly predicted TD. Differences in cognitive functioning were not significantly different after controlling for baseline covariates. The TD subjects also had higher ratings of psychopathology, EPSE, and akathisia.

CONCLUSION

Our results confirm the established relationships between the presence of TD and age, duration of treatment with antipsychotics, treatment with a conventional antipsychotic, treatment with anticholinergics, the presence of EPS and akathisia, and substance abuse. Subjects with TD had higher ratings of psychopathology as measured by the PANSS. We found no support for DM or hypertension increasing the risk of TD, or for TD being associated with cognitive impairment.

Benzodiazepines for neuroleptic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a potentially disfiguring movement disorder of the orofacial region often caused by the use of neuroleptic drugs. A wide range of strategies have been used to help manage tardive dyskinesia and, for those who are unable to have their antipsychotic medication stopped or substantially changed, the benzodiazepine group of drugs has been suggested as a useful adjunctive treatment.

OBJECTIVES

To determine the effects of benzodiazepines for people with neuroleptic-induced tardive dyskinesia and schizophrenia or other chronic mental illnesses.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-2002), the Cochrane Schizophrenia Group's Register of trials (February 2002), EMBASE (1980-2002), LILACS (1982-2002), MEDLINE (1966-2002), PsycLIT (1974-2002), SCISEARCH (2002), hand searching the references of all identified studies and contacting the first author of each included trial.

SELECTION CRITERIA

All randomised clinical studies focusing on people with both schizophrenia or other chronic mental illnesses and neuroleptic-induced tardive dyskinesia and comparing benzodiazepines with placebo or no intervention.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality assessed and data extracted. Data were excluded where more than 50% of participants in any group were lost to follow up. For binary outcomes a fixed effects risk ratio (RR) and its 95% confidence interval (CI) was calculated. Where possible, the weighted number needed to treat/harm statistic (NNT/H), and its 95% confidence interval (CI), was also calculated. For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were synthesised using a weighted mean difference (WMD). If statistical heterogeneity was found by Mantel-Haenszel chi-square test, random effects models were used.

MAIN RESULTS

Two small trials (total n=32) were included. Using benzodiazepines as adjunctive treatment did not result in any clear changes for a series of tardive dyskinesia medium term outcomes (RR not improved to a clinically important extent 1.08 CI 0.57 to 2.05, n=30, 2 RCTs; RR not improved at all 1.19 CI 0.3 to 5.3, n=30, 2 RCTs; RR deterioration 1.85 CI 0.3 to 10.1, n=30, 2 RCTs). Adverse effects were not reported.

REVIEWER'S CONCLUSIONS

The 2002 update has added almost no extra data. This is clearly not an area of active research. Benzodiazepines may have something to contribute to the care of people with tardive dyskinesia but the use of this group of compounds should be considered experimental. Large definitive studies are indicated.

Angiotensin converting enzyme gene insertion/deletion polymorphism: case-control association studies in schizophrenia, major affective disorder, and tardive dyskinesia and a family-based association study in schizophrenia

Angiotensin converting enzyme (ACE) is a candidate gene for psychiatric disorders. We examined the frequency of a functional insertion/deletion (I/D) polymorphism in the 16th intron of the ACE gene (located on chromosome 17q23) in groups of patients with schizophrenia (n = 104 and 113), major depression (n = 55), and bipolar disorder (n = 87) compared to healthy control subjects (n = 87). There was no evidence for allelic or genotypic association of the polymorphism with any of the disorders or with tardive dyskinesia (TD) in patients with schizophrenia. In a sample of nuclear families (n = 61) made up of one or more patients with schizophrenia recruited with their parents, there was no evidence for biased transmission of ACE I/D alleles. Particularly in the case of schizophrenia, these findings do not support an association of the ACE I/D polymorphism with the phenotypes examined.

Negative symptoms as a risk factor for tardive dyskinesia in schizophrenia

Investigation of the relationships between negative schizophrenic symptoms, abnormal involuntary movements and age in 179 chronic schizophrenic patients confirmed that both orofacial and trunk and limb dyskinesia are associated with negative symptoms, but only orofacial dyskinesia showed a significant increase in prevalence with increasing age. Estimation of the mean age of onset of orofacial dyskinesia from the observed variation in prevalence of orofacial dyskinesia with age indicated that patients having negative symptoms tend to develop orofacial dyskinesia at an earlier age. The estimated mean age of onset was 43.6 years in patients with substantial negative symptoms, and 54.6 years in patients without substantial negative symptoms. These findings support the proposal that the pathological process underlying negative symptoms can contribute to the occurrence of both orofacial and trunk and limb dyskinesia, but, in the case of orofacial dyskinesia, there is a synergistic interaction between the pathological process underlying negative symptoms and age-related neuronal changes.

Striatal binding of 11C-NMSP studied with positron emission tomography in patients with persistent tardive dyskinesia: no evidence for altered dopamine D2 receptor binding

Dopamine D2 receptor binding characteristics were studied by positron emission tomography (PET) using N-11C-methyl spiperone as receptor ligand in patients on longterm treatment with neuroleptic drugs and in control subjects. Eight of the patients had symptoms of tardive dyskinesia whereas three patients did not have any symptoms. Control subjects comprised 5 healthy volunteers and 7 patients with pituitary tumors. All patients had been free of neuroleptic drugs for at least 4 weeks. The time dependent regional radioactivity in the striatum was measured and the receptor binding rate, k3, proportional to receptor number, Bmax and association rate for the receptor was calculated in relation to the cerebellum. The lack in difference in k3 values between TD patients, neuroleptic treated patients without TD and control subjects throws doubt on the hypothesis that changes in striatal D2 dopamine receptor number or binding affinity is an etiological mechanism for persistent TD.

Abnormal involuntary movements and chronic schizophrenic disorders

We hypothesized that chronic schizophrenic patients with abnormal involuntary movements would exhibit specific psychopathological, neurological, and cognitive disturbances at a more severe level than those free of such movements. Twenty-two chronic schizophrenic patients were assessed for abnormal movements, cognitive impairment, psychopathology, and medication history. Unequivocal evidence of movement abnormality on the Abnormal Involuntary Movement Scale divided the subjects into groups with (n = 13) and without (n = 9) involuntary movement anomaly. Age, education, length of illness, depressive symptoms, total symptom ratings, and medication variables did not differ in the two groups. However, the group with involuntary movements had more negative symptomatology, greater impairment on voluntary motor tasks, lower premorbid intelligence, and a trend toward poorer recall on mental status examination. These results demonstrate that schizophrenic patients with abnormal involuntary movements have more severe psychopathology as reflected in certain defect symptoms, more abnormal voluntary movements, and more cognitive impairment than schizophrenic patients without involuntary movements.

Lifetime antipsychotic-drug exposure, dyskinesia and related movement disorders in the developmentally disabled

The relationship between dyskinesia and related movement disorders was examined as a function of cumulative exposure to antipsychotic drugs (APD). Lifetime drug-exposure histories were obtained for 162 developmentally disabled (DD) persons; drug-exposed groups were compared to nondrug-exposed groups. There were no statistically significant relationships between dyskinesia and the amount of lifetime APD exposure, nor between dyskinesia and the number of long-term APDs, mean exposure, peak exposure, recency of exposure, duration of exposure, changes in medication levels, number of drug interruptions, age, gender, cerebral palsy, epilepsy, or IQ. Of the other movement disorders, a positive relationship was noted only between akathisia and long-term APD exposure; the increased prevalence of akathisia persisted beyond four years after APD withdrawal.

Anomalous dominance and persistent tardive dyskinesia

We examined handedness and cerebral hemispheric asymmetries on computed tomography (CT) scan in a sample of schizophrenic patients who were rated also for the presence or absence of persistent tardive dyskinesia (TD). Patients with TD showed a more standard dominance pattern, with dextral hand preference and normal occipital asymmetry. Anomalous dominance was associated with a marked underrepresentation of TD. Stepwise discriminant analyses indicated that the statistical prediction of TD was enhanced by the inclusion of dominance measures. Schizophrenic patients with strong standard dominance patterns may be more susceptible to developing TD, or conversely, anomalous dominance may confer protection against TD.

[Opinion: informed consent and mental capacity in clinical psychiatric practice (a Quebec perspective)]

This paper on informed consent and psychiatry, asks the fundamental question if informed consent doctrine applies or not to psychiatric practice. In a dialectic between systems of thought in psychiatry and law, the author stresses the importance of particular clinical situations which can be addressed or not in terms of application of informed consent doctrine. The purpose of the paper is not to give a final answer but to bring questions and stimulate thought.

Dyskinesia, antipsychotic-drug exposure and risk factors in a developmentally-disabled population

The relation between antipsychotic drug (APD) exposure and the prevalence of dyskinesia (DK) was examined in a large, developmentally-disabled (DD) population. Using qualitative data in a cross-sectional, retrospective design, the drug-exposed group was systematically compared with a non-drug-exposed group, controlling for age and gender. When the population was evaluated with no regard to APD-exposure, age and female gender were significant risk factors, as in many prior studies. When APD-exposure was considered, it proved to be a complex variable dependent on the recency of exposure to APD, and the outcome depended on the method of analysis: when APD-exposure was considered as a binomial variable (yes/no), the relationship between APD and DK was not significant; when APD-exposure was controlled for recency of exposure, however, a significant relationship between APD and DK was demonstrated (p less than 0.01) although the relationship accounted for less than 3% of the variance. Analysis of the relation between DK-prevalence and recency-of-APD-exposure revealed a pattern of diminished prevalence during APD use and increased prevalence during early withdrawal.

Down-regulation of haloperidol-induced striatal dopamine receptor supersensitivity by active analogues of L-prolyl-L-leucyl-glycinamide (PLG)

Tardive dyskinesia, a clinical syndrome, is one of the major side effects of protracted treatment with neuroleptics in schizophrenic patients. Functional supersensitivity of striatal dopamine receptors is believed to contribute to the pathogenesis of schizophrenia and tardive dyskinesia. In a rodent model of neuroleptic-induced dopamine receptor supersensitivity, we investigated the efficacy of structurally modified analogues of PLG to down-regulate the striatal dopamine receptor supersensitivity as determined by alterations in [3H]spiroperidol binding to striatal membranes in vitro. The PLG analogue, L-prolyl-L-leucyl-(+)-thiazolidine-2-carboxamide-HCl, when given at the dose of 10 mg/kg IP for 5 days prior to haloperidol (3 mg/kg IP 21 days) significantly prevented the up-regulation of striatal dopamine receptor supersensitivity, thus demonstrating a prophylactic effect. Two other analogues, L-prolyl-L-leucyl-5-aminomethyltetrazole and L-prolyl-L-leucyl-glycine-dimethylamide at a dose of 10 mg/kg IP when given concurrently with haloperidol for 21 days, suppressed the development of dopamine receptor supersensitivity. None of the analogues tested in the post-haloperidol session reversed the haloperidol-induced increase in the density of striatal dopamine receptors. Active PLG analogues hold promise as potential therapeutic agents for the amelioration of tardive dyskinesia.

The impact of neuroleptic medication on tardive dyskinesia: a meta-analysis of published studies

To quantify the impact of chronic exposure to neuroleptic medication on the occurrence of tardive dyskinesia (TD), we conducted a meta-analysis of data collected from 21 studies published between 1966 and 1985. The observed prevalence of dyskinesia was greater among exposed subjects in all 21 studies; we estimate that, on the average, the occurrence rate was 2.9 times greater in exposed persons than would be expected if they had been unexposed. We estimate that 65 per cent of exposed cases and 51 per cent of all cases in these investigations were caused by long-term neuroleptic exposure. Among adult United States residents in 1980, we estimate that there were approximately 193,000 neuroleptic-induced TD cases of which about 60 per cent occurred in outpatients. We also observed substantial heterogeneity of effect (rate ratio) across studies, however, partially explained, by changes and differences in the rate of dyskinesia, by differences in the frequency of certain effect modifiers, and by differences in diagnostic methods. Methodologic limitations of the studies and their possible effects on our results are discussed.

Predictors of tardive dyskinesia: results of a cross-sectional study in an outpatient population

A cross-sectional study was conducted to identify predictors of tardive dyskinesia (TD) in a group of 180 psychiatric outpatients maintained on neuroleptic medications. The estimated prevalence of this involuntary movement disorder was 33% in the total study population. Using multiple logistic regression, we found that TD was independently related to five factors: being 55 yr of age and older; being male; using depot (injectable) neuroleptics; having 6 or more years of neuroleptic exposure; and having less than 6 months of psychiatric hospitalization. In addition, the effect of depot medication was much greater in white males than it was in other race-sex groups. We observed no other interaction effects between pairs of predictor variables, nor did we find significant independent effects of race, denture use, DSM III diagnosis, current neuroleptic dose and potency, percent time on neuroleptics, and recent use of antiparkinsonian drugs or lithium. This study is serving as a pilot investigation for a large prospective incidence study that has already begun among patients at risk of developing TD in the same source population.

The nullification by diazepam of haloperidol-induced increases in the level of striatal dopamine but not in the activity of glutamic acid decarboxylase

In the therapeutic management of neuroleptic-induced tardive dyskinesia, diazepam, baclofen or gamma-vinyl-gamma-aminobutyric acid have been advocated. It has been postulated, but not proven, that the beneficial effects of these agents in tardive dyskinesia may be mediated by enhancing GABAergic transmission. In this study, it is reported that, during a 3-day withdrawal period following daily administration of 3 mg/kg of haloperidol (i.p.) for 3 weeks, the activity of glutamic acid decarboxylase in the striatum increased from 72.6 +/- 7.8 to 92.5 +/- 10.2 nmol 14CO2/mg protein/hr, and the concentration of dopamine in the striatum increased from 7.87 +/- 0.23 to 8.86 +/- 0.38 micrograms/g wet tissue. Diazepam (5 mg/kg, i.p.), given during the withdrawal period from haloperidol was able to nullify the enhancement in the concentration of dopamine but not in the activity of glutamic acid decarboxylase in the striatum. The results of these studies are interpreted to indicate that the reported beneficial effects of diazepam and GABA-mimetic agents in ameliorating the symptoms of tardive dyskinesia may occur through a mechanism which does not necessarily link transmission involving both dopamine and GABA.

Chemical and structural changes in the brain in patients with movement disorder

Neurochemical indices of dopaminergic function were assessed in basal ganglia of post-mortem brains of control subjects and schizophrenic patients who had been rated in life for the presence of movement disorder and neuroleptic intake. In schizophrenics who had been treated chronically with doses of neuroleptics, concentrations of dopamine D2 receptors were significantly increased above controls, whereas dopamine D1 receptors and dopamine metabolism were unchanged. Increased D2 receptors were also observed in basal ganglia of drug-free patients. Concentrations of dopamine D1 and D2 receptors in schizophrenics with movement disorder. Moreover, no relationship was found between dopamine receptor levels and the severity of movement disorder. Concentrations of the dopamine metabolite homovanillic acid were increased in the putamen and nucleus accumbens in a small number of patients with movement disorder compared with controls or patients without movement disorder. No changes were observed in markers of cholinergic and GABA-containing neurones. The present findings are not consistent with a "dopamine receptor hypersensitivity" concept of movement disorder in schizophrenia.