Tardive dyskinesia and tardive dystonia are movement disorders caused by long-term use of medications that block dopamine receptors, mainly antipsychotics and some anti-nausea medicines. “Tardive” means late: the movements appear after months or years of treatment and can persist after the medication is stopped. In tardive dyskinesia the movements are repetitive, especially of the mouth, tongue and face. In tardive dystonia they are sustained twisting postures, typically the neck pulled backward and the trunk arched.
Severe tardive syndromes that do not improve with medication changes respond very well to pallidal deep brain stimulation. A meta-analysis of 117 patients found a 76% improvement on the dystonia rating scale and 62% on the abnormal involuntary movement scale.[1] In a double-blind study, every patient improved by 44% to 75% at six months.[2]
Tardive dyskinesia vs tardive dystonia
| Tardive dyskinesia | Tardive dystonia | |
|---|---|---|
| Type of movement | Repetitive, rhythmic, choreic | Sustained, twisting, posturing |
| Typical body parts | Lips, tongue, jaw, face, fingers | Neck (often pulled back), trunk, arms |
| Typical picture | Lip smacking, chewing, tongue thrusting | Retrocollis, trunk arching, arm twisting |
| Pain | Less common | Common |
| DBS response | Good | Very good |
Many patients have both. Doctors then speak of a tardive syndrome.
What causes tardive syndromes?
Dopamine-receptor-blocking medications are prescribed for schizophrenia, bipolar disorder and depression, and some are used for nausea and stomach problems. Long-term use can change how the brain’s movement circuits respond to dopamine. The risk rises with longer treatment and older age. Patients should never stop psychiatric medication on their own; any change is planned with the treating psychiatrist.
How are tardive dystonia and tardive dyskinesia treated?
- Review of the medication with the psychiatrist: lowering the dose or switching to an agent with lower risk, if the psychiatric condition allows.
- Medications for tardive dyskinesia, some of which are specifically approved for this condition in several countries.
- Botulinum toxin for focal tardive dystonia, for example of the neck.
- Pallidal deep brain stimulation for severe, disabling tardive syndromes that persist despite these steps. See DBS for tardive dystonia.
Why is DBS so effective in tardive dystonia?
Unlike dystonia caused by brain injury, tardive dystonia occurs in a structurally normal brain, so the stimulated circuits are intact. The results resemble those in primary dystonia. In the meta-analysis by Macerollo and Deuschl, 109 of the 117 patients received GPi stimulation, mean follow-up was about two years, and the improvement averaged 76% on the dystonia scale.[1] The authors concluded that DBS appears beneficial and relatively safe and may be considered for severe, medication-resistant cases.
Psychiatric stability comes first. Patients with tardive syndromes have an underlying psychiatric condition. Before DBS we coordinate with the treating psychiatrist and our own psychiatric team to make sure the condition is stable and the patient can take part in follow-up.
Frequently asked questions
Is tardive dyskinesia permanent?
It can improve, especially when found early and the medication is adjusted, but in many patients it persists. Severe persistent cases can be treated with DBS.
Can DBS help tardive dyskinesia?
Do I need to stop my psychiatric medication before DBS?
No. Many patients continue their psychiatric treatment. Any change is decided with the psychiatrist.
Sources
- Macerollo A, Deuschl G. Deep brain stimulation for tardive syndromes: systematic review and meta-analysis. J Neurol Sci. 2018;389:55–60. doi:10.1016/j.jns.2018.02.013 Source
- Damier P, Thobois S, Witjas T, et al. Bilateral deep brain stimulation of the globus pallidus to treat tardive dyskinesia. Arch Gen Psychiatry. 2007;64(2):170–176. Source