Sub-syndromes of tardive dyskinesia

Orofacial dyskinesia post resection of pineal gland tumor

We reported a case of a 33-year-old lady who was diagnosed with a Pineal tumor and underwent craniotomy and gross total surgical resection of the mass through a right occipital transtentorial approach. Immediately upon extubation, the patient started to have persistent chewing-like movements typical of orofacial dyskinesia that resulted later in buccal mucosal injury and swelling of the lips. The movements spontaneously resolved after 3 days. The patient was not taking any medications that were known to induce such movements. Literature review showed that one of the possible mechanisms could be that the suddenly reduced melatonin level in the acute postoperative period leads to dysregulation of dopamine secretion in the nigrostriatal and limbic system causing these abnormal movements. To the best of our knowledge, this is the first such reported complication of orofacial dyskinesia post craniotomy for resection of the pineal tumor in humans.

Tardive dyskinesia update: the syndrome

Tardive dyskinesia is a common iatrogenic neurological and neurobehavioural syndrome associated with the use of antidopaminergic medication, especially antipsychotics. Prior to the introduction of the newer antipsychotics in the 1990s, it was one of the major areas of psychiatric research but interest waned as the new drugs were reputed to have a reduced liability to extrapyramidal adverse effects in general, a claim now discredited by numerous pragmatic research studies. Early small-scale short-term prevalence studies were presented as evidence to support the assumption that patients on the newer drugs did indeed have a lower prevalence of tardive dyskinesia but recent large-scale review of studies with patients exposed for longer suggest that things have not changed. This article presents a clinical overview of a complex and varied syndrome in terms of its phenomenology, epidemiology and risk factors; a companion article will consider treatment. This overview aims to highlight tardive dyskinesia once again, especially to practitioners who have trained in an environment where this was considered mainly in historical terms.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

Switching antipsychotic treatment to aripiprazole in psychotic patients with neuroleptic-induced tardive dyskinesia: a 24-week follow-up study

Aripiprazole is a second-generation antipsychotics, acting as a partial dopamine D2 receptor agonist. Previous studies on aripiprazole for tardive dyskinesia (TD) treatment were limited and inconclusive. This study was aimed to examine the effectiveness of aripiprazole in psychotic patients with a pre-existing TD. This was an open-label 24-week prospective cohort study conducted in a public mental hospital in Northern Taiwan from January 2009 to February 2010. Psychotic patients were cross-titrated of prior antipsychotics with aripiprazole, and the severity of TD was assessed at baseline and at weeks 2, 4, 8, 12, 16, 20, and 24. The primary study outcome was the change of TD severity, assessed by Abnormal Involuntary Movement Scale (AIMS) total score. Responder was defined as the reduction of AIMS total scores of no less than 50% from baseline to the study endpoint (24 weeks). Thirty psychotic patients with neuroleptic-induced TD were recruited. The AIMS total scores significantly decreased from baseline to the study endpoint (-7.17±5.55). The significant decrease of AIMS total scores started at week 2 (P<0.0001), and the change remained significant throughout the entire study period (P<0.0001). A greater severity of TD (adjusted odds ratio: 1.35, 95% confidence interval: 1.04-1.76, P=0.03) or a lower severity of parkinsonism (adjusted odds ratio: 0.78, 95% confidence interval: 0.61-0.99, P=0.04) at baseline was significantly associated with treatment responders. Our findings implicated that aripiprazole can be a promising treatment for clinicians considering drug switch in psychotic patients with TD. Further large randomized, controlled trials are warranted to confirm our findings.

Dyskinesia in chronic schizophrenia: an examination of the psychiatric nurse's perspective and its implications for physiotherapy

The emerging biological explanation for dyskinesia in schizophrenia may allow physiotherapists to become involved in their treatment. However, this could be influenced by the views of psychiatric nurses who are major referers to physiotherapy. The aim of this study was to explore nurses' views on the aetiology and management of dyskinesia in schizophrenia. Four out of six nurses (randomly selected from a population of 83) took part in an unstructured group interview. Content analysis of transcripts identified five abnormal movement categories (oro-facial, posture, hand tremors, gait, and head, trunk and limbs) and five aetiological symbols (drugs, abnormal mental state, eclectic, mood, and behaviour). Contingency analysis revealed that drugs were the most consistent aetiological factor in all movement categories. Organic causes were not mentioned. An acknowledgement of these biological explanations by nursing staff may enhance the future development of physiotherapy intervention in mental illness.

Markers of basal ganglia dysfunction and conversion to psychosis: neurocognitive deficits and dyskinesias in the prodromal period

BACKGROUND

Movement abnormalities and cognitive deficits may represent external markers of an underlying neural process linked with the early etiology of psychosis. As basal ganglia function plays a governing role in both movement and cognitive processes, an understanding of the relationship between these phenomena stands to inform etiologic conceptualizations of vulnerability and psychotic disorders.

METHODS

In this investigation, trained raters coded movement abnormalities in videotapes from structured interviews of adolescents and young adults with a prodromal risk syndrome (n = 90). The participants were administered a neuropsychological battery including measures of verbal comprehension, perceptual organization, immediate/delayed auditory memory, and an estimate of full-scale intelligence quotient. Diagnostic status was followed for a 2-year period utilizing structured clinical interviews, during which time 24 high-risk participants (26.66%) converted to an Axis I psychotic disorder.

RESULTS

Elevated dyskinetic movements in the upper-body region were correlated with deficits in domains of verbal comprehension, perceptual organization, and both immediate and delayed auditory memory. Further, discriminant function analyses indicated that baseline movement abnormalities and neurocognitive deficits significantly classified those high-risk participants who would eventually convert to a psychotic disorder (72.3%).

CONCLUSIONS

Results support a common cortico-striato-pallido-thalamic circuit irregularity, underlying both movement abnormalities and cognitive deficits in individuals at high risk for psychosis. Models incorporating external markers of progressive basal ganglia dysfunction may enhance detection and preventive intervention for those high-risk individuals most in need of treatment.

Tardive dyskinesia and DRD3, HTR2A and HTR2C gene polymorphisms in Russian psychiatric inpatients from Siberia

BACKGROUND

Pharmacogenetics of tardive dyskinesia and dopamine D3 (DRD3), serotonin 2A (HTR2A), and 2C (HTR2C) receptors has been examined in various populations, but not in Russians.

PURPOSE

To investigate the association between orofaciolingual (TDof) and limb-truncal dyskinesias (TDlt) and Ser9Gly (DRD3), -1438G>A (HTR2A), and Cys23Ser (HTR2C) polymorphisms in Russian psychiatric inpatients from Tomsk, Siberia.

METHODS

In total, 146 subjects were included. Standard protocols were applied for genotyping. TDof and TDlt were assessed with AIMS items 1-4 and 5-7, respectively. Two-part model, logistic and log-normal regression analyses were applied to assess different variables (e.g., allele-carriership status, age, gender, and medication use).

RESULTS

TDlt, but not TDof, exhibited an association with Ser9Gly and Cys23Ser (with 9Gly and 23Ser alleles exhibiting opposite effects). However, -1438G>A was not associated with TDof and Dlt.

CONCLUSIONS

This is the first pharmacogenetic report on tardive dyskinesia in Russians. Subject to further replication, our findings extend and support the available data.

Clinical rating scales and instruments: how do they compare in assessing abnormal, involuntary movements?

OBJECTIVE

Recent studies have shown that quantitative instrumental measurements are more sensitive than clinical rating scales to subclinical dyskinesia and parkinsonism. We therefore hypothesized that an instrumental assessment would be more sensitive to the presence of dyskinetic and parkinsonian movements than the Abnormal Involuntary Movement Scale (AIMS), the Dyskinesia Identification Scale, Condensed User Version (DISCUS), and the Simpson-Angus Scale (SAS). We also hypothesized that the DISCUS, by virtue of its more detailed protocol, would be more sensitive than the AIMS.

METHOD

Using blinded raters, we compared the clinical rating scales with instrumental measurements in 100 patients referred to a movement disorders clinic. We collected demographic data, risk factors for tardive dyskinesia, current medication use, Axis I and III disorders, and an estimate of cognitive functioning using the Mini-Mental Status Examination.

RESULTS

There was no significant difference between the AIM and the DISCUS in the identification of dyskinesia. However, an instrumental assessment revealed a significantly greater prevalence of dyskinesia. The Mini-Mental Status Examination was the most prominent predictor of both instrumental and clinical measurements of parkinsonian and dyskinetic movements.

CONCLUSIONS

It appears that even trained raters, utilizing standard rating scales, may underestimate the prevalence of some motor abnormalities. Instrumental ratings may be helpful to both the clinician and investigator, particularly when abnormal movements are not clinically obvious. The relationship between cognitive impairment and motor abnormalities remains an important area for further research.

Tardive dyskinesia in a chronically institutionalized population of elderly schizophrenic patients: prevalence and association with cognitive impairment

BACKGROUND

Chronically hospitalized geriatric inpatients with schizophrenia are at particular risk for both tardive dyskinesia (TD) and cognitive impairment but have been insufficiently studied in this regard. Similarly, the relationship between TD and cognitive impairment has not be adequately addressed in this population.

OBJECTIVES

(1) To determine the prevalence of TD in a cohort of chronically institutionalized schizophrenic geriatric inpatients. (2) To examine the relationship between the manifestations of TD in various body regions and several potentially related variables including current pharmacological regimen, age, age at first hospitalization and cognitive status.

METHOD

TD was assessed by the Modified Simpson Dyskinesia Scale and cognitive status by the Mini-Mental State Examination (MMSE). The relationship between manifestations of TD and other variables was examined by t-tests, ANOVA, MANOVA and correlational analysis.

RESULTS

The prevalence of TD was 60%. Prevalence increased with age but was not related to current antipsychotic or anticholinergic regimen. Mean MMSE score did not differ between groups of patients with and without TD as defined by the criteria of Schooler and Kane (1982); however, the mean MMSE score was significantly (p < 0.0004) lower in subjects with orofacial TD as defined by Waddington and Youssef (1996), and the difference was not entirely accounted for by the older age of the latter group.

CONCLUSIONS

TD and cognitive impairment both increase with age. However, TD alone does not account for the severity of cognitive impairment in this population. The present study provides further support for the hypothesis that the correlation between TD and cognitive impairment holds primarily for the orofacial manifestations of TD.

The Maryland Psychiatric Research Center scale and the characterization of involuntary movements

The Maryland Psychiatric Research Center involuntary movement scale (MPRC scale) has been used in the evaluation of 1107 patients referred for drug-induced movement disorders. The scale has increased discrimination of body area and severity compared to other scales. Validity was examined using principal component analyses, pharmacologic response studies and associations with AIMS, global judgement and motor diagnosis. Reliability was examined using Cronbach's alpha, intraclass correlation coefficient (ICC) between raters and test-retest measurements. The prevalence of dyskinetic and parkinsonian signs at several levels of severity are reported. Total dyskinesia was strongly correlated with AIMS score, r = 0.97. Inter-rater reliability was 0.81-0.90 for total dyskinesia score. Receiver Operating Characteristic (ROC) analysis shows a total dyskinesia score of 4 or above to predict tardive dyskinesia, consistent with RDC-TD criteria. Hand dyskinesia showed a high prevalence comparable to that of oral dyskinesias. The MPRC scale is a valid, sensitive and reliable instrument for the rating of neuroleptic-induced dyskinetic and parkinsonian syndromes and may offer advantages over other scales in neurophysiologic research and brain imaging with its ease of use, uniform structure and greater discrimination of anatomic place and severity in the rating of involuntary movements.

Risk factors for orofacial and limbtruncal tardive dyskinesia in older patients: a prospective longitudinal study

Although there is a consensus that orofacial and limbtruncal subtypes of tardive dyskinesia (TD) exist and may represent distinct pathophysiologic entities, few studies have examined the incidence of and risk factors associated with the development of these TD subtypes. Two hundred and sixty-six middle-aged and elderly outpatients with a median duration of 21 days of total lifetime neuroleptic exposure at study entry were evaluated at 1- to 3-month intervals. Using "mild" dyskinesia in any part of the body for diagnosis of TD, the cumulative incidence of orofacial TD was 38.5 and 65.7% after 1 and 2 years, respectively, whereas that of limbtruncal TD was 18.6 and 32.6% after 1 and 2 years. Preclinical dyskinesia was predictive of both orofacial and limbtruncal TD. History of alcohol abuse or dependence was a significant predictor of orofacial TD only whereas tremor was a significant predictor of limbtruncal TD only. Findings support suggestions that orofacial and limbtruncal TD may represent specific subsyndromes with different risk factors.

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.

New findings on tardive dyskinesia in a community sample

In a geographically defined area sample of 141 long-term psychiatric patients in day care in south London, the relationship between tardive dyskinesia (TD) and other aspects of illness, treatment, and social and psychological functioning were studied. The results are compared with previous findings. TD was significantly associated with parkinsonian symptoms and with the number of years in contact with the psychiatric services. There was a trend, in affective disorder only, towards an association with current neuroleptic dose. The patients with affective disorder also had higher rates of TD than patients with schizophrenia and paranoid psychosis. History of treatment with ECT correlated negatively with TD among those with schizophrenia, and positively among those with affective disorder. As in other studies, duration of neuroleptic treatment did not correlate with the presence or absence of TD. In contrast to some previous reports, age and cognitive status were not related to TD status. Possible reasons for this are discussed.

Biological determinants and risk factors for tardive dyskinesia in schizophrenia

Tardive dyskinesia (TD), a neurological side effect of chronic neuroleptic treatment, develops in 20%-30% of psychiatric patients. The biological characteristics that distinguish schizophrenic patients who develop TD from those who fail to develop TD during neuroleptic treatment are currently the subject of intense research. The aim of the present report is to present biological characteristics and risk factors of schizophrenic patients with TD. The findings of the study demonstrate that: (1) the timing of onset of schizophrenia is a biological determinant for the development of severe TD. (2) the mode of onset of schizophrenia and specifically, an insidious onset is a biological risk factor of TD. (3) belligerent behavior may be a risk factor for TD. (4) postmenopausal schizophrenic patients are at increased risk for TD.

Subjective awareness of abnormal involuntary movements in schizophrenia

A wide majority of schizophrenic patients with Tardive dyskinesia, a neurological disorder produced by chronic neuroleptic therapy, lack awareness of their involuntary movements. This by contrast to patients with Parkinsonism who usually are aware of their abnormal movements. In the following communication we present a series of studies which are aimed at providing further insight into the issue of awareness of involuntary movements in schizophrenic patients with tardive dyskinesia. In addition, we investigated whether edentulosness, which may be a risk factor for orofacial dyskinesias in the elderly, is also a risk factor for neuroleptic-induced orofacial dyskinesias. We found that: (a) one's awareness of involuntary movements is related to some but not all muscle groups, (b) tardive dyskinesia may be associated with a significant distress, (c) lack of awareness may be a feature of frontal lobe dysfunction in schizophrenia, (d) patients who lack awareness of their involuntary movements have a higher prevalence of pineal calcification, and (e) edentulosness, which is related to deficits in the orofacial sensorimotor system, increases the risk for neuroleptic-induced orofacial dyskinesias.

Sub-syndromes of tardive dyskinesia and some clinical correlates

Syndromes of dyskinetic movements in subjects (N = 70) with chronic schizophrenia were investigated, using principal components analysis of AIMS ratings. Consonant with previous research, three discrete groupings were found, namely dyskinetic movements of lips-jaw-tongue, limb-truncal and facial movements. These were then related to demographic, psychological and movement disorder variables. The limb-truncal, but neither the lips-jaw-tongue nor facial movements components, were associated with negative symptoms and cognitive impairment.

Akathisia: clinical phenomenology and relationship to tardive dyskinesia

Akathisia and tardive dyskinesia (TD) are disorders of movement that are often associated with administration of antipsychotic medication. We surveyed 196 outpatients in a schizophrenia clinic, all receiving antipsychotic medication, for the presence of these disorders. Clinical global ratings of akathisia were reliable. Akathisia was found in 36% of patients, and TD in 23.5%. Akathisia was disproportionately common in patients receiving high-potency neuroleptics. The data affirmed recent revisions in the dose-equivalence formulas used with fluphenazine decanoate. Akathisia and TD did not seem to be interrelated. Because akathisia is common and often limits medication dose and contributes to noncompliance, psychiatrists must take this into account when prescribing antipsychotic medication.

Risk factors for neuroleptic-induced movement disorders

Chronic neuroleptic therapy may be associated with the development of diverse movement disorders including Tardive dyskinesia (TD), Parkinsonism, dystonia, and akathisia in a subset of schizophrenic patients. It is presently unknown why only a proportion of neuroleptic-treated patients develop these movement disorders. In the following communication, we present a series of studies which demonstrate that the development of these movement disorders may be facilitated by certain risk factors including disturbances in pineal melatonin functions, diabetes mellitus, cognitive deficits, suicidal behavior, and disturbances in the functions of the choroid plexus. Recognition of these biological factors may prove useful in: (a) further understanding of the pathophysiology of these disorders, and (b) identifying patients at risk for these movement disorders.

Computed tomographic evaluation of patients with tardive dyskinesia

X ray computed tomography has been used since its introduction to evaluate patients with tardive dyskinesia (TD). A critical review of the 18 reports which have appeared since 1976 suggests that TD may be associated with neuroanatomical abnormalities. In particular, a meta-analysis of the reports of ventricular brain ratio found a trend for patients with TD to have larger lateral ventricles than unaffected patients. The magnitude of the difference appears to be small, however, and several well conducted studies have reported negative results. A careful analysis revealed that low statistical power, concurrent neuroleptic treatment, insensitive measures of ventricular dilatation, and variable diagnostic criteria for TD may have led to negative findings in most of the investigations. The possible significance of these results and suggestions for further research are discussed.

Neuroradiological covariates of drug-induced parkinsonism and tardive dyskinesia in schizophrenia

Computed tomographic (CT) studies have demonstrated structural brain abnormalities including cortical atrophy and enlarged lateral ventricles in a subset of schizophrenic patients including those with abnormal involuntary movements. In the following series of studies, we present our findings pertaining to neuroradiological covariates of drug-induced Parkinsonism and Tardive dyskinesia in schizophrenic patients. In these studies we have explored the relationship of Parkinsonism and Tardive dyskinesia to pineal and choroid plexus calcification. In addition, we also investigated the relationship of pineal calcification to schizophrenia, and specifically to the paranoid and nonparanoid subgroups. In a further series of studies, we investigated the neuroradiological covariates of disorders of gait and posture as well as tremor in schizophrenic patients with drug-induced Parkinsonism. In addition, we explored the relationship of Tardive dyskinesia and its subsyndromes to CT scan measurements of cortical and subcortical atrophy in schizophrenia. Our findings highlight the significance of the pineal gland in the pathophysiology of schizophrenia and drug-induced movement disorders. Furthermore, these studies underscore the heterogeneity of Parkinsonism and Tardive dyskinesia.

Tardive dyskinesia in Alzheimer's disease: clinical features and neuropathologic correlates

Medical record review was conducted on 14 patients with neuropathologically confirmed Alzheimer's disease, all of whom had been treated with antipsychotic medications, to determine the relationship between neuropathology and the development of tardive dyskinesia. Four cases were found to have chart descriptions of hyperkinetic movement disorders consistent with tardive dyskinesia. When the group with tardive dyskinesia was compared to the group without tardive dyskinesia, there were no statistically significant differences regarding gender, age of onset of dementia, duration of dementia, age at death, or duration of antipsychotic treatment. Neuropathologic comparisons revealed greater degenerative changes in the substantia nigra in those patients with tardive dyskinesia. These preliminary observations suggest that patients with Alzheimer's disease and significant coexisting substantia nigra pathologic changes may be at higher risk for developing tardive dyskinesia when treated with antipsychotic medication.

The relationship of tardive dyskinesia to positive schizophrenia

Investigations aimed at identifying the clinical characteristics that discriminate Tardive dyskinesia (TD) from non-TD patients have yielded disparate findings. A number of studies have suggested that TD may be a feature of negative schizophrenia. In particular, the association of TD with high prevalence of "soft" neurological signs, cognitive deficits, and abnormal brain morphology on CT scan in some patients, have led several investigators to propose that negative schizophrenia may be a risk factor for TD. The neurochemical profile of TD, however, is not consistent with this hypothesis. In the following communication, we present our studies which suggest that TD is specific to and an intergral part of positive schizophrenia. The data suggest that schizophrenic patients with predominant positive symptoms may be at increased risk for the development of TD. In addition, we present evidence linking TD with left cerebral hemispheric dysfunction. By comparison, we provide evidence that negative schizophrenia is related to diencephalic damage, and discuss its relevance to negative schizophrenia and to Parkinsonism. We also provide evidence that negative schizophrenia may be a risk factor for acute drug-induced dystonia. Thus, these findings are consistent with our model that negative schizophrenia is a risk factor for Parkinsonism, whereas positive schizophrenia is related to TD. In analogy with the positive/negative dichotomy of schizophrenia, we propose that TD could be considered a "positive," where Parkinsonism a "negative" movement disorder.

A statistical trial of subclassification for tardive dyskinesia

The authors applied a statistical method to subclassify tardive dyskinesia (TD) in 71 psychiatric patients. Based on two-step statistical procedures and findings reported previously, TD is considered to consist of 2 subgroups: a classical dyskinesic group and a dystonic group. Symptoms manifested in the former group are seen most frequently in the oral region while the latter group, which is usually called tardive dystonia, is manifested by movement disorders in the trunk and extremities, predominantly. Abnormal movements occurring in the facial region characterize a population whose members may belong to either group.

Cognitive dysfunction in schizophrenia followed up over 5 years, and its longitudinal relationship to the emergence of tardive dyskinesia

In this study, 51 chronic schizophrenic in-patients were evaluated for a range of demographic, clinical and medication variables, and followed up over five years. There was no significant overall change in cognitive function in this patient group as a whole, suggesting the absence of active disease at this stage of the illness. The only correlate of individual instances of cognitive deterioration over the study period was the emergence of new cases of tardive buccal-lingual-masticatory but not of limb-truncal dyskinesia, and the greater severity of such movement disorder. A positive family history was also identified prospectively as a predictor of the emergence of tardive dyskinesia in chronic schizophrenia.

The relationship of pineal calcification to subtypes of tardive dyskinesia in bipolar patients

Recent studies have suggested that bipolar patients may be at high risk for developing tardive dyskinesia (TD) if exposed to chronic neuroleptic therapy. It has been suggested that reduced melatonin secretion may favor the development of TD in bipolar and schizoaffective patients. Since pinealectomized rats have been reported to develop increased incidence and severity of abnormal chewing movements, and as depression is associated with reduced melatonin secretion, the increased risk of TD in bipolar patients may be associated with diminished melatonin secretion. Evidence suggestive of an inverse correlation between pineal calcification and reduced melatonin secretion, led me to study the relationship between pineal calcification on CT scan and the severity of axial (truncal) and limb and orofacial dyskinesias in bipolar patients with TD. The incidence of pathologically enlarged pineal calcifications (i.e., greater than 1 cm in diameter) in the bipolar patients was 25 times greater than the reported incidence in the literature among nonpsychiatric patients. In addition, there was a significant difference in scores of axial dyskinesias between patients with pineal calcification of less than 1 cm in diameter compared to those with pineal calcification of greater than 1 cm in diameter (F = 3.24; p = .04, one-way ANOVA). There was no significant association between scores of limb and orofacial dyskinesias and pineal calcification. These findings suggest a meaningful association between the presence of enlarged pineal calcification, and axial dyskinesias in bipolar patients. Further studies using direct plasma melatonin measurements are required to more precisely define the association between TD and melatonin secretion in bipolar patients.

The relationship between ECT responsiveness and subtypes of tardive dyskinesia in bipolar patients

Despite intensive research, the mechanisms of action of electroconvulsive therapy (ECT) remain elusive. In addition, there are no known biological factors predicting ECT responsiveness in bipolar patients. A study was conducted to investigate the relationship between ECT responsiveness and tardive dyskinesia (TD), a common side effect of neuroleptic therapy, and its subtypes (i.e., orofacial and limb-axial dyskinesias) in a group of 18 bipolar patients. There was a significant difference in orofacial dyskinesia scores between ECT responders and non-responders (p less than 0.005), while there was no significant association in scores of limb-axial dyskinesia between ECT responders and non-responders. These findings suggest an association between ECT responsiveness and the presence of orofacial dyskinesias in bipolar patients with TD and add further support to the notion that TD is a heterogeneous disorder comprising at least two subtypes with distinct underlying pathophysiological mechanisms.

Plasma HVA, tardive dyskinesia and psychotic symptoms in long-term drug-free inpatients with schizophrenia

Plasma homovanillic acid (pHVA) levels were measured in 16 chronically ill patients with schizophrenia who also suffered from tardive dyskinesia, and in a group of 14 chronically ill patients with schizophrenia who did not have tardive dyskinesia. All patients were studied following an extensive drug-free period (mean = 32.9 months). Patients with orofacial dyskinesia had significantly lower levels of pHVA than did controls. In patients without tardive dyskinesia, pHVA levels were significantly correlated with both positive and negative symptomatology. In contrast, pHVA levels from patients with tardive dyskinesia bore neither a significant nor a nearly significant relationship to symptomatology. The implications of these findings for dopaminergic models of tardive dyskinesia are discussed.

Pineal calcification and subtypes of tardive dyskinesia

There is evidence that reduced melatonin secretion is associated with the pathophysiology of tardive dyskinesia (TD). To investigate the relationship between melatonin secretion and TD, I evaluated scores of subtypes of TD with CT scan measurements of pineal calcification (PC) size in 77 chronic institutionalized schizophrenic and bipolar patients. There was a significantly greater incidence of pathologically enlarged calcified pineal glands (greater than 1 cm in diameter) in the patients (18.1%) compared to the reported incidence in the literature in nonpsychiatric subjects (1%). In addition, there was a significant association between scores of limb-axial (but not orofacial) dyskinesias and the presence of pathologically enlarged PC (p less than 0.05). These findings support the notion that the pathophysiology of orofacial dyskinesias may be distinct from limb-axial dyskinesias. In addition, since it is possible that a pathologically enlarged calcified pineal gland is associated with reduced melatonin secretion, these findings add further support to implicate decreased melatonin secretion in the pathophysiology of TD. Further studies using direct measurements of plasma melatonin levels are required to define more precisely the relationship between TD and melatonin secretion.

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.

Abnormal involuntary movements

The differential diagnosis of an athetoid arm movement in a 54-year-old lady with a psychiatric history of affective disorder was discussed. Further investigations after the conference yielded a firm diagnosis that unified both physical and mental symptoms.

The significance of subtyping tardive dyskinesia: a study of prevalence and associated factors

The prevalence of tardive dyskinesia (TD) in 137 Nigerian psychiatric patients was 27%. There were no differences in the prevalence rate between patients with affective disorder and those with schizophrenia. There were also no significant differences between the sexes but a trend for the more severe forms of dyskinesia to be commoner in females was noticed. Demographic, clinical and treatment variables were investigated for association with TD and each of its two putative subsyndromes: orofacial and appendicular dyskinesias. Two cases of severe and persistent tardive dystonia, associated with orofacial TD, were seen in two young adults, one with relatively short exposure to neuroleptics. After initial univariate screening, multivariate statistical methods revealed that different factors were associated with each of the two subsyndromes. While length of hospitalization correlated significantly with orofacial dyskinesia, cumulative duration of exposure to high-potency neuroleptics and number of ECTs received were significantly associated with appendicular TD. Neither age nor sex correlated with either of the subsyndromes. The findings confirm and extend previous observations suggesting that these dyskinesias may involve different pathophysiological mechanisms.

Platelet monoamine oxidase activity and tardive dyskinesia

A few studies of chronic psychiatric inpatients have reported an inverse association between platelet monoamine oxidase (MAO) activity level and tardive dyskinesia (TD). In contrast to these earlier findings, we found no significant or consistent association between platelet MAO activity level and TD occurrence when we controlled for other TD predictors in a case-control study of 80 outpatients maintained on neuroleptic medications. We did find, however, that black subjects had significantly lower levels of MAO activity than did whites in an analysis controlling for age, sex, and neuroleptic dose.

Heterogeneity of tardive dyskinesia. A multivariate analysis

To determine whether tardive dyskinesia (TD) is a single abnormal movement syndrome or multiple syndromes involving different anatomical areas, we examined 228 out-patients diagnosed with TD at the Connecticut Mental Health Center in New Haven. Application of factor analysis to the seven anatomical severity scores of the Abnormal Involuntary Movement Scale yielded three statistically independent factors involving abnormal movements primarily of the jaw-tongue, face-lips, and extremities-trunk. Using logistic regression to predict the severity of these factors, we found that the severity of the orofacial scores was positively associated with age, schizoaffective or affective disorder, and living alone, while severity of non-orofacial movement was positively associated with current neuroleptic dose, non-use of psychiatric medication, and living alone. Our findings suggest that orofacial and non-orofacial dyskinetic movements may involve distinct clinical syndromes of TD, each having a different set of prognostic and, possibly, aetiological determinants.

The effect of sodium valproate on tardive dyskinesia--revisited

As a treatment for tardive dyskinesia, sodium valproate was tested in a double-blind placebo-controlled parallel group trial, with 6-week base-line observation period followed by 6 weeks of treatment. Sodium valproate was not found to be an effective treatment for either tardive dyskinesia or drug-induced Parkinsonism, and did not affect mental state or behaviour.

Serum dopamine beta hydroxylase activity and tardive dyskinesia

A case-control study was done to test the effect of serum dopamine-beta-hydroxylase (DBH) activity on tardive dyskinesia (TD) among 85 schizophrenic outpatients treated with neuroleptics. In contrast to the results of several previous studies, we found no significant association between serum DBH activity and the occurrence or severity of TD, controlling for other TD predictors.

Late onset involuntary movements in chronic schizophrenia: relationship of 'tardive' dyskinesia to intellectual impairment and negative symptoms

Intellectual impairment, negative symptoms, and medication history were assessed in chronic schizophrenic patients with and without abnormal involuntary movements (tardive dyskinesia). Patients with involuntary movements had received neither longer nor more intensive treatment with neuroleptics or anticholinergics. However, the presence or absence of involuntary movements was prominently associated with the presence or absence of intellectual impairment/negative symptoms; these features are characteristic of the defect state/type II syndrome of schizophrenia, in which structural abnormalities of the brain may be over-represented. The role of subtle organic changes in conferring vulnerability to the emergence of such involuntary movements should be re-evaluated.

The clinical phenomenon of akathisia

The subjective and motor phenomena of neuroleptic-induced akathisia were studied in two different populations of psychiatric patients. Thirty nine (41%) of 95 patients attending community psychiatric centres and psychiatric day hospitals experienced a compulsion to move about, and 52 (55%) complained of restlessness of the body. Of 842 psychiatric in-patients 159 found to have marked hyperkinesis were divided into three groups; group 1 with motor restlessness, and a subjective desire to move about or marching on the spot (27 patients), group 2 with choreo-athetotic movements and motor restlessness (79 patients) and an indeterminate group 3 (53), bearing more similarities to group 1 than group 2. Motor disturbances associated with akathisia were repeated leg crossing, swinging of one leg, lateral knee movements, sliding of the feet and rapid walking.

Long-term depot maintenance of chronic schizophrenic out-patients: the seven year follow-up of the Medical Research Council fluphenazine/placebo trial. III. Relapse postponement or relapse prevention? The implications for long-term outcome

The relapse and admission histories revealed a positive correlation between number of schizophrenic episodes and time on maintenance medication, probably reflecting severity of illness. Relapse rates after drug discontinuation rose to 45% within 13 months. There were no differences of predictive value between those relapsing on or off medication. The relationship between relapse rates, drug treatment, and social outcome is complex; antipsychotic drugs may postpone relapse, and frequent relapses might inhibit improvement in social performance long after florid symptoms have been controlled by medication.

Comparative neurochemical investigation of tardive dyskinesia and neuroleptic-induced chronic parkinsonism

Cerebrospinal fluid (CSF) homovanillic acid (HVA), cyclic adenosine 3', 5'-monophosphate (cAMP), and serum prolactin were measured in schizophrenic male patients with tardive dyskinesia (TD) and in those exhibiting the symptoms of chronic neuroleptic parkinsonism (P). The patients (nine TD and eight P) were chronic paranoid schizophrenics. Levels of HVA in CSF were found to be significantly higher in the TD group. Normal prolactin levels were observed in both groups and are indicative of tolerance developed in the hypothalamic tuberoinfundibular dopaminergic system.

Diazepam in tardive dyskinesia

Tardive dyskinesia, a syndrome of involuntary motor movements, can be a permanent consequence of the long-term use of antipsychotic drugs. While there is no well-established drug treatment, case reports and the results of a few clinical studies suggest that drugs that facilitate the GABA-ergic system may decrease the abnormal movements. One such class of drugs is the benzodiazepines. We administered diazepam to 13 subjects in a 24-week, crossover design study. Tardive dyskinesia and psychopathology were assessed by blind raters using the Abnormal Involuntary Movement Scale and the Brief Psychiatric Rating Scale (BPRS). The means of all movement measurements improved from the baseline, with orofacial, subtotal, symptom severity, and total reaching significance. However, we were unable to demonstrate a drug effect; the patients improved to a similar degree whether or not they received diazepam. Their psychiatric disorders did not worsen with diazepam administration and, in fact, improved slightly; the activation factor of the BPRS was significantly improved over baseline. Our results suggest that diazepam is not effective in managing the movements of tardive dyskinesia and that behavior modification strategies be investigated to help patients control symptoms.

A comparison of purposeless movements in psychiatric patients treated with antipsychotic drugs, and normal individuals

Oro-facial dyskinesia and purposeless trunk and limb movements were assessed, using a standard videotape rating technique, in 182 psychiatric patients receiving antipsychotic medication, in a second sample of 43 elderly psychiatric patients also receiving antipsychotic drugs, and 85 normal, drug-naive subjects. In both the first patient sample and the group of normal subjects, oro-facial dyskinesia was more common over 50 years of age. Statistical analysis of the data suggested that drug-induced oro-facial dyskinesia has a characteristic pattern of movement distribution significantly different from that of idiopathic oro-facial dyskinesia. The videotapes of the first patient sample and the normal subjects were viewed by a neurologist who assessed and categorised all movements. Purposeless trunk and limb movements were classified as either normal or abnormal. Normal purposeless movements were significantly more common in the drug-naive subjects. The presence of abnormal movements such as choreiform movements, dystonias and stereotypies and mannerisms was limited, almost exclusively, to the patients.

Tardive dyskinesia: a 3-year follow-up study

A prospective study of tardive dyskinesia was carried out to gain information regarding the natural history of the condition and to identify risk factors. Out of an original cohort of 182 psychiatric patients receiving maintenance antipsychotic drugs 99 were available for reassessment after 3 years. In this follow-up group the point prevalence of oro-facial dyskinesia increased from 39% to 47% over the 3-year period. Twenty-two patients developed the disorder, while remission occurred in 14 others. Risk factors predicting the presence of oro-facial dyskinesia at follow-up included being over 50 years of age and the presence of akathisia. There was no convincing association between the duration of antipsychotic drug treatment and the presence or severity of oro-facial dyskinesia. Patients receiving over 1000 mg chlorpromazine equivalents of antipsychotic drug per day were unlikely to have the condition. The amount of purposeless trunk and limb movement present proved to be a relatively stable phenomenon, showing only a slight increase with age and no change over the follow-up period. The implications of these findings are discussed, with particular consideration being given to the effects of loss of patients to follow-up.

Reliability and validity of a tardive dyskinesia videotape rating technique

Ninety-four psychiatric in-patients, receiving regular antipsychotic medication, were videotaped using a standard procedure. The tapes were rated by blind observers using a simple scoring system for the duration of abnormal movements. Using this combined videotape and rating scale assessment technique the re-rating reliability, inter-rater reliability and test-retest reliability were high. In order to demonstrate the validity of the technique the rating scale scores in a sub-sample of 30 patients, were compared with the assessment of three experienced clinicians on the same patients, and AIMs scores. Central (lip, tongue, jaw and neck movements) scores showed close agreement with the clinicians' assessment, suggesting that clinical diagnosis is based principally on the presence and severity of oro-facial dyskinesia. Total rating scale scores were in close accord with total AIMs scores. When the two scales were carried out on the same patients on the same occasion a diagnostic criterion level of 2 or more on the central score produced a tardive dyskinesia prevalence rate identical to that produced by an AIMS criterion level of 2 or more on the global severity rating. The tardive dyskinesia prevalence rate based on the central score criterion level showed an increase with age.

Statistics in question. Assessing methods--many variables

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