Do you find yourself moving your body involuntarily? Let's talk about Tardive Dyskinesia!

Do you sometimes feel like parts of your body, like an arm or a leg, or facial expressions, just move uncontrollably? Or has someone you know developed these strange symptoms after taking certain medications? If you've heard of such a thing, then the condition we're going to talk about today, called Tardive Dyskinesia, will be important to you. Although it's a bit of a long word, let's simply understand what it is.

What is Tardive Dyskinesia?

Simply put, Tardive Dyskinesia (TD) is a neurological syndrome, or collection of symptoms, in which your body's muscles move involuntarily, without your control. Like a hand twitching or a facial expression changing suddenly.

The main cause of this condition is the long-term use of certain medications for mental illness, especially first-generation antipsychotic medications (neuroleptics). However, these medications are not the only ones that can cause this. Some other medications can also cause this.

The word "Tardive" means "delayed" or "late." "Dyskinesia" means involuntary, that is, uncontrolled muscle movements. So in this condition, these involuntary movements appear after you start taking a medication for a while, sometimes years. However, sometimes this condition can occur even after taking the medication for a short time. This condition is especially likely to occur in people over the age of 65, even with short-term use of the medication.

How common is this situation?

Researchers say that at least 20% of people taking first-generation antipsychotics develop tardive dyskinesia. The exact incidence of this condition with other types of drugs has not been studied, so it is difficult to give an exact figure.

What are the symptoms of Tardive Dyskinesia?

Tardive dyskinesia can cause movements in places like these that you can't control:

• The muscles in your face
• Tongue
• Neck
• Trunk muscles
• Hands and feet

Involuntary movements of the face:

• Lip-smacking or sucking motions.
• Grimacing or frowning for no reason.
• Sticking out the tongue or pressing the tongue into the cheek.
• Chewing movements.
• Puffing cheeks.
• Rapid eye blinking / blepharospasm. Imagine how annoying it would be if you just kept blinking your eyes.

Other involuntary movements:

• Repetitive finger movements, like playing a piano.
• Thrusting or rocking your pelvis.
• Walking with a duck-like gait.
• The inability to sit still, a constant feeling of restlessness (akathisia). This can be a very uncomfortable experience.

These symptoms may be very mild and barely noticeable for some people, but for others they can be so severe that they can affect daily activities to the point of being impossible .

Doctors may use words like these to describe these symptoms:

• Dystonia: Uncontrolled muscle contractions.
• Myoclonus: A sudden, brief jerking of a muscle.
• Buccolingual stereotypy: Repetitive movements involving the mouth and tongue.
• Tics: Habitual muscle contractions, especially in the face.

What are the causes of Tardive Dyskinesia?

Researchers don't know exactly what causes this. However, the main idea is that it may be caused by the use of drugs called ``dopamine antagonists`` that block the receptors for the neurotransmitter ``dopamine`` in the brain. This can happen whether you take these drugs for a short time or for a long time. However, the risk is higher when you take them for a long time. Sometimes, TD can occur after stopping these drugs, changing the dose, or even reducing it.

Imagine, when you take dopamine receptor blocking drugs for a long time, the dopamine receptors in the brain (especially those in the basal ganglia, a part of the brain that helps control movement) become extra sensitive. It is thought that this uncontrolled movement is caused by too much dopamine or the receptors becoming overly sensitive.

In addition to dopamine, other neurotransmitter receptors, such as serotonin, acetylcholine, and GABA, are also thought to be involved. This may be why TD is sometimes caused by medications other than antipsychotics.

What medications cause Tardive Dyskinesia?

Tardive dyskinesia can be caused by the use of the following medications:

• Antipsychotic medications / neuroleptics: These are the main cause.
• Metoclopramide or other anti-nausea medication.
• Some antidepressants .

Very rarely, these medications can also cause TD:

• Lithium.
• Antiseizure medications.
• Antihistamines, especially hydroxyzine.
• Antimalarials are medicines given for malaria.

Antipsychotic medications and TD

Antipsychotic drugs (neuroleptics) are mainly used to treat mental illnesses such as schizophrenia. These drugs are the most common cause of TD.

First-generation ("typical") antipsychotics are thought to have a higher risk of causing TD than second-generation ("atypical") antipsychotics.

Some examples of first-generation antipsychotics:

• Chlorpromazine `(Chlorpromazine)`
• Fluphenazine `(Fluphenazine)`
• Haloperidol `(Haloperidol)`
• Perphenazine `(Perphenazine)`
• Prochlorperazine `(Prochlorperazine)`
• Thioridazine `(Thioridazine)`
• Trifluoperazine `(Trifluoperazine)`

Metoclopramide and tardive dyskinesia

Metoclopramide is a medication that is used to treat chronic acid reflux (GERD), a severe form of gastritis. It is also used to treat diabetes-related gastroparesis.

There is a strong association between metoclopramide and TD. Risk factors for developing TD due to this medication include:

• Being 65 years of age or older.
• Being a woman.
• Having diabetes.
• Taking metoclopramide for 12 weeks or more.

Antidepressants and TD

Antidepressants are used to treat conditions such as depression, anxiety, and obsessive-compulsive disorder. These medications are most likely to cause TD in people over the age of 65. This is because the brain changes with age. This is usually much less common than the TD caused by antipsychotic medications.

The following antidepressants are related to `(TD)`:

• Trazodone (this is a serotonin modulator).
• Amitriptyline, clomipramine, and doxepin (these are tricyclic antidepressants).
• Fluoxetine and sertraline (these are SSRIs).
• Phenelzine and rasagiline (these are MAOIs).
• Selegiline (also an MAOI) has been linked to TD when taken with levodopa.

Lithium and TD

Lithium is a medication used to treat bipolar disorder. It is also linked to TD. However, if you take lithium along with an antipsychotic medication, your risk of developing TD is much higher.

Antiseizure medications and TD

Antiseizure medications are used to prevent and control seizures. Carbamazepine and lamotrigine are associated with TD, but they are less likely to cause TD. Phenytoin has also been linked to TD.

Antihistamines and TD

Antihistamines help with allergy symptoms. Hydroxyzine, in particular, has been linked to TD if used long-term.

People over the age of 65 who have previously used phenothiazines (typical antipsychotics) are more likely to develop TD when taking hydroxyzine.

Antimalarials and TD

Antimalarials such as chloroquine and amodiaquine are related to TD.

What are the risk factors for Tardive Dyskinesia?

Certain factors may increase your risk of developing tardive dyskinesia. Some of them include:

• Age: People over the age of 40 are more likely to develop TD. People over the age of 65 are especially at risk due to changes in the nervous system that occur with age.
• Gender: Women are more likely to develop TD. Post-menopausal women who take antipsychotic medications for about a year have a 30% higher risk of developing TD.
• Race: Some studies have shown that black Americans are more likely to develop TD than whites. Also, people of Filipino and Asian descent are less likely to develop TD than those of Caucasian descent. (Further local studies are needed to determine how this applies to Sri Lanka.)
• Bipolar disorder: People with bipolar disorder may be more sensitive to TD than others when taking antipsychotic medications.

Researchers are also currently studying genetic factors that increase or decrease the risk of developing TD.

What are the possible complications of Tardive Dyskinesia?

The uncontrolled movements caused by tardive dyskinesia can be very uncomfortable. It can also affect your social and emotional well-being. This can have a major impact on your mental health. It can also make it difficult to carry out everyday tasks.

TD is not usually a fatal condition. However,Very rarely, if TD becomes severe and affects the larynx (where the vocal cords are located - laryngospasm) and diaphragm (the muscle that helps you breathe), it can cause breathing difficulties and be life-threatening.

How is Tardive Dyskinesia diagnosed?

Your doctor will ask about your symptoms, medical history, and medication use. Your doctor may suspect tardive dyskinesia (TD) if you are taking a medication known to cause tardive dyskinesia. They will do a physical exam and a neurological exam. You may also be referred to a specialist, such as a neurologist, movement disorder specialist, or psychiatrist.

Doctors use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to diagnose tardive dyskinesia. According to the DSM-5 , to be diagnosed with tardive dyskinesia, symptoms must have persisted for at least one month after stopping medication. If you are 40 years old or younger, you must have been on medication for at least three months, or if you are over 40, you must have been on medication for one month.

Your doctor may order other tests to confirm TD or to rule out other conditions with similar symptoms, such as Huntington's disease. These may include laboratory tests and imaging tests, such as a CT scan or MRI of the brain. However, TD is usually a clinical diagnosis. This means that doctors make the diagnosis based on a thorough medical history and a thorough physical examination, without additional tests.

What are the treatments for Tardive Dyskinesia?

Studies on the management of tardive dyskinesia have shown mixed results. Some studies show that symptoms improve when the dose of antipsychotic medication is reduced or stopped. Others show that there is no difference.

Your doctor may recommend stopping the medication that is causing your TD, if possible. Unfortunately, this is not always possible. This is because stopping the medication can worsen the underlying condition that the medication was controlling.

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

Aside from stopping or switching antipsychotics, the strongest evidence for the treatment of TD is currently available for a class of drugs called VMAT inhibitors. Deutetrabenazine and valbenazine have now been shown to be safe and effective. If you have moderate to severe TD that is affecting your quality of life, your doctor may recommend these medications.

Can Tardive Dyskinesia be cured? (Can it be reversed?)

Unfortunately, most cases of tardive dyskinesia are chronic, meaning they last a long time. While medications can help manage symptoms, they cannot completely cure or reverse the condition.

What should I expect if I have Tardive Dyskinesia?

Tardive dyskinesia doesn't affect everyone the same way. Symptoms can range from mild to severe. Also, while treatment helps some people manage their symptoms, it may not for others. Your doctor will work with you to find the best treatment plan. They can give you a good idea of ​​what to expect.

Can Tardive Dyskinesia be prevented?

Tardive dyskinesia is a difficult condition to predict. Not everyone who takes certain medications will develop it.

If you have risk factors that make you more likely to develop this condition, talk to your doctor. You may be able to prevent tardive dyskinesia by using a different medication. To reduce your risk of developing TD, your doctor will prescribe the lowest effective dose of an antipsychotic medication for the shortest possible time.

If you are taking a medication known to cause TD, talk to your doctor about getting routine screenings for movement disorders. Early detection of TD symptoms can help reduce their severity. It is best to have these screenings within three to six months of starting a medication that can cause TD.

How can I take care of myself if I have Tardive Dyskinesia?

Your doctor will work with you to tailor your treatment plan as needed. Here are some other steps you can take to manage TD:

• Have a routine symptom assessment with your doctor every three to six months.
• Keep a record of your symptoms. If you develop new symptoms, let your doctor know.
• Practice self-care, including physical activity. Exercise can help relieve some movement symptoms.
• Talk to your doctor about your daily activities and quality of life.
• If your mental and social health is being affected by TD, seek help from a mental health counselor .

When should I go to the emergency room?

If you are having difficulty breathing due to tardive dyskinesia, call 911 (1990 in Sri Lanka) immediately or go to the nearest emergency room.

Finally, things to remember (Take-Home Message)

Tardive dyskinesia (TD) affects people differently. For some, it can have a significant impact on their quality of life. But remember, your doctor will work with you to monitor and manage your TD. They can recommend and modify a treatment plan to suit your needs, and suggest self-care strategies that can help. Never stop taking your medication or change the dosage without your doctor's advice. Talk to your doctor about any questions or concerns you may have.

` Tardive dyskinesia, involuntary movements, medication side effects, antipsychotics, neuropathies, dopamine, VMAT inhibitors