I’ve had two people ask for an indepth post on this, so get ready for an infodump!
What is Tardive Dyskinesia?
Tardive dyskinesia (aka TD) is a disorder where people develop uncontrollable repetitive movements / tics. It is caused by long-term use of neuroleptic drugs, most notably antipsychotics.
These symptoms usually appear after 1-2 years of taking antipsychotics continuously, and it almost never appears before 3 months.
What makes TD so serious is that it’s pretty much permanent, even if you stop taking the medication that caused it.
What does TD actually look like?
There are a couple of different kind of movements that your character could have:
- Facial & oral movements (which are by far the most common)
- Facial expressions (Frowning, blinking, smiling, grimacing)
- Lips (Puckering, pouting, smacking)
- Jaw (Biting, clenching, chewing, mouth opening, lateral movement)
- Tongue (Darting in and out of mouth)
- Extremity movements
- Upper (arms, wrists, hands, fingers)
- Lower (legs, knees, ankles, feet)
- Trunk movements (Neck, shoulders, and hips)
- Rocking, twisting, squirming, pelvic gyrations
Check out this video for some examples! (Note - there is a full description of this video behind the jump at the end of this post. Feel free to use the way I describe the movements in your own writing!).
While TD is usually pretty noticeable, it can be subtle in the early stages (note the lip puckering in #5 and the cheek muscle in #7 in the video above).
Symptoms of TD get worse when the person is more emotional, and they mostly disappear when the person is asleep.
What causes TD?
The current theory is that TD is caused by a dopamine blockade at the D2 receptors, which causes a compensatory supersensitivity to dopamine.
I know I’ve lost you. Hell, a few months ago I would have been lost too!
So I have a story that will (hopefully) clear things up a little.
Reece has just gotten a new roommate, Anne. This is a pretty sweet deal for Reece, as he gets to save money and thus overall improve his quality of life.
However, it soon becomes clear that Reece and Anne aren’t a good fit. Anne is a bit of a slob and doesn’t do chores.
While he at first tidied up after her, Reece eventually can’t take it anymore. He confronts Anne, and she doesn’t take it well. She tells him that she’s not going to change, and that if her messiness bothers him, he should just clean up her messes for her.
After this conversation, Reece and Anne are no longer on friendly terms with one another, and now resent each other so much that they’ll never be able to be friends again.
Now, the little things that Reece used to let slide (like leaving dishes in the sink) become grounds for a screaming argument. He has become supersensitive to the things Anne does, and the slightest thing can activate his rage. The longer Reece lives with Anne, the worse things are going to get.
Reece eventually kicks Anne out and tries to find a new roommate. However, Reece’s normal state now is that of being supersensitive; even though Anne is gone, he’s still wary of future roommates, just in case they’re going to be like Anne. Reece becomes so intolerant of messiness that he’ll even yell at his friends and family if they so much as track a tiny bit of mud into the house or leave a cup on the table.
After living with Anne, Reese’s low tolerance for messiness never goes away.
Reese is your D2 Receptors and Anne is an antipsychotic. The “messes” Reese cleans up is dopamine. Reese’s permanent low tolerance for messiness is compensatory supersensitivity to dopamine. The angry outbursts whenever Reese has to deal with messes are what cause tardive dyskinesia.
There are a number of factors that can increase the risk of developing TD, but the most important one is how old the character is. Elderly people are ~3 times more likely than younger people to develop TD.
Another big risk factor is what medication your character is taking, as well as how big a dosage it is.
Older antipsychotics (aka typical antipsychotics) like haliperidol (Haldol) and chlorpromazine (Thorazine) are associated with high rates of causing TD. While generally atypical antipsychotics don’t cause TD at anywhere near the same rate, using a high enough dose of an atypical antipsychotic means that it actually becomes just as likely to cause TD as a typical one.
Note: One atypical antipsychotic, Clozapine, is notable for its extremely low rate of causing TD (it’s so low that it’s at the point that many researchers describe it as never causing TD). However, it has a potentially deadly side effect that requires getting regular blood tests as long as you take it. As such, it’s not frequently prescribed unless other antipsychotics aren’t working or someone already has TD and they’re trying to keep it from progressing.
Why are typical and atypical antipsychotics different?
The fancy psych answer is that typical antipsychotics have high affinity for dopamine D2 receptors, and atypical antipsychotics not only have a lower affinity to those receptors, but they also work on serotonin receptors.
WTF does that mean? Well, let’s go back to the roommate analogy!
A typical antipsychotic is like having a roommate that rarely leaves the house. It’s a lot easier to get overwhelmed by their messiness, because they’re constantly there creating it.
An atypical antipsychotic is like having a roommate that has a significant other and stays over at their place half of the time. It’s still possible to end up with a bad roommate, but because they’re not always around, it’s not as likely you’ll reach that point of no return.
What treatments are available?
CW: brief suicide mention
There is no cure for tardive dyskinesia once it develops. Taking someone off the antipsychotic quickly can prevent TD from getting worse, but that can result in a relapse of the symptoms that necessitated taking the antipsychotic in the first place. Your character may need to be switched to a different medication that has a lower rate of causing TD (see Clozapine above).
There are some ways to manage symptoms once they’ve developed:
- Valbenazine is a brand-spanking-new drug that was only approved a few months ago! It’s really promising, and doesn’t seem to have that many side effects.
- Tetrabenazine - this was traditionally used to treat TD, but it can have some serious side effects and can increase the risk of suicide.
- There are other medications, but they seem to have mixed support as to their efficacy.
- Also, interestingly, if someone has smaller, simple, more localized movements (think the cheek movements in #7 in the video), botox can actually be used to paralyze the affected muscle.
Why bother writing about this?
Well, it adds an element of realism to a character who’s taking antipsychotics. Even if you don’t want your character to develop tardive dyskinesia, it could be something your character worries about while taking the drugs, or even be given as a reason they don’t want to take them!
It’s the kind of detail that the Shrink never sees addressed in media, and I’ll automatically give bonus points to anything that includes a detail like this.
A full description of the earlier video is after the jump.