tongue is characterised by a slow and repetitive retraction, ora sweeping tongue movement within the oral cavity, producinga bulge in the cheek, referred to as the
When thepatient is asked to extend the tongue, irregular, worm-likecontractions of the tongue muscles are frequently observed.Grimacing, with a lifting or arching of eyebrows or frowning,can also be a symptom of classical TD. Most patients exhibituncoordinated
exion/extension movements of individual
ngers, somewhat resembling guitar or piano playing move-ments. Dyskinesias of the legs
givethe impression of slowly walking in place or shifting body weight from one foot to the other.
Dyskinesia of thediaphragm may lead to an irregular, uneven rhythm of speech oruncontrollable grunting and groaning. Other movements thathave been described in classical TD include hip-rocking move-ments, to-and-fro movements of the upper torso, head nodding,and
exion/extension movements of the toes, wrists, and ankles.
Stereotypy, which is de
ned as a seemingly purposeful, coordi-nated but involuntary, repetitive, ritualistic gesture, mannerismor utterance, was reported by Stacy
tobe the most common form of TD. Some experts suggested thattardive stereotypy is probably a more appropriate term thanclassical TD to describe the repetitive, rather than random,movements. However, the stereotypic movements in classicalTD are very characteristic and similar in almost all patients withthis disorder, differentiating it from other types of stereotypiesseen in patients with autism and psychosis.
Since the earliest reports of TD, a variety of involuntary movements, in addition to the well known oro-buccal-lingualmasticatory movements, have been described, includingdystonia. The term
ned by Burke
to represent an involuntary movement predominated by dystonia and associated with the use of DRBAs.
For reasonsnot fully understood, young adults seem to be particularly susceptible to this disorder.
According to Burke
, dystoniamust be present for more than a month and occur either duringongoing treatment with a DRBA or within 3 months of itsdiscontinuation.
Although choreiform movements may occur,the principal movement must be dystonia. Dystonic movementsin tardive dystonia are strikingly different from the classical TD.Firstly, dystonic movements, de
ned as a syndrome of sustainedmuscle contractions frequently causing twisting and abnormalpostures, tend to be action speci
c. They occur consistently with certain actions and do not exhibit clear-cut periodicity asclassical TD. Secondly, many patients with dystonia note thattheir movements can be partially controlled by simple tactilemanoeuvres, termed sensory tricks or
, suchas touching the chin to alleviate torticollis.
Third, tardivedystonia occurs more often among men than women, the genderat greater risk for classic TD.
Finally, the shorter duration forneuroleptic exposure develops tardive dystonia and it tends tooccur in populations with a lower age of onset when comparedwith other TS.
Without a reliable history, tardive dystonia may be indistin-guishable from idiopathic torsion dystonia, including sensory tricks and distribution of dystonia. However, there are somedifferent features for identi
cation of these disorders (table 1).Tardive dystonia has a special predilection for cranial andcervical muscles. When it affects the neck, it usually results inretrocollis (
gure 1), in contrast to laterocollis or torticollis inidiopathic cervical dystonia. When involving the trunk, itusually produces severe scoliosis or opisthotonic posturing(
gure 2). When involving the upper limbs, internal rotation of the arms, extension of the elbows, and
exion of the wrists arecommon postures in tardive dystonia.
The legs are only infrequently involved. Tardive dystonia often occurs with otherTS, while idiopathic torsion dystonia rarely does.
Akathisia refers to a feeling of inner restlessness and jitterinessthat is often manifested by semi-purposeful movements.Subjectively, the most common complaint is the inability tokeep the legs still which are associated with vague inner tension,unease, or anxiety. Objectively, patients are seen rocking fromfoot to foot, walking in place, grunting, moaning, or trunkrocking. In addition to its common occurrence as an acuteadverse effect of neuroleptics, akathisia can become chronic(tardive akathisia).
Not surprisingly, tardive akathisia usually coexists with classic TD. The mean age of onset is 58 years, asthe age of onset of patients to whom neuroleptics are adminis-tered typically is younger than those taking other agents.
Box 3 Risk factors of tardive syndromes
1. Older age (young age in case of tardive dystonia)2. Female gender3. African American population4. Typical neuroleptics5. Higher dose and longer duration of neuroleptic use6. Pre-existing mood disorders7. Cognitive impairments8. Presence of negative symptoms9. Alcohol and substance abuse10. Use of antiparkinsonian agents and lithium11. Early extrapyramidal symptoms12. Diabetes13. HIV seropositive status
A comparison of tardive dystonia and idiopathic torsion dystonia
Clinical features Tardive dystonia Idiopathic torsion dystonia
Cervical dystonic posture Retrocollis Torticollis, laterocollisAxial dystonic posture Opisthotonic posturing Lateral twisting of trunkUnique characteristics: internalrotation of the arms, extension of theelbows, and ﬂexion of the wristsFrequent in young men NoneLeg involvement Less frequent Frequent in primary generalised dystoniaDystonia after voluntary action Reduced ExacerbatedCoexist with other tardive syndromes Frequent None
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