Differential diagnosis is key to identifying and managing tardive dyskinesia (TD)

TD is distinct1-4

Although the symptoms of TD and drug-induced parkinsonism (DIP) may appear similar, they are the 
result of different pathophysiological mechanisms. It is therefore important to appropriately diagnose TD 
and DIP because they require distinctly different therapeutic management. Treating either condition with 
a therapy not specifically indicated for it could lead to a worsening of symptoms.

Appropriate management of TD requires differentiating between TD and DIP

TD

DIP

30.0% of patients treated with typical APDs5,6

7.2% of patients treated with atypical APDs5,6

prevalence.webp

Prevalence

20% to 35% in patients taking APDs (typical and/
or atypical)7

Dopamine blockade upregulates dopamine receptors and increases dopamine signaling7

mechanism.webp

Mechanism

Dopamine blockade reduces
dopamine signaling7

Delayed—occurs months or years following administration of APD therapy6,8

Elderly persons may develop symptoms sooner6,8

timing.webp

Timing of onset

Acute—occurs within days or weeks following administration of APD therapy7

Acute: may fail to improve or may induce withdrawal dyskinesia6

Chronic: may reduce chance of worsening6

antipsychotic.webp

Decrease antipsychotic dose/potency

May improve or resolve symptoms6,7

prevalence.webp

Prevalence

TD DIP

30.0% of patients treated with typical APDs5,6

7.2% of patients treated with atypical APDs5,6

20% to 35% in patients taking APDs (typical and/or atypical)7

mechanism.webp

Mechanism

TD DIP

Dopamine blockade upregulates dopamine receptors and increases dopamine signaling7

Dopamine blockade reduces dopamine signaling7

timing.webp

Timing of onset

TD DIP

Delayed—occurs months or years following administration of APD therapy6,8

Elderly persons may develop symptoms sooner6,8

Acute—occurs within days or weeks following administration of APD therapy7

antipsychotic.webp

Decrease antipsychotic dose/potency

TD DIP

Acute: may fail to improve or may induce withdrawal dyskinesia6

Chronic: may reduce chance of worsening6

May improve or resolve symptoms6,7

LEARN MORE: EVALUATING TD SYMPTOMS

AUSTEDO® (deutetrabenazine) tablets may cause parkinsonism in patients with Huntington’s disease or tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors. The risk of parkinsonism may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops parkinsonism, the AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.

When treating TD, consider all options available to you, including those that may not require APD adjustments9

While APD manipulation has historically been used, it is not always effective:

  • Changes in APD dosing can have a negative impact on psychiatric status9
  • Withdrawal can exacerbate TD symptoms6
  • TD symptoms often persist even after discontinuation or dose reduction6

View Demystifying EPS: TD Is Distinct—a 3-part series on the importance of differential diagnosis

Watch: Chapter 1

Considering the landscape of antipsychotic usage

Watch: Chapter 2

Opposing mechanisms of TD and DIP

Watch: Chapter 3

Differential diagnosis of TD

APD, antipsychotic drug; EPS, extrapyramidal symptoms; VMAT2, vesicular monoamine transporter 2.

REFERENCES: 1. Motor systems: basal ganglia. In: Neuroanatomy. 409-421. Accessed June 9, 2022. http://www.neuroanatomy.wisc.edu/coursebook/
motor2.pdf 2. Hauser RA, Truong D. Tardive dyskinesia: out of the shadows. J Neurol Sci. 2018;389:1-3. 3. Caroff SN, Hurford I, Lybrand J, Campbell EC. Movement disorders induced by antipsychotic drugs: implications of the CATIE schizophrenia trial. Neurol Clin. 2011;29:127-148. 4. Correll CU, Schenk EM. Tardive dyskinesia and new antipsychotics. Curr Opin Psychiatry. 2008;21:151-156. 5. Carbon M, Hsieh C-H, Kane JM, Correll CU. Tardive dyskinesia prevalence in the period of second-generation antipsychotic use: a meta-analysis. J Clin Psychiatry. 2017;78(3):e264-e278. 6. Waln O, Jankovic J. An update on tardive dyskinesia: from phenomenology to treatment. Tremor Other Hyperkinet Mov (N Y). 2013;3:tre-03-161-4138-1. doi:10.7916/D88P5Z71 7. Ward KM, Citrome L. Antipsychotic-related movement disorders: drug-induced parkinsonism vs. tardive dyskinesia—key differences in pathophysiology and clinical management. Neurol Ther. Published online July 19, 2018. doi:10.1007/s40120-018-0105-0 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013. 9. Caroff SN, Miller DD, Dhopesh V, Campbell EC. Is there a rational management strategy for tardive dyskinesia? Curr Psychiatr. 2011;10(10):22-32.