Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Tardive dyskinesia: Prevention and treatment

Daniel Tarsy, MD
Section Editor
Howard I Hurtig, MD
Deputy Editor
John F Dashe, MD, PhD


Tardive dyskinesia (TD) is a hyperkinetic movement disorder that appears with a delayed onset, usually after prolonged use of dopamine receptor blocking agents, mainly the antipsychotic drugs (also called neuroleptics) and the antiemetic drug metoclopramide.

TD has numerous clinical manifestations that include chorea, athetosis, dystonia, akathisia, stereotyped behaviors, and, rarely, tremor. The term "tardive" differentiates these dyskinesia from acute dyskinesia, parkinsonism, and akathisia, which appear very soon after exposure to antipsychotic drugs. TD is a clinical diagnosis, but tests may be performed to exclude other causes of the patient's symptoms.

This topic will review the prevention and management of TD. Other aspects of TD are discussed separately. (See "Tardive dyskinesia: Etiology and epidemiology" and "Tardive dyskinesia: Clinical features and diagnosis".)


Prevention of TD and the early detection and treatment of potentially reversible cases of TD are of paramount importance. The only certain method of TD prevention is to avoid treatment with antipsychotic drugs and metoclopramide.

The use of antipsychotic drugs, particularly for longer than three months, requires careful evaluation of indications, and risks and should be limited to situations where there is no safer effective therapy.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Jul 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
  1. Tancredi LR. Malpractice and tardive dyskinesia: a conceptual dilemma. J Clin Psychopharmacol 1988; 8:71S.
  2. Tardive dyskinesia: summary of a Task Force Report of the American Psychiatric Association. By the Task Force on Late Neurological Effects of Antipsychotic Drugs. Am J Psychiatry 1980; 137:1163.
  3. Tardive dyskinesia: a Task Force Report of the American Psychiatric Association. American Psychiatric Association Press, Washington, DC 1992.
  4. Guy W. ECDEU Assessment Manual for Psychopharmacology: Publication ADM 76-358. US Department of Public Health, Education, and Welfare, Washington, DC 1976.
  5. Tarsy D. Tardive Dyskinesia. Curr Treat Options Neurol 2000; 2:205.
  6. Soares-Weiser K, Rathbone J. Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia. Cochrane Database Syst Rev 2006; :CD000459.
  7. Soares-Weiser K, Fernandez HH. Tardive dyskinesia. Semin Neurol 2007; 27:159.
  8. Bhidayasiri R, Fahn S, Weiner WJ, et al. Evidence-based guideline: treatment of tardive syndromes: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013; 81:463.
  9. Lieberman JA, Saltz BL, Johns CA, et al. The effects of clozapine on tardive dyskinesia. Br J Psychiatry 1991; 158:503.
  10. Tamminga CA, Thaker GK, Moran M, et al. Clozapine in tardive dyskinesia: observations from human and animal model studies. J Clin Psychiatry 1994; 55 Suppl B:102.
  11. Factor SA, Friedman JH. The emerging role of clozapine in the treatment of movement disorders. Mov Disord 1997; 12:483.
  12. Spivak B, Mester R, Abesgaus J, et al. Clozapine treatment for neuroleptic-induced tardive dyskinesia, parkinsonism, and chronic akathisia in schizophrenic patients. J Clin Psychiatry 1997; 58:318.
  13. Emsley R, Turner HJ, Schronen J, et al. A single-blind, randomized trial comparing quetiapine and haloperidol in the treatment of tardive dyskinesia. J Clin Psychiatry 2004; 65:696.
  14. Sasaki Y, Kusumi I, Koyama T. A case of tardive dystonia successfully managed with quetiapine. J Clin Psychiatry 2004; 65:583.
  15. Bouckaert F, Herman G, Peuskens J. Rapid remission of severe tardive dyskinesia and tardive dystonia with quetiapine. Int J Geriatr Psychiatry 2005; 20:287.
  16. Tarsy D, Baldessarini RJ, Tarazi FI. Effects of newer antipsychotics on extrapyramidal function. CNS Drugs 2002; 16:23.
  17. Caroff SN, Mann SC, Campbell EC, Sullivan KA. Movement disorders associated with atypical antipsychotic drugs. J Clin Psychiatry 2002; 63 Suppl 4:12.
  18. Gunne LM, Häggström JE, Sjöquist B. Association with persistent neuroleptic-induced dyskinesia of regional changes in brain GABA synthesis. Nature 1984; 309:347.
  19. Jeste DV, Wyatt RJ. Therapeutic strategies against tardive dyskinesia. Two decades of experience. Arch Gen Psychiatry 1982; 39:803.
  20. Bhoopathi PS, Soares-Weiser K. Benzodiazepines for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2006; :CD000205.
  21. Thaker GK, Nguyen JA, Strauss ME, et al. Clonazepam treatment of tardive dyskinesia: a practical GABAmimetic strategy. Am J Psychiatry 1990; 147:445.
  22. Bobruff A, Gardos G, Tarsy D, et al. Clonazepam and phenobarbital in tardive dyskinesia. Am J Psychiatry 1981; 138:189.
  23. Tarsy D, Kaufman D, Sethi KD, et al. An open-label study of botulinum toxin A for treatment of tardive dystonia. Clin Neuropharmacol 1997; 20:90.
  24. Brashear A, Ambrosius WT, Eckert GJ, Siemers ER. Comparison of treatment of tardive dystonia and idiopathic cervical dystonia with botulinum toxin type A. Mov Disord 1998; 13:158.
  25. Hauser RA, Factor SA, Marder SR, et al. KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia. Am J Psychiatry 2017; 174:476.
  26. FDA approves first drug to treat tardive dyskinesia. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm552418.htm (Accessed on April 24, 2017).
  27. Godwin-Austen RB, Clark T. Persistent phenothiazine dyskinesia treated with tetrabenazine. Br Med J 1971; 4:25.
  28. Kazamatsuri H, Chien C, Cole JO. Treatment of tardive dyskinesia. I. Clinical efficacy of a dopamine-depleting agent, tetrabenazine. Arch Gen Psychiatry 1972; 27:95.
  29. Kazamatsuri H, Chien CP, Cole JO. Long-term treatment of tardive dyskinesia with haloperidol and tetrabenazine. Am J Psychiatry 1973; 130:479.
  30. Kang UJ, Burke RE, Fahn S. Natural history and treatment of tardive dystonia. Mov Disord 1986; 1:193.
  31. Lang AE, Marsden CD. Alpha methylparatyrosine and tetrabenazine in movement disorders. Clin Neuropharmacol 1982; 5:375.
  32. Fernandez HH, Factor SA, Hauser RA, et al. Randomized controlled trial of deutetrabenazine for tardive dyskinesia: The ARM-TD study. Neurology 2017; 88:2003.
  33. Suzuki T, Hori T, Baba A, et al. Effectiveness of anticholinergics and neuroleptic dose reduction on neuroleptic-induced pleurothotonus (the Pisa syndrome). J Clin Psychopharmacol 1999; 19:277.
  34. Zhang WF, Tan YL, Zhang XY, et al. Extract of Ginkgo biloba treatment for tardive dyskinesia in schizophrenia: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry 2011; 72:615.
  35. Jeste DV, Lohr JB, Clark K, Wyatt RJ. Pharmacological treatments of tardive dyskinesia in the 1980s. J Clin Psychopharmacol 1988; 8:38S.
  36. Gardos G, Casey DE, Cole JO, et al. Ten-year outcome of tardive dyskinesia. Am J Psychiatry 1994; 151:836.
  37. Fernandez HH, Krupp B, Friedman JH. The course of tardive dyskinesia and parkinsonism in psychiatric inpatients: 14-year follow-up. Neurology 2001; 56:805.
  38. Tammenmaa IA, Sailas E, McGrath JJ, et al. Systematic review of cholinergic drugs for neuroleptic-induced tardive dyskinesia: a meta-analysis of randomized controlled trials. Prog Neuropsychopharmacol Biol Psychiatry 2004; 28:1099.
  39. Lohr JB, Kuczenski R, Niculescu AB. Oxidative mechanisms and tardive dyskinesia. CNS Drugs 2003; 17:47.
  40. Adler LA, Peselow E, Rotrosen J, et al. Vitamin E treatment of tardive dyskinesia. Am J Psychiatry 1993; 150:1405.
  41. Dabiri LM, Pasta D, Darby JK, Mosbacher D. Effectiveness of vitamin E for treatment of long-term tardive dyskinesia. Am J Psychiatry 1994; 151:925.
  42. Lohr JB, Cadet JL, Lohr MA, et al. Alpha-tocopherol in tardive dyskinesia. Lancet 1987; 1:913.
  43. Egan MF, Hyde TM, Albers GW, et al. Treatment of tardive dyskinesia with vitamin E. Am J Psychiatry 1992; 149:773.
  44. Shriqui CL, Bradwejn J, Annable L, Jones BD. Vitamin E in the treatment of tardive dyskinesia: a double-blind placebo-controlled study. Am J Psychiatry 1992; 149:391.
  45. Dorevitch A, Kalian M, Shlafman M, Lerner V. Treatment of long-term tardive dyskinesia with vitamin E. Biol Psychiatry 1997; 41:114.
  46. Soares-Weiser K, Maayan N, McGrath J. Vitamin E for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2011; :CD000209.
  47. Angus S, Sugars J, Boltezar R, et al. A controlled trial of amantadine hydrochloride and neuroleptics in the treatment of tardive dyskinesia. J Clin Psychopharmacol 1997; 17:88.
  48. Soares-Weiser KV, Joy C. Miscellaneous treatments for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2003; :CD000208.
  49. Adelufosi AO, Abayomi O, Ojo TM. Pyridoxal 5 phosphate for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2015; :CD010501.
  50. Bona JR. Treatment of neuroleptic-induced tardive dyskinesia with levetiracetam: a case series. J Clin Psychopharmacol 2006; 26:215.
  51. Konitsiotis S, Pappa S, Mantas C, Mavreas V. Levetiracetam in tardive dyskinesia: an open label study. Mov Disord 2006; 21:1219.
  52. Woods SW, Saksa JR, Baker CB, et al. Effects of levetiracetam on tardive dyskinesia: a randomized, double-blind, placebo-controlled study. J Clin Psychiatry 2008; 69:546.
  53. Soares K, Rathbone J, Deeks J. Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia. Cochrane Database Syst Rev 2004; :CD000203.
  54. Pouclet-Courtemanche H, Rouaud T, Thobois S, et al. Long-term efficacy and tolerability of bilateral pallidal stimulation to treat tardive dyskinesia. Neurology 2016; 86:651.
  55. Trottenberg T, Paul G, Meissner W, et al. Pallidal and thalamic neurostimulation in severe tardive dystonia. J Neurol Neurosurg Psychiatry 2001; 70:557.
  56. Eltahawy HA, Feinstein A, Khan F, et al. Bilateral globus pallidus internus deep brain stimulation in tardive dyskinesia: a case report. Mov Disord 2004; 19:969.
  57. Franzini A, Marras C, Ferroli P, et al. Long-term high-frequency bilateral pallidal stimulation for neuroleptic-induced tardive dystonia. Report of two cases. J Neurosurg 2005; 102:721.
  58. Trottenberg T, Volkmann J, Deuschl G, et al. Treatment of severe tardive dystonia with pallidal deep brain stimulation. Neurology 2005; 64:344.
  59. Tai CH, Tseng SH, Liu HM, Wu RM. Bilateral deep brain stimulation of subthalamic nucleus alleviates tardive dystonia. Neurology 2006; 66:1778.
  60. Gruber D, Trottenberg T, Kivi A, et al. Long-term effects of pallidal deep brain stimulation in tardive dystonia. Neurology 2009; 73:53.