Tardive dystonia, like tardive dyskinesia, develops after long-term use of antipsychotics (or other dopamine receptor antagonists). Tardive dystonia is often missed or misdiagnosed. It is not well known how often it occurs, but percentages around 10% have been reported for patients on long-term antipsychotics, if the less affected cases are also included. Less affected cases often recover on their own, but severe forms often persist without treatment 1-10.

It is possible that tardive dystonia develops after a relatively short period of using antipsychotics. About one fifth of the case series (N = 67) developed in the first year, and half in the first five years of treatment with antipsychotics11. Tardive dystonia can affect any area of the body. Some examples are neck twisting in all directions (torti, retro, latero or ante collis), blepharospasm, oromandibular, laryngeal, arm, trunk, and leg dystonia.

Tardive dystonia mainly occurs in the head / neck area, but the arms / hands are also frequently affected.

Tardive dystonia often starts insidiously. In about three-quarters of cases, the dystonia spreads to multiple muscle areas but rarely to a generalized form.

There may be a relationship between the age at which the dystonia develops and its ultimate severity; patients with generalized dystonia were younger than patients with focal (one muscle region) dystonia.

A special phenomenon in tardive dystonia are the so-called ‘sensory tricks’ (see video). These are tactile or proprioceptive stimuli that reduce the severity or the subjective burden of the dystonia; for example, the pain caused by a torticollis is reduced by the patient touching his chin, or the blepharospasm disappears when the patient strokes his eyebrow, or the torticollis is reduced by moving the arm12.

Fatigue or stress can make dystonia worse, while relaxation, hypnosis and sleep can reduce dystonia. Sometimes when you wake up, the dystonia has disappeared completely but returns after a few hours. Not infrequently, tardive dystonia causes pain.

Literature

1.         van Harten PN, Matroos GE, Van Os J. The course of tardive dystonia in Afro Caribbean patients, a population-based study: the Curacao extrapyramidal syndromes study: VII. Schizophr Res 2008; 98(1-3): 79-83.

2.         van Harten PN, Matroos GE, Hoek HW, Kahn RS. The prevalence of tardive dystonia, tardive dyskinesia, parkinsonism and akathisia The Curacao Extrapyramidal Syndromes Study: I. Schizophr Res 1996; 19(2-3): 195-203.

3.         van Harten PN, Hoek HW, Matroos GE, Koeter M, Kahn RS. The inter-relationships of tardive dyskinesia, parkinsonism, akathisia and tardive dystonia: the Curacao Extrapyramidal Syndromes Study II. Schizophrenia research1997; 26(2-3): 235-42.

4.         van Harten PN, Hoek AW, Matroos GE, van Os J. The incidence of tardive dystonia and tardive dyskinesia in patients on long-term antipsychotic treatment. Schizophrenia Research 2004; 67(1 Suppl): 185.

5.         van Harten PN. Tardive dystonia: male:female ratio. The British journal of psychiatry  the journal of mental science 1991; 159: 440.

6.         van Harten PN, Kahn RS. Tardive dystonia. Schizophrenia bulletin 1999; 25(4): 741-

7.         Harten PNv. De behandeling van tardieve dystonie. Psyfar 2007; 2(2): 32-5.

8.         Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. Handb Clin Neurol 2019; 165: 415-28.

9.         Wojcik JD, Falk WE, Fink JS, Cole JO, Gelenberg AJ. A review of 32 cases of tardive dystonia. Am J Psychiatry1991; 148(8): 1055-9.

10.       Mentzel CL, Tenback DE, Tijssen MA, Visser-Vandewalle VE, van Harten PN. Efficacy and safety of deep brain stimulation in patients with medication-induced tardive dyskinesia and/or dystonia: a systematic review. J Clin Psychiatry2012; 73(11): 1434-8.

11.       Kang UJ, Burke RE, Fahn S. Tardive dystonia. Adv Neurol 1988; 50: 415-29.

12.       Shalash AS, Abushouk AI, Elsherbeny MY, Elrassas H, Kamel T. Refractory Open Jaw Oromandibular Tardive Dystonia with a Sensory Trick, Treated with Botulinum Toxin: A Case Report. Neurol India 2019; 67(4): 1110-1.

Movies

Tardive dystonia with commentary

Example of a sensory trick for neck dystonia

Spasmodic dysphonia which can also occur as a form of tardive dystonia. Note the pinched voice. Sometimes singing is quite good, as with this patient. Spasmodic aphonia gives a whispering voice or hoarseness.