Different Symptom Onset

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision, or DSM-5-TR, recognizes DIP and TD as distinct medication-induced movement disorders.

DIP: ACUTE ONSET

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Early onset of symptoms

The onset of symptoms occurs within a few weeks of

  • Starting a medication (eg, an antipsychotic drug [APD])
  • Increasing the dosage of a medication
    (eg, an APD)
  • Reducing the dosage of a medication used to treat drug-⁠induced movement disorders (eg, an anticholinergic)

TD: DELAYED ONSET

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Delayed onset of symptoms

The onset of symptoms occurs after using an APD for at least a few months to years.

  • Elderly persons may develop TD symptoms in a shorter period of time
  • In some patients, movements may appear after discontinuation or reduction in dosage
    • If symptoms persist for longer than 4 to 8 weeks, it is considered TD

Different Movement Types

DIP

Blue icon of person hunched forward using a cane.

DIP movements may include

  • Parkinsonian tremor (rhythmic, occurring at a rate of 3-6 cycles per second)
  • Muscular rigidity
  • Akinesia

    Loss or absence of movement

  • Bradykinesia

    Slowness of movement

TD

Purple icon of person with zigzag lines on each side.

TD movements may include

  • Involuntary

    athetoid

    Slow, writhing

    or

    choreiform

    Randomly flowing and jerky

    movements, most commonly affecting the face, but may also occur in the trunk or extremities

View Abnormal Movements

Key features that differentiate DIP from TD include the nature of movements, frequency of movements, and degree of muscle tone. Click on the videos to see examples of abnormal movements.

DIP

 

Movements associated with DIP
are rhythmic.

TD

 

Movements associated with TD are irregular, unpredictable, and twitchy.

Patient images used with permission.

DIP

 

DIP is characterized by a paucity of movement. This may be seen in the face and/or while the patient is walking.

TD

 

TD is associated with movements that are continuous and excessive.

Patient images used with permission.

DIP

 

DIP is often associated with muscular rigidity, which can be confirmed during a physical examination. A lack of arm swing while walking may indicate rigidity and raise suspicion of DIP.

TD

 

TD is associated with normal muscle tone and normal arm swing while walking.

Patient images used with permission.

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PerfecTD:

Pencil and open spiral notebook with √TD written in it.

Question 1 of  

Thank you for completing

DIP vs TD: Chapter 3

Symptoms

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Summary

DIP and TD have different clinical presentations, characterized by symptom onset and movement type.

Chapter 3 references

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. Washington, DC: American Psychiatric Association; 2022.

Caroff SN. Neuropsychiatr Dis Treat. 2019;15:785-794.

Hauser RA et al. CNS Spectr. 2022;27(2):208-217.

Jain R. Psych Congress Network. 2020. Accessed April 16, 2023. https://www.hmpgloballearningnetwork.com/site/psychbehav/qas/qa-updates-dr-rakesh-jain-managing-
tardive-dyskinesia.

Munetz MR, Benjamin S. Hosp Community Psychiatry. 1988;39(11):1172-1177.

Patel T, Chang F. Can Pharm J (Ott). 2015;148(3):142-149.

Ward KM, Citrome L. Neurol Ther. 2018;7(2):233-248.

INDICATIONS AND USAGE

AUSTEDO® XR (deutetrabenazine) extended-release tablets and AUSTEDO® (deutetrabenazine) tablets are indicated in adults for the treatment of chorea associated with Huntington’s disease and for the treatment of tardive dyskinesia.

IMPORTANT SAFETY INFORMATION

Depression and Suicidality in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO can increase the risk of depression and suicidal thoughts and behavior (suicidality) in patients with Huntington’s disease. Balance the risks of depression and suicidality with the clinical need for treatment of chorea. Closely monitor patients for the emergence or worsening of depression, suicidality, or unusual changes in behavior. Inform patients, their caregivers, and families of the risk of depression and suicidality and instruct them to report behaviors of concern promptly to the treating physician. Exercise caution when treating patients with a history of depression or prior suicide attempts or ideation. AUSTEDO XR and AUSTEDO are contraindicated in patients who are suicidal, and in patients with untreated or inadequately treated depression.

Contraindications: AUSTEDO XR and AUSTEDO are contraindicated in patients with Huntington’s disease who are suicidal, or have untreated or inadequately treated depression. AUSTEDO XR and AUSTEDO are also contraindicated in: patients with hepatic impairment; patients taking reserpine or within 20 days of discontinuing reserpine; patients taking monoamine oxidase inhibitors (MAOIs), or within 14 days of discontinuing MAOI therapy; and patients taking tetrabenazine or valbenazine.

Clinical Worsening and Adverse Events in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO may cause a worsening in mood, cognition, rigidity, and functional capacity. Prescribers should periodically re-evaluate the need for AUSTEDO XR or AUSTEDO in their patients by assessing the effect on chorea and possible adverse effects.

QTc Prolongation: AUSTEDO XR and AUSTEDO may prolong the QT interval, but the degree of QT prolongation is not clinically significant when AUSTEDO XR or AUSTEDO is administered within the recommended dosage range. AUSTEDO XR and AUSTEDO should be avoided in patients with congenital long QT syndrome and in patients with a history of cardiac arrhythmias.

Neuroleptic Malignant Syndrome (NMS), a potentially fatal symptom complex reported in association with drugs that reduce dopaminergic transmission, has been observed in patients receiving tetrabenazine. The risk may be increased by concomitant use of dopamine antagonists or antipsychotics. The management of NMS should include immediate discontinuation of AUSTEDO XR and AUSTEDO; intensive symptomatic treatment and medical monitoring; and treatment of any concomitant serious medical problems.

Akathisia, Agitation, and Restlessness: AUSTEDO XR and AUSTEDO may increase the risk of akathisia, agitation, and restlessness. The risk of akathisia may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops akathisia, the AUSTEDO XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.

Parkinsonism: AUSTEDO XR and AUSTEDO 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 XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.

Sedation and Somnolence: Sedation is a common dose-limiting adverse reaction of AUSTEDO XR and AUSTEDO. Patients should not perform activities requiring mental alertness, such as operating a motor vehicle or hazardous machinery, until they are on a maintenance dose of AUSTEDO XR or AUSTEDO and know how the drug affects them. Concomitant use of alcohol or other sedating drugs may have additive effects and worsen sedation and somnolence.

Hyperprolactinemia: Tetrabenazine elevates serum prolactin concentrations in humans. If there is a clinical suspicion of symptomatic hyperprolactinemia, appropriate laboratory testing should be done and consideration should be given to discontinuation of AUSTEDO XR and AUSTEDO.

Binding to Melanin-Containing Tissues: Deutetrabenazine or its metabolites bind to melanin-containing tissues and could accumulate in these tissues over time. Prescribers should be aware of the possibility of long-term ophthalmologic effects.

Common Adverse Reactions: The most common adverse reactions for AUSTEDO (>8% and greater than placebo) in a controlled clinical study in patients with Huntington’s disease were somnolence, diarrhea, dry mouth, and fatigue. The most common adverse reactions for AUSTEDO (4% and greater than placebo) in controlled clinical studies in patients with tardive dyskinesia were nasopharyngitis and insomnia. Adverse reactions with AUSTEDO XR extended-release tablets are expected to be similar to AUSTEDO tablets.

Please see accompanying full Prescribing Information, including Boxed Warning.