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.
Early onset of symptoms
The onset of symptoms occurs within a few weeks of
Delayed onset of symptoms
The onset of symptoms occurs after using an APD for at least a few months to years.
DIP movements may include
Akinesia
Loss or absence of movement
Bradykinesia
Slowness of movement
TD movements may include
athetoid
Slow, writhing
choreiform
Randomly flowing and jerky
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.
Movements associated with DIP
are rhythmic.
Movements associated with TD are irregular, unpredictable, and twitchy.
Patient images used with permission.
DIP is characterized by a paucity of movement. This may be seen in the face and/or while the patient is walking.
TD is associated with movements that are continuous and excessive.
Patient images used with permission.
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 is associated with normal muscle tone and normal arm swing while walking.
Patient images used with permission.
Question 1 of
For the following patient history, decide whether you think the patient has DIP or TD.
Patient history
Answer: DIP
DIP frequently develops within about 3 weeks of initiating or increasing the dose of an APD.
For the following patient history, decide whether you think the patient has DIP or TD.
Patient history
Answer: TD
TD generally develops after prolonged exposure to an APD (months to years). The minimum exposure history required for the diagnosis of TD is APD use for at least 3 months (or 1 month in middle-aged or elderly individuals). By contrast, DIP develops within weeks of initiating or increasing the dose of an APD.
After reviewing the video, decide whether you think the patient has DIP or TD.
Patient image used with permission.
Answer: TD
The patient is experiencing excessive movement consistent with TD. The tongue protrusions are random, also consistent with TD, rather than rhythmic, which characterizes movements associated with DIP. Moreover, involuntary abnormal orofacial movement of the tongue is one of the most common presentations of TD.
After reviewing the video, decide whether you think the patient has DIP or TD.
Patient image used with permission.
Answer: DIP
The movement of the hand is rhythmic, which is characteristic of DIP. Movements in TD are often jerky and irregular.
After reviewing the video, decide whether you think the patient has DIP or TD.
Patient image used with permission.
Answer: TD
The movements of the hand are random and twitchy, consistent with TD. Movements associated with DIP are rhythmic.
After reviewing the video, decide whether you think the patient has DIP or TD.
Patient image used with permission.
Answer: DIP
The patient shows an overall paucity of movement in the face, consistent with DIP. TD is characterized by excessive abnormal movements.
Thank you for completing
DIP vs TD: Chapter 3
Symptoms
Summary
DIP and TD have different clinical presentations, identifiable by
onset of symptoms (acute versus delayed) and differentiations in
types of involuntary movement (regular versus irregular).
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.
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.
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.