Can tardive dyskinesia occur in the first month of antipsychotic use?

Tardive Dyskinesia in the First Month of Antipsychotic Use

Tardive dyskinesia typically does not occur within the first month of antipsychotic use, as it is associated with long-term use of antipsychotics rather than acute exposure. 1

Timing of Movement Disorders with Antipsychotic Use

• Acute extrapyramidal symptoms (EPS) occur early in treatment, typically within the first few days to weeks after starting antipsychotic medication or increasing the dose 1
• Acute dystonia specifically tends to occur after the first few doses of medication or after an increase in dosage 2
• Akathisia generally occurs within the first few days of antipsychotic medication therapy 2
• Tardive dyskinesia is typically associated with the long-term use of neuroleptics, developing after prolonged use of antipsychotics, usually after months or years of treatment 2, 1

Differentiating Early Movement Disorders from Tardive Dyskinesia

Early Movement Disorders (First Month)

• Acute dystonia: Involuntary motor tics or spasms usually involving the face, extraocular muscles (oculogyric crisis), neck, back, and limb muscles 2
• Akathisia: Subjective feeling of restlessness, which manifests as pacing or physical agitation, often misinterpreted as psychotic agitation or anxiety 2
• Drug-induced Parkinsonism: Characterized by bradykinesia, tremors, and rigidity 1

Tardive Dyskinesia (After Prolonged Use)

• Characterized by rapid involuntary facial movements (blinking, grimacing, chewing, or tongue movements) and extremity or truncal movements 2
• Respiratory dyskinesia can include orofacial dyskinesia, dysphonia, dyspnea, and respiratory alkalosis 2
• Unlike acute movement disorders, tardive dyskinesia may persist even after medication discontinuation 1

Risk Factors and Incidence

• The cumulative incidence of presumptive TD was found to be 6.3% after 1 year of follow-up in first-episode psychosis patients 3
• Higher risk with typical (conventional) antipsychotics compared to atypical antipsychotics 4
• Risk factors include older age, female gender, higher doses, longer duration of exposure, and intellectual impairment 4
• Poor response to treatment of the first psychotic episode is a significant predictor of time to TD development 3

Clinical Implications

• The FDA label for haloperidol notes that tardive dyskinesia may develop in patients treated with antipsychotic drugs, with higher risk in elderly patients, especially elderly women 5
• Both the risk of developing tardive dyskinesia and the likelihood of it becoming irreversible increase with duration of treatment and total cumulative dose 5
• Regular monitoring for abnormal movements should begin at baseline and continue throughout treatment, with assessments recommended every 3-6 months using standardized tools like the Abnormal Involuntary Movement Scale 2
• If tardive dyskinesia is suspected, consider medication dose reduction or switching to an atypical antipsychotic with lower TD risk 2

Important Caveat

While true tardive dyskinesia is rare in the first month, clinicians should be aware that withdrawal dyskinesia can occur with either gradual or sudden cessation of neuroleptic agents, which could be confused with early-onset tardive dyskinesia 2. Additionally, some studies have suggested a disease-related vulnerability to TD that may manifest with antipsychotic drug exposure 3, potentially accelerating the timeline in vulnerable individuals.