Does dyskinesia occur in treatment-naive patients?
In 1919, Kraepelin⁵ wrote the following on Dementia Praecox:

“The spasmodic phenomena in the musculature of the face and of speech, which often appear are extremely peculiar disorders.  Some of them resemble movements of expression, wrinkling of the forehead, distortion of the corners of the mouth, irregular movements of the tongue and lips, twisting of the eyes, opening them wide, and shutting them tight, in short, those movements which we bring together under the name of making faces or grimacing; they remind one of the corresponding disorders of choreic patients.  The outspread fingers often show fine tremor.  Several patients continually carried out peculiar sprawling irregular choreiform, outspreading movements, which I think I can best characterize by the expression ‘athetoid ataxia’.”

If this had been written today, most would agree that it is a good description of tardive dyskinesia.

Kraeplin omitted to give the age of his patients, or the length of their illness.  A more contemporary study⁶, conducted at Shenley Hospital in the UK, studied 52 patients (mean age 68 years) who had never received antipsychotics.  Nevertheless, just over half of them (52%) had movement disorders.  Of these, six showed disorders of gait; 18 of the face; nine of the upper limbs; nine of the trunk, and ten of the lower limbs.  These findings were not supported by Chorfi and Moussaoui⁷. In their study of 50 patients who had never been treated, none was found to have dyskinesia (using the abnormal involuntary movements (AIMS) scale).  However, this study involved a much younger population (mean age 24 years) with a mean length of illness of 11 months.

When McCreadie and Ohaeri⁸ looked at a middle aged group of patients we again found no dyskinesia in 12 never-medicated patients. Thus we have two groups of studies, one suggesting the possibility of dyskinesia in the absence of medication, the other refuting this suggestion.  It should be noted, however, that  the studies that find abnormal movements tend to include severely ill and institutionalized patients.

The Madras study
The Madras study⁹ was therefore established to examine elderly (>50 years) never-medicated patients in a wide variety of community settings.  Four groups were chosen:  never-medicated patients; medicated patients; first-degree blood relatives; and normal subjects.  The project was carried out in Madras, India, where the average life expectancy is 56 years.

Three hundred and eight people participated in the study: 101 normal subjects, 103 relatives,
83 medicated patients and 21 never-medicated patients. Movement disorders were assessed using standard scales: for dyskinesia, AIMS and Schooler and Kane criteria; for parkinsonism, the Simpson and Angus scale (score >0.3); and for akathisia, the Barnes akathisia scale (score of 2 or more on the global scale). The results obtained are shown in Table 3.
 

Patient group  Normals  Relatives  Medicated  Never-medicated  Prevalence of dyskinesia (%)  15  15  41  38

Table 3. Prevalences of dyskinesias in four patient groups, according to Schooler and Kane criteria¹⁰.

The prevalence and severity of dyskinesia were found to be almost the same in medicated and never-medicated patients.  Dyskinesia was associated with negative symptoms and was attributed to part of the illness in elderly schizophrenic patients.  From the results of these studies, it seems that antipsychotic medication alone does not produce tardive dyskinesia, but brings forward in time a phenomenon that eventually shows itself.

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