Newsletter

 2006

Volume 1, No 9
 

Psychotherapeutic Medication-Induced
Movement Disorders

Drug Classifications

Many, if not most of the pharmacological therapies available to treat
psychiatric conditions can cause adverse effects that, in turn, may require the
formulation of a specific treatment plan.  The most common of the adverse
effects are the movement disorders related to the dopamine receptor antagonists,
which are also referred to as neuroleptics or antipsychotics. 

The numerous pharmacological agents used to treat psychiatric disorders are
 referred to by three general terms that are used interchangeably: 

•      Psychotropic Drugs
   
•      Psychoactive Drugs
   
•      Psychotherapeutic Drugs
  
  
  Traditionally, those agents were divided into four categories:
   
•      Antipsychotic or Neuroleptic drugs - used to treat psychosis  
    
•      Antidepressant drugs-used to treat depression
   
•      Antimanic drugs - used to treat bipolar disorder
   
•      Antianxiety or anxiolytic drugs - used to treat anxious states, although those same drugs were also effective as hypnotics in higher doses.    
  
  
  The division, however, is less valid now than it was in the past for the following reasons:
   
•    Many drugs of one class are used to treat disorders previously assigned to another class.  For example, many antidepressant drugs are used to treat anxiety disorders, and some antianxiety drugs are used to treat psychosis, depression, or bipolar disorder.
   
•    Drugs from all four categories are used to treat disorders not previously treatable by drugs.  For example, eating disorders, panic disorders, and impulse control disorders.
   
•    Such drugs as Clonidine (Catapres), Propranolol (Inderal), and Verapamil (Isoptin)
  can effectively treat a variety of psychiatric disorders and do not fit easily into the aforementioned classification of drugs.
   
•    Some descriptive psychopharmacological terms overlap in meaning.  For example, anxiolytics decrease anxiety, sedatives produce a calming or relaxing effect, and hypnotics induce sleep.  However, most anxiolytics also function as sedatives and at high doses can be used as hypnotics.  All hypnotics can be used at low doses for daytime sedation.

The DSM-IV

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-!V)
introduced a new diagnostic category, "medication-induced movement disorders," in its appendix that contains diagnostic criteria provided for further study.  When the diagnosis
of a medication-induced movement disorder is made and is a focus of specific treatment,
the movement disorder diagnosis should be listed on Axis I of the DSM-IV multiaxial diagnostic formulation.  This introduction of this diagnostic category will help the nurse
and physician understand such conditions and develop focused treatment approaches. 
It is important for clinicians to recognize and treat medication-induced movement
 disorders as early as possible, since those symptoms can lead to medication
noncompliance, as well as to psychosocial and occupational impairments.
 

Neuroleptic-Induced Movement Disorders

The most common neuroleptic-induced movement disorders are parkinsonism,
acute dystonia (a state of disordered tonicity of muscles), and acute akathisia (a condition
characterized by uncontrollable motor restlessness).  90% of dystonia cases
started in the first 4.5 days after medications were started.  90% of parkinsonism cases occurred in the first 72 days and 90% of akathisia cases occurred in the first 73 days after meds were started.

•      Neuroleptic-Induced Tardive Dyskinesia is a late-appearing adverse effect of  
  neuroleptic drugs and can be irreversible; however, recent data indicate that the syndrome, although still serious and potentially disabling, is less pernicious that was
  previously thought.  Neuroleptic malignant syndrome is a life-threatening and often
  misdiagnosed condition.
   
•      Neuroleptic-Induced Parkinsonism is characterized principally by the triad of
  tremor, rigidity, and bradykinesia (also called akinesia, which is a loss or impairment of
  voluntary activity as of a muscle).  The tremor is most often a rhythmic, 3 to 6 cycle-per-second motion that is present at rest.  The tremor can be intermittent, can sometimes be suppressed by the patient, and can affect the limbs, head mouth or lips (also called a rabbit syndrome).  The syndrome of bradykinesia can include the masklike facial appearance of the patient, the development of drooling because of a decrease in pharyngeal motor activity, decreased accessory arm movements while the patient is walking, and a characteristic difficulty in initiating movement.  There is usually a general decrease in spontaneous movements, and normal everyday behaviors
   (for example, combing hair).
  
  Neuroleptic-induced parkinsonism may develop in as many as one half of the patients who are treated with neuroleptic drugs.  The symptoms most commonly develop two to four weeks after the initiation of treatment, or after an increase in dose.  Elderly female patients are at the highest risk for neuroleptic-induced parkinsonism.  Other risk factors are a past history of the condition; a coexisting delirium, dementia, or other neurological condition; and possibly young age (that is, children).
  
  Treatment:  The benefits and the risks of prophylactic treatment with medications-
    for example, anticholinergics and Amantadine (Symmetrel) or antihistamines -
  continue to be debated. However, once parkinsonian symptoms do appear,
  the three steps in treatment are to reduce the dosage of the neuroleptic, institute antiextrapyramidal system medications, and possibly change the drug. (extrapyramidal symptoms, also called EPS symptoms, are used interchangeably with medication-induced movement disorders).
   
•      Neuroleptic-Induced Acute Dystonias are brief or prolonged contractions of
  muscles, usually resulting in obviously abnormal movements or postures,
   including tongue protrusion,  trismus (spasm of the muscles of mastication),
  torticollis (a twisting of the neck to one side that results in abnormal carriage of
  the head and is usually caused by muscle spasms -- called also wryneck),
  and dystonic postures of the limbs and trunk.
  
  The pathophysiological mechanism for dystonias is not clearly understood, although changes in neuroleptic concentrations and the resulting changes in homeostatic mechanisms in the basal ganglia may be the major causes of dystonias.
  
  Treatment:  Treatment should be immediate, most commonly with
  anticholinergic or antihistaminergic drugs.  If a patient fails to respond  to three
  doses of those drugs within two hours, the clinician should consider a cause of the dystonic movements other than neuroleptic medications.
  
  Source:  Kaplan, Harold M.D. and Sadock, Benjamin M.D.  Comprehensive Textbook
  of Psychiatry / VI, Volume 2.   Baltimore: Williams & Wilkins, pages 1909-1912.
  
  Source:  Definitions from:  Merriam-Webster Dictionary.
  
   
•      Neuroleptic-Induced Acute Akathisia
  
  Subjective complaints of restlessness accompanied by observed movements
  (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, or inability to
   sit or stand still) developing within a few weeks or starting or raising the dose of a neuroleptic medication (or after reducing a medication used to treat EPS symptoms).
  
  A.     The development of subjective complaints of restlessness after
  exposure to a neuroleptic medication.
  
  B.     At least one of the following is observed:
  
  (1)     fidgety movements or swinging of the legs
  (2)     rocking from foot to foot while standing
  (3)     pacing to relieve restlessness
  (4)     inability to sit or stand still for at least several minutes 
  
  C.  The onset of the symptoms in criteria A and B occurs within four weeks of
  initiating or increasing the dose of the neuroleptic, or of reducing medication used
  to treat (or prevent) acute extrapyramidal symptoms (e.g., anticholinergic agents).
  
  D.  The symptoms in criterion A are not better accounted for by a mental disorder (e.g., schizophrenia, substance withdrawal, agitation from a major depressive or manic episode, hyperactivity in attention-deficit / hyperactivity disorder).  Evidence that symptoms may be better accounted for by a mental disorder might include the following:  the absence of increasing restlessness with increasing neuroleptic doses, and the absence of relief with pharmacological interventions (e.g., no improvement
  after decreasing the neuroleptic dose or treatment with medication intended to
  treat the akathisia).
  
  E.     The symptoms in criterion A are not due to a nonneuroleptic substance
  or to a neurological or other general medical condition.  Evidence that symptoms
  are due to a general medical condition might include the onset of the symptoms preceding the exposure to neuroleptics or the progression of symptoms in
  the absence of a change in medication.
  
  Source:  Diagnostic and Statistical Manual of Mental Disorders, ed 4.
   Table 32.2-3.  Copyright American Psychiatric Association, Washington 1994.
  
  
  Abnormal Involuntary Movement Scale (AIMS Scale)
  
  The AIMS Scale is a rating scale that was designed in the 1970s to measure involuntary movements.  The AIMS test was originally developed for administration by trained clinicians.  People who are not health care professionals, however can also be
  taught to administer the test by completing a training seminar.  The entire test
  can be completed in about 10 minutes. 

The test has a total of twelve items rating involuntary movements of various areas
of the patient's body.  These items are rated on a five-point scale of severity from 0-4. 
The scale is rated from 0 (none), 1 (minimal), 2 (mild), 3(moderate), 4(severe). 
Two of the 12 items refer to dental care.  The patient must be calm and sitting in a
firm chair that doesn't have arms, and the patient cannot have anything
 in his or her mouth.  The clinician asks the patient about the condition of his or her
teeth and dentures, or if he or she is having any pain or discomfort from dentures.

The remaining 10 items refer to body movements themselves.  In this section of the
test, the clinician or rater asks the patient about body movements.  The rater also looks
at the patient in order to note any unusual movements first-hand.  The patient is
asked if he or she has noticed any unusual movements of the mouth, face, hands or feet.
 If the patient says yes, the clinician then asks if the movements annoy the patient
or interfere with daily activities.  Next, the patient is observed for any movements while
sitting in the chair with feet flat on the floor, knees separated slightly with the hands on the knees.  The patient is asked to open his or her mouth and stick out the tongue twice
 while the rater watches.  The patient is then asked to tap his or her thumb with each finger very rapidly for 10-15 seconds, the right hand first and then the left hand.  Again the rater observes the patient's face and legs for any abnormal movements.

After the face and hands have been tested, the patient is then asked to flex (bend) and
extend one arm at a time.  The patient is then asked to stand up so that the rater can
observe the entire body for movements.  Next, the patient is asked to extend both
arms in front of the body with the palm facing downward.  The trunk, legs and mouth are
again observed for signs of abnormal movements.  The patient then walks a few paces,
while his or her gait and hands are observed by the rater twice.

RESULTS:  The total score on the AIMS test is not reported to the patient.  A rating of 2 or higher on the AIMS scale, however, is evidence of tardive dyskinesia.  If the patient has mild TD in two areas or moderate movements in one area, then he or she should be given a diagnosis or TD.  The AIMS test is considered extremely reliable when it is given by experienced raters.

If the patient's score on the AIMS test suggests the diagnosis of TD, the physician must
consider whether the patient still needs to be on an antipsychotic medication.
 This question should be discussed with the patient and his or her family.  If the
 patient requires ongoing treatment with antipsychotic drugs, the dose can often be
lowered.  A lower dosage should result in a lower level of TD symptoms.  Another
option is to place the patient on a trial dosage of Clozapine (Clozaril), a newer antipsychotic medication that has fewer side effects than the older neuroleptics.

Source:  http://www.minddisorders.com/A-Br/Abnormal-Involuntary-Movement-Scale.html

To see a sample of the AIMS test;  Click Below:

http://www.klis.com/chandler/pamphlet/bipolar/Abnormal%20Involuntary%20Movement%20Scale.htm