patient care perspectives

Early Recognition of the Clinical Features of Tardive Dyskinesia

by Rakesh Jain, MD, MPH

Overview

Prevention, close monitoring, and the earliest possible diagnosis are all critical aspects of optimizing outcomes in tardive dyskinesia (TD). The Abnormal Involuntary Movement Scale (AIMS) remains a powerful tool, and regular screening is recommended.

Expert Commentary

Rakesh Jain, MD, MPH

Clinical Professor
Department of Psychiatry
Texas Tech University Health Sciences Center School of Medicine - Permian Basin
Midland, TX

"To identify TD early, clinicians need to use the AIMS appropriately and administer it routinely. That may be the key (ie, screening routinely with the AIMS—not just when there is an elevated suspicion of TD)."

Rakesh Jain, MD, MPH

There are 2 basic methods involved in detecting TD. First, we rely on our powers of observation, and we elicit specific activation maneuvers. Second, we ask the patient whether they have noticed any symptoms since their last visit. So, for example, you might say something like, "Since I last saw you, have you noticed that your muscles are doing things that you do not intend for them to do?"  

Both observation and asking the patient or their family about abnormal movements are essential. The standard structured assessment for the initial screening and routine monitoring of TD symptoms is the AIMS, which was developed in 1976. To identify TD early, clinicians need to use the AIMS appropriately and administer it routinely. That may be the key (ie, screening routinely with the AIMS—not just when there is an elevated suspicion of TD).

It is important to maintain fidelity to the AIMS, including in eliciting patient and family reports. I will often ask patients, "When you are looking in the mirror, do you notice that your face does unusual things, such as your eyes blinking more than normal, or that your jaw, lips, or anything else move(s)?" If they respond "no," I might then ask, "How about when your mouth is closed? Do you find that your tongue is moving around in ways that you find unusual?" Affirmative answers to such questions could be an early indication of TD that might otherwise be missed if one is relying only on the clinical examination.

It is also important to capture TD in patients who lack insight into their condition. This is the critical element of the AIMS, which really allows for both a subjective and an objective examination. The AIMS has remained unaltered since its development. There is no AIMS 2.0, for example, because the original iteration was a near-perfect combination of subjective and objective ways to detect all severities of TD, regardless of the patient's level of insight. Some patients will have almost no insight, and they will not report symptoms of abnormal movement that, to others, are quite obvious. However, we also have patients who are highly functional and insightful, and these individuals may be able to report the development of TD symptoms months or even years in advance of the frank symptoms that might be recognized during an office visit. This underscores the importance of asking patients directly about these symptoms. Increasingly, TD is occurring in people with mood disorders, and many of these patients have great insight into their symptoms.

TD is genuinely a progressive illness in the vast majority of people. Its arrival is more like dawn than it is like a tornado, meaning that there is not a single precise moment in which one can say that it was dark out before, but now there is light. The problem with TD is that we often wait until high noon (ie, when the sun is out), so to speak, before we actually diagnose it. We want to help our patients minimize their impairment by catching TD earlier, and the best way to catch it and to follow it is the AIMS.

References

Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983. doi:10.4088/JCP.19cs12983

Citrome L, Saklad SR. Revisiting tardive dyskinesia: focusing on the basics of identification and treatment. J Clin Psychiatry. 2020;81(2):TV18059AH3C. doi:10.4088/JCP.TV18059AH3C

Jain R, Correll CU. Tardive dyskinesia: recognition, patient assessment, and differential diagnosis. J Clin Psychiatry. 2018;79(2):nu17034ah1c. doi:10.4088/JCP.nu17034ah1c

Kane JM, Correll CU, Nierenberg AA, Caroff SN, Sajatovic M; Tardive Dyskinesia Assessment Working Group. Revisiting the Abnormal Involuntary Movement Scale: proceedings from the Tardive Dyskinesia Assessment Workshop. J Clin Psychiatry. 2018;79(3):17cs11959. doi:10.4088/JCP.17cs11959

Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 2020;177(9):868-872. doi:10.1176/appi.ajp.2020.177901

McEvoy JP. How to assess tardive dyskinesia symptom improvement with measurement-based care. J Clin Psychiatry. 2020;81(6):NU19047BR4C. doi:10.4088/JCP.NU19047BR4C

Saklad SR. Identifying tardive dyskinesia: risk factors, functional impact, and diagnostic tools. J Clin Psychiatry. 2020;81(1):TV18059BR1C. doi:10.4088/JCP.TV18059BR1C

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