Abnormal Involuntary Movement Scale (aims)

This scale was developed initially for use in patients suffering from schizophrenia who often developed TD while utilizing first-generation, typical antipsychotics. In some institutions it is considered the standard of care to perform this evaluation annually if the patient is on an antipsychotic, with the intention to detect TD in its early stages when it is less likely to become permanent

The risk for developing TD is the greatest for those who have accumulated the most days on active antipsychotic therapy. Furthermore, the elderly and those with affective disorder components are likely at greater risk

With the introduction of the second-generation atypical antipsychotics, it appears that the TD rates are lower, but as noted in the first two cases in this book, it is still possible to develop TD with use of atypical antipsychotics

Following is an example of how the AIMS scale is administered. Furthermore, it is scored objectively and can be used as a diagnostic tool and as an outcome measure to determine if TD is worsening or improving

Perhaps this scale should be more readily utilized with the increased use of atypical antipsychotics in non-schizophrenia-based illnesses

Aims instructions

1. Ask patient to remove shoes and socks

2. Ask patient if there is anything in his/her mouth (e.g., gum, candy); if there is, to remove it

3. Ask patient about the current condition of his/her teeth. Ask patient if he/she wears dentures. Do teeth or dentures bother the patient now?

4. Ask patient whether he/she notices any movements in mouth, face, hands, or feet. If yes, ask to describe and to what extent

They currently bother patient or interfere with his/her activities

5. Have patient sit in a chair with hands on knees, legs slightly apart, and feet flat on the floor

(Look at entire body for movements while in this position)

6. Ask patient to sit with hands hanging unsupported; if male, between legs, if female and wearing a dress, hanging over knees

(Observe hands and other body areas)

7. Ask patient to open mouth

(Observe tongue at rest in mouth)

Do this twice

8. Ask patient to protrude tongue

(Observe abnormalities of tongue movement)

Do this twice

9. Ask patient to tap thumb, with each finger, as rapidly as possible for 10–15 s; separately with right hand, then with left hand

(Observe facial and leg movements)

10. Flex and extend patient’s left and right arms (one at a time)

(Note any rigidity)

11. Ask patient to stand up

(Observe in profile. Observe all body areas again, hip included)

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Finally, many of the psychiatric medications that clinicians prescribe may cause abnormal movements

Clinicians most often think of TD but our antipsychotics may also induce dystonia or parkinsonism’s resting tremor

Antidepressants may induce a fine, intention tremor

Mood stabilizing, epilepsy medications may induce a similar tremor, dysarthria, ataxia, or dysmetria

Stimulant medications may also induce an intention tremor, but more prominently, may induce tic disorders

Part 3: Rating scale rant (a six-minute seminar now…) Treatment guidelines are numerous for MDD. The American Psychiatric Association’s guidelines suggest routine rating scale use in MDD. This case may be used to highlight some of their suggestions. The third edition American Psychiatric Association treatment guidelines for major depressive disorder of November 2010 also suggests

Maintain therapeutic alliance, complete a full axis I/II assessment (published prior to DSM-V), provide for patient safety, evaluate patient’s functional status and level of treatment acuity

Utilize outcome measures routinely

Coordinate care with all providers and include family members when possible; educate all parties

Foster appointment and medication adherence

Maximize monotherapy antidepressant for dose and duration of treatment

For partial response, consider augmentation with lithium, thyroid hormone, anticonvulsants, stimulants, second-generation antipsychotics (atypical antipsychotics)

Utilize depression-focused psychotherapies such as CBT, IPT, problem-solving psychotherapy

There are several full treatment guidelines that may be reviewed for further information. Most guidelines suggest the approaches simplified here.

These guidelines become very specific with regard to the management of depressive disorder in the acute phase, continuation phase, and after remission occurs.

It is also important to consider how long the patient has been depressed, how many depressive episodes the patient has been through, and if they have been suicidal.

This type of patient history is important when considering how aggressively to treat a patient with psychotropic medication. In general, mild depression is treated with psychotherapy whereas more moderate to severe depression and recurrent or chronic depression is more often treated with medications, psychotherapy, or both modalities.

Generally speaking, the longer a patient has been depressed, the more recurrences they have, and the more medications they have taken, the more likely they are to be considered to have more TRD. In these cases, once remission is obtained, the medication regimen is often continued over the long term, as a recurrence or relapse is highly probable.