What should be done for a patient with bipolar disorder experiencing shaking while on Abilify (aripiprazole)?

Evaluation and Management of Shaking in a Bipolar Patient on Abilify

Immediately assess whether this shaking represents extrapyramidal symptoms (EPS) from aripiprazole, which requires prompt evaluation and potential intervention, as EPS can occur even with atypical antipsychotics like Abilify and may necessitate dose reduction, anticholinergic treatment, or medication discontinuation. 1, 2

Clinical Assessment Algorithm

Step 1: Characterize the Movement Disorder

Determine the specific type of movement abnormality:

• Tremor characteristics: Assess whether this is a resting tremor, action tremor, or intention tremor, as the pattern helps differentiate between EPS, essential tremor, or other causes 2
• Dystonic movements: Look for sustained muscle contractions, abnormal postures, facial grimacing, tongue thrusting, or upper-limb athetosis, which are classic EPS presentations 2
• Akathisia: Evaluate for subjective inner restlessness with inability to sit still, pacing, or constant movement, as this is a common and distressing EPS that can be mistaken for anxiety or agitation 1
• Timing of onset: Document when symptoms began relative to aripiprazole initiation or dose changes, as EPS typically emerges within weeks of starting or increasing the dose 2

Step 2: Rule Out Serious Movement Disorders

Exclude neuroleptic malignant syndrome (NMS) - a potentially fatal complication that requires immediate recognition and intervention 1:

• Check for hyperpyrexia (elevated temperature)
• Assess for muscle rigidity
• Evaluate mental status changes
• Monitor for autonomic instability (irregular pulse/blood pressure, tachycardia, diaphoresis, cardiac dysrhythmia)
• Order creatine phosphokinase level if NMS suspected
• If NMS is present: Immediately discontinue aripiprazole, provide intensive symptomatic treatment and medical monitoring, and treat any concurrent serious medical problems 1

Assess for tardive dyskinesia - potentially irreversible involuntary movements that can develop even after brief treatment periods 1:

• Look for involuntary, dyskinetic movements particularly affecting the face, mouth, tongue, or extremities
• Note that tardive dyskinesia risk increases with duration of treatment and cumulative dose, but can occur after relatively brief treatment at low doses 1
• If tardive dyskinesia is suspected: Strongly consider aripiprazole discontinuation, as the syndrome may remit partially or completely if antipsychotic treatment is withdrawn 1

Step 3: Evaluate for Alternative Causes

Before attributing shaking solely to aripiprazole, systematically exclude:

• Metabolic derangements: Check thyroid function (hyperthyroidism), glucose levels (hypoglycemia), electrolytes (hypomagnesemia, hypocalcemia), and renal function 1
• Medication interactions: Review all concurrent medications for tremor-inducing agents (lithium, valproate, SSRIs, stimulants) or drugs that may interact with aripiprazole 3
• Substance use: Screen for caffeine excess, alcohol withdrawal, or illicit substance use 4
• Anxiety or agitation: Distinguish between physiologic tremor from anxiety versus medication-induced movement disorder, as anxiety itself is common in bipolar disorder 1

Management Strategy

For Confirmed EPS from Aripiprazole

First-line intervention: Administer anticholinergic medication for acute dystonic reactions or bothersome EPS 2:

• Diphenhydramine 25 mg orally every 6 hours provides rapid relief of dystonic symptoms and can be used as needed 2
• Symptoms typically resolve within 24 hours of anticholinergic administration 2
• Alternative agents include benztropine 1-2 mg orally twice daily for ongoing EPS management 4

Dose adjustment: Consider reducing aripiprazole dose, as lower doses may provide therapeutic benefit with fewer EPS 1:

• The FDA label emphasizes using "the smallest dose and the shortest duration of treatment producing a satisfactory clinical response" 1
• For bipolar disorder, effective doses range from 5-15 mg daily, so reduction from higher doses may be feasible 5

Medication discontinuation: If EPS persists despite anticholinergic treatment and dose reduction, or if tardive dyskinesia is suspected, discontinue aripiprazole and transition to an alternative mood stabilizer 1, 2:

• The American Academy of Child and Adolescent Psychiatry recommends lithium or valproate as first-line alternatives for bipolar disorder maintenance 3
• When switching, taper aripiprazole gradually while initiating the new agent to prevent mood destabilization 3

For Akathisia Specifically

If the shaking represents akathisia (inner restlessness with motor restlessness):

• Beta-blockers: Propranolol 10-30 mg two to three times daily is effective for akathisia 4
• Benzodiazepines: Low-dose lorazepam 0.5-1 mg as needed can provide symptomatic relief, though use cautiously to avoid dependence 4, 3
• Dose reduction: Lowering aripiprazole dose is often the most effective long-term strategy 1

Monitoring and Follow-Up

• Reassess within 24-48 hours after initiating anticholinergic treatment to evaluate response 2
• Document movement abnormalities using standardized scales (Abnormal Involuntary Movement Scale) to track progression or improvement 1
• Educate the patient and family about EPS symptoms and the importance of reporting new or worsening movements immediately 1
• Periodic reassessment of the need for continued aripiprazole treatment, as chronic antipsychotic use should be reserved for patients who require it and for whom safer alternatives are not available 1

Critical Pitfalls to Avoid

• Dismissing EPS as anxiety: Akathisia and other EPS are frequently misattributed to psychiatric symptoms rather than medication side effects, leading to inappropriate dose escalation that worsens the problem 1
• Continuing aripiprazole despite tardive dyskinesia: Unlike acute EPS, tardive dyskinesia may become irreversible if the offending agent is not discontinued promptly 1
• Failing to monitor for NMS: This rare but potentially fatal complication requires immediate recognition and aggressive intervention 1
• Overlooking drug interactions: Concurrent medications that affect dopamine or increase aripiprazole levels can precipitate or worsen EPS 3
• Inadequate patient education: Patients must understand that new movement symptoms require immediate medical attention, as early intervention improves outcomes 1, 2