What is the next step for a patient experiencing mouth movement and teeth grinding while on Abilify (aripiprazole) 15mg?

Management of Aripiprazole-Induced Movement Disorder

The next step is to immediately discontinue aripiprazole 15mg and initiate anticholinergic therapy with benztropine 1-2 mg IM/IV or diphenhydramine 25-50 mg IM/IV for acute symptom control, as these mouth movements and teeth grinding represent drug-induced extrapyramidal symptoms (EPS) that require prompt intervention. 1

Immediate Assessment and Intervention

• Document baseline abnormal movements using the Abnormal Involuntary Movement Scale (AIMS) to establish severity and track response to treatment 1, 2
• Administer anticholinergic agents promptly for acute dystonic reactions: benztropine 1-2 mg IM/IV or diphenhydramine 25-50 mg IM/IV 1
• Rule out other serious conditions including serotonin syndrome by checking for hyperthermia, rigidity, autonomic instability, and altered mental status 1

The symptoms described—involuntary mouth movements and teeth grinding (bruxism)—are characteristic of tardive dyskinesia or acute dystonic reactions, both well-documented complications of aripiprazole despite its atypical antipsychotic profile 3, 4. While aripiprazole's partial D2 agonism theoretically reduces EPS risk compared to conventional antipsychotics, it remains a dopamine receptor-blocking agent capable of causing movement disorders 3, 4.

Medication Management Strategy

Discontinue aripiprazole immediately if clinically feasible, as withdrawal is the primary treatment for drug-induced dyskinesia 2

If Psychiatric Treatment Must Continue:

• Consider switching to medications with lower movement disorder risk such as quetiapine or clozapine if antipsychotic therapy is essential 2
• Avoid reintroducing aripiprazole and document this adverse reaction prominently in the medical record to prevent future re-challenge 1

Alternative Pharmacological Options:

If the original indication was depression or anxiety rather than psychosis:

• Switch to non-dopaminergic antidepressants such as bupropion or mirtazapine to avoid EPS recurrence 1
• Consider fluoxetine or citalopram as alternative SSRIs if serotonergic therapy is needed, though citalopram requires caution at doses >40 mg/day due to QT prolongation risk 1

Specific Treatment for Persistent Symptoms

For Bruxism (Teeth Grinding):

• Mirtazapine has demonstrated efficacy for treatment-resistant bruxism, with symptom resolution typically within 3 weeks 5
• Traditional agents (L-dopa, gabapentin, clonazepam, clonidine, baclofen, buspirone, propranolol) are often ineffective for drug-induced bruxism 5

For Orofacial Dyskinesia:

• Low-dose aripiprazole (3 mg/day) paradoxically improved tardive oromandibular dystonia in one case report, though this approach is controversial and should only be considered if symptoms persist after discontinuation and other treatments fail 6
• Sodium channel blockers (carbamazepine 50-200 mg/day or oxcarbazepine 75-300 mg/day) achieve complete remission in >85% of paroxysmal kinesigenic dyskinesia cases, though this is typically for genetic rather than drug-induced forms 7

Monitoring and Follow-Up

• Reassess every 3-6 months using standardized AIMS scoring for any persistent movement abnormalities 1, 2
• Early detection is crucial as tardive dyskinesia may persist even after medication discontinuation in some cases 2
• Serial AIMS assessments after discontinuation are recommended to monitor for covert dyskinesia, which can emerge 2-4 months after stopping aripiprazole 4

Critical Pitfalls to Avoid

Do not continue aripiprazole while "monitoring" symptoms—this is a medication-induced adverse effect requiring immediate discontinuation 1, 2. Aripiprazole is notably associated with covert dyskinesia that emerges after discontinuation and may persist, making it the atypical antipsychotic most commonly reported with this complication 4. The unique partial D2 agonist mechanism does not protect against movement disorders and may actually increase risk through complex receptor dynamics 4.

Do not assume symptoms will resolve quickly—while some acute dystonic reactions respond rapidly to anticholinergics, tardive phenomena may take weeks to months to improve or may become permanent 2, 4.