Using motivational interviewing to talk about tardive dyskinesia (TD)

Using motivational interviewing to talk about tardive dyskinesia (TD)

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When I first speak to my adult patients about tardive dyskinesia, or TD, I’ll start the conversation by asking them, “Do you notice any abnormal body movements you can’t control?” Many patients will say that they’re not aware of any involuntary movements. Patients may answer your questions about their general well-being, but they may not be talking specifically about how TD is affecting them. I think it’s really tough for them to acknowledge that there’s something wrong. They often don’t talk about their involuntary movements because they’ve become used to them. Think about it. If you hurt your leg and you weren’t able to run. At first, it might really bother you—but after a few years, you’d get used to it. Patients aren’t any different. So, I’ve started to look at TD from the patient’s point of view. Today, I’m going to share some of my tips for using an established technique called motivational interviewing—an evidence-based practice often used for conditions such as substance abuse. Using this technique to talk about TD has helped me have more productive conversations with the goal of getting patients to acknowledge symptoms and consider treatment options. I’m Bryce Reynolds. I’m a psychiatrist, currently working with an ACT team based in Durham, North Carolina. I treat patients who have serious mental illnesses, such as schizophrenia, schizoaffective disorder, and bipolar disorder. About ninety percent of my patients are on first- or second-generation antipsychotics, which means that they’re at risk of developing TD. In order to have better conversations with my patients, I needed to figure out a way to get them to recognize that they have involuntary movements, how the movements may be impacting them, and that there are available treatment options. As I mentioned earlier, I started using the established technique of motivational interviewing. Once the patient acknowledges they have TD and how it affects them, and they are given complete control of their treatment decision—then we can get to work. Patients are first given an antipsychotic medication to treat the underlying condition, such as schizophrenia, schizoaffective disorder, and bipolar disorder. These antipsychotics may cause TD. It’s tough enough to get someone to agree to take a medication to treat their underlying condition in the first place. Then, if a problem arises after patients start antipsychotic treatment, it can be hard for them to accept taking another medication. I’ll start the conversation by first asking about their involuntary movements. Are they aware of them? Where are they located? Then I start using motivational techniques. The conversation will focus on how TD makes the patient think, feel, and act. First, I want to know what the patient is thinking. I’ll set up the conversation in terms of when they initially noticed their involuntary movements. I’ll ask, “When you first got these movements, how did they make you think?” And what I typically get is, “I thought they were strange.” Almost always, the patient’s first thought is to stop taking their antipsychotic medication. I usually say, “I can understand that, but I commend you for not stopping your medication because it’s not likely to reduce your TD.” Second, I want to know how they’re feeling. I’ll simply ask, “How do the movements make you feel?” Patients often feel stigmatized; they feel different. They feel aware that they have a mental illness. I’ll also say, “Have other people noticed the movements?” One of my patients was once asked, “What is wrong with you?” I don’t think the person asking that was trying to be mean, but they just didn’t understand what was happening. Obviously, the question made my patient feel uncomfortable and embarrassed. For the third part of the interview, I try to uncover the impact of TD. I usually ask, “How do the movements make you act?” A lot of patients say it doesn’t change anything for them. But as you discuss it, they soon realize that TD does have an effect. Usually, they’re not socializing as much. I had one patient who wouldn’t date. She was embarrassed by her movements. Another patient didn’t go after her career goals because she thought she wouldn’t be able to do the work. When I first speak to my patients about their involuntary movements and a possible treatment, most of them have turned down the additional medication. Immediately, they say, “no.” But what you need to do is ask the patient, “What’s holding you back from taking medication for your TD?” They’re going to question, “Is it safe for me? What side effects will I get? Is it easy to take? What can I expect from it?” You have to work with them through these questions. The more information that you provide about the treatment, the more comfortable they’ll be with adding another medication. It’s important to give the control back to the patient. Then they have the power to make the right decision for themselves. Providers often think that a medicine specifically indicated for the treatment of adults with TD would offer benefits that should be obvious to patients but some patients are still trying to fully understand what TD is. So, I take a step back. When the patient acknowledges their TD and how it affects them, the next step is to agree to a trial of the medication. I give the patient full control during that test period. If the medication doesn’t work, they can let me know at any time and we will reassess. But if they decide that the treatment is reducing their involuntary movements, then I’m going to ask them to consider continuing it. Again, I find that once you give control back to the patient, they usually make the right decision for themselves. In addition to doing a proper assessment for the movements of TD, a conversation using these motivational interviewing techniques takes a few minutes. That’s it. It may take a few extra minutes to discuss the specific attributes of the TD treatment and for the patient to get comfortable with a trial of the medication. Overall, you can have the whole conversation in five minutes. I consider the conversation to be successful when my patient acknowledges their TD and how it affects them, and understands that they are in complete control of their treatment decision. When my patients first say “no” to treatment, I go back to my motivational interviewing techniques to help them acknowledge their TD movements. Within 5 minutes of beginning the motivational interview, my patients will often change their mind and say, “yes.” A few minutes spent using these motivational interviewing techniques can have a big impact with a patient considering their treatment options.

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