Instructional Tutorial Video
Instructional Tutorial Video
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- Extrapyramidal Side Effects (EPS)
There are four commonly tested extrapyramidal side effects of antipsychotics on the licensing exams of Canada (MCCEE, MCCQE) and the United States (USMLE).
Those extrapyramidal side effects are:
Acute Dystonia is an extrapyramidal movement disorder that occurs in the first few hours or days of treatment with an antipsychotic medication. Patients develop muscle spasms or stiffness (e.g., torticollis, trismus), tongue protrusions and twisting, opisthotonos (great rigid spasm of the body, with the back fully arched and the heels and head bent back), and oculogyric crisis (forced sustained deviation of the head and eyes).
Treat with antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine, trihexyphenidyl). Benztropine is often given as an IM injection.
Akathisia occurs in the first few days of treatment. The patient has a subjective feeling of restless and may pace constantly, alternate sitting and standing, and be unable to sit still.
Treat with beta blockers or benzodiazepines (e.g., lorazepam).
Parkinsonism usually occurs in patients taking antipsychotics within the first few months of treatment. Parkinsonism is thought to develop because of dopamine depletion, whereas psychosis is thought to develop because of too much dopamine in the brain. Thus, antipsychotics create an iatrogenic lowering of effective dopamine in the brain by blocking dopamine receptors. The patient develops stiffness, cogwheel rigidity, shuffling gait, mask-like facies and drooling.
Treat with antihistamines (e.g., diphenhydramine) or anticholinergics (e.g., benztropine, trihexyphenidyl).
Tardive dyskinesia appears after years of treatment with antipsychotics. Most commonly the patient develops abnormal involuntary movements usually involve orofacial muscles. The perioral movements (darting, protruding movements of the tongue, chewing, grimacing, puckering). The patient also may have involuntary, choreoathetoid movements of the head, limbs and trunk.
There is no known treatment for tardive dyskinesia. Options are to discontinue the current antipsychotic and consider switching to clozapine or risperidone.
A 28-year-old man is placed on haloperidol after he is diagnosed with schizophrenia. A few days later his concerned mother brings him back to the psychiatrist because he is exhibiting strange movements. The physician observes movements that consist of sustained contractions and twisting motions of his limbs and trunk, with his eyes tonically deviated upward for several minutes. Which of the following adverse reactions is occurring in this patient?
D. Tardive dyskinesia
The correct answer is B. This patient is exhibiting dystonia, an acute extrapyramidal side effect that can be a consequence of neuroleptic therapy. Patients can develop tongue protrusions and twisting. Acute dystonic reactions generally occur within the first few days of the initiation of neuroleptic therapy, tend to occur more frequently in children and young adults, and occur in males more often than females. The sustained eye deviation described in the question is a form of dystonia called an oculogyric crisis. These reactions are reversible with antihistamines (e.g., diphenhydramine), anticholinergic drugs (e.g., benztropine), or diazepam. All of the other answer choices can also be consequences of neuroleptic therapy.
Akathisia (choice A) is an extrapyramidal syndrome characterized by a feeling of restlessness, frequent, repetitive stereotyped movements and an inability to sit still for more than a short period of time. It usually occurs during the first few months of drug use.
Parkinsonism (choice C), as the name implies, is similar to Parkinson's disease: mask-like facies, drooling, tremors, pill-rolling motion, cogwheel rigidity, and shuffling gait all may be present. Parkinsonism can be produced by neuroleptic drugs, usually beginning about three weeks after the initiation of therapy.
Tardive dyskinesia (choice D) is an often irreversible syndrome characterized by involuntary, choreoathetoid movements in patients treated with antipsychotic medications. The frequency of tardive dyskinesia increases with age and with the length of therapy. This disorder would be unlikely to occur within a few days of the initiation of drug therapy.
A 35-year-old man is brought to the emergency clinic by his mother because of an episode of slurred speech associated with the uncomfortable sensation that his tongue is thick and curling up. The episode started suddenly 30 minutes ago. The patient is noted to be holding on to his tongue with his thumb and forefinger. When asked about this, the patient responds with dysarthria, saying that his medication has caused this once before and that he needs a shot to make it go away. His mother reports that the patient has had schizophrenia for 10 years and consistently takes two medications prescribed by his psychiatrist. Several days ago he ran out of one of his medications, but has continued to take the other one. What is the most appropriate initial step in the management of this patient?
B. The patient is experiencing an acute dystonic reaction, which is a form of extrapyramidal side effect (EPS) associated with antipsychotic medications. Patients can develop tongue protrusions and twisting. These side effects are related to antagonism of dopamine receptors in the nigrostriatal pathway. The patient is likely taking a conventional antipsychotic agent plus a prophylactic anticholinergic agent (such as benztropine, diphenhydramine, or trihexyphenidyl). Upon stopping the anticholinergic, the dystonic reaction was more likely to occur. The appropriate initial management of this patient would include immediate IM administration of an anticholinergic agent, such as 2 mg of benztropine or 50 mg of diphenhydramine.
Alprazolam (choice A) is a short-acting, high-potency benzodiazepine commonly used for the short-term management of anxiety. It would not be the appropriate treatment for an acute dystonic reaction. Haloperidol (choice C) is a conventional high-potency antipsychotic agent that would be likely to cause EPS such as dystonia. It would make the dystonic reaction worse. Lorazepam (choice D) is, like alprazolam, a benzodiazepine. It is commonly used in the acute management of severe anxiety and agitation. It would not be appropriate in the management of acute dystonia.
A 64-year-old man is undergoing inpatient psychiatric treatment with haloperidol. After several days of therapy, the patient complains that he feels very restless and agitated and he cannot stop moving his legs. He paces constantly, sits and then stands, and is unable to sit still. Which of the following medications, if given during his initial regimen, might have best prevented this reaction?
B. This patient has evidence of akathisia, the feeling of restlessness that sometimes occurs as a reaction to use of neuroleptic medications, such as haloperidol. Prevention of akathisia is most reliably maintained by use of a benzodiazepine medication, such as lorazepam given during administration of the neuroleptic drug.
Chlorpromazine (choice A) is a neuroleptic medication that would exacerbate akathisia rather than prevent it. Paroxetine (choice C) and sertraline (choice D) are both antidepressant medications that are specific serotonergic reuptake inhibitors (SSRIs). These agents have no effect on the prevention of neuroleptic-induced akathisia.
A 54-year-old woman presents to her primary care physician for her routine yearly health maintenance examination. She denies any new problems. Her only significant medical history includes a 25-year history of schizophrenia, which has been well-controlled with antipsychotic agents, and a 5-year history of hypertension for which she takes a diuretic. Vital signs and physical examination are within normal limits. However, the patient is noted to have occasional irregular puckering and lip-smacking movements. She denies having noticed the abnormal movements, and her speech is normal. Which of the following is the most likely diagnosis?
A. Acute dystonia
C. Tardive dyskinesia
C. Tardive dyskinesia (TD) is a syndrome characterized by abnormal choreiform and athetoid movements occurring late in onset in relation to initiation of antipsychotic treatment. TD usually develops after months to years of treatment with antipsychotic agents, and is presumably much less likely to occur with the use of atypical antipsychotics. Risk factors for TD include older age, longer duration of antipsychotic treatment, and presence of an affective disorder. The abnormal involuntary movements usually involve orofacial muscles but may include the trunk and extremities. Regular examinations should be done to ensure that patients treated with these medications do not develop signs of TD.
Acute dystonia (choice A) is an abrupt reaction consisting of abnormal positioning or spasm of the muscles of the head, neck, limbs, or trunk. This form of extrapyramidal side effect (EPS) associated with antipsychotic medications can be terminated with administration of an anticholinergic agent. Akathisia (choice B) occurs in approximately 50% of patients taking conventional antipsychotic agents. This form of EPS consists of the experience of a subjective feeling of restlessness. Patients may rock, pace, tap, or move restlessly while sitting. This side effect may be confused with anxiety, agitation, tardive dyskinesia, or worsening of psychosis. Treatment includes reducing the antipsychotic dose, switching to another agent, and the use of beta-blockers or benzodiazepines. Parkinsonism (choice C), as the name implies, is similar to Parkinson's disease: mask-like facies, drooling, tremors, pill-rolling motion, cogwheel rigidity, and shuffling gait all may be present. Parkinsonism can be produced by neuroleptic drugs, usually beginning about three weeks after the initiation of therapy.Jul 21, 2015