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extrapyramidal symptoms
Extrapyramidal symptoms (EPS), also known as extrapyramidal side effects (EPSE), are drug induced movement disorders that include acute and tardive symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity, bradykinesia, and tremor), and tardive dyskinesia (irregular, jerky movements). 〔Pierre, JM. Extrapyramidal symptoms with atypical antipsychotics : incidence, prevention and management. Drug Safety 2005; 28(3): 191-208 〕 Antipsychotics are often discontinued due to inefficacy or intolerable side effects such as extrapyramidal symptoms. 〔 Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia. Jeffrey A. Lieberman, M.D., T. Scott Stroup, M.D., M.P.H., Joseph P. McEvoy, M.D., Marvin S. Swartz, M.D., Robert A. Rosenheck, M.D., Diana O. Perkins, M.D., M.P.H., Richard S.E. Keefe, Ph.D., Sonia M. Davis, Dr.P.H., Clarence E. Davis, Ph.D., Barry D. Lebowitz, Ph.D., Joanne Severe, M.S., and John K. Hsiao, M.D. for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. N Engl J Med 2005; 353:1209-1223 September 22, 2005DOI: 10.1056/NEJMoa051688 〕
Since it is difficult to measure extrapyramidal symptoms, rating scales are commonly used to assess the severity of movement disorders. The Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), Abnormal Involuntary Movement Scale (AIMS), and Extrapyramidal Symptom Rating Scale (ESRS) are rating scales frequently used for such assessment and are not weighted for diagnostic purposes. 〔
==Causes==
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that antagonize dopamine D2 receptors. 〔 The most common typical antipsychotics associated with EPS are haloperidol and fluphenazine. 〔 Nevena Divac, Milica Prostran, Igor Jakovcevski, and Natasa Cerovac, “Second-Generation Antipsychotics and Extrapyramidal Adverse Effects,” BioMed Research International, vol. 2014, Article ID 656370, 6 pages, 2014. doi:10.1155/2014/656370 〕 Atypical antipsychotics have lower D2 receptor affinity or higher serotonin 5-HT2A receptor affinity which lead to lower rates of EPS. 〔 Correll C. Mechanism of Action of Antipsychotic Medications. J Clin Psychiatry 2014;75(9):e23 〕 However, some research has shown that atypical antipsychotics are just as likely as conventional antipsychotics to cause EPS. 〔
Other anti-dopaminergic drugs, like the antiemetic metoclopramide, can also result in extrapyramidal side effects. 〔 Moos, DD., Hansen, DJ. Metoclopramide and Extrapyramidal Symptoms: A Case Report. Journal of PeriAnesthesia Nursing Volume 23, Issue 5, October 2008, Pages 292–299 〕 Short and long-term use of antidepressants such as selective serotonin reuptake inhibitors (SSRI), serotonin-norepinephrine reuptake inhibitors (SNRI), and norepinephrine-dopamine reuptake inhibitors (NDRI) have also resulted in EPS. 〔 Madhusoodanan S, Alexeenko L, Sanders R, Brenner R. Extrapyramidal symptoms associated with antidepressants—A review of the literature and an analysis of spontaneous reports. Annals of Clinical Psychiatry 2010;22(3):148-156 〕 Specifically, duloxetine, sertraline, escitalopram, fluoxetine, and bupropion have been linked to the induction of EPS. 〔 Other causes of extrapyramidal symptoms can include brain damage and meningitis. 〔 Ori Scott, Simona Hasal, and Helly R. Goez. Basal Ganglia Injury With Extrapyramidal Presentation: A Complication of Meningococcal Meningitis. J Child Neurol November 2013 28: 1489-1492, first published on September 10, 2012 doi:10.1177/0883073812457463 〕 〔 P. Adnet, P. Lestavel, and R. Krivosic‐Horber. Neuroleptic malignant syndrome. Br. J. Anaesth. (2000) 85 (1): 129-135 doi:10.1093/bja/85.1.129 〕
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