Extrapyramidal symptoms
Encyclopedia
The extrapyramidal system
can be affected in a number of ways, which are revealed in a range of extrapyramidal symptoms (EPS), also known as extrapyramidal side-effects (EPSE), such as akinesia (inability to initiate movement) and akathisia
(inability to remain motionless).
Extrapyramidal symptoms
(EPS) are various movement disorder
s such as acute dystonic reactions
, pseudoparkinsonism, or akathisia
suffered as a result of taking dopamine antagonist
s, usually antipsychotic
(neuroleptic) drugs
, which are often used to control psychosis
.
The Simpson-Angus Scale (SAS) and the Barnes Akathisia Rating Scale (BARS) are used to measure extrapyramidal symptoms.
Extrapyramidal symptoms are also usually present in patients with neuroleptic malignant syndrome
.
used especially in schizophrenia
. Other antidopaminergic drugs like the antiemetic
metoclopramide
or the tricyclic antidepressant
amoxapine
can also cause extrapyramidal side-effects.
Extrapyramidal symptoms can also be caused by brain damage, as in athetotic cerebral palsy
, which is involuntary writhing movements caused by prenatal or perinatal brain damage.
drugs are used to control neuroleptic-induced EPS, although akathisia
may require beta blocker
s or even benzodiazepine
s. If the EPS are induced by an antipsychotic
, EPS may be reduced by dose titration or by switching to an atypical antipsychotic
, such as aripiprazole
, ziprasidone
, quetiapine
, olanzapine
, risperidone
, or clozapine
. These medications possess an additional mode of action that is believed to negate their effect on the nigrostriatal pathway, which means they are associated with fewer extrapyramidal side-effects than "conventional" antipsychotics (chlorpromazine
, haloperidol
, etc.).
Commonly used medications for EPS are benztropine
(Cogentin), diphenhydramine
(Benadryl), and trihexyphenidyl
(Artane).
Extrapyramidal system
In human anatomy, the extrapyramidal system is a neural network located in the brain that is part of the motor system involved in the coordination of movement. The system is called "extrapyramidal" to distinguish it from the tracts of the motor cortex that reach their targets by traveling through...
can be affected in a number of ways, which are revealed in a range of extrapyramidal symptoms (EPS), also known as extrapyramidal side-effects (EPSE), such as akinesia (inability to initiate movement) and akathisia
Akathisia
Akathisia, or acathisia, is a syndrome characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless...
(inability to remain motionless).
Extrapyramidal symptoms
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
(EPS) are various movement disorder
Movement disorder
Movement disorders include:* Akathisia * Akinesia * Associated Movements * Athetosis...
s such as acute dystonic reactions
Dystonia
Dystonia is a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. The disorder may be hereditary or caused by other factors such as birth-related or other physical trauma, infection, poisoning or reaction to...
, pseudoparkinsonism, or akathisia
Akathisia
Akathisia, or acathisia, is a syndrome characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless...
suffered as a result of taking dopamine antagonist
Dopamine antagonist
A dopamine antagonist is a drug which blocks dopamine receptors by receptor antagonism. There are five known types of dopamine receptors in the human body; they are found in the brain, peripheral nervous system, blood vessels, gastrointestinal tract and the kidney.-Uses and examples:* Used as...
s, usually antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
(neuroleptic) drugs
Medication
A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...
, which are often used to control psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
.
The Simpson-Angus Scale (SAS) and the Barnes Akathisia Rating Scale (BARS) are used to measure extrapyramidal symptoms.
Extrapyramidal symptoms are also usually present in patients with neuroleptic malignant syndrome
Neuroleptic malignant syndrome
Neuroleptic malignant syndrome is a life- threatening neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs...
.
Causes
The most common antipsychotic associated with EPS is haloperidolHaloperidol
Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines....
used especially in schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
. Other antidopaminergic drugs like the antiemetic
Antiemetic
An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics, and chemotherapy directed against cancer....
metoclopramide
Metoclopramide
Metoclopramide is an antiemetic and gastroprokinetic agent. It is commonly used to treat nausea and vomiting, to facilitate gastric emptying in people with gastroparesis, and as a treatment for the gastric stasis often associated with migraine headaches.-Medical uses:Metoclopramide is commonly...
or the tricyclic antidepressant
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
amoxapine
Amoxapine
Amoxapine is a tetracyclic antidepressant of the dibenzoxazepine family, though it is often classified as a secondary amine tricyclic antidepressant.- Uses :...
can also cause extrapyramidal side-effects.
Extrapyramidal symptoms can also be caused by brain damage, as in athetotic cerebral palsy
Cerebral palsy
Cerebral palsy is an umbrella term encompassing a group of non-progressive, non-contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement....
, which is involuntary writhing movements caused by prenatal or perinatal brain damage.
Conditions
- Acute dystonic reactionsDystoniaDystonia is a neurological movement disorder, in which sustained muscle contractions cause twisting and repetitive movements or abnormal postures. The disorder may be hereditary or caused by other factors such as birth-related or other physical trauma, infection, poisoning or reaction to...
: muscular spasms of neck – torticollisTorticollisTorticollis, or wryneck, is a stiff neck associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature...
, eyes – oculogyric crisisOculogyric crisisOculogyric crisis is the name of a dystonic reaction to certain drugs or medical conditions. The term "Oculogyric" refers to rotating of eyeballs, but several other responses are associated with the crisis.-Causes:...
, tongue, or jaw; more frequent in children - AkathisiaAkathisiaAkathisia, or acathisia, is a syndrome characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless...
: A feeling of motor restlessness - Pseudoparkinsonism: drug-induced parkinsonismParkinsonismParkinsonism is a neurological syndrome characterized by tremor, hypokinesia, rigidity, and postural instability. The underlying causes of parkinsonism are numerous, and diagnosis can be complex...
(muscular lead-pipe rigidity, bradykinesia/akinesia, resting tremor, and postural instability; more frequent in adults and the elderly). Although Parkinson's diseaseParkinson's diseaseParkinson's disease is a degenerative disorder of the central nervous system...
is primarily a disease of the nigrostriatal pathwayNigrostriatal pathwayThe nigrostriatal pathway is a neural pathway that connects the substantia nigra with the striatum. It is one of the four major dopamine pathways in the brain, and is particularly involved in the production of movement, as part of a system called the basal ganglia motor loop.Loss of dopamine...
and not the extrapyramidal system, loss of dopaminergic neurons in the substantia nigraSubstantia nigraThe substantia nigra is a brain structure located in the mesencephalon that plays an important role in reward, addiction, and movement. Substantia nigra is Latin for "black substance", as parts of the substantia nigra appear darker than neighboring areas due to high levels of melanin in...
leads to dysregulation of the extrapyramidal system. Since this system regulates posture and skeletal muscle tone, a result is the characteristic bradykinesia of Parkinson's. - Tardive dyskinesiaTardive dyskinesiaTardive dyskinesia is a difficult-to-treat form of dyskinesia that can be tardive...
: involuntary assymetrical movements of the muscles, this is a long term chronic condition assosiated with long term use of antipsychotics.
Treatment
AnticholinergicAnticholinergic
An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. An example of an anticholinergic is dicycloverine, and the classic example is atropine....
drugs are used to control neuroleptic-induced EPS, although akathisia
Akathisia
Akathisia, or acathisia, is a syndrome characterized by unpleasant sensations of inner restlessness that manifests itself with an inability to sit still or remain motionless...
may require beta blocker
Beta blocker
Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists, are a class of drugs used for various indications. They are particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction ,...
s or even benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
s. If the EPS are induced by an antipsychotic
Antipsychotic
An antipsychotic is a tranquilizing psychiatric medication primarily used to manage psychosis , particularly in schizophrenia and bipolar disorder. A first generation of antipsychotics, known as typical antipsychotics, was discovered in the 1950s...
, EPS may be reduced by dose titration or by switching to an atypical antipsychotic
Atypical antipsychotic
The atypical antipsychotics are a group of antipsychotic tranquilizing drugs used to treat psychiatric conditions. Some atypical antipsychotics are FDA approved for use in the treatment of schizophrenia...
, such as aripiprazole
Aripiprazole
Aripiprazole is an atypical antipsychotic and antidepressant used in the treatment of schizophrenia, bipolar disorder, and clinical depression...
, ziprasidone
Ziprasidone
Ziprasidone was the fifth atypical antipsychotic to gain FDA approval . In the United States, Ziprasidone is Food and Drug Administration approved for the treatment of schizophrenia, and the intramuscular injection form of ziprasidone is approved for acute agitation in schizophrenic patients...
, quetiapine
Quetiapine
Quetiapine , is an atypical antipsychotic approved for the treatment of schizophrenia, and bipolar disorder....
, olanzapine
Olanzapine
Olanzapine is an atypical antipsychotic, approved by the FDA for the treatment of schizophrenia and bipolar disorder...
, risperidone
Risperidone
Risperidone is a second generation or atypical antipsychotic, sold under the trade name . It is used to treat schizophrenia , schizoaffective disorder, the mixed and manic states associated with bipolar disorder, and irritability in people with autism...
, or clozapine
Clozapine
Clozapine is an antipsychotic medication used in the treatment of schizophrenia, and is also used off-label in the treatment of bipolar disorder. Wyatt. R and Chew...
. These medications possess an additional mode of action that is believed to negate their effect on the nigrostriatal pathway, which means they are associated with fewer extrapyramidal side-effects than "conventional" antipsychotics (chlorpromazine
Chlorpromazine
Chlorpromazine is a typical antipsychotic...
, haloperidol
Haloperidol
Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines....
, etc.).
Commonly used medications for EPS are benztropine
Benztropine
Benzatropine , also known as benztropine , is an anticholinergic marketed under the trade name Cogentin which is used in the treatment of Parkinson's disease, parkinsonism, akathisia, and dystonia.- Indications :...
(Cogentin), diphenhydramine
Diphenhydramine
Diphenhydramine hydrochloride is a first-generation antihistamine possessing anticholinergic, antitussive, antiemetic, and sedative properties which is mainly used to treat allergies. Like most other first-generation antihistamines, the drug also has a powerful hypnotic effect, and for this reason...
(Benadryl), and trihexyphenidyl
Trihexyphenidyl
Trihexyphenidyl , also known as benzhexol, is an antiparkinsonian agent of the antimuscarinic class. It has been in clinical usage for decades...
(Artane).