Extrapyramidal Side Effects From Medication

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Extrapyramidal side effects are a group of symptoms that can occur in people taking antipsychotic medications. Symptoms of extrapyramidal effects include an inability to sit still, involuntary muscle contraction, tremors, stiff muscles, and involuntary facial movements.

They are more commonly caused by typical antipsychotics, but can and do occur with any type of antipsychotic. Antidepressants and other medications can sometimes cause extrapyramidal side effects as well.

This article discusses the symptoms and causes of extrapyramidal side effects. It also covers how these effects are treated as well as some of the other side effects you may experience while taking antipsychotic medication.

Extrapyramidal Symptoms

Extrapyramidal function refers to our motor control and coordination, including being able to not make movements we don't want to make. Extrapyramidal side effects from medications are serious and may include:

Akathisia

Akathisia is a feeling of restlessness that makes it hard to sit down or hold still. Symptoms include tapping your fingers, rocking, and crossing and uncrossing your legs.

Research suggests that this side effect occurs in five to 36% of people who take antipsychotics.

Dystonia

Dystonia is when your muscles involuntarily contract and contort. This can lead to painful positions or movements. It is also potentially dangerous if it affects the muscles of the throat.

Symptoms of dystonia usually start within 48 hours of taking an antipsychotic. Dystonia can be treated with medications including drugs that are used to treat Parkinson's disease. Lowering the dose of the antipsychotic medication may also be helpful.

Certain risk factors make it more likely that dystonia will occur. Some of these risk factors include younger age, being of the male sex, having experienced dystonia in the past, and recent cocaine use.

Because certain risk factors play such a strong role, prevalence estimates vary widely from between 2% to as high as 90% depending on which risk factors are present.

Parkinsonism

Parkinsonism means you have the same symptoms as someone with Parkinson's disease, but your symptoms are caused by medications, not by the disease. These symptoms may include tremors, slower thought processes, slower movements, rigid muscles, difficulty speaking, and facial stiffness.

Such symptoms often begin gradually after you start taking your medication and may be worse if you are taking a higher dosage of antipsychotic medication. These symptoms will eventually fade on their own, but your doctor may also recommend lowering your medication dosage or switching to a different type of antipsychotic drug.

Research has found that among people who experienced parkinsonism, 3.3 cases per 100,000 were associated with drug-induced causes. Typical antipsychotics were the most common cause. These symptoms were more common in women and the risk of experiencing parkinsonism increases with age.

Tardive Dyskinesia

Tardive dyskinesia is when you have uncontrollable facial movements such as sucking or chewing, lip-smacking, sticking your tongue out, or blinking your eyes repeatedly. There are two different subtypes of tardive dyskinesia.

  • Tardive dystonia, which is a more severe and persistent form of dystonia that often affects the neck and torso.
  • Persistent akathisia, which involves rocking and movements of the arms and legs. Such symptoms are longer-lasting and present for at least one month or more after taking the same medication and dose.

This extrapyramidal symptom does not appear until you have been taking the medication for at least six months, and the symptoms may continue even after treatment.

The risk of this side effect may vary depending on the type of medication you are taking. Increased use of second-generation antipsychotics is believed to have reduced the incidence of tardive dyskinesia. However, some estimates suggest that approximately 15 to 20% of people who take antipsychotics develop tardive dyskinesia.

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome is a condition that affects the nervous system that can occur as a reaction to antipsychotic drugs. It leads to symptoms such as muscle stiffness and high fever.

It is rare and potentially life-threatening, occurring in less than one per 1000 people who take antipsychotic medications. While serious, it can be treated with medication.

Recap

Extrapyramidal effects impact your coordination and motor control. Some of these effects include akathisia, dystonia, parkinsonism, tardive dyskinesia, and neuroleptic malignant syndrome.

Diagnosis of EPS

The diagnosis of extrapyramidal symptoms often takes place when family members begin to notice that you are having difficulties. For this reason, it is important that the people close to you are aware of the potential for these effects and what to watch out for. 

During your evaluation, your doctor may want to speak to your family members about the type of symptoms they have observed. 

Your healthcare provider may also use a scale to help evaluate the symptoms you are experiencing and their severity. Examples of scales that your doctor might use include the Extrapyramidal Symptoms Rating Scale (ESRS) or the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS).

Causes of Extrapyramidal Side Effects

Antipsychotic medications work by blocking the actions of dopamine. Extrapyramidal effects are the result of this dopamine blockage or depletion in the basal ganglia.

Dopamine is a neurotransmitter that is known for its role in mood and addiction. It also plays a part in medical conditions such as schizophrenia. Excessive dopamine activity is believed to play a part in schizophrenia, resulting in symptoms such as disordered thinking. By blocking the action of dopamine, antipsychotics are able to help relieve symptoms of psychotic disorders.

Typical antipsychotics are the first generation of antipsychotics and are more likely to have extrapyramidal side effects. The U.S. Food and Drug Administration (FDA) has approved these typical antipsychotics:

  • Compazine (prochlorperazine)
  • Haldol (haloperidol)
  • Inapsine (droperidol)
  • Loxitane (loxapine)
  • Mellaril (thioridazine)
  • Navane (thiothixene)
  • Orap (pimozide)
  • Prolixin (fluphenazine)
  • Stelazine (trifluoperazine)
  • Thorazine (chlorpromazine)
  • Trilafon (perphenazine)

Recap

Extrapyramidal side effects are caused by the dopamine-blocking actions of antipsychotic medications. Typical antipsychotics, also known as first-generation antipsychotics, are the medications that most commonly produce these effects.

Treatment for Extrapyramidal Side Effects

Treatment of these symptoms depends upon the medication that induced them and which symptoms you have.

Your doctor may try decreasing your dose or switching your medication altogether to one that has been shown to have fewer extrapyramidal side effects.

Benzodiazepines are sometimes prescribed to help counteract extrapyramidal side effects, as are anti-parkinsonism drugs called anticholinergics. Antipsychotics block dopamine, which is what causes the extrapyramidal side effects in the first place. Anticholinergics increase dopamine so it becomes leveled out in your system.

Atypical Antipsychotics

Atypical antipsychotics are the newer second-generation of antipsychotics. If you are experiencing extrapyramidal side effects on one of the older, typical antipsychotics, your doctor may switch you to one of these. FDA-approved atypical antipsychotics include:

  • Abilify (aripiprazole)
  • Clozaril (clozapine)
  • Fanapt (iloperidone)
  • Geodon (ziprasidone)
  • Invega (paliperidone)
  • Risperdal (risperidone)
  • Saphris (asenapine)
  • Seroquel (quetiapine)
  • Zyprexa (olanzapine)

Recap

Extrapyramidal side effects can be treated with medication, but lowering the dosage of your medication or switching to a different antipsychotic medication can also be helpful.

Other Side Effects

Antipsychotic medications can produce other side effects as well. You should always talk to your doctor about these potential side effects and be aware of what you should do if you experience any serious side effects from your medication.

Typical Antipsychotics

Beyond extrapyramidal side effects, these are the most common side effects of typical antipsychotics:

  • Blurred vision
  • Diarrhea or constipation
  • Difficulty sleeping
  • Drowsiness and feeling sleepy
  • Dry mouth
  • Feeling agitated
  • Feeling like your mind has slowed down
  • Heartburn
  • Hypotension, which is when your blood pressure suddenly drops
  • Menstrual abnormalities
  • Sexual difficulties
  • Upset stomach
  • Vomiting

These effects may go away in time, but if they don't or you find them bothersome, be sure to contact your doctor.

Atypical Antipsychotics

Other than extrapyramidal side effects, these are the most common side effects of atypical antipsychotics:

  • Constipation
  • Difficulty sleeping
  • Dizziness
  • Drooling
  • Drowsiness
  • Faster heartbeat
  • Headache
  • Higher body temperature
  • Problems urinating
  • Rash
  • Stuffy nose or a runny nose

These effects may go away in time, but if they don't or you find them bothersome, be sure to contact your doctor.

Recap

Antipsychotics can also produce a range of other side effects beyond extrapyramidal side effects. 

Should You Discontinue Your Medication?

If you do experience extrapyramidal symptoms, you might wonder if you should stop taking your medication. If you are having such symptoms, you should start by talking to your doctor. Often the only way to address extrapyramidal effects is to try different drugs, to try lower doses of the medication, or to switch to another medication. 

Depending on what type of antipsychotic drug you are taking, your doctor may also prescribe other medications to help treat the extrapyramidal side effects.

Determining whether you continue your medication is often a process of weighing the benefits of the drug and the risks of no longer taking it against the severity and effects of your extrapyramidal symptoms. You may choose to live and cope with some side effects rather than risk losing the benefits of the medication. This is a decision that you should only make by talking to your doctor.

Never stop taking your medication or reduce your dosage on your own. Discontinuing your medication may cause symptoms of your condition to return or worsen. 

If your extrapyramidal symptoms are severe, you may work with your doctor to find another treatment option that will work for you.

A Word From Verywell

Discontinuing medication without consulting your doctor can lead to complications and side effects. If you are experiencing any troubling side effects from your medication, consult your doctor to discuss the next steps. Your doctor can recommend options that can treat and reduce extrapyramidal symptoms.

Frequently Asked Questions

  • What drugs cause extrapyramidal side effects?

    Typical antipsychotics are the most frequent cause of drug-induced extrapyramidal side effects. However, these side effects can occur with any type of antipsychotic. Some other types of medications can also cause extrapyramidal symptoms including antidepressants and lithium.

  • What is the medical condition EPS?

    EPS stands for extrapyramidal symptoms, which are also referred to as drug-induced movement disorders. EPS is a common adverse effect when taking agents that block dopamine receptors. EPS symptoms can include parkinsonism, dystonia, and akathisia.

  • How can I manage my extrapyramidal symptoms?

    You should always ask your healthcare provider for help managing your extrapyramidal symptoms. Your doctor may recommend a lower dose or a different medication to help minimize these side effects. In some cases, they may prescribe medications that can help you cope such as benzodiazepines and anticholinergics. Never alter your dose or stop taking your medications without talking to your doctor.

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