Extrapyramidal Side Effects From Medication

Extrapyramidal side effects are a group of movement-related symptoms that can occur when taking certain drugs and can include involuntary muscle contractions, stiff muscles, and tremors. These effects are more commonly associated with antipsychotic medications but can also occur with other types of medications and some illegal drugs.

If you're concerned about extrapyramidal side effects in yourself or someone you love, it is helpful to learn the symptoms to watch for and what causes them to occur. We also discuss how these effects can be treated, along with some of the other side effects that may be experienced when taking antipsychotic medications.

Extrapyramidal Side Effects or Symptoms

The extrapyramidal system is responsible for regulating involuntary movements, like when our foot kicks up after tapping below the knee. Some medications can affect this system's function, leading to a variety of extrapyramidal side effects or symptoms. Here are several to watch for.

Akathisia

Akathisia is a feeling of restlessness that makes it hard to sit down or hold still. Research suggests that this side effect occurs in roughly 19.5% of people who take antipsychotics, but can vary between 3.5% and 57% depending on the medication prescribed.

Akathisia symptoms generally involve movements that occur below the hips. This can include pacing, marching in place, rocking while standing, and crossing and uncrossing your legs.

Dystonia

With dystonia, muscles involuntarily contract and contort. This can lead to painful positions or movements and is potentially dangerous if it affects the muscles of the throat. Between 1.4% and 15.3% of individuals taking second-generation antipsychotics experience this extrapyramidal symptom.

Dystonia usually starts within 96 hours of taking an antipsychotic drug. Certain risk factors may make it more likely that these contractions or contortions occur. They include being younger, being male, experiencing dystonia in the past, and recent cocaine use.

Parkinsonism

Parkinsonism involves having Parkinson's disease symptoms but is caused by medications and not the disease. Drug-induced parkinsonism symptoms can include tremors, rigid muscles, slow movement and speed, and postural reflex impairment.

These extrapyramidal symptoms often appear gradually after starting a medication and may be worse when taking a higher dose. They do eventually fade on their own, but may also be reduced by lowering the medication dosage or switching to a different type of antipsychotic drug.

Research has found that 3.3 per 100,000 cases of parkinsonism are induced by drugs, with typical antipsychotics being the most common cause. Additionally, these symptoms are more common in women and the risk of experiencing them increases with age.

Tardive Dyskinesia

Tardive dyskinesia is characterized by uncontrollable facial movements such as sucking, chewing, lip-smacking, sticking the tongue out, or blinking repeatedly. There are two 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, tends to be longer-lasting, and is present for at least one month or more after taking the same medication and dose.
  

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 this category of effects.

Neuroleptic Malignant Syndrome

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

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

Diagnosis of EPS

The diagnosis of extrapyramidal symptoms (EPS) often takes place after family members begin to notice that the person taking antipsychotic drugs is having difficulties. For this reason, it is important that loved ones are aware of the potential for these effects and know what to watch out for. 

If you are being evaluated for EPS, your care provider may want to speak to family members about the type of symptoms they have observed. They may also use a scale to help evaluate the symptoms you are experiencing and their severity.

Two scales used to help diagnose extrapyramidal symptoms include:

• Extrapyramidal Symptoms Rating Scale (ESRS)
• Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS)

Causes of Extrapyramidal Side Effects

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

Dopamine is known for its role in mood and addiction. Excessive dopamine activity is believed to play a part in schizophrenia development. By blocking the action of dopamine, antipsychotics can help relieve symptoms of psychotic disorders.

Typical antipsychotics are the first generation of antipsychotics and more likely to have extrapyramidal side effects. They include:

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

Treatment for Extrapyramidal Side Effects

Treatment of these extrapyramidal symptoms depends upon the medication that induced them and the symptoms experienced. Benzodiazepine drugs are sometimes prescribed to help counteract extrapyramidal side effects. So are anti-parkinsonism drugs called anticholinergics, which increase dopamine.

Your physician may also try decreasing your dose or switching your medication altogether to one that has been shown to have fewer extrapyramidal side effects. Alternative medications include atypical antipsychotics.

Atypical Antipsychotics

Atypical antipsychotics are a newer second-generation of antipsychotics. If you are experiencing extrapyramidal side effects on one of the older, typical antipsychotics, your physician may switch you to one of these.

Atypical antipsychotics include:

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

Other Antipsychotic Side Effects

Antipsychotic medications can produce other side effects as well. Always talk to your care provider 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, the most common side effects of typical antipsychotics include:

• Blurred vision
• Drowsiness and feeling sleepy, or trouble sleeping
• Dry mouth
• Feeling agitated
• Feeling like your mind has slowed down
• Gastrointestinal issues (heartburn, upset stomach, vomiting, diarrhea, and constipation)
• Hypotension, which is when your blood pressure suddenly drops
• Menstrual abnormalities
• Sexual difficulties

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

Atypical Antipsychotics

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

• Blood sugar issues (diabetes)
• Drowsiness
• Increased cholesterol levels
• Lower sex drive
• Seizures
• Sensitivity to the sun
• Weight gain
  

These effects may go away in time. If they don't or they get worse, talk about your options with your care provider.

Should You Discontinue Your Medication?

If you experience extrapyramidal symptoms, you might wonder if you should stop taking your medication. Start by talking with a physician. They may lower your dose or switch you to another medication. Depending on what type of antipsychotic you are taking, they may also prescribe other medications to help treat the extrapyramidal side effects.

Determining whether to 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 lose the benefits of the medication. This decision should only be made after talking with your care provider.

Summary

Discontinuing medication without consulting your healthcare provider can lead to complications and side effects. If you are experiencing any troubling side effects, talk with them to discuss the next steps.

They can recommend options to treat and reduce extrapyramidal symptoms. If your extrapyramidal symptoms are severe, your provider can find another treatment option that may work for you.