Extrapyramidal Symptoms

Extrapyramidal symptoms (EPS) are problems with muscle tone. They include muscle stiffness, tremors, slowed movements or excessive, unwanted movements (from problems with certain brain areas). One of the most important causes of these symptoms is the negative effects that can develop when you take an antipsychotic medication (neuroleptics).

These symptoms may interfere with your daily life and activities, like:

• Social functioning
• Communication
• Movement tasks

Your healthcare provider may refer to these symptoms as extrapyramidal side effects or drug-induced movement disorders.

What does ‘extrapyramidal’ mean?

Your extrapyramidal system is a special network of nerve cells in your brain. They’re essential for keeping good posture and controlling involuntary movements (the ones you can’t control). They involve several brain regions, including your cerebral cortex and cerebellum. But they mainly involve your basal ganglia. The basal ganglia manage the signals your brain sends that help you move your muscles.

“Extrapyramidal symptoms” are called such because they involve movement disorders. Antipsychotic medications affect dopamine levels in your brain. And dopamine affects your extrapyramidal system, especially your basal ganglia.

What your doctor will look for

Providers categorize these changes into acute (sudden) and tardive (delayed). Some are things you may feel (symptoms), and some are things your doctor notices during an exam (signs).

Acute EPS can begin within hours or days of starting an antipsychotic medication. They include:

• Dystonia: Dystonia is long-lasting muscle contractions or starting then stopping muscle contractions. This causes abnormal, often repetitive movements or postures. It can affect many different muscles, ranging from those in your trunk and arms and legs to facial muscles.
• Parkinsonism: Parkinsonism causes slowed movements (bradykinesia), tremors and stiffness or rigidity. It may also cause a stooped posture and a slow, shuffling walking pattern.
• Akathisia: Akathisia makes it difficult to stay still due to inner restlessness. It typically causes repetitive movements, like leg crossing, leg swinging or shifting from one foot to another.

Tardive EPS can develop after taking an antipsychotic medication for several months or years. Symptoms include:

• Tardive dyskinesia: Tardive dyskinesia can cause involuntary facial tics and uncontrollable movements like lip-smacking. It can make chewing, swallowing and talking difficult.
• Tardive dystonia: This involves the same movements as acute dystonia. The difference is that it can develop after prolonged use of antipsychotic medications and typically lasts for much longer, even years.

There’s also tardive Parkinsonism and tardive akathisia. Symptoms are similar to the acute type, but the time at which you develop symptoms happens later.

Extrapyramidal symptom causes

Dopamine-receptor-blocking medications (antipsychotics) are one of the major causes of extrapyramidal symptoms.

Dopamine is a neurotransmitter that plays a role in many body functions, including movement. These medications change the amount of dopamine in your brain. This can lead to extrapyramidal movement disorders.

The first-generation (typical) antipsychotic medications haloperidol and phenothiazine most commonly cause extrapyramidal symptoms.

EPS occurs less frequently with second-generation (atypical) antipsychotics. But your risk of EPS with these second-generation medications increases the more your dose increases.

Other medications that may lead to EPS include:

• Antiemetics (anti-nausea medicines), like metoclopramide, droperidol and prochlorperazine
• Calcium channel blockers
• Lithium
• Serotonin reuptake inhibitors (SSRIs)
• Stimulants
• Tricyclic antidepressants (TCAs)

In rare cases, the following medications have also been linked to EPS:

• Antivirals
• Antiarrhythmics
• Valproic acid

What are the risk factors for EPS?

Researchers are still studying factors that increase your risk of developing extrapyramidal symptoms. So far, studies show that risk factors include:

• Having a high dose of medications
• Taking first-generation antipsychotics
• Having a history of prior EPS

Women after age 65 are more likely to develop Parkinsonism and tardive dyskinesia. Men under age 65 are more likely to develop dystonia.

Extrapyramidal symptoms treatment

Extrapyramidal symptoms, mainly acute symptoms, may go away on their own. But never wait to seek medical attention. Other cases typically improve with medication. This could involve changes to the medication that’s causing EPS and/or additional medications.

In general, your healthcare provider’s first line of treatment will be reviewing the medication that’s causing EPS. They may:

• Switch you to a second-generation (atypical) antipsychotic medication if you’re taking a first-generation (typical) antipsychotic
• Have you stop taking or reduce the dose of the medication that’s causing EPS

In many cases, antipsychotic medications are necessary to manage an underlying condition, like schizophrenia. So, stopping them isn’t always the best option. Your provider will carefully assess your unique needs and recommend a plan that’s best for you. Never stop taking a prescribed medication unless your healthcare provider tells you to do so.

Additional management options for EPS depend on the type of symptoms you have and their severity. Some examples include:

• Antimuscarinic medications, like benztropine or trihexyphenidyl, for acute dystonia, akathisia and parkinsonism
• Benzodiazepines for tardive dystonia, tardive dyskinesia and akathisia
• Botulinum toxin (Botox®) injections for facial dystonia and facial dyskinesia
• Deep brain stimulation or pallidotomy for severe cases of tardive dystonia

What are the possible risks of not treating extrapyramidal symptoms?

Extrapyramidal symptoms can greatly disrupt your life. Studies show that not getting treatment for EPS is linked with:

• Aggression
• Suicidal thoughts
• Violence

In rare cases, severe dystonia can result in laryngospasm and cricopharyngeal spasms. These can cause difficulty breathing.

For these reasons, it’s important to get medical help if you have extrapyramidal symptoms.

If you’re thinking about suicide, it’s also important to talk to someone about it. Know that you’re not alone. Call or text 988 (Suicide & Crisis Lifeline), where someone is available to help, 24/7. Your provider can also help you.

When should extrapyramidal symptoms be treated by a doctor or healthcare provider?

If you develop movement issues after starting a medication, tell your healthcare provider as soon as possible. The earlier you get treatment, the better.

Providers are aware of the potential for extrapyramidal symptoms when prescribing antipsychotic medications. So, they’ll carefully monitor symptoms with regular appointments after you start one.

As always, it’s important to discuss the possible side effects of any medication you’re going to begin taking. That way, you can be prepared for what signs to look out for and understand the risks.