EXTRA PYRAMIDAL SYMPTOMS

INTRODUCTION
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
disorders such as acute dystonic
reactions, pseudoparkinsonism, or

akathisia suffered as a result of taking

dopamine antagonists, 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.

CAUSES

 The most common antipsychotic associated with EPS is haloperidol used especially in
schizophrenia.
 Other antidopaminergic drugs like the antiemetic metoclopramide or the tricyclic
antidepressant amoxapine can also cause extrapyramidal side-effects.
 Another common cause are Selective Serotonin Reuptake Inhibitors (also known as SSRI),
which decrease dopamine and norepinephrine neurotransmission in the Substantia Nigra.
 Extrapyramidal symptoms can also be caused by brain damage, as in athetotic cerebral
palsy, which are involuntary writhing movements caused by prenatal or perinatal brain
damage.
 Other common causes of extrapyramidal symptoms include encephalitis and meningitis.
Extrapyramidal symptoms are distinct presentations of Japanese Encephali

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CATEGORIES
Extrapyramidal symptoms are usually divided into different categories:-

AKATHISIA: Akathisia is a syndrome characterized by unpleasant sensations of inner

restlessness that manifests itself with an inability to sit still or remain motionless.

Onset- Occurs 2wks after treatment begins

Symptoms- restlessness, difficulty sitting
still, strong urge to move about, anxiousness.
Treatment- Akathisia is difficult to control.
 Propranolol (Inderal) with daily dose of 80-
120mg (divided dose) can be an effective
treatment.
 A benzodiazepine such as chlorazepam
(Ativan) 1mg orally can be helpful.

Nursing responsibility:
 Monitor the client’s blood pressure when using this agent.
 Nurse should educate the patient to take medicine regularly in time.
 Administer medication as ordered. Encourage to more fluids frequently.
 If the clients feels uncomfortable with the sensation then stop the medicine.
 Anticipate dose reduction and change drug class.

TARDIVE DYSKINESIA:
(Abnormal movements) most frequent adverse effect resulting from termination of drug. It is
manifested as abnormal movements of voluntary muscle groups may affect any muscle group but
most commonly affected are those of face, mouth, tongue, grimace, lips making, protrusion of
tongue, and writing movement of fingers.

Onset: Occurs in approximately 3% to

st
5% of clients taking antipsychotic in 1 10
yrs.
Treatment: There is no effective
treatment of tardive dyskinesia.
 Reduce dose to stabilizing or
minimize adverse effect.
 The use of vitamin E has shown some
benefits.
 Benodidizepine beta blocker or
clozapine have less risk of causing
tardive dyskinesia.
 Screening clients for late appearing
movement’s disorder with Abnormal
Involuntary Scale.

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Nursing Responsibility:
 Anticipate dose reduction and change drug class.
 The Abnormal Involuntary Movements Scale (AIMS) is used to screen for symptoms of
movement disorders.
 The client is observed in several positions & the severity of symptom is rated from 0-4
 AIMS can be administered every 3-6 months.
 If nurse detects any severity in symptom she should notify the physician.

DYSTONIA: refers to irregular, often sustained, muscle contractions causing the body parts to
become temporarily twisted into contorted positions.

The person experiences constant pain

and can no longer use these body parts in a
normal fashion. This condition, a
neurological movement disorder, may
affect large areas of the body, one side of
the body, or small muscle groups. These
reactions include spasm of eye
(oculogyriccrisis), neck (Torticollis), back
(Rectrocollis), tongue (gloss spasm) or
other muscle which can be frightened to
the client.
Onset: May occur any time from a
few minutes to several hours after
st
1 dose of anti psychotic drugs (2%
to 90%).
Treatment: Readily reversed with
iron injection of 50mg of
diphenylhydramine (benadeyl) or 1
or 2mg. I/M of Benztropine
(cogentin).

PSEUDOPARKINSONISM: - OR Neuroleptic induced Parkinsonism includes a shuffling

gait, mask like faces, muscle stiffness (continuous) or wheeling rigidity (ratchet- like movements
of joints), drooling & akinesia (slowness & difficulty in initiating movements).

Onset: Usually appear in the first few days

after starting or increasing the dosage of an
antipsychotic medication.

Treatment: Treatment of pseudo

Parkinsonism & prevention of further
dystonic reaction are achieved with the
medications.

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 Nursing responsibility:
 Anticipate dose reduction and change drug class.
 Administer medication as ordered.
 If the clients feels uncomfortable with the sensation then stop the medicine.

NEUROLEPTIC MALIGNANT SYNDROME: - a condition that closely resemble

malignant hyperthermia (Generally ranges from 101.3o F to 107.6o F but rarely it can be
normal). Charecterised by a rapid rise in temperature, muscle rigidity, severe catatonia
(immobility with muscle rigidity), mental confusion, unstable pulse and blood pressure,
diaphoresis, delirium, agitation, stupor and coma, electrolytes abnormalities and metabolic
acidosis. It may be fatal.

The clinical course of NMS usually begins with rigidity and autonomic changes, followed
by fever within several hours to onset. Symptoms of NMS usually evolved over 24-72 hrs. if
left untreated symptoms persist for up to 2 weeks.

Treatment:
1. Bromocriptine, Dantrolene, Beclofen, general supportive care. Add on lorazepam,
occasionally ECT

Complication: Myocardial infarction, rhabdomyolysis, renal failure, aspiration pneumonia,

respiratory failure, pulmonary embolism, coagulopathy and sepsis.

Drugs which produces extra pyramidal symptoms

CHEMICAL NAME GENERIC (TRADE NAME) EPS
PHENOTHIAZINES Chlorpromazine (Thorazine) 3
Fluphenazine (Prolix in) 5
Mesoridazine (serenity) 2
Perphenazine (Trilafon) 4
Prochlorperazine (Compazine) 4
Promazine (Sparine) 3
Thioridazine (Mellaril) 2
Trifluoperazine (Stelazine) 4
Triflupromazine (Vesprin) 3
THIOXANTHENES Thithixene (Navane) 4
BENZISOXAZOLE Risperidone (Resperidal) 1
BUTYROPHENONE Haloperidol (Haldol) 5
DIBANZOXAZEPINE Loxapine (Loxitane) 4
DIHYDROINDOLONE Molindone (Moban) 4
DIBENZODIAZEPINE Clozapine (Clozaril) 1
THIENDOBENZODIAZEPINE Olanzapine (Zyprexa) 1
DIPHENYLBUTYLPIPERIDINE Pimozide (Orap) 4
BENZOTHIAZOLYLPIPERAZINE Ziprasidone (Geodon) 1

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 Key: - 1- Very low, 2- Low, 3- Moderate, 4- High, 5- Very high

Drugs used to treat extra pyramidal side effects

Drug class Generic trade name Oral Doses (mg) IM, IV, Doses
Dopaminergic Amantadine (Symmetrel) 100 BD or TDS -
agonist
Anticholinergic Benztropine (cogentin) 1-3 BD 1-2
Biperiden (Akineton) 2 TDS /qid 2
Procyclidine (Kemadrin) 2.5-5 TDS -
Trihexiphenidyl 2-5 TDS -
Benzodiazepine Dizepam (Valium) 5 TDS 5-10
Lorazepam (Ativa) 1-2 TDS -
Antihistamine Diphenhydramine (Benadryl) 25-50tds /qid 20-50
Beta blocker Propranolol (Inderal) 10-20 tds up to -
40 qid

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