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'''Extrapyramidal symptoms''' (EPS), also known as '''extrapyramidal side effects''' (EPSE), are drug-induced movement disorders that include acute and tardive symptoms.  
[[File:Four types of EPS.png|275px|thumbnail|right|An image that quickly summarizes the four types of extrapyramidal symptoms with illustrations.]]
'''Extrapyramidal symptoms''' (EPS), also known as '''extrapyramidal side effects''' (EPSE), are drug-induced movement disorders that include acute and tardive/chronic symptoms. They are mainly caused by the blockade of dopamine at dopaminergic receptors.


These symptoms include:
==Types and their symptoms==


*'''Muscle contractions''' - Uncontrolled and severe contractions can occur in one's head, neck, and limbs and may cause a stiff tongue, arched back, or twisted neck.
===Acute dystonia===
*'''Continuous [[muscle spasms]]'''
[[File:Medication-induced dystonia.JPG|275px|thumbnail|right|A patient experiencing acute dystonia caused by a dopamine-blocking medication.]]
*'''Restlessness''' - This can include nervous energy such as pacing or tapping one's foot.
Acute dystonia is a painful and often severe type of extrapyramidal symptoms that occurs shortly (within less than a day){{citation needed}} after the administration of an [[dopamine|antidopaminergic]] agent.
*Parkinsonism (characteristic symptoms such as rigidity)
*'''Decreased bodily movement'''
*'''[[Tremors]]'''
*'''Stiff posture''' - This can include the lack of arm movement when walking.
*tardive dyskinesia (irregular, jerky movements).<ref>http://link.springer.com/article/10.2165%2F00002018-200528030-00002</ref>


*Uncontrolled movements of your tongue, jaw, lips, or face, such as pursing, chewing, or frequent eye blinking
[[Muscle spasms|Continuous muscle contractions]] can occur in the head, neck, and limbs and may cause a stiff tongue, arched back, or twisted neck. Dystonia also includes a lack of ability to move muscle and low muscle tone.
*Uncontrolled movements of your fingers or toes, head nodding, or pelvic thrusting
 
*Fast, irregular breathing with grunts, gasping, or sighing
Treatment of acute dystonia is often an anticholinergic agent and/or a benzodiazepine.{{citation needed}}
*Weak voice, drooling, or little or no facial expression
===Akathisia===
Akathisia is characterized by restlessness, a need to move, constant sitting down and standing up, pacing, etc. Treatments for akathisia are anticholinergics, beta blockers, or [[benzodiazepines]]. Akathisia typically develops some time during a medication regimen{{citation needed}}
===Psuedoparkinsonism===
Psuedoparkinsonism occurs often further than akathisia.{{citation needed}} It is often noticed by seeing:
*tremoring hands in a "pill-rolling" pose,
*a stooped posture,
*slowed movements,
*shuffling, small steps,
and others.  Others also include that when the person turns, they must do so very slowly and sometimes cannot change positions, such as standing to sitting, without a support.
===Tardive dyskinesia===
This disorder develops over long periods of time{{citation needed}} and is noticed by these signs: involuntary chewing, lip smacking or sucking, twitching, and/or involuntary movements of the limbs that are often jerky. It is treated by putting the patient on a dopaminergic medication regimen, such as using valbenzaine, tetrabenazine, ropinirole, or pramipexole.


==Causes==
==Causes==
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that [[Antagonist|antagonize]] [[dopamine]] D2 [[receptors]].
Extrapyramidal symptoms are most commonly caused by typical antipsychotic drugs that [[Antagonist|antagonize]] [[dopamine]] D2 [[receptors]].
The most common typical [[antipsychotics]] associated with EPS are [[haloperidol]] and fluphenazine.<ref>https://www.hindawi.com/journals/bmri/2014/656370/</ref>
The most common typical [[antipsychotics]] associated with EPS are [[haloperidol]] and fluphenazine.<ref>Note, I. (2009). Extrapyramidal adverse effects. Biomed Res Int., 2014, 30–32. https://doi.org/10.1155/2014/656370</ref>


Other antidopaminergic drugs, like the [[Nausea suppression|antiemetic]] metoclopramide, can also result in extrapyramidal side effects.<ref>Moos, D. D., & Hansen, D. J. (2008). Metoclopramide and Extrapyramidal Symptoms: A Case Report. Journal of Perianesthesia Nursing, 23(5), 292–299. https://doi.org/10.1016/j.jopan.2008.07.006</ref>


Other anti-dopaminergic drugs, like the [[Nausea suppression|antiemetic]] metoclopramide, can also result in extrapyramidal side effects.<ref>http://www.jopan.org/article/S1089-9472(08)00242-6/abstract</ref>
Short and long-term use of antidepressants, such as selective serotonin reuptake inhibitors ([[SSRI]]), serotonin-norepinephrine reuptake inhibitors (SNRI), and norepinephrine-dopamine reuptake inhibitors (NDRI) has also resulted in extrapyramidal symptoms. Specifically, duloxetine, sertraline, escitalopram, fluoxetine, and bupropion have been linked to the induction of extrapyramidal symptoms.<ref>Madhusoodanan, S., Alexeenko, L., Sanders, R., & Brenner, R. (2010). Extrapyramidal symptoms associated with antidepressants--a review of the literature and an analysis of spontaneous reports. Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 22(3), 148–56. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20680187</ref>


==Treatment==
[[File:Akineton Advertisement, 1966.jpg|400px|thumbnail|right|Advertisement for Akineton (biperiden), used for pseudoparkinsonism.]]


Short and long-term use of antidepressants such as selective serotonin reuptake inhibitors ([[SSRI]]), serotonin-norepinephrine reuptake inhibitors (SNRI), and norepinephrine-dopamine reuptake inhibitors (NDRI) have also resulted in extrapyramidal symptoms. Specifically, duloxetine, sertraline, escitalopram, fluoxetine, and bupropion have been linked to the induction of extrapyramidal symptoms.<ref>https://www.ncbi.nlm.nih.gov/pubmed/20680187</ref>
[[Acetylcholine|Anticholinergic]] drugs are used to control neuroleptic-induced EPS, although akathisia may require beta blockers or even [[benzodiazepines]]. If the EPS are induced by an [[antipsychotic]], EPS may be reduced by dose [[Tapering|titration]] or by switching to an atypical [[antipsychotic]], such as aripiprazole, ziprasidone, [[quetiapine]], olanzapine, [[risperidone]], or clozapine.  


==Treatment==
Commonly used medications for EPS are [[acetylcholine|anticholinergic]] agents such as benztropine (Cogentin), biperiden (Akineton), [[diphenhydramine]] (Benadryl), and trihexyphenidyl (Artane). Another common course of treatment includes [[dopamine]] [[agonist]] agents, such as pramipexole and ropinirole. These medications reverse the symptoms of extrapyramidal side effects caused by [[antipsychotics]] or other drugs that either directly or indirectly inhibit [[Dopamine|dopaminergic]] neurotransmission.


[[Acetylcholine|Anticholinergic]] drugs are used to control neuroleptic-induced EPS, although akathisia may require beta blockers or even [[benzodiazepines]]. If the EPS are induced by an [[antipsychotic]], EPS may be reduced by dose [[Tapering|titration]] or by switching to an atypical [[antipsychotic]], such as aripiprazole, ziprasidone, [[quetiapine]], olanzapine, [[risperidone]], or clozapine.
==Literature==


Commonly used medications for EPS are [[acetylcholine|anticholinergic]] agents such as benztropine (Cogentin), [[diphenhydramine]] (Benadryl), and trihexyphenidyl (Artane). Another common course of treatment includes [[dopamine]] [[agonist]] agents such as pramipexole. These medications reverse the symptoms of extrapyramidal side effects caused by [[antipsychotics]] or other drugs that either directly or indirectly inhibit [[Dopamine|dopaminergic]] neurotransmission.
==External links==
[https://en.wikipedia.org/wiki/Extrapyramidal_symptoms Extrapyramidal symptoms (Wikipedia)]


==See also==
==See also==
*[[Antipsychotics]]
*[[Antipsychotics]]
**[[Haloperidol]], one of the most common agents associated with EPS
**[[Risperidone]], another agent known to induce EPS
*[[Diphenhydramine]], an agent sometimes used to treat EPS
*[[Responsible drug use]]
*[[Responsible drug use]]
*[[Dopamine]]
*[[Dopamine]]
==Citations==
==References==
 
[[Category:Approval]]
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