EXTRAPYRAMIDAL SYMPTOMS: CAUSES, TYPES AND TREATMENT - ECONOMÍA - 2024

The extrapyramidal symptoms are side effects shown by the use of antipsychotic drugs or other agents that block dopamine in the brain. They are characterized by involuntary contractions of the muscles that affect posture, gait and movements.

These symptoms are generally associated with side effects of typical antipsychotics, and less commonly, of some antidepressants. They occur more often in women and older people.

Extrapyramidal symptoms can develop acutely, be delayed, or overlap, making the diagnosis very complex.

Historically these symptoms were very common, but today they are not so frequent due to the use of new antipsychotic agents and preventive therapy.

These symptoms were first discovered in the 1950s, with the introduction of antipsychotic medications. They are also known as "traditional", "first generation" or "typical" antipsychotics for the treatment of schizophrenia.

Extrapyramidal symptoms can occur in up to 75% of patients who are prescribed a typical antipsychotic. These can cause great discomfort that affects adherence to treatment.

That is, these patients abandon pharmacological treatment to eliminate extrapyramidal symptoms, although this would cause the reappearance of psychotic symptoms.

It is important to carry out a differential diagnosis, since they can easily be confused with other disorders such as anxiety, major depression, bipolar disorder, cerebral palsy, Tourette syndrome, lupus, intoxication, etc.

Causes of extrapyramidal symptoms

Typical antipsychotics, also called neuroleptics, appear to work by blocking dopamine D2 receptors. These drugs are used to reduce the symptoms of psychiatric diseases such as schizophrenia, since it is assumed that in this disease there is an excess of dopamine receptors in the brain.

However, typical antipsychotics can cause side effects. For example, if the D2 receptors in the basal ganglia are blocked, motor responses can be altered, leading to extrapyramidal symptoms.

On the other hand, these drugs also produce changes in the levels of other neurotransmitters such as serotonin, acetylcholine or norepinephrine, and may also contribute to the onset of extrapyramidal symptoms.

Typical or first-generation antipsychotics were developed in the 1950s. They were created to decrease psychotic symptoms, improve mood and behavior.

However, these drugs appeared to cause a number of dangerous side effects. For example, cardiovascular problems, neuroleptic malignant syndrome and, of course, extrapyramidal symptoms.

For this reason, second-generation antipsychotics or atypical antipsychotics were developed. They are currently chosen as first-line therapy to treat psychotic symptoms. This is because they are more effective and do not cause extrapyramidal symptoms or other side effects.

Other medications that can also cause extrapyramidal symptoms are some decongestants, anticonvulsants, antihistamines, and selective serotonin reuptake inhibitors antidepressants.

Types

There are four main types of extrapyramidal symptoms which are:

Parkinsonian symptoms

They are characterized by abnormal movements similar to those seen in Parkinson's disease, and include:

- Fine tremor that appears when a specific part of the body is at rest and disappears when it moves voluntarily. It generally occurs on the hands, although it can also occur in the mouth. In the latter case, what is known as the "rabbit syndrome" would occur, that is, the puckering and trembling of the lips.

- Stiffness in the muscles, which leads to the joints becoming inflexible.

- Slowness in movements, especially in complex voluntary movements (bradykinesia). Absence of movement (akinesia) may also occur. Limbs, fine motor skills, and walking movements may be affected.

Likewise, problems with the voice, swallowing difficulties and making facial expressions may occur.

Dystonia

This is a movement disorder that is characterized by involuntary contractions of the muscles. It presents as sudden contractions and repetitive movements that can be painful.

It can affect all the voluntary muscles of the body such as those of the neck (torticollis), those of the eyes (oculogyric crisis), those of the jaw, the tongue and even those involved in breathing.

Dystonic reactions are most common in young people and in people who have been using antipsychotic medications for a short time.

Akathisia

It is the inability of a person to stay still, presenting the need to move because they feel restless or uncomfortable.

People with akathisia cannot remain seated and continually get up by rolling, rubbing their thighs, or rocking. Akathisia also causes feelings of anxiety and inability to relax.

Tardive dyskinesia

It is characterized by slow and irregular involuntary movements of different parts of the body. It occurs most often on the tongue, lips, face, and neck, although it can also occur on the trunk and extremities.

They may click on the lips, the tongue in and out of the mouth, or grimace. The person with tardive dyskinesia may not be aware of these movements, which are very obvious to an observer.

These symptoms can appear several months or even years after starting treatment with typical antipsychotics, which is why it is called “late”.

It can also occur as a side effect of medications used by the elderly. Generally this effect is reversible, although there are isolated cases in which it is irreversible.

It can also occur when the patient increases or decreases the dose of a typical antipsychotic. In these cases the symptoms may be short-lived.

Treatment

Most extrapyramidal symptoms disappear with the discontinuation of typical antipsychotics or by replacing them with atypical antipsychotics. In most cases, reducing the dose can lead to symptom relief, except for tardive dyskinesia, which cannot be predicted.

Akathisia is reduced with the discontinuation of typical antipsychotics and with the use of anxiolytic medications such as lorazepam, diazepam, or alprazolam. Propanolol blockers such as inderal may also be effective.

Dystonias can develop acutely and immediate intervention using anticholinergic or antiparkinsonian agents is necessary. These should be prescribed with caution because they have side effects like psychosis, dependence, dry mouth, tachycardia, blurred vision, confusion, etc.

References

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2. Courey, T. (2007). Detection, Prevention, and Management of Extrapyramidal Symptoms. Obtained from Medscape: medscape.com.
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