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The Importance of Early Recognition of Extrapyramidal Symptoms (EPS) in a Community Mental Health Clinic

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Extrapyramidal symptoms (EPS) are one of the most common and neglected side effects during the treatment of schizophrenia

The risk factors of EPS in Chinese patients with schizophrenia and its relationship with psychiatric symptoms and mood symptoms of schizophrenia remain unknown. Compared with the non-EPS group, the EPS group patients are older, and they have a longer duration since first prescribed antipsychotics. The EPS group patients have higher frequency of atypical antipsychotics polytherapy and typical and atypical antipsychotics polytherapy or combined treatments with mood stabilisers.

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Symptoms can occur in both adults and children and may be severe. Early symptoms may begin shortly after you start a medication. They often show up a few hours after your first dose but can show up anytime within the first few weeks. Timing may depend on the specific side effect. Delayed symptoms can happen after you’ve been taking the drug for some time

With akathisia, you may feel very restless or tense and have a constant desire to move. In children, this might show up as physical discomfort, agitation, anxiety, or general irritability. You might find that pacing, shaking your legs, rocking on your feet, or rubbing your face helps ease the restlessness. Research suggests risk of akathisia increases with higher doses of medication. Akathisia symptoms have also been associated with a higher risk of another condition called tardive dyskinesia. Anywhere from 5 to 36 percentTrusted Source of people taking antipsychotics may develop akathisia. Some medications, including beta-blockers, may help relieve symptoms. Lowering the dose of antipsychotic medication may also lead to improvement. Dystonic reactions are involuntary muscle contractions. These movements are often repetitive and might include eye spasms or blinking, twisting head, protruding tongue, and extended neck, among others. Movements might be very brief, but they could also affect your posture or stiffen your muscles for a period of time. They most often affect your head and neck, though they can occur in other parts of your body. Dystonia can cause painful muscle stiffness and other discomfort. You can also choke or have trouble breathing if the reaction affects muscles in your throat.

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The differential diagnosis of dystonia is extensive including primary genetic disorders and secondary forms including neurodegenerative disorders, structural abnormalities of the brain, and metabolic and toxic etiologies. Drug-induced dystonia is distinguished by recent antipsychotic treatment, negative family history, focal and non-progressive course, and absence of associated neurologic signs (Kane JM, Fleischhacker WW, 2009). The co-occurrence of dystonia or other EPS with behavioral disturbances narrows the differential to disorders associated with both features, e.g., Huntington’s and Wilson’s disease, neuroacanthocytosis, etc. Although most often associated with the initiation of antipsychotics, dystonia may also be seen if dosages are increased, a second antipsychotic is added, for the few days each time after long-acting injectable antipsychotics are administered, if another drug, e.g., paroxetine, is added that inhibits antipsychotic metabolism, or following the discontinuation of antiparkinsonian agents (Gelenberg AJ. 1987). Dystonia also occurs in a tardive form, which may respond to anticholinergic treatment, but first appears or worsens rather than resolves when antipsychotic drugs are discontinued. The relationship between the acute and tardive forms is unknown

Apart from antipsychotic drugs, dopamine antagonists used as anti-emetics or sedatives (prochlorperazine, metoclopramide), anticonvulsants, antimalarials, stimulants and serotonergic agents have been implicated. Dystonias are encountered with levodopa during the course of treatment of Parkinson’s disease. Toxins (manganese, carbon monoxide, carbon disulfide) have also been implicated.

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In summary, it was first described in 1952 after chlorpromazine-induced symptoms resembling Parkinson disease. A variety of movement phenotypes has since been described along the EPS spectrum, including dystonia, akathisia, and parkinsonism, which occur more acutely, as well as more chronic manifestations of tardive akathisia and tardive dyskinesia. The symptoms of EPS are debilitating, interfering with social functioning and communication, motor tasks, and activities of daily living

This is often associated with poor quality of life and abandonment of therapy, which may result in disease relapse and re-hospitalization, particularly in schizophrenic patients stopping pharmacologic therapy.

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Gelenberg AJ. Treating extrapyramidal reactions: some current issues. J Clin Psychiatry. 1987 Sep;48(Suppl):24–27.

Bras JM, Singleton A. Genetic susceptibility in Parkinson’s disease. Biochim Biophys Acta. 2009 Jul;1792(7):597–603.

Kane JM, Fleischhacker WW, Hansen L, Perlis R, Pikalov A, 3rd, Assuncao-Talbott S. Akathisia: an updated review focusing on second-generation antipsychotics. J Clin Psychiatry. 2009 May;70(5):627–643.

Bratti IM, Kane JM, Marder SR. Chronic restlessness with antipsychotics. Am J Psychiatry. 2007 Nov;164(11):1648–1654.

Poyurovsky M. Acute antipsychotic-induced akathisia revisited. Br J Psychiatry. Feb;196(2):89–91.

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