psychiatry.

asia

May 2016

Article: Extrapyramidal symptoms and the

new antipsychotics
Sajid Mahmood, Adnan Akram

Sign & Symptoms, EPS prevention

Authors
Dr Mian Sajid Mahmood
Consultant Physician

Antipsychotic medication commonly produce extrapyramidal

symptoms (EPS) as side eects. The extrapyramidal symptoms
include acute dyskinesia and dystonic reactions, tardive
dyskinesia, Parkinsonism, akinesia and neuroleptic malignant
syndrome.

Dr Adnan Akram
Registrar in Psychiatry

In general, (EPS) maybe categorized according to the following criteria:

Dr Mian Sajid Mahmood is a

Consultant Physician with
special interest in Geriatric
Medicine. He often encounters
patients presenting at his out
patient clinic in Karachi
Pakistan with mental health
disorders and EPS. He
developed an interest in
antipsychotics and research in
EPS that led to writing an
article with his psychiatry
colleague.

Dr Adnan Akram is a Registrar

in Psychiatry. He has interest in
adult inpatient and substance
misuse psychiatry. Dr Adnan
works at a private psychiatry
clinic in Karachi Pakistan.
Address for correspondence
242 Fatima Jinnah road
Karachi 75530
Pakistan
email: camp [at] psychiatry.asia

a. Acute, tardive or mixed

b. Side-eects of treatment, or independent of antipsychotic
drugs
c. Single syndromes, such as akathisia, or a mixture of syndromes.
d. Reversible or irreversible
e. Recognized or not recognized by the patient.

How to minimize the occurrence of Extrapyramidal

symptoms
Key factors that can help to reduce the occurrence of EPS
include:

a. More knowledge of EPS among doctors and the medical sta.

b. More awareness of the signs and symptoms of EPS.
c. The introduction of specific EPS examination procedures and
more knowledge of alternate treatments.
The crucial tests can aid the identification of EPS as listed in
table 1. Many psychiatrists do not carry out these simple, but very
valuable observations. Rating scales such as the St Hans rating
scale for extrapyramidal syndromes may encourage a systematic
approach and prevent Parkinsonism being overlooked.

Extrapyramidal Symptoms and the new Antipsychotics by Mian Sajid Mahmood and Adnan Akram

psychiatry.asia

May 2016

Table 1. EPS Observation principles

The prevention of EPS

A number of principles emerge for preventing the occurrence of EPS:

a. Closely observe particularly vulnerable patients such as the elderly, and patients with a previous history
of EPS.
b. Restrict the use of D2-blocking antipsychotics. The use of antipsychotics in negative symptoms may
well increase with the advent of new antipsychotics which avoid EPS.
c. Minimize D2-receptor blockade by using the lowest eective dose, antipsychotics with low D2 blockade
(such as clozapine o other new agents), and potential non-dopamine antipsychotics.
d. Anticholinergics have only symptomatic eect: they reduce akathisia, dystonia/acute dyskinesia,
Parkinsonism, but aggravate tardive dyskinesia and tardive akathisia.
The new antipsychotics are as dierent from each other as they are from stndard agents. They include the
D2 antagonists, sulpride and amisulpride: the D2-5HT2-alpha1 antagoists, risperidone, ziprasidone, and
sertindole; and the multi receptor antagonists clozapine, quetiapine and olanzapine.

Risperidone and zipasidon show classical D2-receptor blockade, and in high doses they will cause
traditional EPS and also some autonomic side-eects due to alpha1 blockage. Sertindole. clozapine,
olanzapine, and quetiapine are all interesting drugs because they all produce a relatively low D2 receptor
blockade, in contrast to all other antipsychotics. In vitro studies show that Sertindole provides strong D2
blockade, but studies in vivo show only mild D2 antagonism. Clozapine is a multi receptor antagonist.
Olanzapine closely resembles clozapine but does not block many receptors. Quetiapine is unique due to
its atypical receptor profile.
Studies have confirmed that clozapine produces much less EPS than the classical drugs, such as
haloperidol. Tardive dyskinesia may disappear when patients are prescribed clozapine.

Aside from EPS, other side eect must also be considered. Depression and emotional indierence are
Extrapyramidal Symptoms and the new Antipsychotics by Mian Sajid Mahmood and Adnan Akram

psychiatry.asia

May 2016

clearly lower on clozapine compared with haloperidol. Sexual problems, caused by eects on prolactin
levels, are also less pronounced with clozapine.

In conclusion
EPS are disabling and distressing, and in some patients are painful and irreversible. EPS are often not
recognized by the physician or patient and may become accepted as unavoidable. People working in
psychiatry should be taught more about EPS and be trained in simple EPS examination and techniques.

Prevention and treatment strategies should focus on reducing D2-receptor blockade. Clozapine produces
less EPS but has other side eects. Drugs such as quetiapine, olanzapine an sertindole oer low D2receptor antagonism, which promises a god EPS profile.

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Extrapyramidal Symptoms and the new Antipsychotics by Mian Sajid Mahmood and Adnan Akram