Drug-Induced

E x t rapy rami d al Syn d rom e s

Implications for Contemporary Practice

a, b
Stanley N. Caroff, MD *, E. Cabrina Campbell, MD

KEYWORDS
 Antipsychotic drugs  Schizophrenia  Tardive dyskinesia  Catatonia
 Neuroleptic malignant syndrome  Akathisia  Parkinsonism  Dystonia

KEY POINTS
 Awareness of acute drug-induced extrapyramidal syndromes (EPS) remains important for
patient safety in clinical practice.
 Investigations of new treatments offer promise for managing patients with tardive
dyskinesia.
 Advances in understanding the genetics and pathophysiology of EPS may illuminate the
mechanisms of action of antipsychotic drugs and the biological bases of psychotic
disorders.

INTRODUCTION

Although the origins of antipsychotic pharmacology began with the search for
compounds to improve anesthesia, clinicians reported unusual “psychic indifference”
as the defining effect of these drugs.1 Nevertheless, early antipsychotics were thought
to be useful primarily for sedation rather than specific antipsychotic effects, whereas
drug-induced extrapyramidal syndromes (EPS) were considered necessary indicators
that therapeutic doses had been achieved. Thus, the neurologic properties received
pride of place in the original designation, “neuroleptics.”
However, it soon became apparent that EPS can be mistaken for or worsen
psychotic symptoms, are sometimes irreversible or lethal, necessitate additional
burdensome adverse effects from antiparkinsonian agents, can be disfiguring and

Disclosure: Dr S.N. Caroff received a research grant from Sunovion Pharmaceuticals Inc and
served as a consultant for Auspex Pharmaceuticals Inc.
a
Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 300 Blockley
Hall, Philadelphia, PA 19104, USA; b Department of Psychiatry, Perelman School of Medicine, Uni-
versity of Pennsylvania, Corporal Michael J. Crescenz Veterans Affairs Medical Center-116A, Uni-
versity & Woodland Avenues, Philadelphia, PA 19104, USA
* Corresponding author. Department of Psychiatry, Perelman School of Medicine, University of
Pennsylvania, 300 Blockley Hall, Philadelphia, PA, 19104.
E-mail address: [email protected]

Psychiatr Clin N Am 39 (2016) 391–411

http://dx.doi.org/10.1016/j.psc.2016.04.003 psych.theclinics.com
0193-953X/16/$ – see front matter Published by Elsevier Inc.
392 Caroff & Campbell

Abbreviations
ECT Electroconvulsive therapy
EPS Extrapyramidal syndromes
FGA First-generation antipsychotic
NMS Neuroleptic malignant syndrome
SGA Second-generation antipsychotic
TD Tardive dyskinesia
VMAT2 Vesicular monoamine transporter type 2

stigmatizing, and may influence compliance, relapse, and rehospitalization.2–4 As a

result, EPS dominated concerns about tolerability of antipsychotics and drove new
drug development.
In 1988, Kane and colleagues5 reported that clozapine had broader
efficacy in schizophrenia with negligible EPS, stimulating the search for new
antipsychotics. Industry-sponsored trials heralded subsequent “second-generation
antipsychotics” (SGAs) as superior to “first-generation antipsychotics” (FGAs) in
causing fewer EPS.6–13 Cumulative evidence, including the general consensus of
clinicians, confirmed reduced liability for EPS with SGAs, contributing to their
market dominance and the concept of “atypicality” in their mechanism of
action.14–21
However, subsequent postmarketing studies challenged the advantages of
SGAs in reducing EPS. The discrepancy between effectiveness and marketing trials
stems from the choice of comparator drugs and dosages. Although haloperidol
was a reasonable choice as a comparator in industry-sponsored trials as the
first-line antipsychotic drug at the time, subsequent studies suggested that the
advantages of SGAs in reducing EPS were diminished when lower doses or lower
potency FGAs are used, or if prophylactic antiparkinsonian drugs are
administered.19,22–30 This implies that haloperidol is not paradigmatic of all FGAs;
therefore, the dichotomy between first- and second generation drugs and
the concept of SGA “atypicality” based on EPS liability was overstated. Antipsy-
chotic drugs should be considered a single drug class with a spectrum of risk for
EPS depending on dopamine D2 receptor binding affinity combined with affinity
for other receptors.
Even though there is some reduction in risk of EPS with the SGAs, it remains
important for clinicians to be familiar with EPS for several reasons. First, because
dopamine D2 receptor blockade is preserved in all currently marketed antipsychotics
and is necessary for antipsychotic efficacy, EPS remains a potential liability for all
drugs in this class. Second, FGAs are still used in psychiatry, in medical settings,
and in developing nations. Third, EPS must be balanced with risk for other significant
adverse effects, for example, the metabolic syndrome. Fourth, the higher costs of
newer drugs may be a consideration. Fifth, although the proportion of patients
who develop EPS may be reduced, aggressive marketing and off-label prescribing
contribute to an ever-widening population at risk. This development is especially
concerning related to high-risk groups such as children, the elderly, and
medically compromised patients. Familiarity with tardive dyskinesia (TD) is important
because new drug treatments are likely to become available. In the future, genetic
testing may uncover genetic susceptibilities to drug-induced EPS. Finally, research
into EPS may provide insights into the mechanism of action of antipsychotic drugs.
We, therefore, provide an updated review of the literature on diagnosis and
management of the classic EPS syndromes including emerging evidence on treat-
ment of TD.1,30–32
 Drug-Induced Extrapyramidal Syndromes 393

DYSTONIA
Clinical Features
Drug-induced dystonia is an acute movement disorder that can be painful and dis-
tressing, and can erode patient trust and medication adherence.1,33,34 It is character-
ized by briefly sustained or intermittent spasms or contractions of antagonistic muscle
groups resulting in twisting, sustained, and repetitive movements or postures.
Drug-induced dystonia is usually focal and can affect any muscle group, but most
commonly involves the head, neck, jaw, eyes, and mouth, resulting in spasmodic torti-
collis, retrocollis or anterocollis, trismus and dental trauma, forced jaw opening or
dislocation, grimacing, blepharospasm, distortion of the lips, and tongue biting, pro-
trusion, or twisting.31,35,36 It is not clearly established whether it is action or sensory
stimulus dependent. Subjective symptoms, including anxiety, muscle pain, cramps
or tightness of the jaw, and tongue swelling with difficulty speaking or chewing, may
precede dystonia or occur alone. Dystonia may also present as an oculogyric crisis
or with other forced eye movements, or with dysarthria, dysphagia, or potentially lethal
respiratory stridor if pharyngeal or laryngeal musculature is affected. Less frequently,
dystonia may affect axial, truncal, or limb movements, occasionally leading to
camptocormia (anterior flexion of the trunk), pleurothotonus or “Pisa syndrome”
(lateral tilting of the trunk) or opisthotonus (arched extension of the trunk or spine).

Differential Diagnosis
The differential diagnosis of dystonia includes primary genetic disorders (eg, primary
torsion dystonias) and secondary forms including neurodegenerative disorders
(eg, Parkinson’s disease), structural abnormalities of the brain (eg, after a stroke),
and metabolic and toxic etiologies (eg, carbon monoxide poisoning).34,36–38
Drug-induced dystonia is distinguished by associated drug treatment, negative family
history, a focal and nonprogressive course, and absence of associated neurologic
signs. Dystonia still may be diagnosed erroneously as conversion disorder if clinicians
are unaware that dystonia can also fluctuate depending on whether the individual is
stressed and anxious or is relaxed. On the other hand, some individuals may feign
symptoms to avoid taking antipsychotic drugs or to abuse anticholinergic drugs.35

Course and Outcome

Dystonia is usually observed within a few hours of a single dose, especially after
parenteral administration, but may appear after a delay of several hours to a few
days.31 In 95% of cases, dystonia appears within the first 5 days of treatment.31,35
Although most often associated with drug initiation, dystonia may also occur when
the dose is increased, a second antipsychotic is added, for the few days each time
after long-acting injectable antipsychotics are administered, if another drug is added
that inhibits antipsychotic metabolism, or after the discontinuation of antiparkinsonian
agents. Dystonic reactions last a few seconds or several hours and may be sustained,
fluctuating, or episodic.1 After drug discontinuation, dystonia usually resolves within
24 to 48 hours.36 Dystonia also occurs in a tardive form, which first appears or worsens
when antipsychotics are discontinued. Dystonia occurs in 2% to 5% of patients
receiving FGAs.31,35,36 However, in young men receiving high-potency antipsychotics
parenterally, the frequency approaches 90% in some studies.31

Risk Factors
Patient risk factors for dystonia include younger age, male gender, black race, pre-
vious dystonic reactions, family history of dystonia, cocaine use, mood disorders,
394 Caroff & Campbell

hypocalcemia, hypoparathyroidism, hyperthyroidism, and dehydration.35,36,39 Chil-

dren and young adults are highly vulnerable and more likely to develop generalized
dystonia, similar to the pattern in primary dystonias, whereas drug-induced dystonia
is less common after 45 years of age.35 Although knowledge of the genetics of pri-
mary idiopathic dystonias has progressed rapidly in recent years,34,38,40 it remains
unclear whether drug-induced dystonias are more likely to occur in people with
the same genetic mutations that are found in families affected with primary
dystonias.
Drug dosage, potency, and the rate of titration correlate with risk of dysto-
nia.35,36,41 Moderate to high doses of antipsychotics are associated with dystonia,
whereas low or very high doses are involved less often.1,39 Antipsychotics
with weak dopamine antagonism and prominent anticholinergic (specifically, anti-
muscarinic) effects diminish the risk of dystonia, whereas the newer SGAs seem
to have reduced liability as well.14,15 Although haloperidol had up to a 4 times
greater risk of causing dystonia than SGAs in industry-sponsored trials,6,8,42
when the less potent FGA, perphenazine, was compared with SGAs in the Clinical
Antipsychotic Trials of Intervention Effectiveness (CATIE) project, the rate of dysto-
nia was only 0.4% overall, with no difference between treatment groups.30 The
CATIE data suggest that, in older patients with chronic schizophrenia, the use of
a less potent FGA at modest doses presents no greater risk for dystonia than
SGAs.
The advantages of SGAs over FGAs in reducing dystonia are also mitigated if an
anticholingeric drug is given prophylactically along with the FGA.33 However, using
prophylactic anticholinergics can be problematic owing to adverse anticholinergic
effects, which are especially hazardous in the elderly. But in young or other high-
risk patients receiving parenteral, high-potency antipsychotics, or in paranoid or other
patients ambivalent about treatment, the benefits of preventing dystonia with anticho-
linergics far outweigh potential risks.43

Treatment
Dystonia is responsive within 10 to 20 minutes to anticholinergic or antihistaminic
agents administered parenterally. Benzodiazepines have been effective in some
cases. If response is not achieved, a search for underlying disorders should be
conducted or tardive dystonia considered.44 After dystonia is suppressed, oral
anticholinergics are continued for 24 to 48 hours if the antipsychotic is discontinued,
or for at least several days if antipsychotic treatment is continued with gradual
tapering to prevent recurrence. However, some patients may need continued pro-
phylaxis, including those with a prior or recent history of dystonia or a history of
particularly severe dystonic reactions, and those at higher risk such as young and
male patients.

Pathophysiology
The exact pathophysiology of drug-induced dystonia is unresolved.1,31,34,45 It re-
mains unclear whether excessive dopaminergic activity from a compensatory in-
crease in turnover after drug-induced receptor blockade causes dystonia as
antipsychotic drug levels diminish (the “miss–match” hypothesis; ie, more dopamine
being released presynaptically at the same time that postsynaptic dopamine recep-
tor blockade declines), or whether dystonia results from dopamine antagonism per
se, or from imbalances in relation to other neurotransmitters.31 Recent clarification
of the genetics of primary dystonia may shed light on mechanisms of drug-
induced forms.34,36,38,40
 Drug-Induced Extrapyramidal Syndromes 395

PARKINSONISM
Clinical Features
Drug-induced parkinsonism is a subacute syndrome that mimics Parkinson’s disease.
Although less acute than dystonia, it is more common, more difficult to treat, and may
cause significant disability, especially in the elderly. Patients may initially complain of
fatigue, weakness, cognitive slowing, or depression.1 Bradykinesia is prominent and
accompanied by masked facies (hypomimia), reduced blink rate, positive glabellar
tap (Myerson’s sign), reduced arm swing, slowed initiation of activities, and dysphonic
speech.31 Bilateral and usually symmetrical rigidity of the neck, trunk, and extremities,
which can be either “cog-wheel” or “lead-pipe” in tone, is a core finding. Resting,
postural, or action tremors are also observed symmetrically and generalized,
occasionally affecting the perioral muscles (“rabbit syndrome”). Patients may experi-
ence autonomic dysfunction, sialorrhea associated with dysphagia, postural changes
(truncal hyperextension; ie, standing stiffly upright with a backward lean or “poker
spine”), and gait disturbances (shuffling, festinating [ie, compulsive, small steps for-
ward as if running], freezing [ie, hesitating to move], and anteropulsion or retropulsion
[ie, difficulty stopping forward or backward motion]).1

Differential Diagnosis
It is important to differentiate drug-induced parkinsonism from negative symptoms of
schizophrenia and psychomotor retardation associated with depression. It can be
difficult to distinguish drug-induced from idiopathic parkinsonism. Parkinson’s
disease is more likely to be asymmetric, with an invariably progressive course, and
is characterized by greater prominence of rigidity, tremor, and gait disturbance.
Evidence of idiopathic disease may precede treatment and would not resolve even
after antipsychotic drugs are discontinued. In contrast with patients with drug-
induced forms, patients with Parkinson’s disease show nigrostriatal degeneration
on dopamine transporter scans and sympathetic dysregulation on iodine-123-
metaiodobenzylguanidine cardiac scintigraphy.46 Interestingly, olfactory deficits
(hyposmia) have been reported in drug-induced parkinsonism and, therefore, may
not be useful in differentiation from idiopathic parkinsonism, but may predict risk for
prolonged symptoms after drug discontinuation owing to underlying Parkinson’s dis-
ease.47,48 The differential diagnosis also includes other causes of parkinsonism,
including vascular parkinsonism, which also tends to be asymmetric.

Course and Outcome

Although dopamine receptor blockade occurs within hours after drug administration,
the onset of parkinsonism may be delayed from days to weeks, with 50% to 75% of
cases occurring within 1 month and 90% within 3 months.31 Parkinsonism may also
occur after doses are increased, a second antipsychotic is added, anticholinergic
drugs are discontinued, or another drug is added that reduces dopamine activity or
increases plasma levels of the antipsychotic. In most cases, symptoms are reversible
in days or weeks, but occasionally, especially in the elderly, or if long-acting injectable
antipsychotics are used, symptoms may last for months. In about 15% of cases,
parkinsonism may persist after antipsychotic drug discontinuation, raising the possi-
bility of underlying Parkinson’s disease.46,49

Risk Factors
The incidence of drug-induced parkinsonism is variable depending on risk of the
population studied, duration of follow-up, sensitivity of diagnosis, and potency of
396 Caroff & Campbell

the drugs used, but has been estimated to occur in a range of 15% to 40% of patients
treated with FGAs.1,31 It is the second most common cause of parkinsonism after
Parkinson’s disease. The risk of drug-induced parkinsonism has been associated
with advancing age, female gender, and abnormalities of brain structure including de-
mentia, human immunodeficiency virus infection, and preexisting extrapyramidal dis-
ease or family history of Parkinson’s disease.31,46,50 Research on the genetics of
susceptibility to drug-induced parkinsonism is limited, but offers the promise of iden-
tifying patients at risk, including those with underlying disease likely to be unmasked
by drug treatment.1,40,51
Although parkinsonism has correlated with increased dosages and potency, and
reduced anticholinergic properties of antipsychotics,52 dose–response relationships
have not always been clear in view of differences in individual susceptibility. Although
haloperidol was associated with 2 to 4 times the risk of parkinsonism compared with
SGAs (22%-38% vs 4%-14%) in industry trials,6,8,14,15,42,53,54 there were no signifi-
cant differences in the CATIE trial when perphenazine was compared with SGAs in
the proportion of patients exhibiting parkinsonism, again suggesting that a less potent
FGA at modest doses may present a similar risk compared with SGAs.28–30
Furthermore, judging by the severe motor worsening experienced by patients with
Parkinson’s disease after receiving antipsychotics, even SGAs may cause significant
parkinsonism in susceptible individuals, with the exception of clozapine and quetia-
pine.14,15 Patients with Lewy body dementia may experience a potentially lethal “neuro-
leptic sensitivity syndrome,” which is characterized by worsening parkinsonism,
confusion, sedation, and postural instability, when exposed to either FGAs or SGAs.55

Treatment
Prophylaxis of parkinsonism with anticholinergic drugs is less compelling than for dys-
tonia and introduces significant risk of anticholinergic toxicity. Given the delayed onset
of drug-induced parkinsonism, close monitoring for parkinsonian symptoms with
prompt consideration of lowering dosages or switching to lower risk antipsychotics
takes precedence, albeit with attendant risk of psychotic relapse. If a given antipsy-
chotic is effective and cannot be changed, and if parkinsonism persists, treatment
may include anticholinergic drugs or amantadine. However, there is surprisingly limited
controlled evidence for the use of these agents.44 Specific dopaminergic therapy is inef-
fective, owing to ongoing drug-induced blockade of dopamine receptors, and raises the
risk of worsening psychotic symptoms. Once patients have been maintained on adjunc-
tive antiparkinsonian therapy for 3 to 6 months, cautious tapering may be attempted.31
However, several studies have shown that 62% to 96% of patients may still experience
worsening parkinsonism after antiparkinsonian drug discontinuation.56

Pathophysiology
The mechanisms underlying drug-induced parkinsonism parallel Parkinson’s disease
itself.1 Antipsychotics induce a functional dopamine deficiency in the corpus striatum
by blocking dopamine receptors. Their liability for inducing parkinsonism, therefore, is
the product of dopamine receptor binding affinity balanced by affinity for blocking
muscarinic receptors.52

AKATHISIA
Clinical Features
Akathisia is another common drug-induced EPS.1,31,50,57–60 However, akathisia is
distinctive: it is defined as much by subjective as well as by objective features, it
 Drug-Induced Extrapyramidal Syndromes 397

more often affects the lower extremities, it remains a frequent problem even with
SGAs,57 and it is more resistant to treatment. Subjectively, patients complain of inner
tension, restlessness, anxiety, an urge to move, an inability to sit still, and drawing sen-
sations in the legs. Motor features are complex, semipurposeful, and repetitive,
including foot shuffling or tapping, shifting of weight, rocking, pacing incessantly,
and even running. Although the severity of these sensations varies with stress and
arousal, they can become intolerable and have been associated with violence and
suicide.57,59
Differential Diagnosis
Acute drug-induced akathisia must be distinguished from tardive akathisia, neurode-
generative conditions, and drug-related states. Akathisia resembles restless legs syn-
drome, but the latter occurs during relaxation, rest, or sleep, mostly in the evening or
night. Misdiagnosis of restless legs syndrome instead of drug-induced akathisia may
lead to prescription of dopamine agonists, which could worsen psychosis in turn,
leading to increased antipsychotic use, and further compounding akathisia.58 Finally,
distinguishing akathisia from agitation and anxiety can be challenging.
Course and Outcome
Akathisia may begin within several days after treatment but usually increases with
duration of treatment, occurring in up to 50% of cases within 1 month and 90% of
cases within 3 months.31,60 Akathisia should resolve after drug discontinuation, but
could temporarily worsen or persist in withdrawal or tardive forms.
Estimates of the incidence of akathisia vary from 21% to as high as 75% across
studies of FGAs, with an estimated prevalence on average of at least 20% to 35%
of patients depending on the susceptibility of the sample population, sensitivity of
diagnosis, and the potency of drug treatment.1,57,60
Risk Factors
Risk factors for akathisia may include increasing age, female gender, negative symp-
toms, cognitive dysfunction, iron deficiency, prior akathisia, concomitant parkin-
sonism, and mood disorders.1,58,59 There has been even less work on genetic
susceptibility to akathisia compared with other EPS, but several genetic loci described
in relation to restless legs syndrome may reveal common mechanisms.1,40,61,62
In most but not all clinical trials, SGAs have resulted in a significantly lower incidence
of akathisia compared with FGAs.57 Akathisia developed at a rate of about 2 to 7 times
greater with haloperidol (15%-40%) compared with SGAs (0%-12%),6,8,14,15,42,53,54
but when perphenazine rather than haloperidol was the comparator, there were no dif-
ferences from SGAs in the incidence of akathisia.28–30
Treatment
There are no data on prophylaxis and, given its subacute onset, close observation for
early signs is the best preventive measure. Once developed, akathisia should prompt
reassessment of antipsychotic therapy, with a reduction in dosage, discontinuation, or
switching to a less potent dopamine antagonist, all of which incur the risk of psychotic
exacerbation or relapse. Evidence for the efficacy of treatments for akathisia derives
mostly from small, short-term clinical trials without active comparative groups.59,63
Lipophilic beta-adrenergic blockers have been effective in some studies, although
limited by hypotension, bradycardia, and medical contraindications. Anticholinergics
have been used traditionally, but evidence of their efficacy is limited; there were no
randomized clinical trials that met inclusion criteria in a metaanalysis to support or
398 Caroff & Campbell

refute their use in akathisia.64 It has been suggested that anticholinergics may be more
effective in the presence of concomitant parkinsonism, but this supposition is also
untested.1 Benzodiazepines have been useful owing to their anxiolytic and sedative
properties. Amantadine may be effective in some cases. Recently, 5-HT2A receptor
antagonists have attracted interest, with mirtazapine showing equal efficacy and
better tolerability in treating akathisia compared with propranolol.59
Pathophysiology
The pathophysiology of akathisia remains obscure, but dopamine antagonism under-
lying antipsychotic-induced akathisia, and treatment of restless legs syndrome with
dopamine agonists, underscore the importance of dopamine-dependent mecha-
nisms. Responses to beta-adrenergic and serotonergic blockers, suggest a role for
other neurotransmitters as well.

CATATONIA
Clinical Features
Catatonia remains a continuing source of controversy as to its rightful place in psychi-
atric nosology.65,66 However, it is essential for clinicians to be familiar with drug-
induced catatonia and we include it here because, like drug-induced EPS syndromes,
it is associated with antipsychotic drugs, it is characterized in part by abnormalities of
posture and movement, and it mimics the well-known idiopathic form.
Catatonic symptoms that have been associated with antipsychotics include akine-
sia, rigidity, stupor, and mutism (akinetic mutism), and less often catalepsy and waxy
flexibility.67,68 More complex and qualitative catatonic behaviors typical of chronic
psychotic disorders (stereotypies, echophenomena, verbigeration, automatic obedi-
ence) are rarely seen in drug-induced cases. In some patients, antipsychotics could
transform preexisting catatonia into a more malignant form (malignant catatonia/
neuroleptic malignant syndrome [NMS]).69,70
Differential Diagnosis
The differential diagnosis of catatonia includes a broad range of neurodegenerative,
developmental, metabolic, toxic, infectious, and structural conditions affecting brain
function.71 Catatonia can occur in schizophrenia and mood disorders, or indepen-
dently,72 leading to the “catatonic dilemma,”73 in which it may be difficult to distinguish
primary catatonia from the effect of drug treatment itself. This dilemma may be
resolved by discontinuing the antipsychotic medication, which leads to resolution of
the catatonia in iatrogenic cases.
Course and Outcome
Drug-induced catatonia develops within hours to days and should resolve in a similar
period of time after drug discontinuation. The onset of catatonia with antipsychotics
has been reported to occur after discontinuation of concomitant benzodiazepines or
antiparkinsonian agents. Only 5 cases of “catatonic neuroleptic syndrome” were re-
ported among 86,439 patients receiving antipsychotics in a retrospective drug surveil-
lance program.74
Risk Factors
Patient-related risk factors for drug-induced catatonia include past episodes and
preexisting catatonic symptoms. Catatonia is observed mostly in association with
high-potency drugs.68 SGAs are not without risk; there are published case reports
documenting both the occurrence and worsening of catatonia with SGAs, including
 Drug-Induced Extrapyramidal Syndromes 399

precipitation of malignant catatonia or NMS.14 However, SGAs have also been pro-
posed as treatments for catatonia.75,76
Treatment
There are no data on whether prophylaxis with benzodiazepines or other agents may
prevent catatonia. A more conservative approach would be to avoid using antipsy-
chotics in catatonic patients, and to treat preexisting catatonia with benzodiazepines
or electroconvulsive therapy (ECT). For patients at risk, clinicians should consider using
other agents for the underlying psychiatric disorder, for example, lithium for mania. How-
ever, patients who require antipsychotic treatment merit careful monitoring. Treatment
of drug-induced catatonia has not been studied, but must include reconsideration of the
offending agent to prevent medical complications, including NMS. Specific treatment
includes benzodiazepines, but some evidence suggests possible utility of amantadine
or memantine.68,77 Patients who fail to respond to these measures may require ECT.
Pathophysiology
The pathophysiology of drug-induced catatonia is unknown, but most likely involves
drug effects on parallel dopamine pathways in basal ganglia-thalamocortical circuits
subserving motor, arousal, volitional, and imitative behaviors.78 Several investigators
studied the genetic basis of idiopathic catatonia, which may correspond with drug
sensitivity as well.79–81

NEUROLEPTIC MALIGNANT SYNDROME

Clinical Features
NMS represents an extremely rare but potentially lethal form of EPS combining
features of advanced parkinsonism and catatonia.4,82–84 Classic signs are hyperther-
mia, generalized rigidity with tremors, altered consciousness, and autonomic insta-
bility.85 Rigidity is described as “lead pipe,” tremors are often generalized, and
other motor findings include dyskinesias, myoclonus, dysarthria, and dysphagia. In
its extreme form, NMS presents as a hypermetabolic crisis with muscle enzyme ele-
vations, myoglobinuria, leukocytosis, metabolic acidosis, hypoxia, elevated serum
catecholamines, and low serum iron levels.
Differential Diagnosis
The differential diagnosis of NMS includes other disorders with increased tempera-
tures and encephalopathy, such as malignant catatonia owing to psychosis,70 central
nervous system infections,86,87 benign EPS, agitated delirium, heatstroke,88 serotonin
syndrome, stimulant intoxication, and withdrawal from dopamine agonists, sedatives,
or alcohol. In the perioperative setting, NMS may be confused with malignant hyper-
thermia of anesthesia.89 Although no laboratory test is diagnostic for NMS, a thorough
assessment is necessary to exclude other serious medical conditions.
Course and Outcome
NMS may develop within hours but usually evolves over days; about two-thirds of
cases occur during the first 1 to 2 weeks after drug initiation.82 Once dopamine-
blocking drugs are withheld, two-thirds of NMS cases resolve within 1 to 2 weeks,
with an average duration of 7 to 10 days.82 Patients may experience prolonged
symptoms if injectable long-acting drugs are implicated. Occasional patients develop
a residual catatonic/parkinsonian state after acute metabolic symptoms subside
that can last for weeks to months unless ECT is administered.90 If not recognized,
NMS remains potentially fatal owing to renal failure, sudden cardiorespiratory
400 Caroff & Campbell

arrest, disseminated intravascular coagulation, pulmonary emboli, or aspiration

pneumonia.91
Risk Factors
The incidence of NMS is about 0.02% among patients treated with antipsychotic
drugs.74 Potential risk factors include dehydration, exhaustion, agitation, catatonia,
previous episodes, and high doses of high-potency drugs given parenterally at a rapid
rate.82 The effect of concurrent use of multiple antipsychotics, lithium, and serotonin
or serotonin–norepinephrine reuptake inhibitors on the risk of NMS has been sug-
gested.92 Most of these putative risk factors are commonly present and, therefore,
of limited value in predicting NMS, which is a rare occurrence. The presence of
such risk factors does not outweigh the value of antipsychotic drugs when they are
indicated.
NMS has been associated with all antipsychotic drugs, but is more likely to occur
with the use of high-potency agents. Haloperidol has accounted for about one-half
of all reported cases. The SGAs have been implicated in case reports, but large-
scale surveys suggest reduced risk compared with FGAs.83,84 Atypical or milder forms
have been reported in association with SGAs, but NMS has always varied in severity
even with FGAs.
Treatment
The management of NMS consists of early diagnosis, discontinuing dopamine antag-
onists, and providing supportive medical care. In addition to these general measures,
the use of benzodiazepines, dopamine agonists, dantrolene, and ECT have been
advocated, but controlled trials comparing these agents may not be feasible because
NMS is rare, often self-limited after drug discontinuation, and heterogeneous in pre-
sentation, course, and outcome.83 We proposed that these agents be considered
empirically in individual cases, and based on symptoms, severity, and duration of
the episode.83
Pathophysiology
Several lines of evidence strongly implicate drug-induced dopamine receptor
blockade as the primary triggering mechanism in the pathogenesis of NMS.78 How-
ever, the involvement of other neurotransmitter systems and alternative autonomic
or neuromuscular hypotheses have also been proposed.93 Genetic findings have
been reported in case reports, but without consistent results.

TARDIVE DYSKINESIA
Clinical Features
In contrast with acute EPS, TD is insidious in onset, arises after prolonged antipsy-
chotic treatment, and is often masked by ongoing treatment. TD is irreversible in
most cases, but usually mild, whereas acute EPS are transient but unmistakable
and incapacitating.1 Even so, TD can become socially disfiguring and compromise
eating, speaking, breathing, or ambulation. Although the risk of TD may have
decreased with SGAs, it is not absent, and it persists as a legacy of treatment with
FGAs for thousands of patients.
TD presents as a polymorphous, involuntary movement disorder.31,94,95 Unlike the
reaction to acute EPS, subjective symptoms are often described as minimal or denied
by patients with TD, at least in mild cases. In the CATIE trial of chronic schizophrenia,
patients were 10 times more likely to discontinue treatment because of acute EPS
compared with TD.29,96 However, in more functional patients, or in those with severe
 Drug-Induced Extrapyramidal Syndromes 401

dyskinesias, TD can be quite disturbing and emotionally intolerable. In its most com-
mon choreoathetoid form, the motor signs of TD are heterogeneous, involuntary, non-
rhythmic, repetitive, purposeless, and hyperkinetic. In 60% to 80% of patients, TD
primarily affects orofacial and lingual musculature (“buccolinguomasticatory syn-
drome”) with chewing or bruxism of the jaw; protrusion, curling, twisting, or vermicular
movements of the tongue; lip smacking, puckering, sucking and pursing, and retrac-
tion; grimacing or bridling of the mouth; bulging of the cheeks; or eye blinking and
blepharospasm.1,31 Choreoathetoid movements of the fingers, hands, and upper or
lower extremities are common. Axial symptoms affecting the neck, shoulders, spine,
or pelvis may be observed.
Tardive movements other than the classical choreoathetoid dyskinesias may
develop as the predominant feature or in combinations with other movement types.
These other movements, such as tardive dystonia, may represent subtypes of a tar-
dive syndrome and may be associated with increased risk of progression, persistence,
and severe disability. For example, tardive dystonia, estimated to occur in 3% to 5%
of treated patients,1,44,97 may be more generalized and disabling than TD, and may
respond to anticholinergic agents. Akathisia, tics, and other movement disorders
also occur as tardive variants.98 Dyskinesias increase with emotional arousal, activa-
tion, or distraction, and diminish with relaxation, sleep, or volitional effort. As a result,
symptoms of TD fluctuate over time, such that repeated measurements are necessary
for reliable assessment of severity and persistence.

Differential Diagnosis
A neurologic evaluation is indicated for new-onset dyskinesias. Clues to primary
neurologic causes include family history, sudden onset or progressive course, and
associated medical or neurologic abnormalities. TD can be symmetric or unilateral.
The differential diagnosis of TD includes neurodegenerative disorders, structural
abnormalities of the brain, and metabolic and toxic etiologies. Persistent TD may be
difficult to distinguish from acute EPS, transient withdrawal dyskinesias, or sponta-
neous dyskinesias associated with schizophrenia and aging.

Course and Outcome

The onset of TD occurs insidiously over 3 months or more of treatment and may begin
with ticlike orofacial or lingual movements or increased eye blink frequency. TD is sup-
pressed or masked by ongoing antipsychotic treatment, becoming apparent only
when treatment is reduced, switched, or discontinued.
The natural course of TD has become increasingly clear. Early studies showed that
withdrawal of antipsychotics may lead to an initial worsening of TD in 33% to 53% of
patients, but 36% to 55% of patients eventually improve, which led to recommenda-
tions for drug reduction or withdrawal.99 However, complete and permanent revers-
ibility beyond the withdrawal period may be uncommon.100,101 In a metaanalysis,
Soares and McGrath102 reported that 37.3% of patients assigned to placebo across
studies showed some improvement in TD, but concluded that evidence was insuffi-
cient to support antipsychotic drug cessation or dose reduction in view of the risk
for psychotic relapse.
Data on the prevalence of TD during continued treatment with antipsychotics have
been inconclusive, with some studies showing an increase and others a decrease or
no change at all.96 Roughly 50% of patients have persistent TD symptoms, 10% to
30% have a reduction, and 10% to 30% show increased symptoms during continued
treatment.103 Long-term studies estimated that between 2% and 23% of patients
show loss of observable TD symptoms during treatment with FGAs.96 Similarly,
402 Caroff & Campbell

studies of SGAs have generally shown reduction of TD ratings over time during the
course of treatment, with some studies showing greater or lesser reductions and
some showing no difference in comparison with FGAs.96 Improved outcome of TD
correlates in some studies with younger age, lower doses, reduced duration of drug
treatment and of dyskinesia, and increased duration of follow-up.
The CATIE trial added important data on the course of TD during antipsychotic treat-
ment; there was a significant decline in TD severity among patients with TD at baseline
who were randomized to treatment with SGAs, but there were no significant differ-
ences between SGAs in the decline in ratings.96 Of these patients who had TD at base-
line, 55% continued to meet criteria for TD at 2 consecutive visits after baseline, 76%
met criteria at some or all postbaseline visits, 24% did not meet criteria at any subse-
quent visit, and 32% showed at least a 50% decrease and 7% showed at least a 50%
increase in AIMS scores compared with baseline ratings. Thus, most of the patients
who already had TD before randomization showed either persistence or fluctuation
in observable symptoms during the trial.

Risk Factors
The risk of TD has been extensively studied; several studies have shown a cumulative
incidence of TD of about 4% to 5% annually, with a prevalence rate of 20% to 25%.94
In studies of first episode patients, the incidence of TD was 6% to 12% in the first year
even when low doses of antipsychotics were used.104,105 The annual incidence of TD
in patients over the age of 45 years was 15% to 30% after 1 year of treatment, with a
prevalence rate of up to 50% to 60%.106 Previous studies of TD risk have suggested
an association with increasing age, female gender, psychiatric diagnosis, longer dura-
tion of antipsychotic treatment, greater cumulative drug doses, concomitant drug
treatments, higher ratings of negative symptoms and thought disorder, greater cogni-
tive impairments, presence of acute EPS, substance abuse, and diabetes.107
An increasing number of genes have been studied in TD based on theories of path-
ogenesis, including neurotransmitter metabolism and receptor dysfunction, enzymes
protecting against oxidative stress, and pharmacokinetics.1,40,108 In relation to pro-
posed treatment of TD with tetrabenazine, a vesicular monoamine transporter type
2 (VMAT2) inhibitor, an association between ratings of TD and a single nucleotide poly-
morphism in the gene encoding VMAT2 was reported recently.109 Although an asso-
ciation for this VMAT2 marker with TD was found among candidate genes studied in
the CATIE trial,110 no single marker or haplotype association attained statistical signif-
icance in this analysis. In a genome-wide association study of the same sample of
CATIE patients, a single nucleotide polymorphism different from the VMAT2 marker
was associated significantly with ratings of dyskinesias on the AIMS.111 Further inves-
tigations are needed to test the validity of these genetic predispositions mediating TD.
Differences in liability for TD between FGAs and SGAs have been studied exten-
sively. Compared with the incidence of TD with haloperidol, industry-sponsored trials
of SGAs found a 6- to 12-fold reduction in risk for TD.12,27,112–114 It remains question-
able whether clozapine causes TD at all.115 In contrast with industry studies using
haloperidol, in the CATIE trial there were no differences in the incidence of TD among
groups receiving perphenazine or SGAs.28,29

Treatment
Because there is no proven treatment for TD, it is important to minimize the risk by pre-
vention and early detection (Fig. 1). Some preventive principles are to confirm the indi-
cation for antipsychotics, use conservative doses opting for lower potency agents,
inform patients and caregivers of risk, assess on a regular basis for incipient signs,
 Drug-Induced Extrapyramidal Syndromes 403

Prevention
(check diagnosis, dose, Classic tardive dyskinesia
detection)

Taper anticholinergics
(except for tardive dystonia, acute EPS)

Switch antipsychotic Continue current antipsychotic Antipsychotic withdrawal

(lower risk drug) (lower dose, consent, monitoring always) (psychotic relapse risk)

Second low risk antipsychotic

Specific suppressive agents
or clozapine

Cholinergics Antioxidants Antidopaminergics Miscellaneous

Tardive Dystonia Cholinesterase Vitamins E, Tetrabenazine Amino acids
Anticholinergics inhibitors, cholinergic B6, melatonin, Calcium channel
Tetrabenazine agonists ginkgo biloba, blockers
Reserpine omega-3 fatty Adenosine 2A antagonists
Botulinum toxin acids
DBS
NMDA agents
D-serine, amantadine

GABAergics
Benzodiazepines, levetiracetam, piracetam,
acamprosate

Fig. 1. Treatment algorithm for tardive dyskinesia. DBS, deep brain stimulation; EPS, extra-
pyramidal syndromes; NMDA, N-methyl-D-aspartate. (Adapted from Caroff SN, Hurford I,
Lybrand J, et al. Movement disorders induced by antipsychotic drugs: implications of the
CATIE schizophrenia trial. Neurol Clin 2011;29:140; with permission.)

and consider differential diagnosis and reconsider drug treatment if symptoms

emerge.
Once TD is detected, the first concern of management is to decide about antipsy-
chotic treatment. Although drug withdrawal had been recommended in the past,
about 33% to 53% of patients will experience worsening of dyskinesias initially,
36% to 55% may show improvement over time,99 but few will show complete resolu-
tion of symptoms,101 and patients with schizophrenia incur a significant risk of psy-
chotic relapse. In patients without an underlying psychotic disorder, such as those
who develop TD while taking dopamine antagonists like metoclopramide for nonpsy-
chiatric reasons, drug continuation may be difficult to justify.
A second option in a patient who requires antipsychotic therapy and has good con-
trol of psychotic symptoms is to reduce the dose of antipsychotic gradually, inform pa-
tients of risks, document the decision, and monitor carefully. In most cases, TD is not
progressive even with continued antipsychotic treatment, although symptoms may
worsen in some cases.96 Another alternative is to switch antipsychotics; more potent
FGA antipsychotics suppress symptoms of TD in about 67% of patients, although
limiting recovery and exacerbating acute EPS.103 Switching to SGAs has also been
associated with reduction of TD symptoms.14,15 The CATIE trial provided direct
evidence that randomization to an SGA resulted in a significant decline in mean ratings
of TD severity.96 Although most patients who had TD at baseline and were randomized
to SGAs showed a persistent (34%) or fluctuating course (42%), 24% did not meet
criteria on any visit at follow-up, and 32% showed a greater than 50% reduction in
TD scores, whereas only 7% showed increased ratings.96 Clozapine has been recom-
mended for suppressing TD, especially the tardive dystonia variant.116 Existing data
404 Caroff & Campbell

are inconclusive as to whether recovery rather than simply suppression occurs during
treatment with SGAs or FGAs.
If anticholinergic drugs have been prescribed, a decision also should be made about
whether continuation is necessary or gradual tapering could be considered. Anticho-
linergic drugs probably worsen TD generally, such that improvement in TD severity
ratings has been noted in up to 60% of patients withdrawn from these agents.103 How-
ever, anticholinergic drugs may have been prescribed for concurrent acute EPS or for
tardive dystonia, which are likely to worsen after anticholinergic withdrawal.

Pathophysiology
Apart from optimizing antipsychotic and anticholinergic therapy, there are a large
number of specific agents under investigation for the treatment of TD based on
competing theories of pathogenesis (see Fig. 1).1,103,117–119 For example, antioxidants
have been studied based on findings that drug-induced dopamine receptor blockade
increases production of free radicals, which in turn may cause neuronal damage un-
derlying TD.119
The hypothesis of dopamine supersensitivity may explain the suppressive effects of
dopamine antagonists on TD, and has rekindled interest in tetrabenazine, which
depletes presynaptic dopamine by inhibiting VMAT2, as a treatment for TD. Observa-
tional studies showing its suppressive effect in TD are being confirmed in controlled
trials.119–121 Based on evidence of antipsychotic drug-induced striatal glutaminergic
hyperactivity underlying TD, and reported benefits in treating levodopa-induced
dyskinesias, amantadine is also under study.118,122
Another hypothesis proposes that TD results from diminished cholinergic activity
owing to damage of striatal cholinergic interneurons after the loss of dopamine-
mediated inhibition.123–125 Indirect support stems from the observation that anticholin-
ergic agents probably worsen TD.103 We inferred that cholinesterase inhibitors or
cholinergic agonists may be effective in suppressing TD by directly enhancing post-
synaptic cholinergic activity, compensating for the loss of presynaptic cholinergic
neurons. Preliminary trials have explored the use of cholinesterase inhibitors with
mixed results.124,125 However, cholinesterase inhibitors nonspecifically increase
cholinergic activity at multiple receptors, whereas more recent studies have shown
beneficial effects of specific nicotine and muscarinic agonists on both levodopa-
induced and antipsychotic-induced dyskinesias in animal models, suggesting that
further investigations of specific nicotinic and muscarinic agonists in TD may be
worthwhile.126–128

SUMMARY

New antipsychotics allow clinicians to tailor pharmacotherapy to the needs and

vulnerabilities of individual patients. Antipsychotics should be conceptualized as a
single drug class with a spectrum of risk for EPS depending on their receptor binding
profile and individual patient susceptibility. Notwithstanding whether SGAs have
reduced liability for EPS because of weaker dopamine receptor affinity or “atypical”
mechanisms, their dominance in clinical practice has reduced significantly the fre-
quency of EPS. However, knowledge of drug-induced EPS remains important for medi-
colegal and clinical reasons, and a better understanding of their pathophysiology and
genetics may provide insights into the mechanism of action of antipsychotics and the
biological basis of psychotic disorders. Continued study of TD is especially important
and a moral imperative, given that treatments are being developed that offer new hope
for thousands of patients left with dyskinesias as a legacy of antipsychotic treatment.
 Drug-Induced Extrapyramidal Syndromes 405

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