Extrapyramidal Side Effects

Question 1

What causes extrapyramidal side effects (EPS)?

Answer 1

Dopamine (D2) blockade in the nigrostriatal pathway

Question 2

Which neurotransmitter increases when dopamine is blocked, causing EPS?

Answer 2

Acetylcholine

Question 3

Mnemonic for EPS types

Answer 3

DRAPE

Dystonia
Restlessness (Akathisia)
Akinesia
Parkinsonism
Exaggerated movement (Tardive dyskinesia)

Question 4

What is acute dystonia?

Answer 4

Sudden, painful muscle spasms

Question 5

Common symptoms of acute dystonia

Answer 5

Neck twisting
Facial grimacing
Tongue spasm
Stiff neck
Painful muscle contractions

Question 6

What is an oculogyric crisis?

Answer 6

Sustained upward deviation of the eyes (medical emergency)

Question 7

Acute dystonia is often mistaken for what?

Answer 7

Agitation or psychotic movements

Question 8

First-line treatment for acute dystonia

Answer 8

Benztropine (Cogentin)

Question 9

What is akathisia?

Answer 9

Motor restlessness with inability to sit still

Question 10

Key symptoms of akathisia

Answer 10

Pacing
Rocking
Constant movement
Subjective inner restlessness

Question 11

Akathisia is most often mistaken for what?

Answer 11

Anxiety

Question 12

Assessment tools for akathisia

Answer 12

Barnes Akathisia Rating Scale
Extrapyramidal Symptoms Rating Scale

Question 13

Treatment options for akathisia

Answer 13

Propranolol (beta-blocker)
Benztropine
Benzodiazepines

Question 14

What is akinesia?

Answer 14

Absence or difficulty initiating movement

Question 15

Symptoms of akinesia

Answer 15

Slowed movement
Difficulty starting movement
Subjective lack of motivation to move

Question 16

Treatment for akinesia

Answer 16

Benztropine (Cogentin)

Akinesia —> “no kinetic energy” give cogentin to restore movement

Question 17

What causes pseudo-parkinsonian symptoms?

Answer 17

D2 blockade mimicking Parkinson’s disease

Question 18

Symptoms of pseudo-parkinsonism

Answer 18

Shuffling gait
Rigidity
Tremor
Pill-rolling
Mask-like face
Motor slowing

Question 19

Treatment for pseudo-parkinsonism

Answer 19

Benztropine (Cogentin)

Question 20

What is tardive dyskinesia?

Answer 20

Involuntary abnormal movements, often irreversible

Question 21

Classic symptoms of tardive dyskinesia

Answer 21

Tongue protrusion
Lip smacking
Sucking motions
Facial and jaw movements
May involve limbs

Question 22

FDA-approved treatments for tardive dyskinesia

Answer 22

Austedo (deutetrabenazine)
Ingrezza (valbenazine)

Question 23

What medication is CONTRAINDICATED in TD?

Answer 23

Benztropine (Cogentin)

Question 24

What is the initial management of tardive dyskinesia

Answer 24

Reduce dose or switch antipsychotic

Question 25

Which non-psychiatric medication can cause TD-like symptoms?

Answer 25

Metoclopramide (Reglan)

Question 26

Which EPS is treated with propranolol?

Answer 26

Akathisia

Question 27

Which EPS looks like anxiety but isn’t?

Answer 27

Akathisia

Question 28

Which EPS looks like negative symptoms but isn’t?

Answer 28

Akinesia or pseudo-parkinsonism

Question 29

Which EPS is most likely irreversible?

Answer 29

Tardive dyskinesia

Question 30

Which antipsychotic has the lowest risk of extrapyramidal side effects (EPS) and why?

Answer 30

Clozapine (Clozaril) Weak D2 blockade Strong 5-HT2A antagonism Preserves dopamine in nigrostriatal pathway Minimal EPS & lowest TD risk

Question 31

Why is clozapine rarely first-line despite minimal EPS?

Answer 31

Agranulocytosis Seizures Myocarditis Severe metabolic effects ➡️ Reserved for treatment-resistant schizophrenia