Detection,

Prevention, and
Management of
Extrapyramidal Symptoms
Tamra Jean Courey
ABSTRACT

Extrapyramidal symptoms (EPSs), such as

akathisia, dystonia, psuedoparkinsonism, and
dyskinesia, are drug-induced side effects
that can be problematic for persons who
receive antipsychotic medications (APMs)
or other dopamine-blocking agents.The
clinical manifestations include a number of
atypical involuntary muscle contractions
that influence gait, movement, and posture.
The symptoms can develop acutely, be
delayed, or overlap making diagnosing a
challenge. Preventive interventions include
selective prescribing of APMs, close monitoring of uncharacteristic movements
through the use of screening instruments,
prompt management of symptoms, and
thorough client education. Nurse practitioners who do not practice in psychiatric
mental health nursing on a regular basis or
who infrequently prescribe psychotropic
medications must be cautious with these
potential life-threatening symptoms.
extrapyramidal symptoms, movement disorders, neuroleptic agents, psychiatric mental health nursing

Keywords:

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CASE EXEMPLAR
The objective of this article is to enhance awareness for
the nurse practitioner (NP) concerning extrapyramidal
symptoms (EPSs).A review of assessment criteria, detecting, preventing, and managing EPS through evidencebased interventions are highlighted.
Michelle is a 23-year-old African American who
sought treatment in the emergency department with
bizarre behaviors. She was brought to the hospital by
the police who were called by neighbors reporting that
Michelle was standing naked in front of her home.
When approached by the police, she stated the FBI
was coming for the mission. She became agitated and
a danger to herself. Michelle was involuntarily admitted to the psychiatric mental health unit, but had to
wait in the emergency department for an available bed.
While waiting, Michelle was placed in a quiet area
under constant observation.The acute care NP ordered
a one-time dose of haloperidol (Haldol) 5 mg and
lorazepam (Ativan) 2 mg, which was a common order
for aggressive clients.Within 30 minutes, Michelle was
calmer; however, she had a grin on her face, her neck
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was slightly twisted to one side, and she was staring at

the ceiling.The emergency triage nurse documented
Michelles behavior as delusional. In the following 30
minutes she was reassessed by a mental health nurse
before transport to the unit. Her condition was quickly
diagnosed as an acute dystonic reaction to the antipsychotic medication (APM) that was administered. At this
time, her upper extremities were rigid and her back
arched, her tongue was firm, and she displayed slurred
speech.The mental health nurse promptly managed the
situation by collaborating with the emergency department NP. Michelle was administered 2 mg benztropine
mesylate (Cogentin) intravenously. Michelles physiologic condition became more stable; however, her delusions heightened. Michelle was transported to the mental health unit for close observation of physiologic and
psychological variations.

graphic characteristics such as age and sex.Women and

older adults appear to be at higher risk of experiencing EPSs.3
DIFFERENTIAL DIAGNOSES
EPSs can easily be mistaken for other disorders, including
anxiety, major depression, manic episodes of bipolar disorder, psychosis,Tourette syndrome, cerebral palsy, intoxication, stoke, restless leg syndrome, lupus, or poor-fitting
dentures.1-3 Pseudoparkinsonism, one category of EPSs,
has a striking resemblance to Parkinson disease, making
early detection difficult even for a seasoned NP.Although
most APMs are prescribed for clients experiencing mental health decline, NPs must consider their additional uses
such as in antiemetic treatment, relief from hiccups, and
preoperative relaxation.

PATHOPHYSIOLOGY
EPSs are commonly attributed to the sensitive connection
INTRODUCTION
between the APM, also known as the neuroleptic, and the
EPSs, or abnormal induced movement disorders, are
dopamine D2 receptor-blocking properties.2 The term neuunwanted symptoms commonly originating from the
roleptic implies holding the neuron, designating the serioususe of APMs.The four different groups of symptoms
ness of the side effects produced from the APM.1 It is theinclude akathisia, dystonia, pseudoparkinsonism, and
1
orized that administering APMs, which are D2 antagonists,
dyskinesia. The symptoms can range from minimal discomfort to permanent involinitiates blockage of dopamine
untary muscular movements,
receptors in the basal ganglia, thus
and they can occur after one
creating a reduction of dopamine
dose of the APM or progresresponses to the brain.1,4 This
Historically, EPSs were
sively advance several weeks
reduction can generate alteration
common in clients
into treatment.
in a persons movement and funcprescribed APMs, but
Historically, EPSs were
tioning, thus resulting in EPSs.
common in clients preAlthough there are significant
today they are not seen as
scribed APMs, but today
pathophysiologic changes in
frequently
because
of
the
they are not seen as fredopaminergic activity, fluctuations
use of newer therapeutic
quently because of the use
in other neurotransmitters such as
of newer therapeutic
serotonin, norepinephrine, and
antipsychotic agents and
antipsychotic agents and
acetylcholine may also contribute
prophylactic therapy.
prophylactic therapy.The
to the symptoms.4 Two classificadistinctive characteristics of
tions of APMs are involved in
EPSs were first discovered in
blockage of dopamine transmisthe 1950s when the APMs, also called traditional,
sion, the first and second generation.
Traditional first-generation APMs (Table 1), were first
first-generation, conventional, or typical agents were
introduced in the 1950s to help regulate the activity of
introduced for the treatment of schizophrenia. EPSs
dopamine and to reduce the symptoms of many psychican occur in up to 75% of clients who are prescribed
atric illnesses, including schizophrenia.5,6 These medications
typical APMs, and they can create considerable dis2
diminish the florid psychotic symptoms of schizophrenia,
comfort while affecting adherence with treatment.
Onset of symptoms can be associated with demowhile reestablishing normalcy of thought, mood, and
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Table 1. Approved Typical, Traditional, Conventional, First-Generation Antipsychotic Medications (APMs) and the
Maintenance Dosage Range5,6
Approved Typical, Traditional,
Conventional, First-Generation APMs
Haloperidol (Haldol)
Haloperidol decanoate (Haldol Decanoate)
Trifluoperazine (Stelazine)
Fluphenazine (Prolixin)
Fluphenazine decanoate (Prolixin Decanoate)
Thiothixene (Navane)

Maintenance Dosage Range

(mg/day)
1.5-13.5
*
5-30
2.5-15.0
**
5-40

Loxapine (Loxitane)

20-200

Molindone (Moban)

20-200

Perphenazine (Trilafon)

6-42

Chlorpromazine (Thorazine)

150-750

Chlorprothixene (Taractan)

75-600

Thioridazine (Mellaril)

150-550

Mesoridazine (Serentil)

100-400

* This text was corrected after publication. The haloperidol decanoate (Haldol Decanoate) dosing schedule is 50100 mg, given typically every 4 weeks
because it is long-acting medication.
** This text was corrected after publication. Fluphenazine decanoate (Prolixin) is a long-acting medication and the dosage range is 12.525 mg given
typically every 1 to 4 weeks.

Table 2. Approved Second-Generation, Novel Atypical Antipsychotic Medications (AAPMs)5,6

Approved Second-Generation,
Novel AAPMs
Clozapine (Clozaril)
Risperidone (Risperdal)

Maintenance Dosage Range

(mg/day)
300-900
4-16

Olanzapine (Zyprexa)

5-20

Quetiapine (Seroquel)

300-800

Ziprasidone (Geodon)

40-160

Aripiprazole (Abilify)

10-30

behavior.The main deterrent for adherence to these medications is their potential to induce a range of damaging
side effects, including anticholinergic symptoms, cardiovascular effects, neuroleptic malignant syndrome, and EPSs.
Troublesome side effects from the APMs led to pursuit of improved treatment profiles that included discovery of the second-generation, novel, or atypical antipsychotic medications (AAPMs) (Table 2).5,6 AAPMs are
newer serotonin-dopamine antagonist agents that are
often chosen as first-line therapy in addressing psychotic
symptoms.These drugs are chosen over the first-generation APMs primarily because the incidence of EPSs is
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minimal to nonexistent and their side effect profiles are

atypical for antipsychotic medications.7 In addition,
AAPMs have superior efficacy for therapeutically treating
the other symptoms of schizophrenia such as alogia, anergia, avolition, apathy, and affect flattening, whereas the
first-generation agents lacked this quality. Even though
the AAPMs have a positive side effect profile, there is still
a need for caution when prescribing these medications.
Some of these medications can instigate EPSs especially
at elevated dosages.5,7,8 From the drugs listed in Table 2,
clozapine (Clozaril) initiates EPSs the least and risperidone (Risperdal) the most frequently.5,6
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Table 3. Risk Factors for Tardive Dyskinesia7,12

Older adult
Women
African American
Psychiatric diagnosis
Cognitive deficits
Chemical abuse
Extrapyramidal symptoms (EPSs)

laryngeal or pharyngeal spasms, and potential obstruction,

which becomes a medical emergency. Neck and trunk
symptoms include torticollis, contorting or twisting of the
cervical spine muscles, and opisthotonos, a severe form of
back arching.1-3 In addition, clients may experience oculogyric crisis which is rolling of the eyes in a locked upward
position.This condition can easily be mistaken as delusional
behavior.3 Dystonic reactions can occur after a single dose
of the APM or days after initiating treatment.

Brain damage
Diabetes mellitus
History of mood disorders
Treatment inconsistencies
Early onset of EPSs

In addition to APMs inducing EPSs, there are other

commonly used medications that can also put a client at
risk of developing EPSs. Some cold medications (decongestants), anticonvulsants, antihistamines, and selective
serotonin reuptake inhibitor antidepressants may increase
the risk of EPSs.3,7
CLINICAL MANIFESTATIONS AND ONSET OF SYMPTOMS
Akathisia

One of the most common EPSs is akathisia.This disturbing symptom of inner motor restlessness can have both a
subjective and objective component.1,2,3,9,10 Subjectively,
clients may verbalize that they are unable to remain calm,
have disturbed sleep patterns, or have impaired concentration. Symptoms are often described as anxiety, which is
concerning because it may prompt a clinician to administer an additional APM. Objectively, clients may demonstrate restlessness through actions such as pacing, marching, shuffling, foot-taping, rocking motion, or shifting
body weight from leg to leg. Restlessness can be throughout the entire body or confined to a section of the
extremities.1-3 Akathisia can surface within a few days of
administration of the APM or up to several weeks later.
Dystonic Reactions

Dystonic reactions are involuntary muscle contractions of

the head, neck, trunk, and extremities.The neck and head
muscles are the most commonly affected areas, including
the tongue, throat, face, eyes, and jaw.1-3 Symptoms affecting
the tongue and throat muscles can affect the vocal cords,
causing a hoarse voice, stiff or thick tongue, dysphagia,
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Pseudoparkinsonism

Pseudoparkinsonism, or neuroleptic-induced parkinsonism, includes slow pill-rolling finger tremors, masklike facial expression, weakened voice, absence of arm
swing when walking, stiff stooped posture, and an
impaired shuffling gait. Cogwheeling rigidity, assessed
frequently in the arms, is a ratchet-like motion of the
extremities during extension. Mentally, the client can
display bradyphrenia, or a slowed ability to think
through familiar situations. One unique manifestation
after prolonged use of the APM is the rabbit syndrome
which is tremors of the lips and a constant chewing
motion.2,11 Pseudoparkinsonism can develop after the
first dose of medication is administered or weeks later;
however, it is usually seen early in treatment or when
the APM dosage is increased.
Dyskinesia

Dyskinesia is characterized by rapid, repetitive, involuntary

movements of the face, trunk, respiratory muscles, and
extremities. Facial movements, which often occur in the oral
area, can include a protruding or rolling tongue, lip smacking, grimacing, frowning, sucking or kissing motions, and
facial distortions. Stereotypic movements of the limbs can be
irregular, rapid, purposeless motions or slow serpentine
movements.1-3 A clients trunk may rock, twist, jerk, or thrust
forward. Unlike the other EPSs, dyskinesia is a late-appearing side effect that can emerge months to years after the
APM has been administered, and it is identified as tardive
dyskinesia. In some cases, about 6%, the symptoms are irreversible. However, if the antipsychotic agent is removed
quickly, the tardive dyskinesia may be reversed.2,3 The symptoms of tardive dyskinesia can be disfiguring and embarrassing for clients; therefore, potential for social isolation is a
concern.Age, race, and sex appear to place some persons at a
higher risk of tardive dyskinesia.Table 3 identifies potential
risk factors contributing to this EPS.12
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Table 4. Screening Instruments for Extrapyramidal

Symptoms (EPSs)9,1315
Abnormal Involuntary Movement Scale (AIMS)
Barnes Akathisia Scale
Extrapyramidal Symptom Rating Scale (ESRS)
Liverpool University Neuroleptic Side Effect Rating
Scale (LUNSERS)

or her tongue, walk in a straight line, extend the arms with

palms facing downward, and touch the index finger to the
nose repeatedly are some of the examination procedures.
These actions help identify irregular movements in seven
different areas of the body, including the face, mouth,
extremities, and trunk.16 When an AIMS score is obtained,
it provides quantitative assessment data for the NP to use
in better management of symptoms.

Nursing EPS Assessment Scale

Side Effects Scale/Checklist for Antipsychotic
Medication (SESCAM)
Simpson and Angus Scale
Yale Extrapyramidal Side Effects Scale.

Table 5. Common Anticholinergic and Antiparkinsonian

Agents Used to Manage extrapyramidal
symptoms (EPSs)2,5,6
Anticholineric Agents and
Antiparkinsonian Agents
Diphenhydramine
hydrochloride
(Benadryl)

Oral, intramuscular, or
intravenous dose (mg)
25-50 tid or
qid oral dose
25-50 intramuscular
or intravenous dose

Bromocriptine mesylate
(Parlodel)

1.25-2.0
intramuscular or
intravenous dose

Benztropine mesylate

1-3 bid oral dose

(Cogentin)
1-2 intramuscular or
intravenous dose
Trihexyphenidyl (Artane)

2-5 tid oral dose

SCREENING INSTRUMENTS USED TO ASSESS EPSS

Screening instruments can assist in identifying the specific
category of EPSs as well as the severity of symptoms.
Examples of instruments are noted in Table 4.9,13-15
From Table 4, the 12-item Abnormal Involuntary Movement Scale (AIMS) is commonly used to screen for EPSs
and can be easily accessed from the Internet at www.
testandcal.com or www.atlantapsychiatry.com/forms/AIMS.pdf.
This comprehensive tool measures the atypical movements
as well as the intensity of symptoms. Completing the scale
involves observing the client repeat specific actions and
rating the movements. Directing the client to stick out his
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CLINICAL MANAGEMENT OF SYMPTOMS

Managing EPSs can be challenging even if a screening
tool is used, because the interventions must be based on
the specific category of EPSs being displayed. Most EPSs
will subside with discontinuation of the APM or replacing the medication with an AAPM. In some cases, lowering the dose may provide relief, except for tardive dyskinesia, which is unpredictable. Symptoms of akathisia typically respond to discontinuation of the APM coupled
with anxiolytic medications such as lorazepam (Ativan),
diazepam (Valium), or alprazolam (Xanax). -Blockers
such as propranolol (Inderal) have also proven effective.2,5,6
Dystonic reactions, which can develop acutely, require
immediate interventions to minimize symptoms.Anticholinergic and antiparkinsonian agents are the first line
of defense during acute dystonic reactions (Table 5).2,5,6
These medications relieve dystonic symptoms within
minutes; however, the anticipation for the onset of relief
can be frightening to an anxious client who is experiencing involuntary muscle contractions. Many clients will be
prescribed anticholinergic or antiparkinsonian medications as prophylactic therapy for EPSs. However, they
should be prescribed with caution because the potential
risks of lethality with overdose, dependence, psychosis,
dry mouth, blurred vision, constipation, tachycardia, urinary hesitancy, dizziness, confusion, and the potential to
aggravate tardive dyskinesia.2,5,13
Management of tardive dyskinesia begins with prevention of the symptoms. Screening for tardive dyskinesia
is strongly recommended at least every 3 to 6 months.2,6
Other sources of symptom management for tardive dyskinesia are being explored such as treatment with vitamin
B6 and vitamin E.17
MENTAL HEALTH COMPLICATIONS
Because EPSs may exacerbate a number of emotional variations, a comprehensive psychiatric mental health assessment is indicated. Depression, suicidality, anxiety, and subJuly/August 2007

Table 6. Resources for Extrapyramidal Symptoms

Website
Worldwide Education and Awareness for Movement Disorders

www.wemove.org

Dystonia Medical Research Foundation

dystonia@dystoniafoundation.org

National Institute of Neurological Disorders and Stroke

www.ninds.nih.gov

stance abuse are of particular concern. Substance abuse is

crucial to assess, because the patient may use to obtain relief
from disturbing symptoms.These symptoms can complicate
a clients effort to effectively cope with his or her disorder,
creating a continuum of mental health risk factors. NPs
who do not specialize in psychiatric mental health clinical
nursing practice should seek assistance when prescribing
unfamiliar medications for mental health symptoms.
CLIENT EDUCATION
Clients, like practicing clinicians, must become aware of
the warning signs of EPSs. Early detection is an important strategy to effectively reduce problematic complications. Extra caution should be taken when counseling
clients about actions to take if EPSs are suspected,
because some clients may select to discontinue the medication completely.Abrupt discontinuation of the APM is
not therapeutically recommended and may exacerbate a
continuum of critical psychiatric mental health concerns.
A thorough discussion related to risk factors associated
with APMs should be reviewed with every client, including those who have dosages adjusted. Educational websites are found in Table 6.
CONCLUSION
NPs must recognize the clinical manifestations of EPSs,
complete a prompt assessment that includes the use of
screening instruments, and institute effective management
techniques to minimize serious complications. In addition, being cognizant of mental health problems such as
depression, anxiety, suicidal ideations, or substance abuse
is a vital aspect of care. Because EPSs are physiologically
and psychologically challenging for clients, adherence to
the medications may depend on accurate client education, early detection, aggressive management, and a nonstigmatizing, supportive approach by the NP.

2. Burgyone K, Aduri K, Ananth J, Parameswaran S. The use of

antiparkinsonian agents in the management of drug-induced
extrapyramidal symptoms. Curr Pharm Des. 2004;10(18):2239-2248.
3. Recognition of movement disorders: extrapyrmaidal side effects and
tardive dyskinesia. Available at: www.medicalnewstoday.com. Accessed
July 18, 2006.
4. Gray R, Gournay K. What can we do about acute extrapyramidal
symptoms? J Psychiatr Ment Health Nurs. 2000;7(3):205-211.
5. Mosbys nursing drug reference. St Louis, MO: Elsevier Mosby Inc; 2005.
6. Varcarolis E, Carson V, Shoemaker N. St Louis, MO: Saunder Elsevier. St. Louis;
2006.
7. Bailey K. Do atypical antipsychotic agents cause tardive dyskinesia? J
Psychosoc Nurs Ment Health Serv. 2004;42(10):14-19.
8. Abidi S, Bhaskara S. From chlorpromazine to clozapin: antipsychotic adverse
effects and the clinicians dilemma. Can J Psychiatry. 2003;48(11):749-755.
9. Barnes T. The Barnes Akathisia Rating Scale--revisited. J Psychopharmacol.
2003;17(4):365-370.
10. Akagi H, Kumar T. Akathisia: overlooked at a cost. BMJ. 2002;324(7352):
1506-1507.
11. Schwartz M, Hocherman S. Antipsychotic-induced rabbit syndrome. CNS
Drugs. 2004;18(4):213-220.
12. Levy E, Margolese H, Annable L, Chouinard G. Diabetes, tardive dyskinesia,
parkinsonism, and akathisia in schizophrenia: a retrospective study
applying 1998 diabetes health care guidelines to antipsychotic use. Can J
Psychiatry. 2004;49(6):398-402.
13. Houltram B, Scanlan M. Extrapyramidal side effects. Nurs Stand. 2004;
18(43):39-41.
14. Fagan-Pryor E, May D. Establishment of interrater reliability for a nursing
extrapyramidal side effects (EPS) assessment scale. J Nurs Care Qual.
2000;14(3):54-63.
15. Gharabawi G, Bossie CA, Lasser RA, Turkoz I, Rodriguez S, Chouinard G.
Abnormal involuntary movement scale (AIMS) and extrapyramidal
symptom rating scale (ESRS): cross-scale comparison in assessing tardive
dyskinesia. Schizophr Res. 2005;77(2/3):119-128.
16. Menzies V, Farrell S. Schizophrenia, tardive dyskinesia, and the abnormal
involuntary movement scale (AIMS). J Am Psychiatr Nurses Assoc.
2002;8(2):51-56.
17. Lerner V, Miodownik C, Kaptsan A, et al. Vitamin B(6) in the treatment of
tardive dyskinesia: a double-bind placebo-controlled, crossover study. Am J
Psychiatry. 2001;158(9):1511-1514.

Tamra Jean Courey, MSN, is an assistant professor of nursing at

the Kent State University,Ashtabula Regional Campus,
Ashtabula, OH. She can be reached at Tcourey@kent.edu.
In conjunction with national ethical standards, this author
reports no relationships with business or industry that represent
a conflict of interest.
1555-4155/07/$ see front matter
2007 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2007.04.002

References
1. Pierre JM. Extrapyramidal symptoms with atypical antipsychotics. Drug Saf.
2005;28(3):191-208.

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