Recognizing Extrapyramidal Symptoms

>>Man 1: Just, it’s, tightening and going sideways. A little while ago I was fine. Now it’s starting to move again.>>Man 2: Does it hurt?>>Man 1: My back, right now hurts, then my jaw and whole neck starts hurting.>>Joseph Friedman: This is a man who came in complaining of involuntary muscle spasms. He was not a psychiatric patient. After extensive questioning initially, during which he denied taking any medicine whatsoever, he admitted that he took a medicine but
didn’t know what it was. He had taken it from his girlfriend assuming it would help his low back pain. Man 2: Are you in pain right now?>>Man 1: My back, yeah. My back spasms. My back spasm, twisting. You know, like with a drill.>>Joseph Friedman: He was having recurrent spasms. The spells would last about 20 to 30 minutes at a time.>>Man 2: Right now in your face, are you?>>Man 1: I’m smiling because I can’t help it.>>Man 2: You’re smiling because you can’t help it.>>Man 1: My speech is leaving me again. That’s what’s happening now.>>Man 2: Huh? And how
long each is each episode lasting?>>Man 1: It’s been about a half hour that I was fine.>>Man 2: Yeah.>>Man 1: Now it’s starting to come back again.>>Man 2: Ok. .>>Joseph Friedman: It’s unusual to have a generalized acute dystonic reaction.>>Man 2: Do you want to lie down? That’s okay.>>Joseph Friedman: Most dystonic reactions are from the neck and above. They usually involve the jaw, the tongue, the head turned to one side.>>Man 2: Can you move your leg? Can you bend it at the knee?>>Man 1: Nope.>>Man 2: You can’t bend it?>>Man 1: Not yet. Now I can bend it.>>Joseph Friedman: His dystonic reaction involved his spinal musculature, his leg, and interestingly was asymmetric. That’s one of the many things about acute dystonia we don’t understand. Since your brain is presumably symmetric, why should this sometimes involve one part and not the other? Sometimes it may jump from one
side to the other side. Why should it spare one place and not the
other. Here he is trying to walk, and you can see the severe torticollis.>>Man 2: Okay now, turn around look at me. Is your neck twisted?>>Man 1: Mhmm.>>Man 2: Just stay like that, just stay right there.>>Joseph Friedman: Look at his tongue. That’s involuntary there his tongue was stuck out.>>Man 1: I can, I twist my back.>>Man 2: Can you overcome it if you take your hand and push on your chin on the left?>>Joseph Friedman: They’re asking him at this point whether he has what we call a just antagonist. Patients with dystonia
frequently are able to overcome the dystonia, just with mild touching. They’re not
really pushing their heads over. In the emergency rooms its the nurses who see most of these things, and they’re easily recognized. So, you see a patient who comes in who’s just received Haldol and their eyes are up like this and you talk to them and as they’re talking to you their eyes come down and then they drift back up again and they look like this. If you’ve never seen that before and hadn’t read about it, the first thought, I think, has got to be
that this is part of their psychosis. In which case of course you may be tempted to treat it with more drug that caused it in the first place. So, I think the main differential there is psychogenic.>>Man 2: And then in about 2 or 3 minutes you’ll be all better, okay?>>Man 1: Okay.>>Man 2: Try not to jump, it doesn’t hurt much to go in.>>Joseph Friedman: So, to have a flurry, episodes, of these things, until they’re given intravenous
diphenhydramine or intravenous benztropine, or diazepam, and they go away
within a few minutes of getting the drug.>>Man 2: You feel normal?>>Man 1: Not all the way. No.>>Joseph Friedman: They’re virtually a hundred percent curable with these drugs.>>Man 2: In what way are you not normal?>>Man 1: I still feel the pain
in my neck. That’s it.>>Man 2: Okay, but that’s it?>>Man 1: It’s really stiff.>>Joseph Friedman: So, he’s treated with Benadryl, diphenhydramine, and it went away. He got put on benadryl for a few days, and
it never came back.>>Man 2: Can you open your mouth? Close it again.>>Man 1: Can you tell me what you’re experiencing right now?>>Man 2: I’m anxious. I can’t, well I can stop my legs if I
concentrate.>>Man 1: Can you describe, do you feel any uncomfortable sensation in your legs?>>Man 2: It’s only uncomfortable it’s not painful.>>Man 1: It’s uncomfortable?>>Man 2: Yes.>>Man 1: Can you use any descriptive terms for people who are looking at this? Do you feel restless?>>Man 2: Yes. I feel restless.>>Man 1: Do you get relief by moving around?>>Man 2: Yes.>>Man 1: Now, could you stand and not move?>>Man 2: I can try. I’m standing on one leg.>>Man 1: That makes it easier, huh?>>Man 2: Yes.>>Man 1: Are you moving your toes inside your shoes?>>Man 2: Yes.>>Man 1: Okay. On a scale of one to ten, how uncomfortable would you say this is?>>Man 2: Seven>>Man 1: What was it before?>>Man 2: Nine or ten. It’s just uncomfortable. Not painful.>>Man 1: Now here’s a difficult maybe
impossible question to answer, how would you compare the discomfort
from this, maybe when it was a nine or ten, compared to the discomfort of the
psychiatric illness itself?>>Man 2: Oh, way above.>>Man 1: Which was worse for you?>>Man 2: This.>>Man 1: This was worse for you than actually having the psychiatric disorder?>>Man 2: Yes.>>Man 1: So, you would say that you would rather have been untreated,>>Man 2: Yes.>>Man 1: than to have your thoughts under control but your body this uncomfortable?>>Man 2: Yes.>>Joseph Friedman: Now in general, akathisia is described by the patient as a body restlessness not a mental restlessness.
So, patients will describe the worst restlessness is occurring either on
their thighs or on their abdomen. So I ask them to point to where it
is the worst and if they point here or here it’s more likely the akathisia. If they point to their head, or can’t describe it, it’s somewhat less likely be akathisia.>>Man 1: If you had to rate it on a scale of one to 10 how much would you rate it?>>Barbara: I’d say eight.>>Man 1: About an eight?>>Barbara: Yeah.>>Man 1: Do you sometimes get a 10?>>Barbara: Yeah.>>Man 1: So this isn’t as bad as it can be? Okay.>>Joseph Friedman: The worst disasters that I’ve seen from akathisia are disasters like suicide. A completed suicide is obviously a tragedy.
Especially when it happens from a preventable, or reversible side effect such as akathisia.>>Barbara: After a while it drives you crazy.>>Man 1: It’s driving you crazy, these movements?>>Barbara: Yeah.>>Joseph Friedman: In my 20 years as a consultant, I’ve seen maybe five cases of what i believe to be
akathisia induced suicide. And, there’s been a common theme in those suicides that I’d like to warn clinicians of. The first thing is the akathisia is severe. The second thing that I’ve seen in all cases it’s undiagnosed and the antipsychotic
is raised or continued. Then, the third thing that I think is most important in these disasters is the patient doesn’t know what’s happening to them. They’re not given a diagnosis, they’re not reassured it’s a side effect. So they feel overwhelmed, they feel like they’re losing their mind. They feel desperate,
they don’t know what’s happening and they seem to suicide out of desperation of feeling horrible and not knowing what’s happening and feeling desperate. So a very important part of managing akathisia is to identify the fact that it is a side effect for the patient, reassure the patient it will go away, it’s
horrible, but it will go away. There’s treatment or we can change medicines or something. That then decreases the terror of the patient feeling like this horrible thing is happening to their body and they don’t know what’s happening.>>Barbara: It’s hard. It’s hard for the family, too, I guess, you know. Not just the one that’s having it but the person that has
this is really going through hell. I can understand when people say
that someone committed suicide. I can understand how they felt because
at one time I felt that way too. But, now if I get depressed, I don’t get depressed, no where near as much as I used to.>>Joseph Friedman: The things that I think it missed most in the psychiatric population are the slowness and the change in their walking and their posture. Most schizophrenic patients who were treated with
neuroleptics don’t have significant walking problems or balance problems
even though you may see that they’re a little bit stooped and they don’t swing
their arms so much. They may be a little slow, but it doesn’t really interfere with their activities all that much. In a sense, you can understand it. If their psychosis is under control,
and the patient’s not complaining about something, terrific. You know, leave well enough alone, you know why rock the boat. I think there’s a lot of
parkinsonism that goes on that’s just not recognized, or if it is recognized people say well that’s the price you have to pay in order to get adequate psychosis control.>>Man: Do you ever have tremors, do you ever notice that you shake?>>Woman: Yes. My thighs shake a lot and my fingers shake a lot.>>Man: Okay, does that bother you much?>>Joseph Friedman: The other problem is that they’re often not able to supply history. They often tolerate drug side effects
because they’ve lived with them for 20 or 30 years. I think they probably
just shrug their shoulders and say this is part of what’s wrong with me. Plus, they’ve been treated for so long,
and the development of these things may be so gradual, that they don’t perceive them. You take a drug and all of a sudden your head twists like this you know about it you say it’s the drug. Very clearly identified. But, you develop Parkinsonism, which develops over days weeks or months, and people don’t know it. They notice it when they have a tremor. So, if their hand is going like this they’ll say, oh yeah I shake from my medicines. But, if they’re like this and they move slowly
you know their balance is a bit off. They won’t recognize that and frequently
their doctors don’t either. They all recognized the tremor, but beyond that they frequently
don’t identify the other things, the stooped posture, the absence of arm swing, and the bradykinesia. Those often go unrecognized. This fellow has facial masking. He has diminished, like this, he’s not
much older than me. That would be normal. The left-hand, see he’s very, very brady kinetic. He’s tapping his leg up and down and he should be able to get a much, much higher amplitude and better speed than he’s generating right now. These are manifestations of his brady kinesia.>>Peter J. Weiden: Psychotic patients can be visibly affected by their antipsychotic treatment. I don’t want my patients
to look like they’re on antipsychotic medications.>>Man: We talked about your concern
about the medicines you were on. That you would look medicated in these interviews. Could you tell me about that?
What’s the concern about that?>>Woman: I am afraid that I’m not expressing a full
range of emotions, that I look kind of rigid, that I look kind of medicated, and that people can tell that there’s something wrong with me you know just by
observing me.>>Peter J. Weiden: One of the terrible things about EPS is that it brands you as being on medication.>Woman: Well, it’s kind of an unemotional
quality about it, you know, a lack of animation.>>Peter J. Weiden: The meaning of EPS is that they’re visibly stigmatized by the side effect. Just imagine what compliance to AIDS
medication would be if you took a protease inhibitor that gave you some
sort of physical side effect that made everyone know that you’re on a protease
inhibitor for your AIDS. I mean, think about that.>>Man: You had an honorable discharge before
your psychiatric problems developed.>>Yosef: Right. Two left feet.>>Man: You had two left feet?>>Yosef: When they made that last parade in front of the generals and admirals, and I wasn’t there.>>Man: Okay, and you think that that was because your psychiatric problems were beginning then?>>Yosef: Yeah, because the march. I couldn’t march.>>Man: You couldn’t March because of two left feet? What does that have to do with any
mental illness?>>Yosef: The feet connected to the knee bone, the knee bone connected to the thigh bone.>>Man: And that’s all connected to your
brain, is that right? Yosef: Yeah.>>Man: I see, okay.>>Peter J. Weiden: Tardive dyskinesia is of very serious
concern because of the threat to the patient that it can be permanent. All of the other side effects are reversible, but the threat to tardive dyskinesia is
it’s potential irreversibility. The irony is that while on one level
it’s the most serious on another level it’s one of the least problematic on a
day-to-day basis because tardive dyskinesia, for most patients, tends to be mild and not distressing. Whereas, parkinsonism and akathisia tend to be very distressing.>>Man: Keep your mouth open. Okay, that’s fine.>>Dorothy: I don’t have much strength.>>Joseph Friedman: With the choreic disorders, the constant random movements, patients either are unaware or underestimate how bad their movement disorders are. Whereas, patients with tardive dystonia are very much aware of their syndrome.>>Man: Turn sideways to me. That’s right, that’s perfect.>>Joseph Friedman: Dorothy has these involuntary movements of her arms particularly her left arm but the major
problem here was the arm and the axial dystonia, so that she’s leaning backwards.>>Man: Just gone by itself, huh? Can you hold your hands out in front of you? Both hands?>>Joseph Friedman: During this entire time, her psychosis was completely controlled, but they weren’t able to find any other medications that could treat her, and she was intolerant of reserpine, it induced a severe depression. She was placed on clozapine which actually did nothing at all for her movement disorder. The rational for using clozapine was to allow this passive healing business and also hopefully to treat the tardive distonia, but it really didn’t treat the tardive dystonia. But, when we added reserpine she was able to tolerate it this time and she became dramatically, dramatically better. This is, I think, a year or two later.>>Man: Tap your foot. And the other one.>>Joseph Friedman: Now, the thing to notice is, look at her left arm. Look at her posture. Look at her head. Now, you will see that she’s a little parkinsonian, but it was a price she was willing to pay because she was so much more comfortable. In other words, she’s not normal now, but she’s so much closer to normal. Even though she’s a little bit further
in the direction towards parkinsonism. I mean, this is dramatic. This is why people like going to movie theaters. You have the occasional patient who you can improve so much. This is control. She wasn’t cured because eight years later she still has this movement disorder, and when her drugs were adjusted she’s got it back again.>>Dorothy: It’s like agony. It’s just like you, well, your shaking all the time and you can’t sit down. Then they give me the shots for my neck
and made it where I forget turning more and more. It’s just like, uh, let’s
say you’re walking on hot sand on the beach and you couldn’t get to the cold
sand, and you’re like that for about 20 minutes. By time you get to the cool sand you’re
relieved. Finally, I can breathe. That’s about
what it is to get relief from tardive dyskinesia. Cause you shake and you can’t
sit down it’s just complete discomfort.>>Peter J. Weiden: So what do i do if i see mild tardive dyskinesia on a patient who is on maintenance antipsychotics? The first thing I do is not panic. Some of the biggest disasters I’ve seen in my
practice, or as a consultant, is mild TD, the patient panics, the doctor panics, the
patient goes off medicine, there’s a relapse, there’s a suicide, or whatever. So, the first thing I want to reassure the patient and myself, is don’t panic.>>Woman: Now I want you to take your right hand and touch each finger with your thumb.>>Joseph Friedman: We found that once you develop tardive dyskinesia it doesn’t mean it’s going to get worse. It doesn’t mean it’s going to evolve
into some really excruciatingly terrible syndrome. But it may. You have to worry about each one of these patients. That when you see this, that you know in two years they’re going to be like this, or something really bad. But, most patients that doesn’t happen. If you talk, when I’ve talked, to psychiatrists and I show them videotapes of people like Yosef, or people who have other bizarre
syndromes, they’ll say, I’ve never seen that. And, it’s true they may have treated
500 or a thousand schizophrenics and they’ve never seen it. I’m the movement disorder person who
sees you know the bad ones from the whole catchment area you know the whole
state and I see it and if I show videotapes of some of these patients to
other people who are movement disorder people, they won’t even, without a
history they’ll say, oh that’s neuroleptic induced. You know, there is virtually no differential. They don’t think this Huntington’s disease,
they don’t think this is stroke. They say this is from a neuroleptic. I mean they’re very easy to identify. How do you identify those patients early on, at the beginning, so you know to get them off their bad drug, and on another drug that’s presumably not
going to cause it? Nobody knows.

6 thoughts on “Recognizing Extrapyramidal Symptoms

  • Wow! as a psychiatry resident, this is extremely helpful, much better than reading it from the books. Are there other videos like this ?

  • Most people will never experience extrapyramidal symptoms (EPS) so they have no idea how horrible they can be. There are many factors contributing to EPS but mainly a dysfunctional dopaminergic and acetylcholinergic neurological system play a role.

    There are so many hyperkinetic movement disorders like dystonia, dyskinesia, akinesia, akathisia, athetosis, ataxia, chorea, myoclonus, ballismus, tics, tremors, Tourette’s, spasms, RLS,etc.. it can make it very hard to distinguish.

    I sympathize for schizophrenics and people who need certain antipsychotics and other medications that exacerbate these movement disorders. Most these medications drastically deplete Dopamine which is one of the main reasons for these extrapyramidal side effects.

    Science has had more than enough time AND MZoNEY to develop a novel medication that should not cause this. Many schizophrenics need glutamate and dopamine regulation (not always “reduction”). There are several dopaminergic receptors and binding sites that can be antagonized and agonized therefore there is ZERO reason why there isn’t a proper neuroleptic to control psychiatric side effects while not exacerbating extrapyramidal side effects OR anhedonia!

    Dopamine agonists can do wonders for EPS and science was able to develop non-ergot agonists which are much much safer yet can’t develop an agonist that will not cause debilitating Dopamine withdrawl Syndrome? Come on that is ridiculousness there is no excuse for no development of one. Or how about an MAOI with no withdrawal? Nope, doesn’t exist 🤦‍♂️

    9-Methyl-β-carboline should be further examined as it appears to have incredible dopaminergic restoration properties. A study was done on rats that proved it. In layman’s terms scientists injected rats with synthetic neurotoxic compounds like 2,4,5-trihydroxyphenethylamine (6-OHDA) and 1-methyl-4-phenyl-pyridinium ion (MPP+) that selectively destroy tyrosine hydroxylase and dopaminergic neurons. So they essentially gave these rats Parkinson’s like symptoms.

    After a few weeks of 9-Methyl-β-carboline administration around 80% of the damaged neurons returned to normal determined by measurements of nicotinamide adenine dinucleotide dehydrogenase activity.

    Also the adamantane derivative called Bromantane and Pentadecapeptide BPC-157 play important roles.

    Yet no ongoing research is being done. 🤦‍♂️

  • Wow. My biological mom has schizophrenia. And whenever we go to the doctors when she is on her worst (because she refuses take meds) they inject this drug (i forgot the name) that works for more than a week. I hated it because she experiences this syndrome and she looks very pitiful and it breaks my heart. This is very educational. Thanks for the info. Im studying pharmacy.

  • I had this once, except some muscle near my tongue and throat was spasming also. I was very scary because it was closing my throat over and I couldn't breath. Only thing that stopped me from death was I found if I put my fingers down my throat to cause a gag reflex it would let the spasm off for a few minutes so I could breath. This went on for a few days if I remember correctly. I do remember my head kept leaning back and I could not stop it.. Scary stuff. This happened to me after taking a friends anti-psychotic.

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