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Extrapyramidal Symptoms
Dystonia
Akathisia
Parkinsonism
Tardive Dyskinesia
Medications
High-Potency Typical Antipsychotics (more EPS & less
histaminic, alpha-adrenergic, and anticholinergic effects):
Haloperidol (Haldol)
Fluphenazine (Prolixin)
Low-Potency Typical Antipsychotics (fewer EPS but more
histaminic, alpha-adrenergic, and anticholinergic effects):
Mesoridazine (Serentil)
Antiemetics:
Metoclopramide (Reglan)
Prochlorperazine (Compro)
Atypical Antipsychotics:
Risperidone (Risperdol)
Paliperidone (Invega)
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Aripiprazole (Abilify)
Antidepressants
Duloxetine (Cymbalta)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Bupropion (Welbutrin)
Dopaminergic Pathways
Mesolimbic Pathway - aka reward pathway; thought to play a
central role in addiction and implicated in schizophrenia (positive
symptoms > negative symptoms) and depression
Mesocortical Pathway - thought to be involved with cognitive
control, motivation, and emotional response; implicated in
schizophrenia and thought to be associated with the negative
symptoms of the disease
Nigrostriatal Pathway - involved with movement; particularly
with initiating movement**
Tuberoinfundibular Pathway - influences secretion of certain
hormones (particularly prolactin)
Pathophysiology of EPS
Requires blockade of 65% mesolimbic dopamine receptors and 80%
nigrostriatal dopamine receptors
Clozapine and quetiapine have lowest risk; haloperidol has highest
Quetiapine preferred because of agranulocytosis risk of clozapine
Risperidone has highest risk out of the atypicals
Rapid dissociation from receptors is important for decreased potential of EPS
Serotonin believed to enhance dopamine release to decrease EPS potential
Prevalence of EPS
Study of chronic institutionalized patients with schizophrenia
Typical neuroleptics caused movement disorders in 61.6% of patients
31.3% had akathisia
23.3% had parkinsonism
32.3% had tardive dyskinesia
Older females at risk of tardive dyskinesia
Young males at risk of dystonia
Elderly are prone to drug-induced parkinsonism
Young age
Male
Mental retardation
Use of high potency neuroleptics
Presence of Tardive Dyskinesia
Dystonia Video
Advanced age
Cognitive impairment
Female
High potency/dose neuroleptic
Iron deficiency
Mental Retardation
Negative symptoms of schizophrenia
Rapid neuroleptic dose escalation
AIDS
Advanced age
Dementia
Female