Psych · Psychopharmacology — EPS and tardive dyskinesia
Extrapyramidal side effects and tardive dyskinesia
Also known as EPS · Drug-induced movement disorders · Acute dystonia · Akathisia · Drug-induced parkinsonism · Tardive dyskinesia · VMAT2 inhibitors · Valbenazine · Deutetrabenazine
Fellowship-depth atlas of antipsychotic-related extrapyramidal syndromes — acute dystonia (including laryngeal), akathisia (Barnes scale), drug-induced parkinsonism, tardive dyskinesia (Schooler–Kane, AIMS, Carbon/Solmi epidemiology), and VMAT2 inhibitor evidence (KINECT 3, ARM-TD, AIM-TD). FRANZCP-primary, globally tagged.
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Target exams
FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Laryngeal dystonia / stridor after dopamine antagonist — airway emergency; parenteral anticholinergic immediately
- Severe akathisia with agitation or self-harm ideation — do not escalate antipsychotic; reduce/switch and treat restlessness
- Fever, lead-pipe rigidity, autonomic instability — treat as possible NMS, not simple EPS
- New or worsening orofacial dyskinesia on chronic antipsychotic — document AIMS, review indication/dose, plan TD pathway
- Mislabeling akathisia as anxiety or 'acting out' — iatrogenic harm and suicide-risk association
- Prolonged high-dose anticholinergic prophylaxis without review — cognitive harm and TD risk concerns
Meet the patient
A 23-year-old man, three days into haloperidol after a first psychotic episode, is brought back to the ward by security. He is pacing the corridor and cannot explain why. He says he feels "wrong in the legs" and asks for something to help him sit down. The nurse has written "escalating agitation, for review".[2][14]
The reflex prescription is more antipsychotic. That reflex is how a treatable drug effect becomes a suicide risk. Every EPS question in every fellowship exam is a variation on this corridor.[2][14][17]
References24ShowHide
- [1]Schooler NR, Kane JM Research diagnoses for tardive dyskinesia Arch Gen Psychiatry, 1982.PMID 6121550
- [2]Barnes TR A rating scale for drug-induced akathisia Br J Psychiatry, 1989.PMID 2574607
- [3]Hauser RA, Factor SA, Marder SR, et al. KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia Am J Psychiatry, 2017.PMID 28320223
- [4]Anderson KE, Stamler D, Davis MD, et al. Deutetrabenazine for treatment of involuntary movements in patients with tardive dyskinesia (AIM-TD): a double-blind, randomised, placebo-controlled, phase 3 trial Lancet Psychiatry, 2017.PMID 28668671
- [5]Fernandez HH, Factor SA, Hauser RA, et al. Randomized controlled trial of deutetrabenazine for tardive dyskinesia: The ARM-TD study Neurology, 2017.PMID 28446646
- [6]Bhidayasiri R, Fahn S, Weiner WJ, et al. Evidence-based guideline: treatment of tardive syndromes: report of the Guideline Development Subcommittee of the American Academy of Neurology Neurology, 2013.PMID 23897874
- [7]Bhidayasiri R, Jitkritsadakul O, Friedman JH, Fahn S Updating the recommendations for treatment of tardive syndromes: A systematic review of new evidence and practical treatment algorithm J Neurol Sci, 2018.PMID 29454493
- [8]Solmi M, Pigato G, Kane JM, Correll CU Clinical risk factors for the development of tardive dyskinesia J Neurol Sci, 2018.PMID 29439776
- [9]Carbon M, Hsieh CH, Kane JM, Correll CU Tardive Dyskinesia Prevalence in the Period of Second-Generation Antipsychotic Use: A Meta-Analysis J Clin Psychiatry, 2017.PMID 28146614
- [10]Ward KM, Citrome L Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Tardive Dyskinesia-Key Differences in Pathophysiology and Clinical Management Neurol Ther, 2018.PMID 30027457
- [11]Rupniak NM, Jenner P, Marsden CD Acute dystonia induced by neuroleptic drugs Psychopharmacology (Berl), 1986.PMID 2871578
- [12]Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia Am J Psychiatry, 2020.PMID 32867516
- [13]Haddad PM, Dursun SM Neurological complications of psychiatric drugs: clinical features and management Hum Psychopharmacol, 2008.PMID 18098217
- [14]Kumar R, Sachdev PS Akathisia and second-generation antipsychotic drugs Curr Opin Psychiatry, 2009.PMID 19378382
- [15]Carbon M, Kane JM, Leucht S, Correll CU Tardive dyskinesia risk with first- and second-generation antipsychotics in comparative randomized controlled trials: a meta-analysis World Psychiatry, 2018.PMID 30192088
- [16]Ricciardi L, Pringsheim T, Barnes TRE, et al. Treatment Recommendations for Tardive Dyskinesia Can J Psychiatry, 2019.PMID 30791698
- [17]Gerolymos C, Barazer R, Yon DK, et al. Drug Efficacy in the Treatment of Antipsychotic-Induced Akathisia: A Systematic Review and Network Meta-Analysis JAMA Netw Open, 2024.PMID 38451521
- [18]Leucht S, Cipriani A, Spineli L, et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis Lancet, 2013.PMID 23810019
- [19]Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia N Engl J Med, 2005.PMID 16172203
- [20]Lindenmayer JP, Verghese C, Marder SR, et al. A long-term, open-label study of valbenazine for tardive dyskinesia CNS Spectr, 2021.PMID 32419679
- [21]Stacy M, Sajatovic M, Kane JM, et al. Abnormal involuntary movement scale in tardive dyskinesia: Minimal clinically important difference Mov Disord, 2019.PMID 31234240
- [22]Correll CU, Citrome L Diagnostic and Treatment Fundamentals for Tardive Dyskinesia J Clin Psychiatry, 2021.PMID 34644461
- [23]Casey DE Motor and mental aspects of acute extrapyramidal syndromes Acta Psychiatr Scand Suppl, 1994.PMID 7914042
- [24]Caroff SN, Citrome L, Meyer J, et al. A Modified Delphi Consensus Study of the Screening, Diagnosis, and Treatment of Tardive Dyskinesia J Clin Psychiatry, 2020.PMID 31995677