Acute drug-induced movement disorders

Joseph H Friedman MD (Dr. Friedman of the Alpert Medical School of Brown University and University of Rhode Island, and Director of the Movement Disorders Program of Butler Hospital, received research grants from Avid and NIH as a site investigator.)
Originally released July 16, 1993; last updated June 14, 2016; expires June 14, 2019

This article includes discussion of acute drug-induced movement disorders and acute dystonic reactions. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Although it is generally believed that drug-induced movement disorders are much less common in the era of atypical antipsychotic drugs, there are little data to support this contention. Both acute and nonacute extrapyramidal disorders still do occur, so neurologists and psychiatrists should be able to recognize and treat them. Akathisia may be mistaken for other conditions, including restless legs, increased psychosis, or anxiety. These problems are occasionally seen with antiemetics, and antipsychotics used for migraines, and may then be less likely to be recognized. Akathisia may be also seen with tetrabenazine, a monoamine-depleting drug approved for the treatment of chorea associated with Huntington disease but also used for other hyperkinetic movement disorders. Although this drug does not cause tardive dyskinesia, it has been associated with acute dystonic reaction. Acute dystonic reactions occur with some, but not all, of the newer antipsychotic medications. Acute akathisia is harder to characterize because of the subjective nature of the symptoms. Neuroleptic malignant syndrome occurs with all antipsychotics, including all the atypicals.

Key points

 

• Extrapyramidal side effects are seen with all first generation, and most second generation, antipsychotic drugs.

 

• Acute akathisia and acute dystonic reactions are usually the first extrapyramidal side effects to develop, usually shortly after initiation of an antipsychotic or a dose increase, and generally before parkinsonism develops.

 

• Akathisia may be difficult to diagnose because of its subjective nature and overlap with anxiety and psychosis but is a very important cause for noncompliance.

 

• Tetrabenazine, introduced to treat chorea in Huntington disease, may cause akathisia and, rarely, acute dystonic reactions.

Historical note and terminology

The term “acute drug-induced movement disorders” refers primarily to acute dystonic reactions and akathisia. These syndromes were first described as adverse drug effects in the mid-1950s (Steck 1954; Delay and Deniker 1968) and were recognized as being similar to the dystonic and akathisic syndromes seen in postencephalitic parkinsonism. Akathisia had been recognized even before the encephalitis epidemic, the term having been coined at the turn of the century to describe psychiatric patients unable to remain seated and thought to suffer from a form of hysteria (Haskovec 1902). The syndrome we currently call akathisia had been described in the 19th century in idiopathic Parkinson disease (Bing 1939). The term “akathisia” was taken up by neurologists after the epidemic of postencephalitic parkinsonism, which was frequently associated with akathisia (Wilson 1941).

These syndromes are thought to have become considerably less common in the current era of atypical antipsychotic drugs but have not been well studied. Non-acute drug-induced movement disorders have been widely thought to have been reduced with the introduction of the atypical antipsychotics, but this may not be the case (Dayalu and Chou 2008; Miller et al 2008).

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