Why do typical antipsychotics cause EPS?

Extrapyramidal symptoms (EPS) are serious side effects that can develop after taking certain antipsychotic medications. They can affect your motor control and coordination. EPS can take several forms, including tardive dyskinesia.

Tardive dyskinesia causes uncontrollable facial movements. It develops after long-term use of certain psychiatric medications that block the neurotransmitter (chemical messenger) dopamine, which plays a role in pleasure and movement. Typical onset of symptoms is about three months after starting the medication. Tic-like movements and involuntary eye blinking are common early signs.

The extrapyramidal system controls voluntary movements. Damage to this system—mostly in a part of the brain called the basal ganglia, a set of structures involved in the integration of multiple sources of information—can result in serious problems with your motor function.

Extrapyramidal symptoms can include:

• Akathisia: This is a feeling of restlessness that can make it difficult to hold still. Crossing and uncrossing legs, tapping fingers, and rocking are examples of this type of side effect.
• Dystonia: With this form of EPS, your muscles contract or contort involuntarily, sometimes resulting in painful movements.
• Parkinsonism:These symptoms look like those associated with Parkinson's disease, including tremors, pill-rolling movements in your fingers, stiff posture, and slow body movements.
• Tardive dyskinesia:While these symptoms can affect your limbs, the main characteristics are abnormal mouth and facial movements.

While tardive dyskinesia falls under the general umbrella of extrapyramidal symptoms, it has very specific characteristics. EPS describes a broad range of symptoms that come on soon after starting certain medications but are not usually permanent. Tardive dyskinesia, on the other hand, involves very specific nonrhythmic involuntary movements that develop later on after long-term medication use. Symptoms of tardive dyskinesia are usually milder and may not be reversible.

The main features of tardive dyskinesia include:

• Chewing
• Teeth grinding
• Jaw protrusion
• Curling or twisting the tongue
• Lip smacking or puckering
• Grimacing
• Bulging cheeks
• Blinking
• Eye twitching

Recap

There are many kinds of extrapyramidal symptoms, and tardive dyskinesia (TD) is one of them. Chewing, lip smacking, and curling the tongue are common TD symptoms.

Causes

Extrapyramidal symptoms and tardive dyskinesia can both be caused by the use of antipsychotic medications. There are several classes of antipsychotics, and each affects the chemicals in your brain, like dopamine and serotonin, in different ways.

The goal of antipsychotic medications is to help control mental disorders like schizophrenia. While these medications work well in treating mental disorders, many are avoided because they can cause severe side effects. Extrapyramidal symptoms develop when dopamine is suppressed, which is what antipsychotic medications do.

There are three classes of antipsychotic medications:

• Neuroleptic or typical or first-generation antipsychotics:First-generation antipsychotics are sometimes called neuroleptics because they cause neurolepsis, a slowing of psychomotor function. They include medications like Thorazine (chlorpromazine) and Haldol (haloperidol). This class of antipsychotics is most likely to cause extrapyramidal symptoms and tardive dyskinesia.
• Atypical or second-generation antipsychotics:This class of antipsychotics works on many of the same receptors and chemicals in the brain as first-generation drugs, but it carries a slightly lower risk of EPS and tardive dyskinesia. Examples include Clozaril (clozapine) and Risperdal (risperidone).
• Dopamine partial agonists or third-generation antipsychotics:These medications have a lower impact on dopamine levels and therefore carry the lowest risk of EPS and tardive dyskinesia. An example of this class of antipsychotic is Abilify (aripiprazole).

Extrapyramidal symptoms can appear with other conditions, like Parkinson's disease, but tardive dyskinesia is specific to the use of antipsychotics.

How Common Is Tardive Dyskinesia With Antipsychotic Use?

Tardive dyskinesia develops within the first year in 6% to 12% of people who take even low-dose antipsychotics. Age can impact the likelihood of developing TD, with 25% to 45% of people over age 45 developing TD after a year of treatment.

Beyond antipsychotics, several other medications have also been linked to tardive dyskinesia. These include:

• Antidepressants, such as Prozac (fluoxetine) and Desyrel (trazodone)
• Anti-epileptic drugs (AEDs), such as Dilantin (phenytoin) and Tegretol (carbamazepine)
• Anticholinergics, such as Cogentin (benztropine)
• Antiemetics (anti-nausea medications), such as Reglan (metoclopramide) and Compazine (prochlorperazine)
  

Recap

Extrapyramidal symptoms like tardive dyskinesia are caused by certain medications like antipsychotics.

Patient Rights 

Many people who are prescribed antipsychotics have conditions like schizophrenia or dementia. Since these conditions can impair your ability to make decisions, concerns have been raised about the forceful administration of these medications.

The sedating nature of these medications and the risk of side effects have led to the creation of legal protections for people who are prescribed antipsychotics. Specifics vary by state, but in most cases—outside of a medical emergency—people have the right to refuse psychiatric treatment, including the use of antipsychotic medications.

Recap

Remember, you have the right to refuse medications, especially ones that are sedating.

Diagnosis

Diagnosing extrapyramidal symptoms and tardive dyskinesia is typically direct. Your doctor will learn what medications you are taking and may quickly make the connection between your symptoms and the use of antipsychotic medications.

With some extrapyramidal symptoms, other conditions like Parkinson's disease will need to be ruled out. There are a number of assessments your doctor may use to diagnose you with these conditions, but most of them rely on observation, questioning, and an assessment of your health and medication history.

Treatment

The primary way to treat extrapyramidal symptoms and tardive dyskinesia is to change medications or dosing or stop antipsychotics altogether. Stopping antipsychotic use or changing dosing may help relieve extrapyramidal symptoms, while the impact on tardive dyskinesia is less clear.

Schizophrenia and other conditions that present with psychotic episodes can be difficult to manage, but for many people with these conditions, the medications used to treat them are even harder to bear. More than 20 years of studies revealed that up to 50% of people who take antipsychotic medications don't take them as they should, largely because of the negative side effects they produce.

Up to half of people with tardive dyskinesia may experience worsening symptoms when stopping medications, although many see improvement over time. In some cases, symptoms are permanent. Arguments can be made both for maintaining and stopping antipsychotic use for tardive dyskinesia because stopping may or may not result in improvement. Stopping antipsychotics, on the other hand, can lead to increases in the psychotic symptoms the medications are prescribed to treat in the first place.

Recap

You may need to change your medication or dosing to help your symptoms, but don't ever make medication changes without talking to your doctor first.

Prevention

If you have a condition that needs to be treated with antipsychotic medications, it can be difficult to completely prevent extrapyramidal symptoms and tardive dyskinesia. If you have been prescribed an antipsychotic medication, you may want to talk to your doctor about the benefits and risks of using first-, second-, or third-generation antipsychotics, as well as non-pharmacological options for treating your condition.

Summary

Extrapyramidal symptoms can affect how you move, and tardive dyskinesia is one form of EPS that mostly affects your face. Both EPS and tardive dyskinesia are caused by antipsychotic medications. However, stopping these medications may not reverse your symptoms. If you have EPS or tardive dyskinesia, talk to your doctor before stopping or changing your medication regimen.

A Word From Verywell

Antipsychotic medications are used to prevent hallucinations and other symptoms that can develop with mental disorders like schizophrenia. These medications work well, but can lead to serious side effects called extrapyramidal symptoms. These symptoms are defined by impaired motor function. Tardive dyskinesia is one of these symptoms, and it mainly affects the face and mouth.

Talk to your doctor if you are experiencing negative side effects while taking antipsychotic medications. Be aware that stopping these medications may or may not improve your symptoms, but can lead to a relapse in psychotic episodes. Consult your doctor before stopping or changing medication dosages on your own.

Frequently Asked Questions

• How different are the symptoms of EPS and tardive dyskinesia?

  Both of these conditions affect your motor function, but tardive dyskinesia symptoms mostly affect the face and mouth.

• Which antipsychotics cause EPS?

  All antipsychotics can cause EPS, but typical or first-generation antipsychotics like Thorazine (chlorpromazine) and Haldol (haloperidol) carry the greatest risk.

• Does EPS turn into tardive dyskinesia?

  Tardive dyskinesia is a form of EPS that features a later onset. You may experience early EPS symptoms and develop tardive dyskinesia after long-term use of antipsychotic medications.

• Are second-generation antipsychotics safe?

  Second-generation antipsychotics are associated with lower rates of EPS and tardive dyskinesia, but it is still possible to experience these side effects with second-generation medications.

• What are pill rolling tremors?

  These are small-movement tremors in your fingers that can make it look like you are moving a small pill between your fingers. This is an early symptom of Parkinson's disease and is a form of EPS.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

1. Caroff SN, Hurford I, Lybrand J, Campbell EC. Movement disorders induced by antipsychotic drugs: implications of the CATIE schizophrenia trial. Neurol Clin. 2011;29(1):127-viii. doi:10.1016/j.ncl.2010.10.002

2. Cornett EM, Novitch M, Kaye AD, Kata V, Kaye AM. Medication-induced tardive dyskinesia: a review and update. Ochsner J. 2017;17(2):162-174.

3. Sanders RD, Gillig PM. Extrapyramidal examinations in psychiatry. Innov Clin Neurosci. July 2012;9(7-8):10-16.

4. Vardanyan R, Hruby V. Chapter 6: Antipsychotics. In: Vardanyan R, Hruby V. In: Synthesis of Best-Seller Drugs. Academic Press; 2016:87-110. doi:10.1016/B978-0-12-411492-0.00006-7

5. Sanders RD, Gillig PM. Extrapyramidal examinations in psychiatry. Innov Clin Neurosci. 2012;9(7-8):10-16.

6. Haddad PM, Brain C, Scott J. Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies. Patient Relat Outcome Meas. June 23, 2014;5:43-62. doi:10.2147/PROM.S42735

7. Guzman F. First vs second- generation antipsychotics. Psychopharmacology Institute.

By Rachael Zimlich, BSN, RN
 Rachael is a freelance healthcare writer and critical care nurse based near Cleveland, Ohio.

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