Nonneuroleptic etiologies of extrapyramidal symptoms.

Antipsychotic or neuroleptic medications are known to produce various extrapyramidal symptoms as common side effects. Extrapyramidal symptoms may present clinically as acute dystonic reactions, tardive dyskinesia, akinesia, Parkinsonism, akathisia, and neuroleptic malignant syndrome. Dopamine blockade or depletion in the basal ganglia produces these symptoms. Not as widely known or understood is that extrapyramidal symptoms can also occur as side effects from a variety of nonantipsychotic agents, namely certain antidepressants, antiemetics, lithium, and, rarely, some anticonvulsants and oral contraceptive agents. These symptoms mimic the naturally occurring, idiopathic pathologies of the extrapyramidal system and basal ganglia disease. Clinicians must be able to recognize these symptoms as side effects, distinguish extrapyramidal symptoms from psychiatric symptoms and, assess the possible nonantipsychotic causes of extrapyramidal symptoms, particularly in nonpsychiatric settings.

Neuroleptic malignant syndrome: liability in nursing practice.

In the summer of 1991, the malpractice case Reyes v Houston International Hospital et al was settled for an amount in excess of $600,000. The case involved the psychiatric treatment received by Marjorie Reyes, a 27-year-old Latin-American mother of three, who was admitted to a psychiatric unit in late October 1986 with a diagnosis of atypical psychosis. Malpractice was charged because her treatment failed to meet any reasonably expected outcome for atypical psychosis. In fact, Reyes developed neuroleptic malignant syndrome (NMS) as a direct result of the antipsychotic medications she was administered. Her treatment outcome was nearly fatal and caused permanent, serious neurological disabilities. The litigation implicated the nursing care delivered in a psychiatric setting. This unfortunate situation illustrates general principles of legal liability in nursing practice as well as offers a unique opportunity to review NMS and to examine the specific implications for the assessment and evaluation of the side effects of antipsychotic medications. Additionally, methods of behavioral control, specifically as they relate to concepts concerning the use of medications, the importance of documentation, and the manner in which nurses plan care, were also addressed in the case. It is important for professionals to be familiar with general legal concepts and liabilities, the potential of the development of this serious side effect, and how clinical decisions regarding the administration of both routine and as-needed medications may incur legal accountability.

Extrapyramidal symptoms are serious side-effects of antipsychotic and other drugs.

Antipsychotic medications commonly produce extrapyramidal symptoms as side effects. The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome. Extrapyramidal symptoms are caused by dopamine blockade or depletion in the basal ganglia; this lack of dopamine often mimics idiopathic pathologies of the extrapyramidal system. Less recognized is that extrapyramidal symptoms are also associated with certain non-antipsychotic agents, including some antidepressants, lithium, various anticonvulsants, antiemetics and, rarely, oral-contraceptive agents. Extrapyramidal symptoms caused by these agents are indistinguishable from neuroleptic-induced extrapyramidal symptoms. Clinicians must be able to recognize these side effects and be able to determine the antipsychotic-induced and non-antipsychotic causes of extrapyramidal symptoms.

Akathisia. When treatment creates a problem.

1. Akathisia is a state of restlessness and motor agitation, which includes subjective feelings of inner tension, emotional unease, anxiety, a constant need to move, restless motor activity, and an inability to tolerate inactivity or rest. 2. Akathisia is often unrecognized or misdiagnosed as agitation or anxiety of psychiatric origin; this often leads to inappropriate increases in the antipsychotic dosage, which then potentiates its severity, or to the misuse of antianxiety agents, which masks symptoms. 3. Akathisia can be easy to recognize by simple clinical observation of the patient's behaviors, especially if the symptoms worsen after increases in antipsychotic dosages or the frequent use of as needed medications. Assessment must also include the patient's own report.