---
title: "Extrapyramidal Symptoms (EPS)"
url: https://mghmclean.org/residents/handbk/part2c/eps.htm
description: "Neuroleptic blockade of the D2 receptors in the basal ganglia may cause a variety of unpleasant, frightening and sometimes life-threatening side effects commonly referred to as..."
published: 2026-08-10
updated: 2026-08-10
---

# Extrapyramidal Symptoms (EPS)

Published 2026-08-10

PART 3 / CH 58

Amy Gagliardi

A. Overview

Neuroleptic blockade of the D2 receptors in the basal ganglia may cause a variety of unpleasant, frightening and sometimes life-threatening side effects commonly referred to as EPS. While more common with typical neuroleptics, they may also occur with newer agents.

B. General approach

1. Go see the patient: identify the onset, time course and symptoms.

2. Do a targeted physical exam with a focus on the motor system.

3. Perform a brief mental status exam.

4. Treat the symptoms quickly.

C. Acute Dystonia

· Characterized by brief or prolonged muscle contractures, usually of the head, neck, and tongue, resulting in abnormal movements.

· Laryngeal or pharyngeal dystonias, which present with hoarse voice or a choking sensation, are a medical emergency.

· Other presentations include oculogyric crisis (one or both eyes turned upward), tongue protrusion, and torticollis.

· Prevalence = 10%

D. Parkinsonism

· The same triad as idiopathic parkinsonism:

1. resting tremor (rhythmic, 3-6 cycles/second)

2. rigidity (lead pipe continuous or cogwheel)

3. bradykinesia (masklike facies, difficulty initiating movement,

shuffling gait with propulsion and retropulsion, decreased arm

swing while walking, decreased spontaneous movements).

· If there is rigidity and disorientation, this is likely *not* parkinsonism and NMS should be ruled out.

· Prevalence = 50%

E. Akathisia

· An objective or subjective feeling of restlessness, characterized by pacing, rocking, or rapid alteration of sitting and standing.

· Patients often describe a sense of "I can't stay still" or "I'm jumping out of my skin."

· Often misdiagnosed as anxiety, agitation, psychosis

· Prevalence ³10% of all patients on neuroleptics

F. Extrapyramidal symptoms: diagnosis

|  | onset | risk factors | ddx |
|---|---|---|---|
| acute dystonia | rapid - often hours after 1st dose up to 5 days out | maleunder 40high potency meds | seizurestetanus |
| parkinsonism | 2-6 weeks or immed. after dose increase | femaleelderlyprevious hx of parkinsonismother neurologicillness | Parkinson’sdiseasecatatonianegative sxs of schizophrenia psychomotor retardationtardive dyskinesia |
| akathisia | 1-4 weeks or immed. after dose increase | femalemiddle-aged | almost anything:anxiety, agitation, psychosis, "acting out" |

G. Extrapyramidal symptoms: treatment

| symptom | treatment recommendations |
|---|---|
| acute dystonia | *If laryngeal dystonia* with airway compromise,cogentin 4 mg IV/IMthen ativan 2 mg IV/IM slowly if needed*otherwise,*1) cogentin 2 mg IM/IV *or*2) benadryl 50 mg IM/IV*If no response* in 20 minutes, repeat above.*If no response after two trials,* ativan 1 mg IM/IV.*After treatment,* neuroleptic can be continued with standing dose of anticholinergic coadministered for two weeks.*If symptoms return,* change to lower potency neuroleptic. |
| **parkinsonism** | 1) dose antipsychotic as low as possible, or switch to low potency antipsychotic, *and*2) cogentin 0.5-2 mg po bid *and/or*3) benadryl 25-50 mg po bid *and/or*4) amantadine 100 mg po bid or tid*note: anticholinergics should be stopped* after 14 days if asymptomatic because long-term use can increase the risk of tardive dyskinesia |
| **akathisia** | *If no other EPS:*1st choice: propanolol 10 to 30 mg po tid2nd choice: lorazepam 1 mg po tid3rd choice: cogentin 1 mg po bid*If other EPS present:*1st choice: cogentin 2 mg po bid2nd choice: cogentin with propanolol as above3rd choice: cogentin with lorazepam as above*After treatment,* neuroleptic may be continued with benzo or beta-blocker indefinitely; anticholinergics should be weaned after two weeks if possible. |

*source*: Hyman SE, Tesar GE (1994). Manual of Psychiatric Emergencies. Little, Brown.