Understanding Antipsychotic-Induced Movement Disorders

Any mental healthcare provider treating mood disorders, like schizophrenia, with antipsychotic medications should be aware of associated movement disorders and how to treat them. In this video from on-site at the 2024 Psych Congress Elevate meeting in Las Vegas, Nevada, Rebecca Barbee, MSPAS, PA-C, CAQ-Psych, explains the differences between dystonia, akathisia, drug-induced Parkinsonism, and tardive dyskinesia, as well as the different management approaches that each unique movement disorder requires.

For more expert insights on schizophrenia treatment and management, visit the Schizophrenia Excellence Forum here on Psych Congress Network.

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Rebecca Barbee, MSPAS, PA-C, CAQ-Psych: Hi, I'm Rebecca Barbee. I am a psychiatric PA from Davidson, North Carolina. I work in a private practice called South Lake Psychiatry.

Psych Congress Network: What are the key aspects of antipsychotic-induced movement disorders? Which treatments are available to manage them?

Rebecca Barbee: With anti-psychotic induced movement disorders, historically we had them grouped under one name: extrapyramidal side effects. We are moving away from that. With our drug-induced movement disorders, we have dystonia, akathisia, drug-induced Parkinsonism, and tardive dyskinesia. Having them grouped under one name historically maybe implied that we should approach treatment of drug-induced movement disorders in one way when the approaches are actually quite different. I like to think of them as our more acute drug induced movement disorders and then tardive dyskinesia, which is more of a delayed onset.

With dystonic reactions, those usually present very soon within hours to days of treatment and you're really not going to miss a dystonic reaction. They're usually painful and very distressing, and are primarily managed with anticholinergic medications. One thing that I like to reiterate and really point out is that once a patient is stable on their dose of antipsychotic medication and they've received an anticholinergic for a dystonic reaction, once they're stable, we really need to then gradually withdraw the anticholinergic medication. I think that's an area where maybe we're lacking a little bit, and so we need to really focus on, hey, once they're stable, we need to start pulling away that anticholinergic.

Akathisia is a big one. This also presents usually more acutely, but it is also very distressing to a patient. It's an internal sense of restlessness. Sometimes we can actually observe objectively that the patient appears restless. Akathisia is of particular importance because it has been shown to be associated with increased rates of suicidal thinking and self-harm because of how distressing it is. Akathisia is typically managed with using beta blockers such as propanolol or considering in my practice, I like to use, if possible, 5-HT2 antagonists such as mirtazapine.

Drug-induced Parkinsonism presents days to months within starting the medication, and the treatment approaches are anticholinergic medications or lowering the dose, if that is an option. I feel there's sometimes a lot of misconception and overlap between trying to identify drug induced parkinsonism and tardive dyskinesia. It's important as providers that we have an understanding and we know what we're looking for when we're trying to differentiate because the treatments are quite different. With drug induced Parkinsonism, it's typically managed with anticholinergic medications. With tardive dyskinesia, which is different in the fact that it can be permanent, that makes it a particularly difficult conversation to have with our patients that are starting this medication, they could develop an adverse effect that is permanent. Tardive dyskinesia is managed with the VMAT-2 inhibitors. They're FDA approved for the treatment of tardive dyskinesia, and it's considered a treatment guideline if our patient is experiencing tardive dyskinesia symptoms that we need to be initiating that treatment. But it's important that we know how to differentiate between drug induced parkinsonism and tardive dyskinesia.

I'm Rebecca Barbee, psychiatric PA. Thank you for joining me today and allowing me to share my thoughts on managing treatment emergent adverse effects in our patients with schizophrenia.

Rebecca Barbee, MSPAS, PA-C, CAQ-Psych, earned her Master of Physician Assistant Studies from the University of Kentucky in 2012, where she took a special interest in pharmacology. Rebecca has worked in psychiatry for 12 years and has been at Southlake Psychiatry in Davidson, NC since 2016. Prior to joining Southlake Psychiatry, she worked in neuropsychiatry where she was able to help a variety of patient populations and broaden her knowledge base on psychiatric, developmental, and neurological disorders. She is passionate about treating children, teens, and adults with a full spectrum of psychiatric disorders including depression, anxiety, bipolar disorder, schizophrenia, obsessive compulsive disorders, gender dysphoria, eating disorders, and post-traumatic stress disorder. Rebecca has also undergone buprenorphine training to provide medication-assisted treatment for opioid dependence.