1. Sue Henderson EPSE & NMS Sue Henderson

2. Sue Henderson Well, I did warn you about the side effects Those tablets you gave me are great but they’re making me walk like a crab

3. Sue Henderson Low potency V High potency Low potency Chlorpromazine (Largactil) 100mg is equivalent to 2mg of Haloperidol (serenace) a high potency anti-psychotic. High potency: high rates of Extra Pyramidal Side Effects (EPSE) Low potency: high rates of anti- cholinergic side effects

4. Sue Henderson Low Potency V High Potency High Anti-cholinergic & Sedative effects High EPSE Haloperidol 2 mg Chlorpromazine 100 mg

5. Sue Henderson Extra pyramidal side effects (EPSE) 1.Acute dystonias: Oculogyric crisis, Torticollis, Lock jaw, Laryngeal spasm, Opisthotonos 2.Akathisia 3.Parkinsonism (Rigidity, bradykinesia, tremor) 4.Tardive dyskinesia

6. Sue Henderson Dystonia: Oculogyric Crisis Muscles that control eyes movements spasm. Eyes roll up & person is unable to look downward.

7. Sue Henderson Oculogryric Crisis

8. Sue Henderson Dystonia: Torticollis Spasm of neck muscles. Neck is flexed backwards or to the side.

9. Sue Henderson Dystonia: Lock jaw (Trismus) Spasm of jaw muscle, also often involves the muscles of the tongue and floor of the mouth.

10. Sue Henderson Dystonia: Opisthotonos Spasm of paravertebral muscles with arching of back.

11. Sue Henderson Dystonia: Laryngeal spasm Rare but potentially fatal reaction causing difficulty with breathing. High risk: Young males on high potency antipsychotic with no anti-parkinson drug.

12. Sue Henderson Treatment Laryngeal spasm Emergency. Stat parenteral benztropine (cogentin). Maintain airway Prevention: Concurrent antiparkinson or diazepam for young males on high potency antipsychotics

13. Sue Henderson Akathisia (Most common EPSE) Restlessness, an irresistible urge to move (unable to sit still, pacing) and a feeling of “nervous energy”. Often mistaken for agitation. Worsened by additional antipsychotic dosage. Common cause of non compliance.

14. Sue Henderson Parkinsonism Muscle stiffness, rigidity, (cogwheel & lead pipe) shuffling gait, tremor, pill rolling, loss of facial expression, slowed movement (bradykinesia), reduced arm swing, absent movement (akinesia), drooling, stooped posture, tremor of lips (rabbit syndrome).

15. Sue Henderson Pyramid shape Drug induced Parkinsonism (reversible) Dopamine & acetylcholine in balance = normal function Dopamine blockade, upsets balance = tremor, rigidity, akinesia

16. Sue Henderson Tardive Dyskinesia Serious, potentially irreversible, effect of prolonged antipsychotics. Abnormal, involuntary movements of the face, eyes, mouth, tongue, trunk, limbs. Most common: twisting, protruding, darting tongue movements. Chewing & sideways jaw movements. Facial grimacing.

17. Sue Henderson

18. Neuroleptic Malignant Syndrome (NMS) Rare but potentially fatal Muscular rigidity (may be localised to head & neck), incontinence, confusion or delirium, excessive variation in BP& P & high Temp. Presentation highly variable: hours after 1st dose to unexpected appearance after months of uneventful treatment.

19. Sue Henderson Treatment NMS Early detection vital to recovery Stop anti-psychotic Hydration Transfer to ICU Bromocriptine 5-10 mg tds but if no response Dantrolene

20. Sue Henderson Side Effect Drugs

21. Sue Henderson S/E Drugs: Classification Antiparkinson: Benztropine (Cogentin), benzhexol, biperiden, orphenadrine Other drugs used to treat EPSE’s 1.Benzodiazepines. 2.Dopamine agonist: Bromocriptive (NMS) 3.Beta blocker: Propanolol (Inderal) & Clonidine (Catapres, Dixarit)

22. Sue Henderson Indication Reduce EPSE of antipsychotics

23. Sue Henderson Side Effect Drugs: Action < = > = ACh DA Excess levels of dopamine (positive schizophrenia) Dopamine blocking antipsychotic drugs decrease effect of dopamine Sometimes antipsychotic drugs block too much dopamine creating a pseudo-parkinsonism Antiparkinson block ACh restoring a relative balance.

24. Sue Henderson S/E Drugs Prescription Routine prescription not advised because: Not all people develop EPSE’s Decrease effect of antipsychotics. Risk of worsening Tardive Dyskinesia.

25. Sue Henderson Side effect drugs cont… EPSE drugs have side effects also. Potential for abuse. Severity of EPSE’s fluctuate Exception: Young males on high potency antipsychotic (high risk of EPSE)

26. Sue Henderson Antiparkinson SE (anticholinergic) Common: dry mouth, dilated pupils, urinary hesitancy, constipation & G.I. Upset, nausea, blurred vision. Less common: tachycardia, dizziness, hallucinations, euphoria, excitement, delirium, hyperpyrexia. Mneumonic for anticholinergic (O/D) Dry as a bone, red as a beet, blind as a bat, hot as a furnace, mad as a hatter.

27. Sue Henderson EPSE risk factor tool Patient factors: Age > 40 Sex: Females, males > 30 years History ECT, previous EPSE Cognitive or mood disorder Treatment factors: High/moderate potency Prolonged exposure Depot injections 2 or more antipsychotics No prophylactic antiparkinson

28. Sue Henderson Antiparkinson effectiveness for EPSE Good response: 1.Parkinsonism 2.Dystonias Poor Response Akathisia Made Worse: Tardive dyskinesia

29. Sue Henderson Summary EPSE management

30. Sue Henderson References Aronne, L. J. (2001). Epidemiology, morbidity, and treatment of overweight and obesity. Journal of Clinical Psychiatry, 62(Suppl 23), 13-22. Fortinash, K. M., & Holoday-Worret, P. A. (2000). Psychiatric mental health nursing ( 2nd ed.). St. Louis: Mosby. Galbraith, A., Bullock, S. & Manias, E. (2001). Fundamentals of pharmacology (3rd ed.). Melbourne: Prentice Hall.

31. Sue Henderson References Kapur, S., Zipursky, R., Jones, C., Remington, G., & Houle, S. (2000). Relationship between dopamine D- 2 occupancy, clinical response, and side effects: A double-blind PET study of first-episode schizophrenia. American Journal of Psychiatry, 157(4), 514-520. Kapur, S., Zipursky, R., Jones, C., Shammi, C. S., Remington, G., & Seeman, P. (2000). A positron emission tomography study of quetiapine in schizophrenia - A preliminary finding of an antipsychotic effect with only transiently high dopamine D-2 receptor occupancy. Archives of General Psychiatry, 57(6), 553-559.

32. Sue Henderson References Lindenmayer, J. P. (2001). Hyperglycemia associated with the use of atypical antipsychotics. Journal of Clinical Psychiatry, 62 Suppl 23, 30-38. Melkersson, K. I., & Hulting, A. L. (2001). Insulin and leptin levels in patients with schizophrenia or related psychoses - a comparison between different antipsychotic agents. Outcomes Management, 154(2), 205-212.

33. Sue Henderson References Therapeutic guidelines. (2000). Psychotropic version 4. Melbourne: Therapeutic Guidelines Limited. Call Number: 615.788 P974P2000 Turrone, P., Kapur, S., Seeman, M. V., & Flint, A. J. (2002). Elevation of prolactin levels by atypical antipsychotics. American Journal of Psychiatry, 159(1), 133-135. Wirshing, D. A., Spellberg, B. J., Erhart, S. M., Marder, S. R., & Wirshing, W. C. (1998). Novel Antipsychotics and New Onset Diabetes. Biological Psychiatry, 44(8), 778-783.