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Have you ever seen someone with schizophrenia displaying tics and tremors, seemingly unable to control their body? It might have startled you, making you want to walk away. What you might not know is that these “weird” movements are often caused by a class of medications called antipsychotics. Understanding this can shift your perspective, fostering empathy and compassion for these individuals who are doing their best to manage their psychiatric symptoms.
For those taking antipsychotics, these side effects can be incredibly distressing, affecting their daily activities, body image, and social interactions. Imagine losing the ability to write, hold a coffee cup steady, or play sports. Sometimes, the discomfort is so severe that individuals stop taking their medications, risking relapse or worsening of their symptoms.
This article aims to explain the different types of movement disorders associated with antipsychotic use, addressing a general lack of understanding in this area. For patients, such knowledge can lead to greater self-acceptance and more proactive efforts in optimizing their treatment regimen. On a broader level, increasing public awareness can help reduce stigma and promote a better understanding of the challenges faced by those undergoing antipsychotic treatment.
How do antipsychotics work?
Dopamine is a crucial neurotransmitter that regulates mood, cognition, and motivation. Scientists discovered that an excess of dopamine in the brain is associated with positive psychotic symptoms, such as delusions, hallucinations, and illogical or magical thinking. Antipsychotics work by blocking specific dopamine receptors, thereby relieving these symptoms for affected individuals.
However, dopamine is also essential for smooth, coordinated movements. There are four major movement disorders linked to antipsychotic use: dystonia, parkinsonism, akathisia, and tardive dyskinesia. These side effects are collectively known as Extrapyramidal Symptoms (EPS), originating from extrapyramidal tracts in the brainstem that control reflexive, involuntary motions. First-generation “typical” antipsychotics, such as haloperidol and chlorpromazine, are strong dopamine receptor blockers, making them more likely to induce EPS. Since the 1980s, second-generation “atypical” antipsychotics have been introduced. These medications are weaker dopamine blockers, less likely to cause EPS, and therefore more widely prescribed today.
Dystonia
Dystonia is when a person’s muscles start contracting uncontrollably, leading to spasms in the face, neck, back, arms, or legs. Imagine dealing with a twitch that just won’t quit. Young male patients with significant muscle mass are most at risk for this side effect.
Acute dystonia strikes fast, usually within five days of starting a new antipsychotic medication. One alarming form affects the tongue and throat muscles, potentially causing laryngospasm—a dangerous condition that makes the person unable to breathe. Because acute dystonia is scary and painful, it needs to be treated immediately with anticholinergic medications such as benztropine and diphenhydramine. For patients and their loved ones, it is important to recognize the early signs of dystonia, seek urgent medical help, and stay as calm as possible as panicking can make the spasms worse.
Parkinsonism
Antipsychotic-induced parkinsonism closely resembles Parkinson's disease, a well-known neurological disorder that affects mostly elderly people. Both conditions result from dopamine deficiency in the basal ganglia and are characterized by tremors, slow movement, and a shuffling gait. Parkinsonism can be distressing for patients and diminish their quality of life. For instance, they may avoid social events due to fear of embarrassment; it takes them longer to walk across a room, and their mask-like facial expressions may be misinterpreted as aloofness. Additionally, parkinsonism increases the risk of falls and injuries.
The good news is that parkinsonism may lessen and eventually resolve as the body adjusts to the antipsychotic medication. To help manage this side effect, clinicians often reduce the dosage or switch the individual to a less potent antipsychotic. Clozapine, an atypical antipsychotic, has shown efficacy in treating both parkinsonian movement abnormalities and psychotic symptoms. If these measures are insufficient, additional medications such as benztropine and amantadine, a medication used to treat Parkinson's disease, may be prescribed.
Akathisia
Akathisia, marked by restlessness and an inability to stay still, is the most common form of EPS. It can emerge within hours to days after starting an antipsychotic medication. Those affected often describe an intense feeling of anxiety, as if they are about to jump out of their own skin. This restlessness is evident in behaviors such as constant pacing, rocking their bodies, swinging their legs, or tapping their feet, even while sitting. Consequently, individuals may struggle to focus and complete tasks, impairing their performance at work or school. Moreover, relationships may become strained as loved ones grapple with the individual's constant need to move.
Akathisia is linked to taking multiple antipsychotics or rapidly increasing doses, so most clinicians avoid these practices. If an individual experiences severe akathisia that disrupts their daily life, they might need a lower dose or a switch in medication, provided their psychotic symptoms remain under control. Additionally, medications like beta blockers (e.g., propranolol) and benzodiazepines (e.g., lorazepam) can help alleviate the anxiety that comes with akathisia.
Tardive dyskinesia
In contrast to the three movement disorders discussed above, tardive dyskinesia (TD) is a lasting side effect from long-term antipsychotic use, typically appearing after six months. "Tardive" means late or delayed, and "dyskinesia" means abnormal movement. Even after stopping the medication that caused it, TD symptoms often persist. TD most commonly affects the face, showing as tongue thrusting, facial grimacing, and jaw chewing motions. These signs might start subtly, making them easy to miss. However, as the condition worsens, it can interfere with speech and cause tongue biting while eating. When TD affects the torso and limbs, symptoms resemble those of acute-onset EPS, such as body rocking or arm jerking.
Preventing TD is the best approach. Individuals on antipsychotics should have regular follow-ups with their treating clinicians, even after their psychotic symptoms have stabilized or resolved. Since patients often don't notice early signs of TD, educating loved ones about this potential side effect is crucial. Patients who develop acute-onset EPS early in treatment are at higher risk for TD and should receive prompt interventions.
Conclusion
Since individuals with schizophrenia make up less than 1% of our population, they often face stereotyping, and their experiences, including the use of antipsychotics, are rarely understood. The next time you see someone with schizophrenia who seems to be moving their body in a funny way, try to suspend judgment and extend a helping hand. Perhaps they’ll appreciate a small gesture, like holding a cup of coffee for them when their hands are shaking too much. Your kindness can make a big difference in their day and help break down the barriers of stigma.
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