Clinical Manifestatations of Extrapyramidal Syndrome

        The term extrapyramidal symptoms (EPS) refers to a group or reactions caused by the use of short-or long-term antipsychotic medication. This term may be made because many of the clinical manifestations skeletal muscle movements, spasms or rigidity, but the symptoms were out of control by corticospinal tract (pyramidal). However, the name is somewhat misleading because some of the symptoms (eg, acathisia) is not at all possible motor problems. Some extrapyramidal symptoms can be found simultaneously in one patient and overlap one another.

Extrapiramidal symptoms are common side effects of antipsychotic medication on. Antipsychotics are medications used to treat psychotic disorders such as schizophrenia and schizoaffective disorder.
Extrapyramidal symptoms often gather in categories of reactions acute dystonia, dyskinesia tardiv, acathisia, and parkinsonism (Parkinson's syndrome).

a. Acute Dystonia reaction (ADR)
        This situation is an involuntary spasm or contraction, of one or more acute skeletal muscle groups that typically arise in a few minutes. Muscle groups most frequently involved are the face muscles, neck, tongue or extraocular muscles, manifest such as torticollis, disarthria, oculogyric crisis and unusual posture. Can be pain or even can be life threatening with symptoms such as dystonia, laryngeal or diaphragmatic. Acute dystonia reactions often occur within one or two days after starting treatment, but can occur at any time. This condition occurs in approximately 10% of patients, more common in younger men, and more frequently with high doses of neuroleptics are potentially higher, such as haloperidol and flufenazine. Acute dystonia reaction is a major cause of non-compliance with neuroleptic medication for the patient's perspective can permanently fade by a dystonic reaction which troublesome.
b. Acathisia
        This symptoms is the most common. Most likely to occur in patients treated with neuroleptic medication, especially in the younger patient population. Consisting of feelings in that restless, nervous or a desire to keep moving. Also been reported as an itching in muscles. Patients may complain of difficulty sleeping because of anxiety or who may mistakenly interpret as a worsening of psychotic symptoms. Instead, acathisia can lead to exacerbation of psychotic symptoms due to extreme discomfort. Agitation, pacing the real, or other physical manifestations of akatisisa can only be found in severe cases. Also, akinesis found in neuroleptic induced parkinsonism can cover any objective symptoms of akathisia. Acathisia often occur soon after starting medication neuroleptik and patients already in place linking uncomfortable feeling. This perceived meds causing problems with patient compliance.

c. Parkinson syndrome
      Another EPS symptom is somewhat unusual to begin hours after the first dose neuroleptics or begins gradually after years of treatment. Manifestations include the following:
1. Akinesia: which includes face mask, interlude of spontaneous movement, decreased arm swing when walking, decreased blinking, and decreased abilty to chewing which can cause salivation. In the milder forms, akinesia only proven to be a state of pause behavior with speech, decreased spontaneity, apathy and difficulty to start normal activities, all of which can be confused with negative symptoms of schizophrenia.
2. Tremor: especially during break, is a classic of the type of pill rollers. Tremor can affect the jaw sometimes referred to as "rabbit syndrome". This condition can be confused with diskenisia tardiv, but can be distinguished by the character more rhythmic, kecerendungan to the tongue and the jaw than responya to anticholinergic medication.
Bent gait: the shuffling round the letter "N" print and loss of arm swing.
Stiffness muscle: mainly of type cogwheeling

d. Tardive dyskinesia
          The name, it can be known is a syndrome that occurs later in the form of koreoatetoid abnormal movements, abnormal muscle movements, involuntary, jerking, ballistic, or like a tick. This is an undesirable effect of antipsychotic drugs. this is due to a relative deficiency of cholinergic effect puntamen supersensitive dopamine receptors in the caudate. Old woman who is easy to get a long-term treatment of the disorder perbagai although it can occur in men and women age level. The prevalence of tardive dyskinesia varies but is estimated to occur 20-40% of patients who seek treatment long. But some cases are very mild and only about 5% of patients showed a real heavy movement. However, severe cases are very debilitating at all, that affects walking, talking, breathing, and eating. 

          Predisposing factors may include advanced age, female gender, and treatment of high-dose or long-term. Patients with affective disorders or organikjuga more likely to experience tardive dyskinesia. Symptoms disappear with sleep, can be intermittent over time and generally worsens with neuroleptic withdrawal.

          Differential diagnosis when considering tardive dyskinesia include Hutington disease, Khorea Sindenham, spontaneous dyskinesia, ticking and drug-induced dyskinesia (eg levodopa, stimulants and others). It should be noted that tardive dyskinesia is thought to be caused by the superpost-synaptic dopamine receptors  due to chronic blockade can be found along with suspected Parkinson syndrome due to insufficient dopaminergic activity. Need for early recognition difficult in advanced cases treated. Many of the proposed therapy but evaluation is difficult because of course of the disease is very diverse and sometimes limited. Early or mild tardive dyskinesia are easily overlooked and some felt that the systemic evaluation, Abnormal Involuntary Movement Scale (AIMS) must be recorded every six months for patients receiving long-term neuroleptic treatment.
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