Drug-Induced Movement Disorders: A Primer

However, symptomatic treatments are indicated to reduce motoric and psychological symptoms that impair social function and worsen quality of life. Recommended treatments for each type of AIM are summarized in Table 21,20–30 and described below. Some of these treatments are within the scope of practice of primary care physicians; others will require referral to specialists. Postural tremors occur for example, when the arms are extended, such as when holding a tray. Action tremors occur for example, when the arm is moving toward the mouth to eat. The mainstay of treatment includes resuming anti-parkinsonian drugs, usually via nasogastric tube because of the dysphagia resulting from severe parkinsonism.

• Your body’s dopaminergic system affects various processes, including movement control and cognition.
• Methylenedioxymethamphetamine (MDMA), better known as ecstasy, is also known to cause movement disorders in addicts.
• Amphetamines bind and reverse the dopamine transporter (DAT) function.
• Consideration about restarting an antipsychotic requires a specialist psychiatric opinion.
• Opioid abuse may also cause quick, involuntary muscle jerks, also known as myoclonus.
• PD is a classic cause of resting tremor that typically occurs unilaterally and improves with motion but can recur as re-emergent tremor when a sustained posture is maintained.

For some people, it is not possible to stop the problematic medication. For example, some people with bipolar disorder or schizophrenia have tried multiple medications to control their mental health issues and the one that works best also causes parkinsonism. In these difficult situations, some amount of parkinsonism might be tolerated in order to maximize the person’s mental health. This is a tricky clinical situation, and one that typically requires the psychiatrist and neurologist to work together to optimize the circumstances. Ms A screamed loudly and made threatening gestures when the ED physician attempted to perform a physical examination. Feeling unsafe, the physician called for the assistance of hospital security officers to ensure his own safety, that of Ms A, and others in the ED.

Food as Medicine: Diet’s Role in Parkinson’s Disease

They include dystonia, tremor, myoclonus, akathisia, tics, and chorea. Hyperkinetic disorders interfere with your day-to-day activities, and you may find it challenging to perform easy tasks. If neuroleptic malignant syndrome is suspected, acute hospital admission is warranted. Management involves immediate cessation of the offending drugs, supportive care (which includes intensive care if severe), and giving a dopaminergic drug, usually bromocriptine. Benzodiazepines can be used to reduce rhabdomyolysis and improve rigidity.

Tremors or Drug-Induced Movement Disorders (DIMD) may harm your quality of life and general well-being. You may find it challenging to perform easy tasks, which may, in turn, affect your social functioning and interpersonal communication. You may also lose your independence as you’d need help performing easy tasks. Tremors may also result in other symptoms like depression and anxiety, which may have severe consequences. Alcohol tremors primarily affect the hands, but they affect the legs and arms in some circumstances. The tremors manifest approximately 8 hours after you stop drinking and peak about 30 hours after your last drink.

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• Typically, it subsides on cessation of the drug, but can last for months.
• Alcohol abuse may result in alcohol shakes, also called jitters or tremors.
• In this manuscript, we review how some common examples of MIT have informed us about the pathophysiology of tremor.
• Founded in 1961, APDA has raised and invested more than $282 million to provide outstanding patient services and educational programs, elevate public awareness about the disease, and support research designed to unlock the mysteries of PD and ultimately put an end to this disease.
• She was started on oral benztropine 1 mg 3 times/day for 3 days as prophylaxis against the return of acute dystonia.
• Some of these treatments are within the scope of practice of primary care physicians; others will require referral to specialists.

It is a sense of internal restlessness, irritability and tension without necessarily manifesting with physical signs, unlike restless legs syndrome which is typically more severe and worse at night. Akathisia has been reported with dopamine receptor blockers, selective serotonin reuptake inhibitors (SSRIs), antiepileptic drugs, and cocaine. It can occur either after starting a dopamine receptor blocker, dose escalation, or when switching to an alternative drug. It is symmetrical and occurs acutely following drug ingestion or dose escalation. Exceptions include tremor secondary to valproate, which can appear at therapeutic or during stable treatment, or, rarely, tardive tremor.

Other drugs can cause tremor, presumably by blockade of dopamine receptors in the basal ganglia (dopamine-blocking agents), by secondary effects such as causing hyperthyroidism (amiodarone), or by other mechanisms. We will attempt to discuss what is known and unknown about the pathophysiology of the most common MITs. No good evidence exists regarding the management of tardive drug-induced movement disorders.15 Treatment usually consists of withdrawing the offending drug, and a trial of a combination of drugs. Resuming the offending drug or changing to an atypical antipsychotic is sometimes required.16 In patients with a chronic psychotic disorder clozapine is preferred. Most recently, vesicular monoamine transporter 2 inhibitors deutetrabenazine and valbenazine have been proposed as treatment options.17,18 Other oral drugs have been tried, including tetrabenazine, amantadine and propranolol. Akathisia is a common, but often under-recognised, drug-induced movement disorder that can occur as an acute, subacute or tardive reaction.

No specific treatment exists for movement disorders caused by illicit drug use. In contrast to idiopathic Parkinson’s disease, drug-induced parkinsonism usually presents as a symmetrical akinetic rigid syndrome which develops over days to weeks to months following ingestion of the offending drug. Additionally, there is a poor response to typical antiparkinsonian drugs, including levodopa, dopamine agonists and anticholinergic drugs. Cessation of the offending drug usually results in complete resolution of the disorder. There is a bidirectional relationship between substance abuse and movement disorders. Some movement disorders develop due to acute use of alcohol or drugs, while others result from withdrawal from drugs.

Withdrawal states and toxin-induced tremors

In addition to the elevated creatine kinase, laboratory investigations usually find leucocytosis, abnormal electrolytes, renal impairment, abnormal liver function tests, and altered coagulation studies. Amphetamines bind and reverse the dopamine transporter (DAT) function. Consequently, they inhibit reuptake, releasing dopamine at the mesocorticolimbic dopaminergic nerve terminals. In extreme cases, it may also induce intracranial hemorrhages, comas, or seizures. Opioid abuse may also cause quick, involuntary muscle jerks, also known as myoclonus. Again, it would be best to seek medical attention if you experience these symptoms.

The differences between Parkinson’s and drug-induced parkinsonism

Depending on the duration of dyskinesia, the levodopa dose can usually be reduced to a lower dose which still maintains efficacy. It is worth noting that mild dyskinesias are often not bothersome to the individual and do not interfere with their function, therefore drug induced tremors a change in levodopa dose may not be required. Referral is recommended for patients with late-stage disease for consideration of device-assisted therapy. Treatment of AIMs is based on the underlying etiology (eg, metabolic, drug induced).

Withdrawal-emergent dyskinesia can occur on abrupt cessation of long-term antipsychotic treatment, particularly in children. Acute dystonic reactions most commonly occur in younger patients soon after taking to dopamine receptor blocking drugs, including antiemetics (e.g. metoclopramide or prochlorperazine) and antipsychotics. Acute sustained dystonic spasm of craniocervical muscles is typical, but oculogyric crises, truncal spasm causing opisthotonos, or limb dystonia can also occur. Acute laryngeal dystonia can be life-threatening due to airway obstruction and requires emergency medical care.

Ms A, a 23-year-old woman, was brought to the emergency department (ED) by police because of increasingly disruptive behaviors in her apartment building over the past week. She described hearing neighbors accuse her of poisoning their pets; moreover, she believed that they were “bugging” her apartment and watching her through her TV. Her medical history was notable for having systemic lupus erythematosus and chronic kidney disease. Although she had an episode of depression during college, she had not received psychiatric treatment for the past 2 years. The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions.