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Movement Disorders
Psychiatrists on call often evaluate patients’ complaints of stiffness, tremor, rigidity, and other abnormal movements. The causes vary, and the clinician should be prepared to manage both commonly encountered and reversible problems such as acute dystonia and more lethal conditions such as neuroleptic malignant syndrome (NMS). Although the more common problems represent some of the most dramatic presentations in the field of psychiatry, they can often be treated rapidly, effectively, and easily. In contrast, more subtle presentations of NMS and acute laryngeal spasm represent life-threatening emergencies that require careful diagnosis and management to minimize relatively high mortality rates. Proper management of NMS and laryngeal spasm entails rapid recognition and work-up and often transfer of the patient to an intensive care unit.
Phone call
Questions
- 1.
Is the patient stable? Does the patient have difficulty breathing? Are there changes in mental status?
- 2.
What are the most recent vital signs (including temperature)?
- 3.
When did the movement disorder start? Was the onset sudden or gradual?
- 4.
Describe the movement disorder. Is it hyperkinetic or hypokinetic? Is it generalized or is it only in certain body regions?
- 5.
Has the patient been given any medications recently? In particular, is the patient taking an antipsychotic or has there been a recent addition of an antipsychotic to the medication regimen?
- 6.
Are there any other associated signs or symptoms, such as focal weakness, muscle spasms, dysphagia, drooling, or tremor?
- 7.
Does the patient have any acute or chronic medical problems?
Orders
Attempt when possible to examine the dystonic patient immediately. The patient should be evaluated before giving any medications; however, the physician may want to ask the nurse to do the following:
- 1.
In the case of suspected acute dystonia, prepare benztropine 1 to 2 mg IM or Benadryl 25 to 50 mg IM (in milder cases use PO).
- 2.
If NMS is suspected (rigidity, vital sign abnormalities, difficulties in respiration, changes in mental status), hold all medications.
Inform RN
“Will arrive in … minutes.”
Elevator thoughts
See Table 15.1 .
Table 15.1
Common Movement Disorders
| Movement Disorder | Type | Description | Types | Treatment | To Be Aware |
|---|---|---|---|---|---|
| Tremor | Hyperkinetic | Involuntary, rhythmic oscillating movement that may involve the head, hands, limbs, lips, jaw, and voice |
|
|
|
| Tics | Hyperkinetic | Intermittent, sudden, brief, stereotyped movements or sounds that may involve head, face, trunk, or extremities | May consist of motor movements or sounds; may be simple jerklike movements or meaningless sounds or complex, coordinated sequences of movements or vocalizations | Treatment not usually urgent; patients often started on clonidine Refractory patients often require neuroleptics |
Neuroleptic-induced tardive syndromes may also present with tics |
| Dystonia | Hyperkinetic | Sustained, spasmodic contractions that result in abnormal posturing of any voluntary muscle | Shocklike (myoclonic) or slow (athetotic) movements Can be categorized as primary (familial, almost always focal) or secondary (due to neurodegenerative diseases, inherited forms, structural neurologic lesion) |
Anticholinergic or antihistaminergic medications |
Seizures can present with dystonic posturing as can neuroleptic-induced tardive dystonias Forms of dystonia include:
|
| Chorea | Hyperkinetic | Involuntary, irregular, sometimes dancelike movements that are brief and nonrhythmic Movements mostly involve distal extremities but may involve tongue, face, trunk, or head |
Can have multiple etiologies (metabolic, toxic, vascular, infectious) Psychotropic medications can cause chorea as a tardive syndrome Prototypical illness associated with chorea is Huntington’s disease |
There is no treatment for Huntington’s disease motor abnormalities; however, symptomatic treatment of behavioral and psychiatric comorbidities is important | Athetosis is similar to chorea but slower and more writhing in nature |
| Hemiballism | Hyperkinetic | Uncontrollable large amplitude flinging of one extremity | Most common cause is contralateral subthalamic nucleus infarct | Valproate has been shown to be helpful in some patients with disabling hemiballismus | Often coexists with chorea |
| Myoclonus | Hyperkinetic | Sudden, involuntary contractions of individual or groups of muscles |
|
Symptomatic treatment may be achieved with benzodiazepine such as clonazepam | |
| Parkinsonism | Hypokinetic | Various levels of bradykinesia, rigidity, resting tremor, and postural instability |
|
If drug induced:
|
Drug-induced parkinsonism is very common, almost 50% of outpatients develop signs or symptoms during course of treatments Consider Parkinson-plus syndromes, as neuroleptics may cause extreme extrapyramidal symptoms:
Elderly patients are susceptible to cognitive impairments with anticholinergics, antihistamines, and amantadine—use sparingly; taper medication gradually as abrupt discontinuation can exacerbate symptoms |
a Atypical antipsychotics (serotonin-dopamine antagonists) may represent an alternative medication strategy, because they possess a lower risk for extrapyramidal side effects. Risperidone is most likely to cause EPS at higher doses (>8 mg). Olanzapine has been shown to increase EPS, especially in patients with a history of EPS or Parkinson’s disease. Quetiapine has been shown not to have a greater risk of EPS compared with placebo. Meanwhile, clozapine has the dopamine-serotonin affinity profile, which makes it least likely to cause extrapyramidal side effects; and in some cases, it has even been shown to improve tardive dyskinesia and other movement disorders.
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