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.

There is rigidity in neuroleptic malignant syndrome whereas myoclonus, hyperreflexia with clonus, and mydriasis are more common in serotonin syndrome. Early recognition of a drug-induced movement disorder is essential to allow for prompt intervention. This includes stopping the offending drug, supportive care, and sometimes other pharmacological treatment. A number of medications can cause parkinsonism because they block the dopamine receptor and thereby mimic the symptoms of PD that are caused by loss of dopamine neurons in the brain. Reviewing a patient’s medications is therefore a critical step for a neurologist when seeing someone with parkinsonism. Anti-psychotics and anti-nausea treatments make up the bulk of the problematic medications, although there are other medications that can also cause parkinsonism.

Levodopa-induced dyskinesia

The altered mental status, autonomic instability, and spasticity or rigidity with raised creatine kinase, overlap with neuroleptic malignant syndrome. In serotonin syndrome the onset is hyperacute, within hours rather than days, and the signs of central nervous system hyperexcitability are more prominent. Management consists of altering the dose of, or if possible stopping, the offending drug, or switching to an alternative drug. Should the offending drug need to be continued, discuss the risks of the adverse effects versus the benefits of continuing to ensure the patient is informed. If the drug is continued, drugs typically used for essential tremor (for example, propranolol) can occasionally be beneficial.

Parkinsonism-hyperpyrexia disorder

The most visually dramatic movement disorder caused by cocaine is transient chorea, also called crack dancing and buccolingual dyskinesias. According to National Center for Drug Abuse Statistics, 12.9 million Americans aged 12 years and above have abused illicit drugs at some point in their lives. A report by the National Institute on Drug Abuse revealed that in 2020, approximately 92,000 U.S citizens died from a drug-related overdose of both illegal drugs and prescription opioids. The American Parkinson Disease Association (APDA) is a nationwide grassroots network dedicated to fighting Parkinson’s disease (PD) and works tirelessly to help the approximately one million with PD in the United States live life to the fullest in the face of this chronic, neurological disorder. 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. The bottom line is, whether you are or are not diagnosed with PD, be aware of changes that may occur upon starting a new medication.

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• They include dystonia, tremor, myoclonus, akathisia, tics, and chorea.
• This includes stopping the offending drug, supportive care, and sometimes other pharmacological treatment.
• Action tremors occur for example, when the arm is moving toward the mouth to eat.
• If you believe you or your loved one’s movement disorder results from drug use, it is best to seek professional help.
• Consequently, they inhibit reuptake, releasing dopamine at the mesocorticolimbic dopaminergic nerve terminals.
• Again, it would be best to seek medical attention if you experience these symptoms.

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.

The primary treatment for this type of parkinsonism is weaning off of the offending medication, if possible. The motor features of PD are often (but not always) very easy to see via a neurologic exam in a doctor’s office. Rest tremor (which is a tremor that goes away with movement, but often returns when the limb is at rest) for example, is seen in virtually no other illness and can therefore be very important in diagnosing PD. But there is one other common condition that induces the symptoms of PD, including a rest tremor, which must be considered every time PD is being considered as a diagnosis, and that is drug-induced parkinsonism. The time of onset of the movement disorder may be acute, subacute, or chronic.

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The majority of MIT are posture holding or kinetic, but some medications (especially lithium, DBAs, valproic acid) can cause resting tremors. PD is a classic cause of resting tremor that typically occurs unilaterally and improves drug induced tremors with motion but can recur as re-emergent tremor when a sustained posture is maintained. Resting tremor typically worsens with distraction and goes away during sleep. Physiological tremor is an action tremor that is mediated by both central and peripheral mechanisms.17,18 It consists of low-amplitude, high-frequency (8–12 Hz) oscillations depending on the stiffness, mass, and other properties of the tremoring body part. EPT can be very similar in appearance and characteristics to ET when EPT becomes clinically symptomatic. Drug-induced tremors typically are symmetric or equal on both sides of the body.

• Tetrabenazine is an earlier VMAT-2 inhibitor; however, it is used as an agent of last resort due to its risk of significant side effects (eg, depression and suicidal ideation).
• If so, then the following case vignette and discussion should prove useful.
• It will also be important to develop further knowledge of neurotransmitters and their receptors that may influence tremor or actually suppress it.
• 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.
• Referral is recommended for patients with late-stage disease for consideration of device-assisted therapy.
• Early recognition of a drug-induced movement disorder is essential to allow for prompt intervention.
• Anticholinergic drugs to prevent, or reduce the severity of, drug-induced movement disorders have been suggested, however there is no evidence to support this.

Medical

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.

Tremors can occur in the setting of withdrawal states, especially with benzodiazepines, ethanol, and opiates. One well-performed study found that patients undergoing ethanol withdrawal had tremors in the range of 8–12 Hz.74 When patients abruptly stop β-adrenergic antagonists such as propranolol, an increase in action and postural tremor can be observed as well. Even 1 month after discontinuing propranolol, increased tremor power was observed in subjects without underlying tremor disorders who were being treated for cardiac conditions.75 Most withdrawal-related tremors appear typical of EPT as with most MIT.

Drug-induced movement disorders can range from tremors to life-threatening syndromes. They can be classified chronologically based on the time of onset after drug ingestion, as acute, subacute or tardive. Both therapeutic and illicit drugs can cause neurological adverse effects, including movement disorders. The most common causes of drug-induced movement disorders are dopamine receptor blocking drugs, including antipsychotics and antiemetics (Table 1). Drug-induced movement disorders can range from tremors to life-threatening syndromes.

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.