Psychiatry

Antipsychotic Side Effects (EPS, NMS, SS)

Psychiatry

Antipsychotic Side Effects (EPS, NMS, SS)

Time-based EPS classification + NMS vs serotonin syndrome.

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Extrapyramidal symptoms by timing

Reaction	Onset	Features	Treatment
Acute dystonia	Hours-days	Painful spasms, torticollis, oculogyric crisis	Benztropine or diphenhydramine
Akathisia	Days-weeks	Inner restlessness, pacing	Propranolol; benzo alternative
Drug-induced parkinsonism	Weeks-months	Bradykinesia, rigidity, tremor	Benztropine or amantadine; lower dose
Tardive dyskinesia	Months-years	Lip smacking, choreoathetoid tongue	Valbenazine (VMAT-2 inhibitor); switch to clozapine. AVOID anticholinergics

NMS vs Serotonin syndrome

Feature	NMS	Serotonin syndrome
Trigger	Dopamine antagonists (haloperidol)	Serotonergic agents (SSRI + MAOI)
Symptoms	Fever + lead-pipe rigidity + ↑CK + myoglobinuria + AMS	Hyperthermia + clonus + hyperreflexia + agitation + autonomic instability
Treatment	Stop drug + hydration + dantrolene or bromocriptine	Stop drug + cyproheptadine

High-yield pearls

◆Mirtazapine: sedating + appetite-stimulating (good for elderly with insomnia + weight loss)
◆Bupropion: activating, no sexual side effects; lowers seizure threshold (avoid in eating disorders)
◆TCA overdose: anticholinergic + QTc/QRS prolongation → sodium bicarbonate

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