Catatonia was originally categorised as a subtype of schizophrenia, but it is found in people with other medical, neurological, and psychiatric disorders, including bipolar disorder. Catatonia is characterised by repetitive non-goal-directed movements or goal-directed movements that are executed in an idiosyncratic way, often affecting gait. Other forms of catatonia include immobility, mutism, staring, and rigidity. Tardive dyskinesia is a ‘hyper-kinetic’ (excessive movement) disorder, characterised by jerky, involuntary movements, usually of the face and/or limbs. Parkinsonism is another common movement disorder associated with schizophrenia and is a ‘hypo-kinetic’ (reduced movement) disorder, characterised by slowness of movement and rigidity. These movement disorders are associated with antipsychotic medications but can arise independent of medication status.

What is the evidence for movement disorders in people with bipolar disorder?

Moderate to low quality evidence finds the prevalence of abnormal involuntary movements in people with bipolar disorder is between 7% and 14%, while catatonic symptoms are found in around 20% of patients.

February 2022

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Movement disorders and extrapyramidal symptoms are common side effects of many antipsychotic medications. They can also be apparent in people with schizophrenia who are have never taken antipsychotic medications and in their relatives. Extrapyramidal symptoms include tardive dyskinesia, a severe and chronic condition involving repetitive, involuntary movements, most commonly occurring around the mouth and face. Akathisia is characterised by a feeling of restlessness and movements such as shuffling of the legs, pacing, rocking from foot to foot, or the inability to sit down or stand still. Dystonia involves muscular spasms and abnormal postures. Medications prescribed to treat the side effects of antipsychotic drugs increase adherence to antipsychotics, which reduces the risk of psychotic relapse.

What is the evidence for medications for movement disorders?

For tardive dyskinesia, moderate to low quality evidence finds large benefits over placebo of the hormone insulin, the antipsychotic promethazine, and pyridoxal 5 phosphate (vitamin B6). There were medium-sized benefits over placebo for the anxiolytic buspirone, the cognitive enhancer/stimulant pemoline, and the alkaloids dihydrogenated ergot alkaloid and L-Stepholidine. There were small benefits over placebo for GABA-acting medications, branched-chain amino acids, enzyme VMAT2 inhibitors, ginkgo biloba, and the antiepileptic levetiracetam. There was a medium to large benefit of the antidepressant isocarboxazid over the anticholinergic procyclidine.

There were no significant benefits for tardive dyskinesia of ceruletide, vitamin E, cholinergic medications, noradrenergic or dopaminergic medications, benzodiazepines, evening primrose oil, lithium, oestrogen, the antidepressants selegiline and ritanserin, melatonin, the antihistamine cyproheptadine, the alkaloid papaverine, the cognitive enhancer piracetam, eicosapentaenoic acid derivative, and the antiepileptic levetiracetam.

For akathisia, moderate quality evidence finds a large benefit of 5-HT2A antagonists over placebo, with no differences in sedation levels. There was no benefit of eicosapentaenoic acid derivative for akathisia. For dystonia, moderate to low quality evidence finds a small benefit of eicosapentaenoic acid derivative over placebo.

For catatonia, only one small study assessed the effects of benzodiazapines and found no benefit over placebo.

February 2022

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Catatonia was originally categorised as a subtype of schizophrenia, but it is found in people with other medical, neurological, and psychiatric disorders. Catatonia is characterised by repetitive non-goal-directed movements or goal-directed movements that are executed in an idiosyncratic way. Other forms of catatonia include immobility, mutism, staring, and rigidity. Tardive dyskinesia is a ‘hyper-kinetic’ (excessive movement) disorder, characterised by jerky, involuntary movements, usually of the face and/or limbs. Parkinsonism is another common movement disorder associated with schizophrenia and is a ‘hypo-kinetic’ (reduced movement) disorder, characterised by slowness of movement and rigidity. These movement disorders are associated with antipsychotic medications but can arise independent of medication status.

What is the evidence for movement disorders in schizophrenia?

Moderate quality evidence finds the overall prevalence of extrapyramidal symptoms in people with schizophrenia taking antipsychotics is around 37%. Parkinsonism prevalence is 20%, akathisia prevalence is 11%, catatonia prevalence is 10%, and tardive dyskinesia prevalence is 7%. Non-white ethnicity and the presence of early extrapyramidal symptoms is associated with a small to medium-sized increase in the risk of tardive dyskinesia in patients treated with antipsychotics. There were no moderating effects of age, sex, or medication dose.

Moderate to high quality evidence finds around 17% of people with schizophrenia who are antipsychotic-naïve show symptoms of parkinsonism, and 9% show symptoms of dyskinesia. This corresponds to a large increase in the risk of dyskinesia and parkinsonism when compared to controls. There was also a small increase in these symptoms in first-degree relatives of people with schizophrenia.

February 2022

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