What are extrapyramidal signs, and how might they present during an MSE?

• A. Only tremor.
• B. Motor signs such as tremor, rigidity, bradykinesia, akathisia, or tardive dyskinesia; may be due to antipsychotic or antidepressant medications or neurodegenerative disease.
• C. Only cognitive slowing without motor features.
• D. Only facial grimacing.

Answer: (B)

Extrapyramidal signs are a cluster of movement abnormalities arising from disruption of dopamine pathways outside the pyramidal tract. They’re most often seen when dopamine D2 receptors in the nigrostriatal system are blocked by antipsychotic medications, but they can also occur with certain antidepressants or from neurodegenerative diseases like Parkinson disease. In a mental status exam this spectrum appears as motor behaviors alongside or instead of cognitive content. You might observe tremor at rest, muscular rigidity, and slowed initiating or executing movements (bradykinesia), which together resemble parkinsonian features. You may also see akathisia, the subjective feeling of inner restlessness with a need to move, or tardive dyskinesia, which involves repetitive, involuntary movements of the face, mouth, tongue, or choreiform movements of the limbs that often develop after long-term exposure to dopamine-blocking drugs. Because extrapyramidal signs cover a broad range of motor disturbances, they’re not limited to a single symptom like tremor, nor are they defined by cognitive slowing or facial grimacing alone. Recognizing the full set of signs helps distinguish medication- or disease-related motor effects from other aspects of the exam.