Book Review: Extrapyramidal Side Effects: A Guide to the Extrapyramidal Side-Effects of Antipsychotic Drugs. Second Edition

Reviewer rating: Excellent This second edition arrives 15 years after the text was first published in 1999, capturing a time period that witnessed a host of atypical antipsychotics (APs) introduced, beginning in the 1990s. Arguably, its focus on AP-related extrapyramidal symptoms (EPS) should now be a quick read, for the 1990s had us believe that EPS was really a thing of the past with the advent of these newer APs. As the author points out in the preface, research in EPS “shrunk to a trickle”p vii since the 1990s, driven by the “genuine belief that the problem was over.”p vii, viii The text tells us otherwise. Content is clearly laid out in the form of 12 chapters divided into 5 sections: Setting the Scene, The Syndromes, Particular Issues, Assessment, and Matters Arising. Professor Cunningham Owens is well positioned to provide expertise on this topic (a clinical psychiatrist and researcher trained by leaders in the field, such as Professor David Marsden, a neurologist and international expert in movement disorders). He acknowledges from the outset that the text reflects an interface of evidence and clinical experience, the former more heavily weighted in this second version. The bulk of the text is as one would anticipate. There are chapters specific to the different movement disorders (acute dystonias, Parkinsonism, akathisia, and tardive dyskinesia), each providing a comprehensive overview that includes background, clinical features, diagnosis, epidemiology, risk factors, course, and treatment. There are also chapters addressing specific topics (tardive and chronic dystonia and special populations), clinical examination, and standardized rating measures. These are clear, well organized, and strengthened by photographs, figures, and tables highlighting key areas (for example, diagnostic criteria, differential diagnosis, prevalence, and course). To my way of thinking, though, what sets this text apart are the 2 chapters preceding the aforementioned chapters, in addition to 2 more that follow them. I like history, and, to my mind, Chapter 1 provides one of the best (and most succinct) overviews that I have read on the introduction of APs and modern psychopharmacology. It dovetails nicely with Chapter 2, which begins by addressing conceptual issues that arose almost immediately following the clinical entry of APs. Thereafter, the discussion turns to classification of drug-related movement disorders and the place of APs within the larger picture of other drug and nondrug causes. At the other end of the book, the final 2 chapters are no less a pleasure but for different reasons. Chapter 11, again, represents one of the better reads I have encountered on the topic of movement disorders in schizophrenia unrelated to AP exposure, while Chapter 12 tackles the fundamental issue of atypicality. It, too, is an enjoyable read, dismantling many of the misconceptions that linger as to what these drugs were meant to do, as well as what the accumulating body of evidence shows they can and cannot do. I also like stories, and it seems Professor Cunningham Owens is a storyteller; this does not diminish the science and is particularly evident in the first and last 2 chapters. It is an interesting story and he tells it well. Indeed, he gives it added life with his personal style, which clearly captures years of thoughtful reflection and clinical experience. I provide 2 examples. In addressing idiopathic, compared with drug-induced, Parkinsonism, he reports one of his own clinical vignettes involving a woman whose “postural stability was such that it seems the examiner’s breath might have tipped her to the ground.”p 89 I found this gentle humour scattered throughout to be refreshing, and counterbalanced at times with a bluntness that had a similar effect, as when he concludes that the value of the term atypicality “lies in marketing, where it has spawned a mighty juggernaugt.”p 304 For history buffs, notes at the end of each chapter add yet additional points of interest that further enhance the story. In short, I liked this book a lot. It is a hardcover text and not cheap. This said, it is clinically useful and represents a timely reminder that while metabolic side effects presently have the stage, it is misguided to believe we are in a position to shelve concerns regarding AP-related EPS.

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