Purple Book

The medications we prescribe are unfortunately not benign. Below, find a list of the most common acute medication side effects and first-line treatments:


  • Extrapyramidal symptoms
    • Acute dystonic reaction: characterized by spasmodic or sustained involuntary contractions of muscles in face, neck, trunk, pelvis, extremities (torticollis – muscle spasm of neck; oculogyric crisis – eyeballs in fixed position, usually upward), neck flexion, widely opened mouth, tongue protrusion, and ocular
      • Give Benadryl 50 mg IM STAT or Cogentin 1 mg IM STAT
      • Repeat dose as necessary
      • Consider 1) decreasing antipsychotic dose, 2) switching to atypical antipsychotic, 3) adding standing Cogentin dose


  • Akathisia: characterized by restless movement, or sensation of needing to move or “crawling out of skin.” At times mistaken for anxiety, insomnia, or agitation, and often overlooked.
    • Decrease antipsychotic dose and/or switch to alternate agent
    • Consider addition of standing propranolol


  • Drug-induced parkinsonism: characterized by cogwheel rigidity, slowed movements and/or resting tremor.
    • Consider scheduling entire dose of antipsychotic at bedtime
    • If possible, decrease dose and try switching to an atypical
    • May consider starting Cogentin (0.5mg BID, up to 2mg BID)
    • May also try Artane (1mg to 4mg daily)


  • Tardive dyskinesia: characterized by involuntary, repetitive, purposeless movements of tongue, face, neck, trunk and Other dopaminergic antagonist medications (metoclopramide) can also cause TDs (more likely to see when rotating through our consult service).
    • Cross-taper to atypical antipsychotic if possible
    • Use lowest effective dose of antipsychotic
    • Due to the chronic and impairing course of TD, we must always consent parents for this possibility with use of antipsychotic medications