Extrapyramidal Side Effects
Extrapyramidal side effects (EPS) are serious side effects of psychotic medications that block dopamine release. EPS include dystonia, akathisia, parkinsonism and tardive dyskinesia. Acute extrapyramidal side effects like dystonic reactions, akathisia and parkinsonian symptoms can occur within a few days or weeks after starting the antipsychotic medication and can be treated by reducing or discontinuing the medication. On the other hand, chronic extrapyramidal side effects such as tardive dyskinesia can develop after months or years of medication use and might not be reversed by discontinuing or reducing the drug. Tardive dyskinesia mostly involves movement of orofacial muscles such as sucking, lip smacking, tongue and lateral jaw movements and grimacing. Treatment for tardive dyskinesia requires stopping the drug or administering valbenazine 40mg daily and increasing it to 80mg in one week. In general, with all antipsychotics there is a risk of EPS development, but the first and second-generation risperidone provides the highest risk. Second-generation antipsychotics like quetiapine, olanzapine and clozapine have the lowest risk of EPS development. Risk factors for EPS development include being >65 years old, prior history of EPS, history of a movement disorder, traumatic brain injury and high doses or rapid titration of medication.

Steven-Johnson Syndrome
Steve-Johnson syndrome (SJS) along with other skin disorders such as erythema multiforme (EM) and toxic epidermal necrolysis (TEN) result as a hypersensitivity reaction of the immune system to certain medications, infections or diseases. SJS and TEN pertain to the same disorders, but differ in their severity. Generally, TEN is more severe than SJS. Steve-Johnson syndrome and TEN have an incidence of 1-2 cases per 1 million and have higher incidences in older patients with HIV/AIDS. Drugs associated with the development of SJS as well as TEN include sulfonamide antibiotics, allopurinol, NSAIDs, phenytoin, carbamazepine and lamotrigine. In terms of infection associated with SJS, the most common is mycoplasma pneumoniae. Other less common infections include yersinia, tuberculosis, syphilis, chlamydia, streptococci and salmonella. These two disorders initially present with influenza-like symptoms for 1-14 days such as fever, sore throat, chills, headache and malaise as well as signs of mucosal irritability like dysphagia, dysuria and conjunctivitis. These symptoms are followed by the development of erythematous macules and target lesions that eventually become blisters. Lesions can expand to form large and painful erythematous patches with a dusky color. Involvement of mucous membranes such as oral, ocular, genitourinary, nasopharyngeal, rectal and respiratory is characteristic of the disorder. Treatment requires stopping the offending medication and providing supportive care.

Kendra’s Law
In 1999, Kendra’s Law was signed in honor of Kendra Webdale, a victim who died after being pushed in front of a NYC subway train by an individual with mental illness. This law makes sure that individuals with a record of mental illness and hospitalization or violence record engage in community services suitable for their issues or needs under a court order of Assisted Outpatient Treatment. This law established strategies to identify individuals at high risk for not compliant with treatment due to living conditions limiting close supervision and treatment participation. High risk individuals are identified and assessed for the need of a court-ordered outpatient treatment.

Serotonin Syndrome
Serotonin syndrome is caused by an increase in serotonin activity in the central nervous system as a result of medication or concomitant use with other drugs. Today, serotonin syndrome is considered a spectrum that goes from autonomic instability, mental status changes to neuromuscular issues. To diagnose serotonin toxicity, the Hunter criteria is used. Under Hunter criteria, patients under the influences of serotonergic agents present with the following symptoms:

1. spontaneous clonus
2. Inducible clonus and agitation/or diaphoresis
3. ocular clonus and agitation/or diaphoresis.
4. Tremor and hyperreflexia
5. hypertonia.
6. Temperature >38 c and ocular clonus or inducible clonus.

Causative agents of serotonin syndrome include SSRI, TCAs, MAOIs, meperidine, tramadol, triptans, linezolid, amphetamines, MDMA, dextromethorphan and herbal supplements like ST. John’s wort. Treatment requires discontinuing the offending agent, supportive care, sedation and serotonin antagonist like cyproheptadine.

Sources:
● Lommel, Karen M., et al.. “Psychiatric Emergencies.” CURRENT Diagnosis & Treatment: Emergency Medicine, 8e Eds. C. Keith Stone, and Roger L. Humphries.New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2172&sectionid=165071095.
● Milana, Carolyn, and Mindy A. Smith.. “Erythema Multiforme, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis.” The Color Atlas and Synopsis of Family Medicine, 3e Eds. Richard P. Usatine, et al. New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2547&sectionid=206804356.
● Mockenhaupt, Maja, and Jean-Claude Roujeau.. “Epidermal Necrolysis (Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis).” Fitzpatrick’s Dermatology, 9e Eds. Sewon Kang, et al. New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2570&sectionid=210424179.
● Pokorna, Olesya, and Emma Samelson-Jones.. “Psychosis.” Behavioral Medicine: A Guide for Clinical Practice, 5e Eds. Mitchell D. Feldman, et al. New York, NY: McGraw-Hill, , http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=2747&sectionid=230251242.
● https://my.omh.ny.gov/analytics/saw.dll?dashboard