Extrapyramidal Symptom

Rating Scale
Introduction

(ESRS)

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 Extrapyramidal Symptom Rating Scale (ESRS)

Overview

 The ESRS-A is the abbreviated version of the ESRS.

 The ESRS-A is a 28-item scale for the comprehensive
measurement of extra-pyramidal symptoms (EPS).
 Each item is rated 0-5 and has well-defined anchors.
 Ratings are made through a combination of a clinical interview, as
well as a motor examination.
 Extrapyramidal Symptom Rating Scale (ESRS)

General Applications

 Type: Physician-rated scale of extrapyramidal side effects.

 Main indications: Designed to measure extrapyramidal side effects
from antipsychotic medication.
 Rating performed by: Physician.
 Time period covered by scale: Clinical condition at the time of the
assessment.
 Time required to complete rating: Approximately 10 minutes.
 Extrapyramidal Symptom Rating Scale (ESRS)

ESRS – A Guidelines

 Clinical Global Impression ratings for the movement

subscales evaluate the rater’s impression of the overall
severity of the movement symptoms.

 These ratings are based on the rater’s clinical experience with

Parkinsonism, dystonia, dyskinesia and akathisia and made
only after completion of the motor examination and rating
sections of the ESRS-A.
 Extrapyramidal Symptom Rating Scale (ESRS)

Definitions

Parkinsonism
 Drug-Induced Parkinsonism consists of six separate sets of motor
disturbances:
 Rigidity
 Tremor
 Reduced facial expression/speech
 Impaired gait/posture
 Postural instability
 Bradykinesia
 Extrapyramidal Symptom Rating Scale (ESRS)

Definitions

Dystonia
 Dystonia is a movement disorder in which muscles are contracted
and contorted.
 Symptoms may co-occur with dyskinesia.
 Symptoms may result in the patient’s assuming abnormal postures
or positions.
 Dystonia may be present at rest and/or during action.
 Dystonia is usually first seen during action.
 In more advanced cases, symptoms may appear both at rest
and during action.
 Extrapyramidal Symptom Rating Scale (ESRS)

Definitions

Dyskinesia
 Dystonia is a movement disorder in which muscles are contracted
and contorted.
 Dyskinesia is characterized by movements that are repetitive,
purposeless, and involuntary.
 The patient may have dyskinetic movements of the arms, legs,
and trunk, as well as a variety of different movements of the face.
 Patients are not necessarily aware of these movements.
 Extrapyramidal Symptom Rating Scale (ESRS)

Definitions

Akathisia
 Akathisia is subjective feelings of inner restlessness with the urge
to move, and/or objective movements such as:
 Restless movement of one extremity
 Fidgeting
 Changing position
 The inability to sit down for long periods
 Pacing back and forth or marching in place
 Terminology used by the patient to describe these feelings may
often be confusing and even idiosyncratic.
 Extrapyramidal Symptom Rating Scale (ESRS)

Definitions

Akathisia
 Terms like “restlessness” must be distinguished from anxiety,
insomnia, or other similar symptoms.
 Subjective akathisia should assess severity from the patient
over the period of the past 7 days.
 Akathisia may look very similar to other movement types,
especially tremors and dyskinesias.
 Akathisias may occur with other symptoms, but they tend to be
under greater voluntary control.
 Akathisia should be related to the underlying urge to move
(However, patient may occasionally not be fully aware of a
compulsion to move).
 Extrapyramidal Symptom Rating Scale (ESRS)

ESRS - A Ratings

 The ESRS-A should be scored after the interview and motor

evaluation are complete.
The Clinical Global Impression of Severity (CGI-S) should be
completed for each movement subtype.
 Severity of ratings should be related to both frequency and
severity/intensity of movement being evaluated.
 Movements often present complexly (in multiples) that can not be
easily specified by any single set of anchors.
 Each rating should represent the most appropriate rating based
overall clinical judgment for the anchor points pertaining to each
symptom.
 The temporal component is considered secondarily.
 Extrapyramidal Symptom Rating Scale (ESRS)

ESRS – A Scoring

0 Absent Symptom is completely absent

1 Minimal Symptom is mild or barely perceptible

2 Mild Some evidence of symptom

3 Moderate Definite presence of symptom

4 Severe Symptom is markedly present

5 Extreme Symptom present majority of time