In school as an NP student and later in clinical practice, I learned that prescribing benztropine (Cogentin) for extrapyramidal side effects was appropriate. What I didn’t realize was that there are times when prescribing benztropine—or any anticholinergic—can actually be problematic.
Why caution with anticholinergics?
Benztropine is an anticholinergic agent that’s useful for treating extrapyramidal symptoms like parkinsonism—but not tardive dyskinesia (TD). In fact, anticholinergics do not alleviate TD symptoms and may even aggravate them.
Tardive dyskinesia involves involuntary, repetitive movements—often affecting the face, limbs, and trunk—caused by long-term use of dopamine receptor-blocking agents, particularly antipsychotics. Prescribing anticholinergics in this setting can further disrupt the brain’s neurotransmitter balance, exacerbating symptoms rather than helping them [1].
As psych NPs, we need to know when anticholinergics like benztropine are appropriate (i.e., parkinsonism) and when they are not (i.e., TD). The body is constantly seeking neurotransmitter equilibrium—treating the wrong movement disorder with the wrong drug works against that balance.
How common is tardive dyskinesia?
Very common. TD is prevalent in a wide range of clinical settings, including outpatient clinics, inpatient units, state hospitals, and long-term care facilities.
- 13% of patients on atypical antipsychotics develop TD
- 32% of those on typical antipsychotics develop TD [2]
If you’re prescribing antipsychotics, there’s always a risk of TD – proper treatment knowledge essential.
Two different conditions, two opposite treatments
Movement disorders like TD and parkinsonism are often managed with completely opposite medications:
- Anticholinergics (like benztropine) for parkinsonism
- VMAT2 inhibitors (like valbenazine or deutetrabenazine) to treat tardive dyskinesia
The mechanisms differ significantly. Anticholinergics increase dopamine signaling, while VMAT2 inhibitors reduce dopamine signaling in the motor striatum.
Understanding VMAT2 inhibitors
You may not have learned about VMAT2 inhibitors in school—I know I didn’t. But they’re crucial in modern psychopharmacology and represent the first-line treatment for TD today [3].
Bottom line for Psych NPs
Give your patients the right treatment for the right movement disorder. It’s fine to prescribe benztropine—if it’s indicated—but know what you’re using it for.
If you want a deeper understanding of how to treat tardive dyskinesia and medication-induced movement disorders, I cover this in more detail in the Mental Disorders Crash Course.
Further learning:
For more on differentiating between psychiatric medication effects, check out this case study on severe mental illness and patient outcomes.
For more clinical tips on diagnosing and treating mental disorders, follow me on Instagram @stressfreepsychnp.
References:
[1] American Psychiatric Association. (2020). Practice Guideline for the Treatment of Patients With Schizophrenia, 3rd Edition.
[2] Carbon M, Kane JM. Tardive dyskinesia risk with typical and atypical antipsychotics. J Clin Psychiatry. 2014;75(3):e269–e277.
[3] Peckham AM, Nicewonder JA. VMAT2 Inhibitors for Tardive Dyskinesia-Practice Implications. J Pharm Pract. 2019;32(4):450-457. doi:10.1177/0897190018756512