A 23-year-old woman comes to the office describing restlessness in her legs and inability to lie or sit still. The patient was diagnosed with schizophrenia a month ago and medication therapy was initiated. Her dose was increased after 2 weeks. She says, "I haven't heard any voices since a few days after the medication was increased." Blood pressure is 140/90 mm Hg and pulse is 90/min. The patient is alert, oriented, fidgety, and anxious. Which of the following is the most likely diagnosis in this patient?

Question

A 23-year-old woman comes to the office describing restlessness in her legs and inability to lie or sit still.  The patient was diagnosed with schizophrenia a month ago and medication therapy was initiated.  Her dose was increased after 2 weeks.  She says, "I haven't heard any voices since a few days after the medication was increased."  Blood pressure is 140/90 mm Hg and pulse is 90/min.  The patient is alert, oriented, fidgety, and anxious.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec160b_3c4d_1af2_9249_397147d2493f_MD0001_00 This patient is experiencing akathisia, a type of extrapyramidal side effect associated with antipsychotic treatment. Akathisia ranges from mild subjective feelings of tension to marked physical restlessness (which can be extremely distressing for patients). It typically presents days to weeks after initiating antipsychotic treatment or increasing the dose. Patients describe an inability to sit or stand in one position and may pace frequently or demonstrate other restless behaviors. Treatment options include decreasing the antipsychotic dose (if feasible) or treating with a beta blocker or benzodiazepines. (Choice A) Acute dystonia is an extrapyramidal side effect characterized by acute onset of involuntary muscle contraction of the neck, mouth, tongue, or eye muscles. It occurs within hours to days of antipsychotic use, especially with rapid dose escalation of high-potency, first-generation antipsychotics (eg, haloperidol), and is treated with anticholinergic medication (eg, diphenhydramine, benztropine). (Choice C) Drug-induced parkinsonism is an extrapyramidal side effect that presents with cogwheel rigidity, masked facies, bradykinesia, tremor, and decreased arm swing. Treatment is usually with anticholinergics (eg, benztropine). (Choice D) Neuroleptic malignant syndrome is an acute, potentially fatal reaction to antipsychotic medications. Patients have hyperthermia, sympathetic hyperactivity (eg, tachycardia, diaphoresis), severe "lead pipe" rigidity, and altered mental status. (Choice E) This patient reports that her auditory hallucinations have resolved and shows no other signs of psychosis. The physical restlessness of akathisia may be mistaken for psychotic agitation. It is important to differentiate the two etiologies as increasing the antipsychotic dose will further exacerbate akathisia. (Choice F) Tardive dyskinesia is an involuntary and potentially irreversible movement disorder due to prolonged antipsychotic exposure (typically years). Characteristic movements include lip smacking, biting, grimacing, tongue protrusions, and choreoathetoid movements of the head, limbs, and trunk. Educational objective: Akathisia is an extrapyramidal side effect of antipsychotic medication characterized by inner restlessness and an inability to sit or stand in one position. Treatment involves a reduction in the antipsychotic dose, if possible, or the addition of a beta blocker or benzodiazepine. __________ References: Drug-induced akathisia. (http://www.ncbi.nlm.nih.gov/pubmed/29282345) Revisiting antipsychotic-induced akathisia: current issues and prospective challenges. (http://www.ncbi.nlm.nih.gov/pubmed/27928948)

A 23-Year-Old Woman Comes to the Office Describing Restlessness in Her