A 53-year-old man is seen for a routine health examination. He has a 30-year history of schizophrenia and was recently diagnosed with type 2 diabetes mellitus. The patient's other medical conditions include hypercholesterolemia and seborrheic dermatitis. Medications include metformin, lovastatin, and haloperidol. The patient's schizophrenia had been controlled for many years on olanzapine until he was hospitalized 6 months ago for an acute psychotic episode that occurred when he was forced to move into a group home following the death of his father. Since discharge, his psychotic symptoms have been well controlled on a stable dose of haloperidol.
On examination, the patient is cooperative but makes little eye contact. He appears extremely anxious and restless. He shifts frequently in his chair and crosses and uncrosses his legs continually. Vital signs are within normal limits. The remainder of the physical examination, apart from moderate obesity, is unremarkable. Laboratory studies, including comprehensive metabolic panel, complete blood count, and TSH, are within normal limits. Hemoglobin A1c is 7%.
Which of the following is the most likely explanation for this patient's symptoms?

Question

A 53-year-old man is seen for a routine health examination.  He has a 30-year history of schizophrenia and was recently diagnosed with type 2 diabetes mellitus.  The patient's other medical conditions include hypercholesterolemia and seborrheic dermatitis.  Medications include metformin, lovastatin, and haloperidol.  The patient's schizophrenia had been controlled for many years on olanzapine until he was hospitalized 6 months ago for an acute psychotic episode that occurred when he was forced to move into a group home following the death of his father.  Since discharge, his psychotic symptoms have been well controlled on a stable dose of haloperidol.
On examination, the patient is cooperative but makes little eye contact.  He appears extremely anxious and restless.  He shifts frequently in his chair and crosses and uncrosses his legs continually.  Vital signs are within normal limits.  The remainder of the physical examination, apart from moderate obesity, is unremarkable.  Laboratory studies, including comprehensive metabolic panel, complete blood count, and TSH, are within normal limits.  Hemoglobin A1c is 7%.
Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_98c0_c35b_853d_f7c3da39b10b_MD0002_00 This patient's anxiety, motor restlessness, and difficulty sitting still are most likely due to akathisia, a common extrapyramidal symptom (EPS) caused by antipsychotic medication. It is more common with high-potency first-generation antipsychotics, such as haloperidol, but also occurs with second-generation antipsychotics. Patients with akathisia frequently fidget, pace, rock while standing, cross and uncross their legs while sitting, and may describe a sense of inner restlessness, inability to sit still and urge to move. Akathisia is often extremely uncomfortable and distressing for patients. It can manifest as anxiety and agitation that may be mistaken for psychotic decompensation. Recognition is important, as increasing the antipsychotic dose will only worsen akathisia. If feasible, the antipsychotic dose should be reduced. Other options include treatment with a beta blocker or benzodiazepine. (Choice A) Acute dystonic reaction is another form of EPS characterized by sudden onset of distressing involuntary contraction of the neck, mouth, tongue, or eye muscles. It typically occurs within the first few days of antipsychotic exposure and is rapidly treated with anticholinergic medication (eg, benztropine, diphenhydramine). (Choice B) This patient's prominent physical restlessness makes akathisia more likely than an anxiety reaction to stress. Adjustment disorder is diagnosed when behavioral symptoms develop within 3 months after the onset of an identifiable psychosocial stressor and are not better explained by another disorder. (Choice D) This patient's psychotic symptoms have been well controlled on a stable dose of haloperidol. Therefore, his anxiety and agitation are more likely manifestations of akathisia. (Choice E) Tardive dyskinesia is an involuntary movement disorder associated with prolonged use of antipsychotic medications. It is characterized by repetitive, purposeless rhythmic movements typically involving the buccolingual masticatory areas and choreoathetoid movements of the trunk and limbs. Although this patient is at risk for tardive dyskinesia, his symptoms of restlessness and inability to sit still are more characteristic of akathisia. Educational objective: Akathisia is a common extrapyramidal symptom caused by antipsychotic medication and is characterized by inner restlessness, difficulty sitting still, and an urge to move. It may be mistaken for psychotic agitation. Management includes antipsychotic dose reduction if feasible and treatment with beta blockers or benzodiazepines. __________ References: The clinical challenges of akathisia. (http://www.ncbi.nlm.nih.gov/pubmed/26683525) Akathisia: an updated review focusing on second-generation antipsychotics. (http://www.ncbi.nlm.nih.gov/pubmed/19389331)

A 53-Year-Old Man Is Seen for a Routine Health Examination