A 39-year-old man with schizoaffective disorder comes to the office for a follow-up appointment. The patient has a history of 4 hospitalizations for manic and psychotic episodes and lives in a supervised group home. Three months ago, he was hospitalized for a manic episode characterized by euphoria, racing thoughts, and grandiose delusions of being a famous performer. At the time, he heard voices telling him that he was "chosen" and commanding him to "sing for glory." During the hospitalization, the patient was successfully treated with valproate and risperidone and continued on these medications following discharge. One month ago, a trial of lowering his risperidone dose was terminated when it resulted in an increased frequency of auditory hallucinations. At today's visit, the patient's mood remains stable but he feels restless and uncomfortable, reporting, "I can't seem to sit still or relax." The patient appears nervous and shakes his right leg constantly during the examination. At one point, he gets up and paces around the room. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 39-year-old man with schizoaffective disorder comes to the office for a follow-up appointment.  The patient has a history of 4 hospitalizations for manic and psychotic episodes and lives in a supervised group home.  Three months ago, he was hospitalized for a manic episode characterized by euphoria, racing thoughts, and grandiose delusions of being a famous performer.  At the time, he heard voices telling him that he was "chosen" and commanding him to "sing for glory."  During the hospitalization, the patient was successfully treated with valproate and risperidone and continued on these medications following discharge.  One month ago, a trial of lowering his risperidone dose was terminated when it resulted in an increased frequency of auditory hallucinations.  At today's visit, the patient's mood remains stable but he feels restless and uncomfortable, reporting, "I can't seem to sit still or relax."  The patient appears nervous and shakes his right leg constantly during the examination.  At one point, he gets up and paces around the room.  Vital signs and physical examination are unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient is experiencing akathisia, a side effect of antipsychotic drugs characterized by a subjective feeling of inner restlessness, urge to move, and inability to sit still. Although more common with first-generation antipsychotics, it also occurs with second-generation antipsychotics. It is distressing for patients and a common cause of medication nonadherence. It is important to recognize akathisia and manage it appropriately; mistaking a patient's restlessness and pacing for increasing psychotic agitation may lead to increasing the antipsychotic dose and potentially worsening akathisia. The initial approach to akathisia is cautious reduction of the antipsychotic dose and monitoring for psychotic exacerbation. However, in this case, reduction in antipsychotic dose resulted in worsening auditory hallucinations. When dose reduction is not feasible, the addition of a beta blocker, such as propranolol, is indicated. Benztropine and benzodiazepines have also been used. (Choice A) Adding haloperidol, a high-potency, first-generation antipsychotic, would only worsen the patient's akathisia. (Choice C) Decreasing the dosage of valproate may result in the return of manic symptoms. Akathisia is not a common side effect of this medication. (Choice D) Lorazepam can be used to treat akathisia. However, discontinuing risperidone would likely result in psychotic relapse. (Choice E) Because the patient is already experiencing side effects from his current dose of risperidone, increasing the dose would likely result in worsening of akathisia. In addition, there is no mention of additional psychotic symptoms that would warrant a dosage increase. Educational objective: Akathisia, characterized by a feeling of inner restlessness, urge to move, and inability to sit still, is a common side effect of antipsychotic drugs that is distressing for patients and can lead to medication nonadherence. When antipsychotic dose reduction is not feasible, a beta blocker, such as propranolol, can be added to treat akathisia. References: Akathisia: an updated review focusing on second-generation antipsychotics. (http://www.ncbi.nlm.nih.gov/pubmed/19389331) Revisiting antipsychotic-induced akathisia: current issues and prospective challenges. (http://www.ncbi.nlm.nih.gov/pubmed/27928948)

A 39-Year-Old Man with Schizoaffective Disorder Comes to the Office