An adult patient was diagnosed with paranoid schizophrenia, and the doctor prescribed him chlorpromazine. After three weeks, the patient developed a subjective sensation of muscle discomfort, which can cause the patient to become agitated, restless, and anxious. What could be the possible condition?

1. A

   Acute dystonia

2. B

   Akathisia

3. C

   Tardive dyskinesia

4. D

   Akinesia

Appeared in: DSSSB 12 August 2024

Explanation

• Akathisia is an extrapyramidal side effect characterized by a subjective feeling of motor restlessness and an inability to stay still.
• The onset of akathisia is typically within a few weeks of starting or increasing the dose of an antipsychotic medication, which aligns with the patient's three-week timeline.
• The patient's symptoms of agitation, anxiety, and a compelling need to move are the classic presentation of akathisia.
• It is the most common acute manifestation of EPS.

Why Other Options Were Wrong

• Option A: Acute dystonia involves sudden, sustained muscle spasms and abnormal postures, not a feeling of restlessness.
• Option C: Tardive dyskinesia is a late-onset side effect, typically appearing after months or years of treatment. It involves involuntary, repetitive movements like lip-smacking or tongue protrusion.
• Option D: Akinesia is characterized by a lack of movement, slowness (bradykinesia), and apathy, which is the opposite of the restlessness and agitation described in the scenario.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Identification and differentiation of Extrapyramidal Symptoms (EPS) secondary to antipsychotic medication in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• A critical nursing responsibility is to differentiate akathisia from worsening psychotic agitation. Mistaking akathisia for psychosis could lead to an inappropriate increase in the antipsychotic dose, which would severely worsen the patient's distress.
• Nurses must perform regular assessments for EPS using standardized scales (like the Barnes Akathisia Rating Scale) and promptly report findings to the prescriber.
• What if the patient developed these symptoms after one year of therapy? In that case, while tardive akathisia is possible, tardive dyskinesia would be a more common consideration, and the assessment would focus on involuntary choreiform movements rather than just restlessness.

How to Approach the Question

• First, identify the core issue: the patient is experiencing adverse effects from an antipsychotic (chlorpromazine). These are likely Extrapyramidal Symptoms (EPS).
• Next, analyze the timeline. The symptoms appeared after 'three weeks'. This helps narrow down the possibilities.
• Then, carefully examine the specific symptoms: 'subjective sensation of muscle discomfort', 'agitated', 'restless', 'anxious'. This describes a state of motor hyperactivity and inner turmoil.
• Compare the timeline and symptoms to the known profiles of each EPS option:
• Acute dystonia is too early (hours/days) and involves spasms.
• Tardive dyskinesia is too late (months/years) and involves different movements.

Concept Tested & Keywords

• Concept Tested: Identification and differentiation of Extrapyramidal Symptoms (EPS) secondary to antipsychotic medication.
• Stem keywords: paranoid schizophrenia, chlorpromazine, three weeks, muscle discomfort, agitated, restless
• Lead-in keywords: possible condition
• Clinical cues: The timeline of 'three weeks' is a critical clue to differentiate between early, intermediate, and late-onset EPS.
• Clinical cues: The description 'subjective sensation of muscle discomfort' and 'restless' points directly to the hallmark features of akathisia.

Question ID

QJQN8vyp1AwIAzdyYr1I6S

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Reference Book

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) pp. 10037-10039, 5076-5078, 9897-9899