HISTORY: ‘Bizarre’ days
Ms. K, age 45, is brought to the ER by her brother, who reports she has been acting “bizarre and crazy” for 3 days. He says his sister—who has bipolar I disorder— has had trouble sleeping, is restless, hears voices, and is contemplating suicide. He adds she was discharged from a psychiatric hospital 2 weeks ago after a 3-month stay.
Risperidone, 2 mg nightly, was controlling Ms. K’s mania until this recent episode. According to her brother, she also has developed continuous involuntary leg and arm movements and cannot sit or stand still. When she tries to sleep, her feet sway back and forth in bed for hours.
We admit Ms. K to the psychiatric inpatient unit because of her suicidality and hallucinations. She is restless and agitated during initial evaluation, pacing around the room or rocking her feet while standing or sitting. Her speech is pressured and the “voices” are urging her to kill herself.
Ms. K is dysphoric and severely distraught about her “nervousness” and continuous urges to move. She says she would rather die than live with incessantly “jittery” legs and arms, yet she wants to be discharged and denies that she is mentally ill. She believes decreased sleep is causing her symptoms and requests a “sleeping pill.”
she habitually views her medications as useless and stops taking them.
The patient has been hospitalized at least 4 times with severe manic and psychotic symptoms. She does not use illicit drugs and is medically healthy.
The authors’ observations
Ms. K’s involuntary movements suggest akathisia, a common extrapyramidal side effect of antipsychotics and other psychotropics (Table).1
Akathisia is characterized by strong feelings of inner restlessness that manifest as excessive walking or pacing and difficulty remaining still. Ms. K’s movements met at least 2 of 5 DSM-IV-TR criteria for acute akathisia (Box). ,2
Akathisia is characterized by at least 5 subtypes: 3
- Acute akathisia begins hours or days after starting the offending medication and lasts
- Tardive is similar to acute akathisia but can arise within 3 to 4 months of starting the offending medication and persists for years.
- Chronic akathisia lasts ≥3 months and usually has no temporal correlation with antipsychotic initiation or dosage increase.4
- Withdrawal akathisia begins within 6 weeks of discontinuing a medication or significantly reducing the dosage.
- Pseudo akathisia consists of objective symptoms of movement without subjective awareness or distress. This subtype usually is seen in older patients.
history of medication nonadherence strongly suggest akathisia secondary to risperidone withdrawal.5 Several
cases of akathisia after risperidone cessation have been reported.5
We know risperidone is not causing acute akathisia because Ms. K responded well to the medication during her last hospitalization with no adverse effects. Also, her family confirmed that she stopped taking risperidone after her most recent discharge.
Mania also can fuel incessant movement and increase physical activity, but patients often do not realize they have a problem while in a manic phase. Also, swinging and rocking of legs is rarely seen in mania. By contrast, Ms. K was morbidly distraught over her akathisia.
Table
Drugs that can cause akathisia
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The authors’ observations
Numerous treatments are available for akathisia:
Beta blockers such as propranolol are most widely used because of their rapid onset of action and overall effectiveness in akathisia.3 Researchers believe these drugs reduce extrapyramidal symptoms (EPS) by blocking the adrenergic system. Propranolol can be used at a maximum 120 mg/d in divided doses.
Beta blockers, however, can cause bradycardia, hypotension, or respiratory distress. Use beta blockers with caution, and monitor for these adverse effects.
Benzodiazepines. Clonazepam, which enhances the inhibitory effect of GABA in the brain, is commonly used for akathisia because of its effectiveness and long elimination half-life3 (30 to 40 hours), which decreases the risk of medication withdrawal.