A 28-year-old woman with first-episode psychosis is started on olanzapine 10 mg/day. After 2 weeks, she develops severe restlessness, inability to sit still, and an overwhelming urge to move her legs. Her psychotic symptoms are well-controlled. Vital signs and ECG are normal. What is the most likely adverse effect, and what is the best management?

Explanation

## Clinical Diagnosis The patient has **akathisia** — a subjective sense of inner restlessness with inability to sit still, appearing 1–2 weeks after antipsychotic initiation. Key features: - Severe subjective distress ("inner restlessness") - Objective motor restlessness (pacing, leg movements) - Normal vital signs and temperature (rules out NMS) - Responsive to treatment within days - Occurs with both typical and atypical antipsychotics ## Pathophysiology **Key Point:** Akathisia is thought to result from dopamine blockade in the **mesocortical and mesolimbic pathways** (not extrapyramidal), causing dysphoria and restlessness. It is NOT a Parkinsonian side effect. ## Management Algorithm ```mermaid flowchart TD A[Akathisia diagnosed]:::outcome --> B{Psychotic control adequate?}:::decision B -->|Yes| C[Do NOT increase antipsychotic]:::action B -->|No| D[Consider dose adjustment]:::action C --> E[Add beta-blocker or benzodiazepine]:::action D --> E E --> F[Propranolol 20-40 mg TID or<br/>Lorazepam 0.5-1 mg BID]:::action F --> G[Symptom relief in 24-48 hours]:::outcome ``` ## Why Other Options Fail | Option | Why Wrong | |--------|----------| | Reduce olanzapine dose | Dose reduction may worsen psychosis; akathisia is NOT dose-dependent and responds to adjunctive agents | | Neuroleptic malignant syndrome | NMS presents with fever, rigidity, altered mental status, elevated CK; this patient has normal vitals and no fever | | Restless leg syndrome + levodopa | RLS occurs at night, improves with movement, and is not an antipsychotic side effect; levodopa antagonizes antipsychotics | ## First-Line Treatments for Akathisia **High-Yield:** 1. **Propranolol** (20–40 mg TID) — beta-blocker; most effective, works within 24–48 hours 2. **Benzodiazepines** (lorazepam 0.5–1 mg BID) — rapid symptom relief, risk of dependence 3. **Mirtazapine** (15–30 mg/day) — alternative if beta-blockers contraindicated **Clinical Pearl:** Do NOT reduce the antipsychotic dose if psychotic control is good — akathisia is managed with adjunctive agents, not dose reduction. **Mnemonic:** **BETA-BENZO** for akathisia = **Beta-blockers** or **Benzodiazepines** are first-line.