A 24-year-old man on risperidone 6 mg/day reports unbearable inner restlessness and a compulsion to pace continuously. His family interprets this as his 'illness getting worse'. His psychiatrist instead increases the antipsychotic dose, after which the restlessness worsens further. What is the correct diagnosis and management?

• A Tardive dyskinesia; reduce dose and start valbenazine
• B Psychotic agitation; add a benzodiazepine and continue titration
• C Anticholinergic delirium; stop risperidone and give physostigmine
• D Akathisia; lower the antipsychotic dose and add propranolol ✓

Explanation

Subjective inner restlessness with an urge to move, without objective repetitive movements, defines akathisia, common with higher-potency agents like risperidone. It is frequently mistaken for worsening psychosis, and increasing the dose aggravates it, as occurred here. Management is dose reduction plus a beta blocker such as propranolol; benzodiazepines are second line. Tardive dyskinesia consists of involuntary orofacial choreoathetoid movements after months of exposure, not subjective restlessness, so valbenazine is inappropriate.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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Written and medically reviewed by the StethoPrep medical team.