A case study is presented to “set the stage.” Answers to these questions may be located in your texts, PowerPoints, or readings. You may also need to do additional research. Questions are listed in the Case Study document and on this page for easy reference.

Case Study #1
Drug-Induced Akathisia in 34-Year-Old
The issue: Balancing efficacy and tolerability
Patient Intake and Assessment
 The patient is a 34-year-old woman with schizophrenia and generalized anxiety disorder
 She has had a tumultuous clinical course over the past 20 years, with multiple hospitalizations,
substantial past drug abuse, and current alcohol abuse
 She presents for outpatient follow-up care following a 10-day hospitalization for worsening positive
symptoms (delusions, auditory hallucinations, paranoia) and aggression
 At the hospital she was put on aripiprazole 20 mg/day, which she has now been taking for 12 days
 Her positive symptoms are improved to the point where she was able to be discharged; however,
she wants to stop taking it because, she says, “I don’t feel right on it. I can’t sit still. It feels like I have
ants in my pants, and it’s driving me crazy. I have never felt like this before.”
 During her appointment, the patient appears restless, bouncing her legs and getting up and down
from her seat
 She reports that she began feeling restless 2 days after starting aripiprazole, and that the hospital
staff attributed it to her anxiety disorder
 She denies any symptoms of depression but appears irritable
Attending’s Notes: Recognition of Akathisia
 Currently, akathisia is diagnosed purely by clinical observation and patient report; the most
commonly used assessment tool is the Barnes Akathisia Rating Scale (BARS)
 Akathisia is often extraordinarily difficult for the patient to describe, in part because there are few
subjective states to which it can be compared
 The objective sign is disordered movement:
Anxiety Mild to moderate akathisia Severe akathisia
Location If observable,
excessive movement
typically manifests in
upper extremity and
facial fidgetiness
Predominantly lower
extremities (usually from
hips to ankles)
Can involve the entire body
Less likely to complain
about a need to move;
movement does not
reduce discomfort
Inner restlessness relieved
by movement
Inner restlessness, need to
Autonomic arousal Shifting positions while
standing or moving the feet
around while sitting
Nearly incessant writhing
and rocking, accompanied
by jumping around, running,
and occasionally jumping
out of a chair or bed
**Questions on Page 2***




1. What causes drug-induced akathisia?
2. Which antipsychotic agent(s) demonstrates the highest association with akathisia? Which
demonstrates the lowest?
3. What medications can be used to treat antipsychotic-induced akathisia? (Discuss at least
three medications and the dosage at which they are given to treat this)
4. Akathisia is considered a drug-induced movement disorder. Three drug-induced movement
disorders that are considered emergencies are: neuroleptic malignant syndrome, serotonin
syndrome, and parkinsonism hyperpyrexia disorder. What are the signs and symptoms of
these? What is the treatment?
5. Abilify is a second generation antipsychotic. What makes first generation “conventional”
antipsychotics different from second generation antipsychotics?


Read chapter 5 from Stahl’s Essential Psychopharmacology, pp. 159-244 (MO1, MO2, MO4, MO5)

Read chapter 2 from Clinical Manual of Geriatric Psychopharmacology, pp. 43-88

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