Psych Vivas · Psychopharmacology
Extrapyramidal side effects and tardive dyskinesia — structured clinical viva
Fellowship viva on EPS tempo taxonomy, dystonia rescue, akathisia, TD risk and VMAT2 RCTs.
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Interpretation
Reveal interpretationShowHide
Classification. Acute dystonia (hours–days after parenteral high-potency agent); akathisia (subjective + objective restlessness — Barnes framework); TD (late orofacial dyskinesia after cumulative exposure).[1][2][8]
Dystonia rescue. Airway if laryngeal. Benztropine 1–2 mg IM/IV; short oral cover; review antipsychotic potency/route.[1]
Akathisia. Do not escalate antipsychotic. Reduce/switch; propranolol if safe; other adjuncts per evidence hierarchy; avoid mislabeling as pure anxiety or psychosis-driven agitation.[2]
TD epidemiology. Carbon 2017: residual prevalence in SGA era remains substantial; Carbon 2018: SGAs lower risk than FGAs but not zero. Prevention and monitoring mandatory.[3][4]
TD care. AIMS document; minimise/switch (clozapine if ongoing AP needed); VMAT2: valbenazine (KINECT 3), deutetrabenazine (ARM-TD, AIM-TD); label-based dosing and safety monitoring.[5][6][7][8]
Pitfalls. NMS if fever/rigidity/autonomic storm; anticholinergics worsen classic TD; inventing legal section numbers for consent discussions.[1][8]
References8ShowHide
- [1]Rupniak NM, Jenner P, Marsden CD Acute dystonia induced by neuroleptic drugs Psychopharmacology (Berl), 1986.PMID 2871578
- [2]Barnes TR A rating scale for drug-induced akathisia Br J Psychiatry, 1989.PMID 2574607
- [3]Carbon M, Hsieh CH, Kane JM, Correll CU Tardive Dyskinesia Prevalence in the Period of Second-Generation Antipsychotic Use: A Meta-Analysis J Clin Psychiatry, 2017.PMID 28146614
- [4]Carbon M, Kane JM, Leucht S, Correll CU Tardive dyskinesia risk with first- and second-generation antipsychotics in comparative randomized controlled trials: a meta-analysis World Psychiatry, 2018.PMID 30192088
- [5]Hauser RA, Factor SA, Marder SR, et al. KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia Am J Psychiatry, 2017.PMID 28320223
- [6]Anderson KE, Stamler D, Davis MD, et al. Deutetrabenazine for treatment of involuntary movements in patients with tardive dyskinesia (AIM-TD) Lancet Psychiatry, 2017.PMID 28668671
- [7]Fernandez HH, Factor SA, Hauser RA, et al. Randomized controlled trial of deutetrabenazine for tardive dyskinesia: The ARM-TD study Neurology, 2017.PMID 28446646
- [8]Correll CU, Citrome L Diagnostic and Treatment Fundamentals for Tardive Dyskinesia J Clin Psychiatry, 2021.PMID 34644461