Extrapyramidal side effects and tardive dyskinesia — structured clinical viva

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]