EPS spectrum and tardive dyskinesia management (MEQ)

(i) Tempo classification. Acute dystonia within hours–days of high-potency/parenteral dopamine blockade is an acute EPS. The later inner restlessness with pacing is akathisia (subacute/acute depending on onset after dose change). Orofacial chewing/tongue movements after months of exposure fit tardive dyskinesia (Schooler–Kane spirit: characteristic dyskinesia after cumulative neuroleptic exposure, other causes excluded). Do not treat all three as one syndrome.[1][2][8]

(ii) Acute dystonia management. Airway assessment (especially if laryngeal symptoms). Immediate benztropine 1–2 mg IM or IV (or local equivalent anticholinergic); repeat if incomplete response per protocol. Short oral anticholinergic cover for 1–3 days after severe episodes. Review antipsychotic: reduce dose, avoid unnecessary parenteral high-potency agents, switch if recurrent. Reassure that the event is iatrogenic and treatable.[1]

(iii) Akathisia. Discriminator: subjective urge to move plus objective restlessness without psychotic content driving the behaviour — use Barnes scale structure. Do not give more IM antipsychotic. First: reduce risperidone or switch to lower-akathisia agent. Adjunct: propranolol if no contraindication (asthma, significant bradycardia/heart block) — exam orientation often start about 10–20 mg two–three times daily, titrate toward 20–40 mg two–three times daily with monitoring and product-information checks. Short-term benzodiazepine or other options (e.g. low-dose mirtazapine) appear in network meta-analytic rankings; anticholinergics are weaker for pure akathisia than for dystonia.[2][3]

(iv) TD pathway. Document with AIMS (severity, disability, awareness). Reassess need/dose of antipsychotic; consider switch to lower-TD-risk strategy (clozapine often discussed when ongoing antipsychotic is essential). Avoid chronic anticholinergics for classic TD. For moderate–severe or functionally impairing TD, offer VMAT2 inhibitor: valbenazine supported by KINECT 3 (once-daily 40/80 mg trial regimens — follow current label); deutetrabenazine supported by ARM-TD and AIM-TD (twice-daily titration with food per label). Monitor class adverse effects (somnolence, parkinsonism, mood/suicidality warnings historically, QT per product information). Shared decision and local formulary access apply.[4][5][6][7]