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Clinical Atlas Prestige · Evidence-first

Psych VivasPsychopharmacology

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.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. A 29-year-old man with first-episode psychosis develops acute torticollis after IM haloperidol, later akathisia on aripiprazole, and after eight months of risperidone shows new orofacial dyskinesia. Discuss classification, acute rescue including doses, akathisia management, TD epidemiology (SGA era), AIMS monitoring, and VMAT2 evidence (name trials).

Interpretation

Reveal interpretation

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]

Key points

Tempo first

Acute dystonia ≠ akathisia ≠ TD — different tools.

Name the VMAT2 trials

KINECT 3 (valbenazine); ARM-TD and AIM-TD (deutetrabenazine).

SGA myth

SGAs reduce TD risk relative to FGAs but do not abolish it.
[3] [4] [5]

References

  1. [1]Rupniak NM, Jenner P, Marsden CD Acute dystonia induced by neuroleptic drugs Psychopharmacology (Berl), 1986.PMID 2871578
  2. [2]Barnes TR A rating scale for drug-induced akathisia Br J Psychiatry, 1989.PMID 2574607
  3. [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. [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. [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. [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. [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. [8]Correll CU, Citrome L Diagnostic and Treatment Fundamentals for Tardive Dyskinesia J Clin Psychiatry, 2021.PMID 34644461