Akathisia Management — MRCPsych Paper B MCQ

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ModerateSchizophrenia & PsychosisAkathisia ManagementMRCPsych Paper B

A 27-year-old woman has taken aripiprazole 15 mg daily for 8 weeks for a first episode of psychosis. Her positive symptoms have resolved. She now describes distressing inner restlessness and a compelling need to move, accompanied by repeated leg movements and an inability to remain seated. She has no rigidity or tremor. What is the most appropriate initial management?

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Correct answer: D — Reduce the aripiprazole dose and consider propranolol

The subjective inner restlessness, compelling urge to move and observable repetitive leg movements indicate antipsychotic-induced akathisia. As her psychosis has responded, the initial approach is a cautious reduction of aripiprazole with monitoring for recurrence. If dose reduction is insufficient or not clinically feasible, propranolol can be considered after checking for contraindications such as asthma, bradycardia and hypotension; its use for akathisia is off-label. Increasing aripiprazole may worsen this dose-related adverse effect. Procyclidine is useful for drug-induced parkinsonism or acute dystonia but is usually ineffective for pure akathisia. Clozapine is not indicated after a successful first antipsychotic trial and is generally reserved for treatment-resistant schizophrenia. Benzodiazepines may occasionally provide short-term relief but long-term diazepam risks tolerance and dependence.

Reference: NHS Greater Glasgow and Clyde Mental Health Services Prescribing Management Group. Guidance on the management of extrapyramidal side effects: Akathisia section. Approved 2024. https://www.rightdecisions.scot.nhs.uk/media/xxqjq5jx/mhs-mrg-43-guidance-on-the-management-of-extrapyramidal-side-effects.pdf