A 26-year-old man with a recent diagnosis of schizophrenia is initiated on haloperidol therapy. As his physician, you will monitor him closely for extrapyramidal symptoms (EPS). Arrange the following clinical presentations of extrapyramidal side effects in the correct chronological order based on their typical onset following the initiation of typical antipsychotic therapy, from earliest onset to latest onset.
- 1Sustained, painful contraction of the neck and extraocular muscles
- 2Intense subjective feeling of inner restlessness and an inability to sit still
- 3Development of a resting tremor, bradykinesia, and cogwheel rigidity
- 4Involuntary lip-smacking, chewing motions, and choreoathetoid movements of the face
Answer
The correct chronological sequence is: sustained neck contractions (acute dystonia), followed by inner restlessness (akathisia), then tremor and rigidity (parkinsonism), and finally choreoathetoid movements (tardive dyskinesia).
Extrapyramidal symptoms present in a predictable chronological sequence following the administration of dopamine D2 receptor antagonists. Acute dystonia (sustained muscle spasms) occurs earliest, within hours to days. Akathisia (inner restlessness) follows, emerging over days to weeks. Drug-induced parkinsonism (bradykinesia, rigidity, tremor) develops over weeks to months. Finally, tardive dyskinesia (involuntary choreoathetoid movements) is a late complication resulting from receptor upregulation after months to years of therapy.
Step-by-Step Solution
Key Concept
The classic chronological timeline for the development of antipsychotic-induced extrapyramidal symptoms follows the sequence: Acute dystonia (hours to days), Akathisia (days to weeks), Parkinsonism (weeks to months), and Tardive dyskinesia (months to years).