S is a 32-year-old moderately obese man brought into the ED by the police after attempting to cut himself with a piece of glass from his bathroom mirror. He said he had to cut himself in order to "let the evil out!"· In the examination room, S looked suspiciously at the interviewer and was muttering to himself.
His Past Medical History is significant for chronic schizophrenia. HTN, hyperlipidemia, and major depressive disorder. Medications include thioridazine, benztropine. paroxetine, atorvastatin, and metoprolol, although he states he discontinued all his medications 3 weeks ago for fear he was being poisoned.
PE: On physical examination, he has noticeable cuts on his hands. During the interview, he demonstrated noticeable facial grimacing and lip smacking, a stooped posture, and sluggish gait.
Case Conclusion S's symptoms are consistent with the diagnosis of uncontrolled chronic schizophrenia (paranoid type). Because S is experiencing positive and negative symptoms and has evidence of(EPS) Extra Pyramidal Symptoms. he should be switched to an atypical antipsychotic agent Olanzapine is traditionally reserved for treatment-resistant patients and is not a first line agent due to the risk of agranulocytosis. Olanzapine and quetiapine can be problematic due to weight gain and potential insulin resistance (if the patient has family history of diabetes mellitus type 2). Risperidone is also associated with a higher incidence of EPS symptoms compared with other atypical agents. In addition, He is also taking paroxetine that can significantly elevate levels of risperidone. Therefore, ziprasidone would be the best choice for this patient
DISCUSSION
Atypical antipsychotic agents or "newer" agents alleviate both positive and negative symptoms. The atypical antipsychotics also improve cognitive deficits associated with schizophrenia. Although these agents are much safer, they have added cost and have been associated with their own class of adverse effects.
Extrapyramidal symptoms are common adverse effects of traditional neuroleptics, although they may still occur with atypical agents. Pseudoparkinsonism, akathisia, and acute dystonic reactions are the three early-onset types of EPS. Atypical agents have a low risk for inducing EPS.The management of early-onset EPS symptoms includes drug discontinuation, dosage reduction of the antipsychotic agent, or switching to an agent with less risk for inducing EPS. Anticholinergic agents (diphenhydramine, benztropine) can be used to treat acute dystonic reactions, parkinsonism, and akathisia.
