The nurse suspects that a patient who is experiencing facial grimacing, involuntary upward eye movement, and muscle spasms of the tongue and face may have which condition?

Acute dystonia is an extrapyramidal side effect (EPS) that can occur soon after starting or increasing the dose of antipsychotic medications, particularly first-generation agents. It is characterized by sustained muscle contractions that can affect the face, neck, tongue, and eyes, potentially causing significant discomfort and posing a risk for airway compromise. Prompt recognition and intervention are essential to prevent complications.

Rationale for correct answer:

B. Acute dystonia – Correct. This condition is marked by sudden, painful, involuntary muscle contractions, including facial grimacing, tongue protrusion, neck stiffness, and oculogyric crises (upward eye movement). Immediate treatment with anticholinergic agents such as benztropine or diphenhydramine is often required.

Rationale for incorrect answer:

A. Akathisia – Akathisia presents as restlessness, pacing, or an inability to sit still. It does not involve sustained muscle contractions or abnormal postures, making it distinct from acute dystonia.

C. Tardive dyskinesia – Tardive dyskinesia typically develops after months to years of antipsychotic therapy and involves slow, repetitive, involuntary movements, most commonly of the face and mouth, unlike the sudden onset seen in acute dystonia.

D. Pseudo-parkinsonism – This EPS mimics Parkinson’s disease, presenting with tremors, bradykinesia, rigidity, and shuffling gait, but does not include the acute, sustained muscle contractions seen in dystonia.

Take-home points:

• Acute dystonia is a sudden-onset EPS requiring prompt intervention.
• Facial grimacing, tongue spasms, and upward eye movement are hallmark signs.
• Treatment often involves anticholinergic medications and close monitoring for airway compromise.

When a patient abruptly stops taking an antipsychotic medication, the therapeutic dopamine blockade is lost, often leading to a rapid recurrence of hallucinations, delusions, and disorganized thinking. The nurse’s priority is to address and prevent relapse of psychosis to ensure safety.

Rationale for correct answer:

D. Symptoms of psychosis are likely to return.
Stopping antipsychotics abruptly can cause rapid reemergence or worsening of psychotic symptoms, greatly increasing the risk of self-harm or harm to others. Immediate intervention is vital to maintain mental stability.

Rationale for incorrect answer:

A. A hypertensive crisis may occur with such abrupt withdrawal of the drug.
Hypertensive crisis is mainly linked to monoamine oxidase inhibitors (MAOIs), not antipsychotics, so it is not the primary concern.

B. Significant muscle twitching may occur, increasing fall risk.
Muscle twitching is not a common withdrawal effect of antipsychotics and is less urgent than psychosis relapse.

C. EPS symptoms such as pseudo-parkinsonism are likely to occur.
Extrapyramidal symptoms are usually a side effect during ongoing therapy, not after discontinuation.

Take-home points:

• Abrupt cessation of antipsychotics can trigger psychotic relapse.
• The nurse’s priority is patient safety and symptom management.
• Hypertensive crisis is not associated with antipsychotic withdrawal.