A 41-year-old patient with schizophrenia presents for follow-up after an antipsychotic dose increase 10 days ago. The patient says: “I feel extremely anxious. I can't sit still.” During the visit, you notice the patient repeatedly: ⚡ Shifts position 🚶 Gets up and paces 🦵 Moves their legs constantly 😣 Reports an uncomfortable feeling of “inner restlessness” The patient says: “When I walk around, it feels a little better.” At first glance, this could sound like anxiety. But the medication timeline and physical presentation should make you pause. 🔎 What would you assess FIRST? A. Increase the patient's anxiolytic medication B. Assess for akathisia C. Reassure the patient that this is expected anxiety D. Increase the antipsychotic 👉 The answer: B — Assess for akathisia. Akathisia can be mistaken for anxiety, agitation, or worsening psychiatric symptoms. Ask: • “Do you feel an uncomfortable sense of inner restlessness?” • “Do you feel like you have to keep moving?” • “Does movement temporarily relieve the discomfort?” • When did symptoms begin relative to the medication change? • Was there a recent dose increase or medication switch? 💡 Clinical Pearl When new severe restlessness appears after a medication change, don't automatically label it anxiety. The medication timeline is part of the diagnosis. 💬 YOUR TURN What clinical clue in this case would make you most suspicious of akathisia?

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A patient says: “When my depression improves, I finally feel like myself.” At first glance, that sounds like a positive response to treatment. But then you hear: ⚡ More energy 😴 Less sleep 📈 More productive And this is where clinical reasoning matters. The patient may not simply be “getting better.” A change in sleep, energy, and activity level can be an important clue that warrants a closer assessment for mania or hypomania, depending on the full clinical picture. 🔎 So, what do you ask next? A. Increase the antidepressant B. Screen deeper C. Ignore it because the patient improved D. Add a stimulant 👉 The answer: B — Screen deeper. Before changing the treatment plan, take a step back and assess the broader symptom pattern. Ask about: • Decreased need for sleep—not simply sleeping less because of a busy schedule • Elevated or unusually irritable mood • Increased goal-directed activity • Racing thoughts • Increased or pressured speech • Impulsivity or risky behavior • Grandiosity • Changes from the patient's baseline • Previous episodes of similar symptoms • Family history of bipolar disorder • Medication/substance changes 💡 The clinical lesson Don't mistake every improvement in depression for recovery. Sometimes the most important diagnostic clues appear when we ask what changed beyond the chief complaint. A patient saying, “I feel better,” is important—but how they feel better matters. Great clinical questions can uncover what the initial presentation doesn't reveal. 💬 YOUR TURN If you noticed more energy + less sleep + increased productivity in a patient being treated for depression, what would be the first question you ask? Drop your answer in the comments 👇 And if you want more case-based clinical reasoning, psychopharmacology education, and real-world psychiatry discussions, stay active inside Psych Mastery With Dr. Mena. 🧠 Think beyond the symptoms. Ask better questions. Make better clinical decisions.