Overview

Akathisia is a neuropsychiatric condition characterized by an intense feeling of inner restlessness and an uncontrollable urge to move. Individuals with akathisia often display constant movements such as pacing, fidgeting, rocking, or shifting from foot to foot. It is commonly seen as a side effect of certain medications, especially antipsychotics and some antidepressants. Akathisia can be distressing and debilitating, affecting both physical comfort and mental well-being. Early identification and management are crucial, as untreated akathisia can lead to worsening anxiety, depression, and even suicidal thoughts.

Causes

Akathisia is most frequently caused by medications that affect dopamine pathways in the brain. Common causes include:

• Antipsychotic Medications: Both first-generation (typical) and second-generation (atypical) antipsychotics can cause akathisia, with higher rates seen with drugs like haloperidol.
• Antidepressants: Certain selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may induce akathisia, especially during dose adjustments.
• Anti-nausea Medications: Drugs like metoclopramide and prochlorperazine, which block dopamine receptors, are known to cause akathisia.
• Withdrawal Syndromes: Sudden discontinuation of certain medications, including benzodiazepines or opioids, can trigger akathisia.
• Parkinson’s Disease Treatments: In some cases, changes in dopaminergic treatment regimens may lead to akathisia-like symptoms.
• Other Neurological Conditions: Rarely, akathisia can occur independently in disorders affecting the basal ganglia or due to brain injury.

Symptoms

The primary symptom of akathisia is a subjective feeling of inner restlessness accompanied by observable motor activity. Symptoms include:

• Inner Restlessness: A persistent uncomfortable sensation that compels movement, often described as anxiety or agitation.
• Constant Movement: Inability to remain still, with pacing, foot tapping, shifting weight, or repetitive leg crossing.
• Increased Anxiety: Heightened feelings of unease, tension, or irritability.
• Sleep Disturbance: Difficulty falling or staying asleep due to the persistent need to move.
• Worsening Mood: Depression, frustration, or even suicidal thoughts, particularly if akathisia persists untreated.
• Difficulty Concentrating: Impaired focus or attention caused by constant discomfort.

Diagnosis

Diagnosis of akathisia is clinical, based on history and physical observation, with specific attention to medication history:

• Clinical History: Review of current and recent medications, especially antipsychotics, antidepressants, or anti-nausea drugs.
• Physical Observation: Noting characteristic motor behaviors such as pacing, fidgeting, or inability to remain seated.
• Subjective Report: Asking the patient about their internal sense of restlessness or agitation.
• Rating Scales: The Barnes Akathisia Rating Scale (BARS) is commonly used to assess the severity of akathisia.
• Exclusion of Other Conditions: Differentiating akathisia from anxiety disorders, restless leg syndrome, agitation, or extrapyramidal symptoms like tremors.

Treatment

The primary goal of treatment is to relieve symptoms while maintaining necessary psychiatric treatment when possible.

Medication Adjustments

• Reducing or Discontinuing Offending Medication: Dose reduction or stopping the causative drug is the most effective treatment when feasible.
• Switching Medications: Changing to an alternative medication with a lower risk of akathisia, especially within the same therapeutic class.

Symptomatic Treatment

• Beta-Blockers: Propranolol is commonly used to reduce physical symptoms of akathisia.
• Benzodiazepines: Short-term use of diazepam, lorazepam, or clonazepam can provide relief, especially for severe symptoms.
• Anticholinergic Medications: Agents like benztropine may be helpful, particularly if other extrapyramidal symptoms are present.
• Serotonin Antagonists: Medications like mirtazapine or cyproheptadine may offer additional benefit in refractory cases.

Supportive Measures

• Environmental Modifications: Providing a calming environment and reassurance to reduce psychological distress.
• Patient Education: Informing patients and caregivers about the condition can improve adherence to treatment and reduce anxiety.

Prognosis

The prognosis for akathisia largely depends on early identification and appropriate intervention. In many cases, reducing or stopping the causative medication leads to rapid improvement of symptoms. When managed promptly, most patients recover without long-term effects. However, chronic or untreated akathisia can significantly impair quality of life, worsen psychiatric symptoms, and increase the risk of self-harm.

With proper management—including medication adjustment and symptomatic treatment—long-term outcomes are generally favorable. Ongoing monitoring is essential for individuals on medications known to cause akathisia, allowing for early detection and effective treatment.