What Is Akathisia?

Akathisia, also spelled acathisia, is a neuropsychiatric syndrome or movement disorder characterized by inner restlessness and the inability to sit or stand still for a reasonable period of time.

Akathisia may appear as a side effect of the long-term use of antipsychotic medications, Lithium, and some other neuroleptic drugs. It is one of the most common side effects of antipsychotic medications; between 15% and 45% of people who take antipsychotic medications experience akathisia. However, it may be hard to describe by patients and thus hard to diagnose by doctors.

When akathisia is induced by drugs, it is known as antipsychotic-induced acute akathisia (AIAA). Because it's known to happen as a result of treating a mental disorder, the prevention of akathisia is key.

This article discusses the symptoms and different types of akathisia. It also explores why it happens, how it is diagnosed, and treatments that can help people cope.

Types of Akathisia

There are several types of akathisia, depending on the onset and longevity of symptoms:

• Acute akathisia: Begins shortly after taking antipsychotics and lasts less than six months
• Chronic akathisia: Begins shortly after taking antipsychotics and lasts less than six months
• Tardive akathisia: Begins after an extended period (one to three months) of antipsychotic use and may begin after antipsychotic discontinuation or dosage reduction
• Withdrawal akathisia: Begins within six weeks after you switch or stop an antipsychotic drug

Symptoms of Akathisia

If you have akathisia, you may have restless movements of the arms and legs. This is sometimes referred to as psychomotor agitation. Your body may feel anxious at the thought of sitting down. Your body will always want to be on the move, almost to the point of fidgeting whenever stillness sets in.

Common signs of akathisia include:

• Crossing and uncrossing the legs
• Fidgeting
• Foot or finger tapping
• Marching in place
• Pacing
• Rocking
• Shifting weight from one leg to another

Other symptoms include:

• Anxiety
• Feelings of tension or panic
• Irritability
• Lack of patience

Diagnosis of Akathisia

Akathisia is generally underdiagnosed or misdiagnosed. The prevalence of missed diagnosis is a dangerous problem as it can lead to negative outcomes such as missed medication dosages, which may exacerbate the psychiatric symptoms the drugs are meant to help manage.

To diagnose akathisia, your doctor will likely perform a physical exam, which includes observing you sitting and standing for several minutes to watch for psychomotor agitation. Your doctor may also fill out the Barnes Akathisia-Rating Scale to assess the severity of your symptoms. This tool can also be used to track your progress during treatment.

Conditions With Similar Symptoms

Akathisia has some similarities to other conditions, including anxiety and tardive dyskinesia. While these conditions may have overlapping symptoms, they are not the same. 

Your doctor will ask about your current medications and rule out any other health conditions that can cause similar symptoms, including:

• ADHD
• Agitated depression
• Anxiety
• Insomnia
• Mania
• Parkinson's disease
• Psychosis
• Restless legs syndrome
• Tardive dystonia
• Tardive dyskinesia (TD)

For example, anxiety is a mental health condition that may cause some restlessness, but it does not create an uncontrollable compulsion to constantly move. While worry and fear that are characteristics of anxiety are not symptoms of akathisia, the condition can be anxiety-provoking for many people.

Tardive dyskinesia involves involuntary movements of the face, fingers, or extremities. Like akathisia, it is a side effect of antipsychotic medications. These movements are involuntary, whereas akathisia involves an internal feeling of restlessness. The two conditions can also occur together.

Causes of Akathisia

While akathisia is a common side effect of certain medications, researchers have yet to understand why or how it causes symptoms of restlessness. Some believe it is caused by a chemical imbalance triggered by the medication. It overstimulates areas of the brain, potentially resulting in the compulsion to move. 

Not everyone who takes antipsychotic drugs will experience akathisia, however, it is often a side effect of older, first-generation antipsychotics used to treat bipolar disorder and schizophrenia, including:

• Compro (prochlorperazine)
• Fluanxol (droperidol)
• Haldol (loxapine)
• Mellaril (thioridazine)
• Moban (molindone)
• Navane (thiothixene)
• Orap (pimozide)
• Prolixin (fluphenazine)
• Stelazine (trifluoperazine)
• Thorazine (chlorpromazine)

Akathisia is also common with haloperidol and the newer, second-generation agents Abilify (aripiprazole) and Latuda (lurasidone). Invega (paliperidone) and Geodon (ziprasidone) are on the very low end of medications thought to cause akathisia.

Other medications known to cause akathisia include:

• Anti-nausea drugs
• Calcium channel blockers
• Drugs that treat vertigo
• Sedatives before surgery
• Selective serotonin reuptake inhibitors (SSRIs)

Unfortunately, just as starting antipsychotic medication may cause akathisia, it is also observed in people who are being gradually taken off their antipsychotic medication or may be advised to gradually decrease their dosages. In these instances, intense dysphoria is often observed as well.

Treatment for Akathisia

If you've been diagnosed with akathisia, your doctor may decrease your dosage or discontinue the medication causing your symptoms. However, modifying your mediation may also cause symptoms to worsen, or cause withdrawal akathisia.

A number of medications have been used to treat the symptoms of akathisia, including:

• Beta-blockers, such as Hemangeol and Inderal (propranolol)
• Anticholinergic medications, such as Cogentin (benztropine) and Akineton (biperiden)
• 5-HT2A antagonists, such as Tolvon (mianserin), Remeron (mirtazapine), Desyrel (trazodone), and Periactin (cyproheptadine)
• Vitamin B6 in high doses (600mg to 1,200mg daily)

Akathisia is generally treatable if it is diagnosed and treated early and the individual is able to stop taking the drug that is causing the problem. Akathisia often goes away after lowering the dosage of the medication. It may take several weeks or months for symptoms to resolve.

When left untreated, the prognosis is poorer, and symptoms may have a serious effect on a person's quality of life. The condition is also linked to an increased risk of anxiety, depression, and thoughts of suicide.

Coping With Akathisia

An important part of coping with akathisia is managing your medication. Do your best to keep a detailed record of the medications you are taking, including the dosage and when you started taking them. If you experience any symptoms of akathisia, share the record with your healthcare provider.

While your prescribing doctor should have your medication history, they may not have it in a compact form.

If you're feeling alone or frustrated about your symptoms, it can also help to confide in a trusted friend or family member. Consider joining an online support group of others who understand what you're going through.

Prevention

Doctors and researchers do not yet fully understand the exact reasons why certain medications cause akathisia. However, certain factors that can increase your risk and trigger akathisia include:

• Your age: Middle age and older adults are more likely to experience this symptom
• The type of medication you are taking: Older, first-generation antipsychotics are more likely to cause akathisia
• Your dose: Taking high doses or increasing your dose too quickly can increase your risk

While akathisia cannot always be prevented, your risk is lower if you start on the lowest dose. Your doctor may then increase your dose gradually.