Akathisia

Akathisia: the inner restlessness

Akathisia is a syndrome characterized by a persistent or periodically occurring sense of inner restlessness, expressed through motor activity. This internal need to move or change posture makes it impossible for the patient to stay in one position for long, forcing constant movement.

This condition occurs due to prolonged use of these medications, exceeding dosages, increasing frequency of intake, or abrupt withdrawal of the drugs after dependence has already developed.

The physical manifestations include:

• Rocking back and forth while standing or sitting
• Shifting weight from foot to foot
• Pacing
• Crossing and uncrossing legs while seated
• Marching in place

The psychological component proves equally distressing – patients report feeling anxious, agitated, and unable to sit still.

Some patients can describe it as “having ants crawling under my skin.”

History of the symptom

The term “akathisia” first appeared in 1901. Translated from Greek, it means “inability to sit still.” This word accurately describes a person suffering from this behavioral deviation. A patient with akathisia constantly requires physical activity to relieve heightened agitation, anxiety, and feelings of internal psychological discomfort.

The term was introduced by Czech psychiatrist Ladislav Haskovec long before the advent of neuroleptics. However, after these medications were developed and became widely used, the number of patients experiencing motor restlessness significantly increased.

Akathisia often accompanies various mental disorders and is most commonly diagnosed in schizophrenia and depression. The disorder may manifest acutely, developing within a week after starting medication or with a sharp increase in dosage. In such cases, discontinuation of the neuroleptic or dose reduction improves the patient’s condition.

Chronic akathisia is typically diagnosed after several months of treatment or abrupt drug withdrawal. In most cases, it persists for life, periodically manifesting with a full clinical picture.

Symptoms

Akathisia is not a single symptom but a complex syndrome consisting of two components: subjective and objective.

• The subjective component involves complaints from the patient about the inability to stay still and a constant urge to change posture. This is accompanied by increasing restlessness, anxiety, inner tension, and sleep disturbances.
• The subjective component can be represented by sensory and/or psychological manifestations:
  • Sensory akathisia is described by patients as sensations of tingling in the legs, twisting joints, pulling muscles, and an overwhelming need to move continuously.
  • Psychological akathisia is associated with feelings of inner restlessness, anxiety, and fear. The person cannot relax, sit, or lie calmly, has trouble falling asleep, and constantly shifts in bed. They may wake up in the middle of the night and start moving, experiencing a desire to “jump out of their skin.”
• The objective component relates to visible motor symptoms, such as:
  • Chaotic leg movements (stomping in place, shuffling, shifting leg positions, moving from one corner of the room to another).
  • Restless legs syndrome (unpleasant sensations in the legs, such as burning, tingling, or crawling, that disappear with movement).
  • Repetitive, meaningless hand movements (crossing fingers, tapping, or manipulating beads).

Motor activity primarily involves the lower limbs—from ankles to thighs. In severe cases, motor restlessness affects the whole body, progressing “bottom-up” and even involving the eyes. This is expressed through constant movements such as writhing, rocking, running, jumping, or making grimaces.

Akathisia can include both components—subjective and objective—or manifest only as motor or sensory agitation. In some cases, it is accompanied by tearfulness, irritability, and even aggression toward others.

A distinctive feature of akathisia patients is their inability to adequately describe their experiences. Their explanations are unclear, vague, and illogical, which complicates diagnosis and often leads to misdiagnosis.

Causes

Akathisia most often occurs as a side effect of antipsychotic medications. Nearly all types of antipsychotics carry a risk of causing motor restlessness.

The condition may also result from treatment with antidepressants, antiemetics, or anticonvulsants. In some cases, the condition is triggered by non-psychotropic medications (e.g., antibiotics, interferons, anti-tuberculosis, antimalarial, and antihistamine drugs).

It can also occur independently of drug-induced effects, such as in Bing-Sekar akathisia, which arises spontaneously in neurological disorders associated with parkinsonism. Internal motor restlessness may also be caused by stroke or traumatic brain injury.

In mental health disorders, spontaneous akathisia is often diagnosed, particularly in conditions such as schizophrenia, anxiety disorders, conversion disorders, and hysteria.

Risk factors for akathisia include:

• Genetic predisposition.
• Cancer.
• Iron or magnesium deficiency.
• Pregnancy.
• Age (elderly, adolescent, or childhood).

Pathogenesis

The pathogenesis of akathisia is not fully understood. It is presumed to involve a complex mechanism linked to dysfunction in the dopaminergic system, which connects the midbrain region with the frontal lobe of the cerebral cortex, predominantly the prefrontal cortex.

Stages and classification

Akathisia manifests as motor restlessness, often accompanied by sensory-psychological symptoms. Without treatment, the patient’s condition worsens, and clinical symptoms become more pronounced.

Given the variety of clinical signs, specialists identify several types of akathisia:

• Motor akathisia: characterized by motor restlessness and an inability to stay still.
• Psychological akathisia: marked by inner restlessness, tension, irritability, and emotional instability.
• Sensory akathisia: accompanied by uncomfortable sensations of twisting, pulling, itching, or discomfort in the joints and muscles.
• Classic akathisia: combines all symptoms equally.
• Withdrawal akathisia: develops after stopping the intake of medications.

Another type of akathisia is immobile akathisia (observed in Parkinson’s disease), characterized by physical sensations of stiffness in the legs.

Types based on onset and duration of symptoms

The timing and duration of symptom manifestation are crucial for treatment. Based on these factors, motor syndromes can be classified as:

• Acute akathisia: motor restlessness that occurs immediately or within the first few days of starting antipsychotic treatment.
• Chronic (subacute) akathisia: develops within the first few weeks or months of medication use and gradually subsides after discontinuing or reducing the dose.
• Tardive (late-onset) akathisia: motor restlessness emerges months or years after starting antipsychotic therapy and sometimes persists for life.

Specialists note that acute akathisia may result from the use of various medications, not just antipsychotics. Chronic and tardive forms, however, are more closely associated with antipsychotic use.

Complications

Akathisia worsens the course of underlying mental illnesses by intensifying anxiety, agitation, hallucinations, and delusions. It also affects personality, making individuals more irritable, intrusive, or prone to crying.

Patients with akathisia often avoid social interactions, leading to social isolation over time.

Prolonged akathisia causes discomfort, a sense of hopelessness, and even a loss of purpose in life, increasing the risk of depression, neuroses, suicidal thoughts, and tendencies. These feelings can lead individuals to harm themselves or others.

The inability to control their condition, the compulsive need to move, and sensory disturbances may drive people to seek relief through alcohol or psychotropic substances, increasing the risk of life-threatening dependencies.

At the first signs of motor restlessness combined with inner tension, anxiety, or irritability, seeking medical help is essential. Medication-induced akathisia can provoke severe mental disorders, potentially leading to irreversible changes in mental health.

Diagnosis

Currently, there are no diagnostic tools that can definitively identify akathisia. Diagnosis relies on observing clinical symptoms, considering the patient’s complaints, and identifying any coexisting conditions.

The Barnes Akathisia Rating Scale is commonly used. It is a rating tool that assesses the severity of akathisia, focusing on both subjective and objective indicators.

Diagnosing akathisia is challenging due to the similarity of its clinical presentation to other pathological processes or its ability to be masked by pronounced symptoms of coexisting conditions.

Patients, unwilling to recognize the presence of psychopathological symptoms, may suppress signs of akathisia through willpower during medical consultations. Vague and unclear descriptions of their condition may also obscure the diagnosis. Observing the patient when they are unaware of being monitored often provides more reliable insights.

Treatment

When prescribing treatment, it is necessary to consider the cause of its occurrence. In most cases, akathisia results from the use of antipsychotics or antidepressants. Therefore, it is crucial to analyze the patient’s treatment regimen and identify the medications that caused the motor restlessness.

If possible, the medication should be discontinued, its dosage reduced, or it replaced with another drug. However, these methods are not suitable if the patient’s condition worsens after discontinuation. This phenomenon is known as withdrawal akathisia.

Depending on the etiology, type, and individual characteristics of the patient’s body, the following treatments are used for akathisia:

• Antiparkinsonian drugs
• Antihistamines
• Benzodiazepine tranquilizers
• Lipophilic beta-blockers
• Alpha-blockers
• Mild opioids
• Anticonvulsants

In most cases, a combination of several medications is used, tailored to the clinical course of the symptom.

The effectiveness of akathisia treatment depends on many factors:

• the etiology
• type
• severity of the syndrome
• individual characteristics of the patient’s body.

In most cases, it is possible to achieve an improvement in the patient’s condition, reduce motor activity and anxiety levels, and prevent complications.

Since akathisia is triggered by medication use, an essential component of its prevention is the careful selection of medications and the development of combined treatment regimens, taking into account the specifics of drug interactions.

Are Akathisia and Tardive Dyskinesia same conditions?

No, tardive dyskinesia (TD) and akathisia are not the same, although both are movement disorders that can be induced by medications, particularly antipsychotics. Here are the key differences:

Tardive dyskinesia presents quite differently. These are involuntary movements that occur without the internal sensation of restlessness. The movements include:

• Repetitive, purposeless motions of the face and mouth
• Tongue protrusion or rolling
• Lip smacking or puckering
• Grimacing
• Chewing movements
• In some cases, trunk or limb movements

Unlike akathisia, tardive dyskinesia usually develops after months or years of antipsychotic use. The word “tardive” means delayed, reflecting this late onset. More concerning: these movements often persist even after stopping the medication.

Key distinguishing features

Time of Onset:

• Akathisia: Days to weeks after medication start/change
• Tardive Dyskinesia: Months to years of medication use

Subjective Experience:

• Akathisia: Strong internal feeling of restlessness
• Tardive Dyskinesia: No internal urge to move

Movement Patterns:

• Akathisia: Large, purposeful movements to relieve discomfort
• Tardive Dyskinesia: Smaller, involuntary movements, often facial

Reversibility:

• Akathisia: Often improves with medication adjustment
• Tardive Dyskinesia: May persist after medication discontinuation

Impact on patient care

For Akathisia:

• Dose reduction of the causative medication
• Beta-blockers (like propranolol)
• Anticholinergic medications
• Benzodiazepines in some cases

For Tardive Dyskinesia:

• VMAT2 inhibitors (valbenazine, deutetrabenazine)
• Careful assessment of antipsychotic necessity
• Consider switching to lower-risk antipsychotics
• Regular monitoring using standardized scales.