Akathisia

What is akathisia?

Akathisia is a neuropsychiatric syndrome and movement disorder that makes it difficult to sit or remain still due to an inner restlessness. The name comes from the Greek word “akathemi,” which means “inability to sit.”

Akathisia is associated with the use of certain types of medications, especially antipsychotic (neuroleptic) medications. A few health conditions have also been linked to akathisia, including Parkinson’s disease.

A person with akathisia experiences an intense sensation of unease or an inner restlessness. This results in a compulsion to move — usually in their lower limbs. In most cases, the movement is repetitive. This uncontrollable need to move can cause extreme distress.

Healthcare providers classify akathisia in a few ways based on its time of onset and duration, including:

• Acute akathisia: When akathisia develops during the early days of starting a medication, usually antipsychotic medication, or shortly after an increase in dosage, it’s considered acute akathisia. It usually lasts for fewer than six months.
• Chronic akathisia: When akathisia signs and symptoms last for more than six months, it’s considered chronic akathisia. Chronic akathisia can last for several months or even years.
• Tardive akathisia: When akathisia has a delayed onset after starting certain medications or increasing the dosage — usually more than three months — it’s considered tardive akathisia. It’s often associated with tardive dyskinesia.
• Withdrawal akathisia: Akathisia may arise following the reduction of dosage or stopping the use of certain medications. This is considered withdrawal akathisia.

Is akathisia the same as anxiety?

Akathisia and anxiety are different conditions. Akathisia is a movement disorder and anxiety is a type of mental health condition.

While the conditions can have some overlapping symptoms, such as a feeling of restlessness and feeling like you can’t control your thoughts and behaviors, akathisia is mainly a compulsion to constantly move. It doesn’t have fear- or worry-based symptoms. However, this uncontrollable need to move often causes anxiety and distress in people with the condition.

Unfortunately, akathisia is often misdiagnosed as persistent anxiety and/or agitation.

How common is akathisia?

Akathisia is the most common movement disorder associated with psychotropic medication, particularly antipsychotic (neuroleptic) medications. Approximately 24% of people who have schizophrenia and are taking medication for it have chronic akathisia.

In one study, akathisia rates were 39% in people taking clozapine and 45% among people taking first-generation antipsychotics (FGA).

What are the signs of akathisia?

Akathisia symptoms are most likely to appear soon after you’ve started antipsychotic (neuroleptic) medications or after your dosage has been increased by your healthcare provider.

The main symptom of akathisia is a feeling of internal restlessness or jitteriness. People with akathisia feel a strong compulsion or need to move — mainly, their lower extremities from their hips to their ankles.

If you have akathisia, you may:

• Cross and uncross your legs repetitively.
• Swing your legs constantly while sitting.
• Shift from one foot to the other repeatedly while standing.
• Rock while you’re sitting.
• Pace back and forth often or march in place.

To other people, these signs and movements may appear as a persistent fidget.

If you’re experiencing these signs and symptoms, it’s important to talk to your healthcare provider as soon as possible.

What does akathisia feel like?

People with akathisia typically describe a feeling of restlessness with a strong, uncontrollable need to move. They describe nervousness and an inability to relax.

They may also have a mounting sense of tension when they need to stand still, such as when waiting in line.

Inner restlessness often causes extreme anxiety and distress in people with akathisia. Chronic cases of akathisia have been associated with a high risk of self-harm or suicidal behavior.

If you’re having suicidal thoughts or thoughts of harming yourself, it’s important to seek immediate medical care.

What causes akathisia?

Scientists don’t know the exact cause of akathisia, but they think it’s due to certain medications blocking dopamine receptors in your brain. Dopamine is a neurotransmitter that plays a role in many important body functions, including movement. The blocking ultimately results in unwanted involuntary movements.

Several medications are associated with akathisia, including:

• Antipsychotic (neuroleptic) medications.
• Antidepressants.
• Other medications.

Certain health conditions are also associated with akathisia, including:

• Parkinson’s disease.
• Encephalitis (brain inflammation).
• Traumatic brain injury (TBI).

Antipsychotic medications associated with akathisia

Akathisia is the most common movement disorder associated with antipsychotic medications. Healthcare providers sometimes refer to this as antipsychotic-induced akathisia.

Antipsychotic medications, also known as neuroleptics, fall into two classes:

• First-generation or “typical” antipsychotics (FGA).
• Second-generation or “atypical” antipsychotics (SGA).

Akathisia is more commonly linked to the use of FGA medications, especially high-potency drugs and high-dose drugs, than SGA medications.

Healthcare providers prescribe first- and second-generation antipsychotics for various neuropsychiatric conditions, including:

• Behavioral disturbances in dementia.
• Bipolar disorder.
• Depression.
• Eating disorders.
• Generalized anxiety disorder.
• Insomnia.
• Obsessive-compulsive disorder (OCD).
• Personality disorders.
• Post-traumatic stress disorder (PTSD).
• Schizoaffective disorder.
• Schizophrenia and related disorders.

Some examples of FGA medications (and their brand names) that have been linked to akathisia include:

• Chlorpromazine (Thorazine®).
• Fluphenazine (Prolixin®).
• Haloperidol (Haldol®).
• Loxapine (Loxitane®).
• Molindone (Moban®).
• Pimozide (Orap®).
• Prochlorperazine (Compro®, Compazine®).
• Thioridazine (Mellaril®).
• Thiothixene (Navane®).
• Trifluoperazine (Stelazine®).

Some SGA medications that are associated with a higher risk of akathisia include:

• Paliperidone (Invega®).
• Ziprasidone (Geodon®).

Antidepressants associated with akathisia

Less commonly than antipsychotic medications, certain types of antidepressant medications have been linked to akathisia, including:

• Selective serotonin reuptake inhibitors (SSRIs): These are the most commonly prescribed antidepressants. Examples include fluoxetine (Prozac®) and paroxetine (Brisdelle®, Paxil® and Pexeva®).
• Monoamine oxidase inhibitors (MAOI): MAOIs were the first type of antidepressant developed. They’re effective, but they’ve generally been replaced by antidepressants that are safer and cause fewer side effects. Examples include isocarboxazid (Marplan®) and phenelzine (Nardil®).
• Tricyclic (TCA) antidepressants: Healthcare providers typically only prescribe these types of antidepressants when other antidepressants don’t work. Examples include clomipramine (Anafranil®) and amitriptyline (Elavil® and Vanatrip®).

Healthcare providers prescribe antidepressants to help manage several conditions, including:

• Depression.
• Bipolar disorder.
• Anxiety disorders.
• Chronic pain.
• Obsessive-compulsive disorder (OCD).
• Panic attacks.
• Post-traumatic stress disorder (PTSD).
• Premenstrual dysphoric disorder (PMDD).

Approximately 10% to 18% of people who have bipolar I disorder and take antidepressants are estimated to develop akathisia.

Other medications associated with akathisia

Other medications that have been linked to akathisia include:

• Medications that treat nausea or vomiting (antiemetics), such as metoclopramide.
• Medications to treat high blood pressure, such as reserpine and methyldopa.
• Calcium channel blockers, such as cinnarizine and diltiazem.
• Sedatives.
• Medications that treat vertigo.
• Azithromycin (a commonly used antibiotic).
• Buspirone (an anti-anxiety medication).

Illicit drugs, including amphetamine, methamphetamine and cocaine, can also cause akathisia.

How is akathisia diagnosed?

Healthcare providers typically rely on clinical observation to diagnose akathisia. There aren’t any laboratory or imaging tests involved in the diagnosis of akathisia. The most commonly used tool for assessing akathisia is the Barnes Akathisia-Rating Scale (BARS).

If you think you have akathisia, your provider will ask you questions about your symptoms, medical history and current medications to make a diagnosis. They’ll also observe your behavior and movements.

Unfortunately, akathisia is often underdiagnosed because its symptoms often mimic or overlap other psychiatric conditions, including:

• Psychosis.
• Mania.
• Attention-deficit/hyperactivity disorder (ADHD).
• Agitated depression.

How is akathisia treated?

There’s currently no definitive treatment for akathisia.

Your provider may manage medication-induced akathisia by switching you to a different medication or by lowering the dose of your medication, if possible.

Some studies have shown that the following medications may help treat akathisia:

• Beta-blockers, such as propranolol.
• Benzodiazepines (a class of drugs commonly used to treat conditions such as anxiety, insomnia and seizures).
• Low-dose mirtazapine (an antidepressant).
• Anticholinergics (medications commonly used to treat asthma and other conditions).
• Vitamin B6.

Can akathisia be prevented?

Scientists are still working to fully understand akathisia and its cause and treatment. They do know that akathisia is more likely if:

• You’re taking strong first-generation antipsychotic medications.
• You take a high dose of the medication.
• Your provider increases the dose very quickly or significantly.
• You’re a middle-aged or older adult.

Given this knowledge, the best way to try to prevent akathisia is for providers to start people at the lowest dose of these medications possible and increase the dose a little bit at a time if needed.

It’s important to always talk to your provider about the risks, benefits and possible side effects of a medication before starting them.

What is the prognosis (outlook) for akathisia?

The prognosis (outlook) of akathisia is generally good if it’s diagnosed early and the drug causing it is stopped (if possible).

If akathisia is left untreated, it generally causes a poor quality of life. Many people with akathisia develop severe anxiety and dysphoria, and it can even lead to suicidal ideations (thoughts).

If you’re experiencing suicidal ideation, it’s important to seek immediate care. Call 911 or the National Suicide Prevention Lifeline at 800.273.8255. Someone will be available to talk with you 24 hours a day, seven days a week.

When should I see my healthcare provider about akathisia?

If you’re experiencing signs of akathisia, it’s important to talk to your healthcare provider. The sooner they can determine the likely cause, the sooner they can adjust your medications and manage the condition.

A note from Cleveland Clinic

Akathisia can be a very distressing side effect of certain medications. If you’re worried about your risk of developing akathisia after starting a medication to treat a mental health or neurological condition, don’t be afraid to ask your healthcare provider questions. If you’re experiencing signs and symptoms of akathisia, let your provider know as soon as possible.