Akathisia: Symptoms, Types, Causes and Treatment

Akathisia is a complex and often distressing movement disorder that has significant impacts on the lives of those who experience it. Most commonly associated with certain medications, especially antipsychotics and some antidepressants, akathisia is characterized by a compelling inner restlessness and the urge to move. This article provides a comprehensive overview of akathisia, including its symptoms, various types, underlying causes, and evidence-based treatment options.

Symptoms of Akathisia

Akathisia is notorious for its profound effect on both mind and body. Recognizing its signs is crucial for timely intervention and improved patient outcomes. Symptoms are broadly categorized into subjective feelings and observable movements, both of which must be considered for an accurate diagnosis.

Symptom	Description	Typical Presentation	Source(s)
Restlessness	Inner sense of unease and urge to move	Inability to sit still, frequent pacing	1 4 5 8 9
Motor Activity	Repetitive, purposeless movements	Leg crossing, foot tapping, rocking	4 5 6 9
Dysphoria	Emotional discomfort, irritability, anxiety	Tension, impatience, panic	2 8 10
Compulsion	Overwhelming need to move	Shifting body position, marching on the spot	1 4 5 7

Table 1: Key Symptoms

Subjective Symptoms

The hallmark of akathisia is a subjective feeling of intense inner restlessness. Patients often describe an "urge to move" that is difficult to suppress. This internal discomfort is deeply distressing and can manifest as:

• Tension or unease
• Anxiety or panic
• Irritability and impatience
• Difficulty articulating the sensation, sometimes mistaken for anxiety or other psychiatric symptoms 2 8 10

These subjective symptoms are essential for diagnosis, as akathisia is not just a movement disorder but also an emotional and sensory experience 5 8.

Objective (Motor) Symptoms

Alongside inner restlessness, akathisia is marked by characteristic movements, such as:

• Shifting weight from foot to foot
• Repeated leg crossing
• Swinging or tapping of legs
• Rocking while sitting or standing
• Pacing or marching on the spot
• Sliding feet or rapid walking 1 4 6 9

Notably, these movements are often purposeless and are attempts to relieve the internal sensation of restlessness.

Emotional and Behavioral Impact

Dysphoric mood—including tension, impatience, and even panic—is frequently reported by those with akathisia 2 10. In severe cases, the emotional distress can contribute to non-adherence with treatment and, in rare instances, suicidal thoughts or behaviors 10 13.

Diagnostic Tools

Validated scales, such as the Barnes Akathisia Rating Scale (BARS), help clinicians objectively assess both subjective and objective symptoms, ensuring accurate diagnosis and monitoring 5 12 15.

Types of Akathisia

Akathisia is not a one-size-fits-all condition. Understanding its subtypes is key for tailored management and better outcomes. The classification is primarily based on the timing of onset and the presence or absence of subjective symptoms.

Type	Defining Feature	Common Scenario	Source(s)
Acute	Rapid onset with drug initiation or dose change	Within days/weeks of starting antipsychotics	1 6 9 13
Chronic	Persistent symptoms over months	Long-term antipsychotic therapy	2 6 17
Tardive	Late-onset after prolonged treatment	Months to years after exposure	6 9 13
Withdrawal	Onset after abrupt cessation or dose reduction	Stopping antipsychotics	9 13
Pseudo-akathisia	Motor symptoms, no subjective restlessness	Observed in some psychiatric patients	2 6

Table 2: Types of Akathisia

Acute Akathisia

Acute akathisia typically develops within days to a few weeks after starting or increasing the dose of an offending drug, most often antipsychotics 1 6 9 13. Symptoms are often intense and may include both inner restlessness and visible motor agitation. Acute akathisia is the most common and best-studied form and may subside if the causative drug is reduced or discontinued.

Chronic Akathisia

When symptoms persist for several months or more, despite adjustments in medication, the condition is considered chronic akathisia 2 6 17. This form can be particularly debilitating and may overlap with tardive forms, especially in patients on long-term antipsychotic therapy.

Tardive Akathisia

Tardive (meaning "late-onset") akathisia emerges after extended use of antipsychotic drugs, sometimes even after the medication has been discontinued 6 9 13. It is often seen in the context of other tardive movement disorders and may be more resistant to conventional treatments.

Withdrawal Akathisia

This subtype arises after the abrupt reduction or cessation of antipsychotic medication 9 13. Symptoms typically mirror those of acute akathisia but are directly tied to medication changes.

Pseudo-akathisia

Pseudo-akathisia is characterized by observable motor restlessness without the subjective feeling of inner agitation 2 6. This is sometimes seen in individuals with chronic psychiatric illness or other movement disorders. Recognition of this variant is important, as it may require different treatment strategies.

Causes of Akathisia

Understanding the causes of akathisia is essential for prevention and effective management. While medication is the most common trigger, several other factors can influence susceptibility and presentation.

Cause	Example/Details	Relative Risk/Notes	Source(s)
Antipsychotic drugs	First and second-generation agents	Most common cause	1 9 13 14 17
Antidepressants	SSRIs, tricyclics	Less common, but well-documented	3 12 13
Other medications	Prochlorperazine, antiemetics	Can induce akathisia, even single dose	11 13
Dose changes	Rapid titration or high doses	Increases risk significantly	1 12 13
Polypharmacy	Multiple akathisia-inducing drugs	Additive risk	12 15
Patient factors	Age, sex, psychiatric diagnosis	Younger patients, males at higher risk	1 2 13 17
Biological factors	Iron deficiency, brain trauma	May increase vulnerability	1 13

Table 3: Causes and Risk Factors

Medications: The Primary Culprit

Antipsychotics:
The leading cause of akathisia is the use of antipsychotic medications, especially first-generation (typical) antipsychotics, though many second-generation (atypical) antipsychotics also carry risk 1 9 13 14 17. Newer agents such as aripiprazole, asenapine, and lurasidone have varying risk profiles, but none are entirely free from this side effect 14 17.

Antidepressants:
SSRIs (such as fluoxetine, sertraline, citalopram, etc.) and tricyclic antidepressants can also induce akathisia, though the risk is lower than with antipsychotics 3 12 13. The mechanism is thought to involve serotonergic inhibition of dopaminergic pathways 3.

Other Medications:
Drugs like prochlorperazine, used as antiemetics, have been shown to cause akathisia, sometimes even after a single dose 11. Other non-psychotropics may also be implicated 13.

Dose-Related Factors

• High doses and rapid titration of antipsychotics increase the risk of developing akathisia 1 12 13.
• Polypharmacy, or the use of multiple medications known to cause akathisia, further amplifies risk 12 15.

Individual Susceptibility

Not all patients are equally at risk. Factors that increase vulnerability include:

• Younger age 1 2 13 17
• Male gender (for certain subtypes) 2
• Pre-existing psychiatric disorders (especially psychotic disorders) 1 2 13
• History of akathisia or extrapyramidal symptoms 1 12 13
• Low serum iron or iron deficiency, which may affect dopamine receptor function 1 13
• Brain trauma or other neurological conditions 12

Pathophysiology

The exact biological mechanisms underlying akathisia are not fully understood. Current theories focus on complex interactions within dopaminergic, serotonergic, and noradrenergic systems in the brain 3 13 14. Iron status may also play a role, though the clinical significance remains under investigation 1 13.

Treatment of Akathisia

Managing akathisia requires a personalized and evidence-based approach. Treatment strategies focus on addressing the underlying cause, alleviating symptoms, and minimizing patient distress.

Strategy	Description	Typical Use/Preference	Source(s)
Dose reduction	Lowering or discontinuing offending drug	First-line where feasible	13 15
Switch medication	Change to drug with lower akathisia risk	If dose reduction fails	9 13 15
Beta-blockers	Propranolol most studied	First-line adjunctive	3 9 13 15 16
Benzodiazepines	E.g., lorazepam	Second-line, add-on	9 13 15 16
Anticholinergics	E.g., benztropine	Used in some cases	9 13 15 16
Other agents	Clonidine, amantadine, vitamin B6, etc.	Refractory cases	9 13 15 16
Non-pharmacologic	Supportive therapy, monitoring	Always, alongside meds	5 13 15

Table 4: Treatment Approaches

First Steps: Address the Cause

The cornerstone of akathisia management is to adjust the causative medication:

• Lower the dose of the offending agent if possible 13 15.
• Discontinue or switch to an alternative medication with a lower risk of akathisia, especially if symptoms are severe or persistent 9 13 15.
• Avoid polypharmacy with multiple akathisia-inducing drugs 15.

Pharmacological Treatments

Beta-Blockers:
Propranolol and other lipophilic beta-blockers are consistently effective and are considered first-line adjunctive treatments for acute akathisia 3 9 13 15 16. They are particularly useful in cases where dose reduction is not feasible.

Benzodiazepines:
Agents such as lorazepam can provide relief from both subjective and motor symptoms and are often used as second-line or add-on therapy, especially if the patient experiences significant distress 9 13 15 16.

Anticholinergics:
Medications like benztropine may help, particularly if parkinsonism is also present, though their efficacy for akathisia per se is mixed 9 13 15 16.

Other Agents:
For treatment-resistant cases, options include clonidine, amantadine, vitamin B6, piracetam, and occasionally dopamine depleters or antidepressants like amitriptyline 9 13 15 16. However, the evidence supporting these options is more limited, and they are usually reserved for refractory cases.

Non-Pharmacologic Interventions

• Patient education is vital: patients should be informed about the risk and symptoms of akathisia to encourage early reporting.
• Regular monitoring with validated scales (such as BARS) helps detect and track symptoms 5 12 15.
• Supportive care and psychological support can help mitigate the distress associated with akathisia 13 15.

Personalized Approach

Treatment should be tailored to each individual, considering factors such as the type and severity of akathisia, the patient’s medication history, and any co-existing medical conditions 13 15. Clinicians should also be mindful of the side effect profiles and contraindications of add-on treatments.

Conclusion

Akathisia is a multifaceted and often underrecognized movement disorder with significant implications for patient comfort, adherence, and overall treatment success. Early recognition and intervention are crucial for minimizing distress and improving quality of life.

Key Takeaways:

• Akathisia manifests as both subjective restlessness and observable motor activity, often accompanied by emotional distress.
• It is commonly induced by antipsychotic and, less frequently, antidepressant medications, but other drugs can also be culprits.
• Several distinct types of akathisia exist, including acute, chronic, tardive, withdrawal, and pseudo-akathisia.
• Risk factors include medication type and dose, polypharmacy, rapid titration, and patient-specific factors such as age, sex, and iron status.
• Treatment focuses first on adjusting the offending medication, then on symptomatic relief with agents such as beta-blockers and benzodiazepines; other options exist for refractory cases.
• A personalized, patient-centered approach, regular monitoring, and patient education are vital for optimal management and prevention of akathisia.

Awareness and understanding of akathisia among clinicians, patients, and caregivers can help detect this distressing condition early and ensure timely, effective intervention.