Akathisia

Akathisia is a common extrapyramidal symptom (EPS) associated with antipsychotic medications. It is characterized primarily by a profound and distressing sense of inner restlessness or discomfort that compels a person to move.

Symptoms and Presentation

People often describe akathisia as an inability to stay still. This internal tension drives repetitive, uncontrollable body movements such as tapping, rocking, or pacing, most commonly involving the legs. Patients may perform intentional movements, like shifting in a chair, to temporarily relieve this discomfort.

If this restlessness is mistaken for psychotic agitation, increasing the antipsychotic dose can severely worsen the akathisia and the patient’s distress. Furthermore, this condition can be so distressing that it has been linked to increased risk of suicide.

Timing and Course

Akathisia most commonly emerges within the first one to three months of starting an antipsychotic medication or increasing its dose, but it can occur at any point, especially following a dose change. A poorly understood variant, tardive akathisia, may persist even after the antipsychotic has been discontinued.

Management

Patients should report any feelings of restlessness to a clinician immediately. The first-line treatment is to attempt to reduce the dose of the offending medication or stop it entirely. If that is not possible, pharmacological options that may be tried include propranolol, benztropine, or benzodiazepines.

• Dose reduction or switching to another LAI may be an appropriate long-term strategy, but in the short run one must treat akathisia to minimize the psychic distress which accompanies this adverse effect.
• Akathisia responds best to propranolol, clonazepam and mirtazapine, although the literature does not strongly support any one option.
• The advantage of mirtazapine is that it does not require titration, is better tolerated than propranolol, and does not have the risk of benzodiazepine misuse or mortality concern for the antipsychotic-benzodiazepine combination. The most common mirtazapine dose studied is 15 mg qhs. Its main side effects are sedation and weight gain.
• Benztropine for akathisia alone (i.e., without Parkinsonism) has limited utility.

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