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Akathisia
Akathisia (/æ.kə.ˈθɪ.si.ə/ a-kə-THI-see-ə) is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and/or an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their bodies. The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts. Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients. However, the attempts to find potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. Apart from these few low-quality studies, there is another more recent and better quality study (a systematic review from 2021) that concludes akathisia cannot be reliably linked to the presence of suicidal behavior in patients treated with antipsychotic medication.
Antipsychotic medication, particularly the first generation antipsychotics, are a leading cause. Other agents commonly responsible for this side-effect may also include selective serotonin reuptake inhibitors, metoclopramide, and reserpine, though any medication listing agitation as a side effect may trigger it. It may also occur upon stopping antipsychotics. The underlying mechanism is believed to involve dopamine. When antidepressants are the cause, there is no agreement on the distinction between activation syndrome and akathisia. Akathisia is often included as a component of activation syndrome. However, the two phenomena are not the same since the former, namely antipsychotic-induced akathisia, suggests a known neuroreceptor mechanism (e.g., dopamine-receptor blockade). Diagnosis is based on the symptoms. It differs from restless leg syndrome in that akathisia is not associated with sleeping. However, despite a lack of historical association between restless leg syndrome and akathisia, this does not guarantee that the two conditions do not share symptoms in individual cases.
If akathisia is caused by an antipsychotic, treatment may include switching to an antipsychotic with a lower risk of the condition. The antidepressant mirtazapine, although paradoxically associated with the development of akathisia in some individuals, has demonstrated benefit, as have diphenhydramine, trazodone, benzatropine, cyproheptadine, and beta blockers, particularly propranolol.
The term was first used by Czech neuropsychiatrist Ladislav Haškovec, who described the phenomenon in 1901 long before the discovery of antipsychotics, with drug-induced akathisia first being described in 1960. It is from Greek a-, meaning "not", and καθίζειν kathízein, meaning "to sit", or in other words an "inability to sit".
Akathisia is usually classified as a medication-induced movement disorder. It can also be considered a neuropsychiatric concern, however, as it can be experienced purely subjectively without apparent movement abnormalities. Akathisia is generally associated with antipsychotics, but was previously described in Parkinson's disease and other neuropsychiatric disorders. It can also present with the use of non-psychiatric medications, including calcium channel blockers, antibiotics, anti-nausea and anti-vertigo drugs.
Symptoms of akathisia are often described in vague terms, such as feeling nervous, uneasy, tense, twitchy, restless, and unable to relax. Reported symptoms also include insomnia, a sense of discomfort, motor restlessness, marked anxiety, and panic. Symptoms have also been said to resemble symptoms of neuropathic pain similar to fibromyalgia and restless legs syndrome. When caused by psychiatric drugs, akathisia usually disappears quickly once the medication is reduced or stopped. However, late-onset akathisia, or tardive akathisia, may persist for months or years after the medication is discontinued.
When misdiagnosis occurs in antipsychotic-induced akathisia, more antipsychotics may be prescribed, potentially worsening the symptoms. If not identified, akathisia symptoms can increase in severity and lead to suicidal thoughts, aggression and violence.
Visible signs of akathisia include repetitive movements, such as crossing and uncrossing the legs and constant shifting from one foot to the other. Other noted signs include rocking back and forth, fidgeting, and pacing. However, not all observable restless motion is akathisia. For example, while mania, agitated depression, and attention deficit hyperactivity disorder may present like akathisia, movements resulting from them feel voluntary, rather than being due to restlessness.
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Akathisia
Akathisia (/æ.kə.ˈθɪ.si.ə/ a-kə-THI-see-ə) is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and/or an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their bodies. The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts. Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients. However, the attempts to find potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. Apart from these few low-quality studies, there is another more recent and better quality study (a systematic review from 2021) that concludes akathisia cannot be reliably linked to the presence of suicidal behavior in patients treated with antipsychotic medication.
Antipsychotic medication, particularly the first generation antipsychotics, are a leading cause. Other agents commonly responsible for this side-effect may also include selective serotonin reuptake inhibitors, metoclopramide, and reserpine, though any medication listing agitation as a side effect may trigger it. It may also occur upon stopping antipsychotics. The underlying mechanism is believed to involve dopamine. When antidepressants are the cause, there is no agreement on the distinction between activation syndrome and akathisia. Akathisia is often included as a component of activation syndrome. However, the two phenomena are not the same since the former, namely antipsychotic-induced akathisia, suggests a known neuroreceptor mechanism (e.g., dopamine-receptor blockade). Diagnosis is based on the symptoms. It differs from restless leg syndrome in that akathisia is not associated with sleeping. However, despite a lack of historical association between restless leg syndrome and akathisia, this does not guarantee that the two conditions do not share symptoms in individual cases.
If akathisia is caused by an antipsychotic, treatment may include switching to an antipsychotic with a lower risk of the condition. The antidepressant mirtazapine, although paradoxically associated with the development of akathisia in some individuals, has demonstrated benefit, as have diphenhydramine, trazodone, benzatropine, cyproheptadine, and beta blockers, particularly propranolol.
The term was first used by Czech neuropsychiatrist Ladislav Haškovec, who described the phenomenon in 1901 long before the discovery of antipsychotics, with drug-induced akathisia first being described in 1960. It is from Greek a-, meaning "not", and καθίζειν kathízein, meaning "to sit", or in other words an "inability to sit".
Akathisia is usually classified as a medication-induced movement disorder. It can also be considered a neuropsychiatric concern, however, as it can be experienced purely subjectively without apparent movement abnormalities. Akathisia is generally associated with antipsychotics, but was previously described in Parkinson's disease and other neuropsychiatric disorders. It can also present with the use of non-psychiatric medications, including calcium channel blockers, antibiotics, anti-nausea and anti-vertigo drugs.
Symptoms of akathisia are often described in vague terms, such as feeling nervous, uneasy, tense, twitchy, restless, and unable to relax. Reported symptoms also include insomnia, a sense of discomfort, motor restlessness, marked anxiety, and panic. Symptoms have also been said to resemble symptoms of neuropathic pain similar to fibromyalgia and restless legs syndrome. When caused by psychiatric drugs, akathisia usually disappears quickly once the medication is reduced or stopped. However, late-onset akathisia, or tardive akathisia, may persist for months or years after the medication is discontinued.
When misdiagnosis occurs in antipsychotic-induced akathisia, more antipsychotics may be prescribed, potentially worsening the symptoms. If not identified, akathisia symptoms can increase in severity and lead to suicidal thoughts, aggression and violence.
Visible signs of akathisia include repetitive movements, such as crossing and uncrossing the legs and constant shifting from one foot to the other. Other noted signs include rocking back and forth, fidgeting, and pacing. However, not all observable restless motion is akathisia. For example, while mania, agitated depression, and attention deficit hyperactivity disorder may present like akathisia, movements resulting from them feel voluntary, rather than being due to restlessness.