What is akathisia?
Akathisia is a feeling of anxiety or restlessness. Its symptoms tend to overlap with the symptoms of other physical and psychological disorders. The diagnosis depends on a very subjective feeling of restlessness. Hence, recognizing akathisia can be somewhat tricky. Movement disorders often lead to akathisia. In Greek, the term means “inability to sit”.
A person with akathisia may experience physical disability or discomfort when it comes to remaining still. There is no known reason why akathisia happens. However, the condition can be due to a complex side effect of various antipsychotic or antidepressant drugs.
Oftentimes, akathisia can be confused as a part of routine stress issues, which is why this disorder is less known to most people. Moreover, people with akathisia experience constant discomfort, a disturbing sense in the mind, and emotional turmoil similar to anxiety and stress. Akathisia can recur after a couple of hours, weeks, or even months after treatment is started. It can also occur when the dose is changed or the prescribed drug is stopped.
Akathisia is believed to be more of an emotional state discomfort rather than a movement disorder. Due to mental disturbance, the person may feel like moving continuously. People with this disorder typically pace for longer periods. They tend to keep on moving even if they are already seated.
In severe cases, akathisia can cause discomfort and pain. Discomfort occurs mostly in the legs, but may tend to be in the hip and pelvic area also. People with this disorder feel the need to be in constant motion.
Akathisia is often characterized by simple everyday activities such as rocking while standing or sitting, continuously fidgeting, or marching on the spot. People who suffer from this medical condition often complain about restlessness, feeling of impatience, and an urge to move around all the time. Akathisia may range from mild to severe. Severe cases may cause extreme anxiety, which may result in suicide.
Akathisia is classified according to its degree or state. Rating scales can help assess the degree of akathisia, which also provides both objective and subjective information about the condition.
The term "akathisia" was coined by neuropsychiatrist Ladislav Haskovec, who was the first one to describe the disorder.
What are the causes of akathisia?
1) Drug-induced akathisia
An adverse reaction from certain drugs can be one of the causes of akathisia. In the past, antipsychotic medications had prominent akathisia side effects. Later on, newer drugs were made, which provided lesser adverse side effects. The major cause of akathisia is the ingestion of neuroleptics and other drugs.
Antipsychotics and antidepressants
Akathisia happens when patients take antipsychotic medications or when they are on long periods of drug withdrawal. Patients may develop a condition similar to decreased dopamine signals in the brain. Akathisia is also linked to increased serotonin signals.
Certain generic non-sedating drugs such as haloperidol, aripiprazole, and risperidone, have akathisia side effects. Apart from these drugs, antidepressant drugs such as tricyclics and trazodone are also known to cause akathisia. In different antidepressant trials, akathisia was mistaken as "emotional lability, agitation, and overactivity". Studies have shown connections between violence and antidepressant-induced akathisia.
Antimigraine or anti-nausea medications
These medications work similar to the above-mentioned drugs. They may also cause akathisia as a side effect, although very rare. Some people may develop this condition within a short time while some may take months to manifest.
Several drugs have withdrawal symptoms such as cocaine, benzodiazepines such as Valium and Xanax, barbiturates, and opioids. When these drugs are withdrawn, it may cause symptoms of akathisia in a matter of weeks. These drugs should be used with proper control. If these drugs are abused, they often result in addiction. It is necessary to look out for any akathisia symptoms after the withdrawal of stimulant drugs or opioids.
This drug is indicated for people with Parkinson’s disease. It is also known to cause akathisia.
Selective serotonin reuptake inhibitors (SSRIs)
When Prozac is taken for a long time, it can induce or place the person at risk of akathisia. It is known to aggravate akathisia in people who already have the condition.
Antihistamine agents can also lead to akathisia. Examples of antihistamines are cyproheptadine and diphenhydramine.
Apart from the ones mentioned above, research has shown that anticonvulsants, interferon alfa, lithium carbonate, sumatriptan, buspirone, and pethidine are also known to contribute to the condition of akathisia. Akathisia happens mostly as a side effect of neurological medications. It can develop shortly after the medication has started or when the drug is stopped.
2) Parkinson’s disease
It has been observed that many people with Parkinson’s disease have developed akathisia. However, it is still not clear whether the disorder is due to Parkinson’s disease or the drug's side effect.
3) Alcohol withdrawal
Abrupt alcohol withdrawal can also cause akathisia. For this reason, a slow withdrawal is recommended to let the body adjust properly to the changes.
People taking higher doses of drugs and those with rapid dose escalations of high–potency neuroleptic medications have higher chances of developing acute akathisia. Another risk factor is a history of neuroleptic-induced akathisia. Middle-aged people and the elderly are more susceptible to akathisia than the younger generation. According to some studies, women are more vulnerable to akathisia than men.
Akathisia is characterized by a lot of movements. The severity of akathisia depends on the nature of the movements and how well the person can resist the urge to move. Some common factors seen in this disorder include:
- Anxiety or panic attacks
- Feeling restless
- Pacing or moving faster
- Discomfort or pain in the knees
- Finding it difficult to stand
- Repeatedly lifting and lowering the foot as if marching on the spot
- Twisting or muscle kinks
- Bad posture
- Constant twisting of the waist or trunk
- Swaying oneself from foot to foot
- Constant nodding of the head
- Bending the neck repeatedly
- Urge to always move
- Uncrossing and crossing of legs repeatedly
- Insomnia or an altered sleeping pattern
- Hyperactivity disorder
- Unpleasant thoughts
These symptoms are similar to restless legs syndrome. Advanced cases may cause anxiety or agitation, irritability, or dysphoria. Severe cases can cause anxiety to reach a point of behavioral disorders such as paranoia, hostility, depression, violence, or suicidal tendencies.
Akathisia is commonly misdiagnosed. A misdiagnosis happens because both the doctor and the patient have very little understanding of the condition. Some practitioners may not be aware of this terminology. Some doctors may even increase the dose of the medicine, which can actually be the root cause of the problem, making the patient's condition worse.
Akathisia can be misdiagnosed with the following conditions:
- Anxiety disorder
- Restless legs syndrome
- Nervous breakdown
- Mood disorders
- Drug withdrawal states
- Tardive dyskinesia
For a more accurate diagnosis, the doctor should look for a good history from the patient and other sources.
The severity of akathisia can be assessed with the help of the Barnes Akathisia Rating Scale. Akathisia is classified as acute, chronic, pseudo, tardive, and rebound akathisia. The main feature that differentiates akathisia from others is its characteristics, which are mostly subjective.
A person who has started taking antidepressants or antipsychotic drugs should be monitored for any signs of akathisia. The following signs can be observed:
- Looking tensed
- Appears distracted
- Quick tempered
- Emotionally troubled
If these problems appear after medication or have become worse after medication, then that person might be suffering from akathisia. In has also been suggested that acute akathisia may be a precursor to tardive dyskinesia.
How long will akathisia last?
Akathisia usually lasts for six months. However, it can also last for years depending on its cause and how the treatment is done. If it lasts for six months, then it is known as acute akathisia. If akathisia lasts for more than six months or goes on for several years, then it is considered as chronic akathisia.
Most cases of acute akathisia are usually resolved within a span of six months by responding to treatment. Chronic akathisia, on the other hand, is slow when it comes to treatment response and lasts for years.
If akathisia is drug-induced, then treatment involves lowering the dose of medication, abandoning the drug completely, or by starting a new drug. However, if a person is taking an antipsychotic or antidepressant drug, then there is a reason behind it, and altering the dosage may either result in further side effects or stronger symptoms of the existing condition.
The following are the treatment options for akathisia:
1) Switching prescriptions - Antipsychotics and antidepressants are capable of slowly inducing akathisia than other types of treatment. Doctors can be consulted for other alternative drugs.
2) Dose adjustment - Akathisia symptoms can be controlled by adjusting the drug's dosage. However, dose adjustments must only be done by the doctor. The doctor should also make sure that reducing the dosage will meet its intended purpose. If the cause of akathisia is due to a benzodiazepine or opioid withdrawal, then it is best to temporarily increase the dosage and then reduce the dosage gradually. This can reflect a significant improvement in the patient. An abrupt withdrawal from neuroleptic drugs may cause further problems.
3) Break from drugs - This should not be done without the doctor’s permission. The possibility of skipping drugs for a certain period should be discussed with the doctor.
4) Anticholinergics - They block neurotransmitters and are used for digestive, respiratory, or sleep-related disorders. They have been known to help in some cases of akathisia. However, they also have some side effects.
5) GABA analogues - Like gabapentin and pregabalin, GABA analogues are generally used to manage acute idiopathic akathisia. This happens especially in cases wherein akathisia is caused due to opioid withdrawal and the patient can no longer carry on with it.
6) Dietary changes - Akathisia symptoms can be reduced by taking vitamin B6 (pyridoxine). You can get this vitamin in meat and starchy vegetables. Vitamin B6 is also beneficial to nerve cells.
7) Other drugs - Drugs such as cyproheptadine (serotonin antagonist), propranolol (adrenergic antagonist), and lorazepam (benzodiazepine) can be helpful in treating akathisia. The best initial approach for people who are treated for akathisia due to the use of high-potency typical neuroleptic drugs are beta-blockers such as propranolol.
The dose can start off with 10 mg three times a day and then gradually titrated up for it to take effect. If the patient cannot tolerate high doses of beta-blockers due to cardiovascular symptoms, anticholinergics can be added or substituted instead. Benzodiazepines such as clonazepam or lorazepam in conjunction with an anticholinergic may also be useful.
However, anticholinergic medications may increase the risk of toxicity. A combination of an anticholinergic and a beta blocker is effective. In general, benzodiazepines along with beta-blockers for the elderly are not recommended.
The beta-blocker used for treating high blood pressure is also used for patients with antipsychotic-induced akathisia. The possible side effects are insomnia, hallucinations, short-term memory loss, etc.
What are the side effects of akathisia?
Anticholinergics are not well-tolerated by the elderly, especially those who have dementia. Moreover, benzodiazepines may cause a marked sedation and an increased risk of falls.
Elders suffering from dementia may also exhibit disinhibition. Beta-blockers are well-tolerated, but patients must be closely monitored for vital signs.
Opioid and barbiturate abuse should be avoided. Consult the doctor for drugs that do not have adverse side effects. It is always best to seek advice from medical professionals for any changes in treatment.
A prevalence rate of 0.1 to 41 percent was reported. The prevalence rate is lower since second–generation antipsychotics have a lower risk of akathisia.
Akathisia: Is it permanent or temporary?
Since akathisia is caused by the use of certain medications, its duration completely depends on how well the condition is handled. Proper medication withdrawal and correct reduction or switching of drugs may be helpful. However, in some cases like opiods, the condition worsens when the drug is withdrawn.
It is noted that some forms of akathisia continue for years even after stopping the drug that caused the problem. How long it lasts really depends on how early the cause is identified and removed. If it is not identified and handled on time, then it may become a permanent condition.