Akathisia is a symptom defined by inner restlessness and an overwhelming need to move irresistibly and incessantly. This sensorimotor disorder is localized primarily in the lower limbs. Akathisia may be accompanied by mood disorders such as depression and anxiety. The cause of akathisia must first be identified and initial treatment must be directed at this cause.
What is akathisia?
Akathisia is a symptom defined by an overwhelming need to move irresistibly and incessantly in one place. This sensorimotor disorder – to be distinguished from psychomotor agitation – is essentially localized in the lower limbs. It occurs mainly while sitting or lying down. Malaise, secondary insomnia, and even despair are often observed in the main forms. Akathisia may be accompanied by mood disorders and anxiety.
The differential diagnosis between akathisia and restless leg syndrome is still debated due to the large clinical overlap between the two. Studies of restless legs syndrome tend to come from neurological literature and sleep and akathisia from the psychiatric and psychopharmacological literature.
How to recognize akathisia?
Currently, akathisia is diagnosed based only on clinical observation and patient reports, as there is no confirmatory blood test, imaging assessment, or neurophysiological examination.
Essential features of neuroleptic-induced acute akathisia include the subjective complaints of impatience and at least one of the following observed movements:
- Impatient movements or swinging of the legs while sitting
- Rocking from one foot to the other or stomping while standing
- Must walk to relieve impatience
- Inability to sit or stand still for several minutes.
The most widely used assessment tool is the Barnes’ Akathisia Rating Scale (BARS), a four-point scale in which the subjective and objective components of the condition are rated separately and then combined. Each item is rated on a four-point scale from zero to three:
The objective component: a movement disorder is present. In mild to moderate severity, the lower limbs are most affected, usually from the hips to the ankles, and the movements manifest as changes in standing position, rocking, crossing and uncrossing the legs, or constantly shifting feet positions when sitting. However, when severe, akathisia can affect the entire body, resulting in almost continuous twisting and rocking movements, often accompanied by pacing
Subjective component: The severity of the subjective discomfort ranges from “mildly bothersome” and easily relieved by moving a limb or changing position, to “absolutely unbearable.” In the most severe form, the sufferer may be unable to hold any position for more than a few seconds. Subjective complaints include a feeling of internal restlessness-most commonly in the legs-a compulsion to move the legs, and pain when the affected person is asked not to move the legs.
Although acute akathisia induced by antipsychotics is often associated with schizophrenia, it appears that patients with mood disorders, particularly bipolar disorder, are actually at greater risk.
Other risk factors may be identified such as:
- Head trauma
- Iron deficiency
Late-onset or chronic akathisia may also be associated with advanced age and female gender.
Causes of akathisia
Antipsychotics: Akathisia is frequently observed after treatment with first-generation antipsychotics, with prevalence rates in the range of 8% to 76% of treated patients, making it probably the most common side effect of these drugs. Although the prevalence of akathisia is lower with second-generation antipsychotics, it is far from zero.
Antidepressants: Akathisia may occur during treatment with antidepressants.
Other drug origins: The antibiotic azithromycin, calcium channel blockers, lithium, and commonly used recreational drugs such as gamma-hydroxybutyrate, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy), and cocaine.
Parkinson’s disease: Akathisia has been described along with a variety of disorders associated with Parkinson’s disease.
Spontaneous akathisia: Akathisia has been reported in some cases of untreated schizophrenia, in which it has been termed “spontaneous akathisia.”
Risks of complications of akathisia
Poor compliance with treatment: The suffering caused by akathisia is considerable and may be the cause of nonadherence to the neuroleptic treatment responsible for this symptom.
Aggravation of psychiatric symptoms: The presence of akathisia also exacerbates psychiatric symptoms, often leading physicians to inappropriately increase agents such as selective serotonin reuptake inhibitors (SSRIs) or antipsychotics.
Suicide: Akathisia may be associated with irritability, aggression, violence, or suicide attempts.
Treatment and prevention of akathisia
The cause of akathisia must first be identified, and initial treatment must be directed at that cause.
Because akathisia occurs primarily as a result of taking psychotropic medications, the first recommendation is to reduce or switch medications if possible. Patients taking first-generation medications should be switched to second-generation agents that appear to cause less akathisia, such as quetiapine and iloperidone.
If iron deficiency is present, it may be helpful to correct the situation.
It should also be noted that akathisia withdrawal may occur: A change in treatment may result in a temporary exacerbation, so the effectiveness of a dose reduction or change in medication should not be assessed for six weeks or more.