Akathisia: What It Is, Causes, Symptoms, & Treatment

What Is Akathisia?

Akathisia is a neurological disorder characterized by an overwhelming sense of restlessness and a compelling need to move. People experiencing akathisia often find it difficult to sit or stand still, leading to constant pacing, shifting of weight, or crossing and uncrossing their legs. This condition can be incredibly distressing and can significantly impact an individual’s quality of life.¹

Akathisia is most commonly associated with the use of antipsychotic medications, although it can also be caused by other medications such as certain antidepressants and medications that treat nausea and vomiting. Antipsychotics work by altering the balance of neurotransmitters in the brain, particularly dopamine. However, this mechanism can sometimes lead to the development of akathisia as a side effect.

Symptoms of akathisia can manifest soon after starting or increasing the dosage of antipsychotic medications. In some cases, symptoms may appear within hours or days, while in others, it may take several weeks for them to become noticeable.¹ Notably, not everyone who takes antipsychotic medications will experience akathisia, and the severity of it can vary. If you are taking antipsychotics and notice any signs of restlessness or an irresistible urge to move, consult with your healthcare provider for proper evaluation and management.

How Common Is Akathisia?

Akathisia is the most common and one of the most distressing of the movement disorders associated with antipsychotics. Akathisia can occur in several forms including acute and chronic akathisia, tardive akathisia, and even withdrawal or rebound akathisia. The prevalence of akathisia varies depending on the specific medication and patient population. Older adults seem to be more susceptible to developing akathisia due to metabolic and overall health differences.

A recent large study among a community sample of patients with schizophrenia on several antipsychotic medications found a prevalence of about 15 – 35%.² Additionally, chronic akathisia and “pseudoakathisia” prevalence were estimated at 24% and 18%, respectively, in patients with schizophrenia. Akathisia rates were reportedly 39% in clozapine-treated patients and 45% among patients treated with first-generation antipsychotics (FGA) in another report.¹

Types of Akathisia

Akathisia can present itself in many ways and is often categorized based on its duration and presentation. If akathisia initially presents within the first couple of days of starting a medication, this is known as acute akathisia. But it can be, and often is, a persistent problem when not addressed. Chronic akathisia is usually defined as the continuation of the signs and symptoms for more than 3 months. Akathisia may also arise after dosage is reduced or the person stops taking antipsychotic medication, which is called withdrawal akathisia.³

Lastly, tardive akathisia, also sometimes referred to as late-onset akathisia, occurs in the absence of any change in drug dose or type, or provoked by stopping anti-akathisia medication as well as persistent akathisia that is particularly disabling and often refractory to treatment.³

Here are the four types of akathisia:³

• Acute akathisia: Typically occurs shortly after starting or increasing the dosage of psychotropic medication and lasts for less than 3 months.
• Tardive akathisia: Appears after prolonged use of certain medications, including antipsychotics. Symptoms may persist even after discontinuing the offending medication.
• Chronic akathisia: Typically occurs after prolonged exposure to medication or as a result of cumulative doses. Symptoms may persist for weeks, months, or even longer.
• Withdrawal akathisia: Occurs upon abrupt discontinuation or significant reduction of medication. Symptoms may present within days to weeks after a medication change and are indistinguishable from acute akathisia.

Causes and Risk Factors for Akathisia

The exact cause of akathisia is not fully understood. But it is believed to involve complex mechanisms linked to imbalances of neurotransmitters, or brain messengers, particularly dopamine. Dopamine is a chemical messenger that plays a crucial role in regulating movement and emotions.¹

Akathisia is most commonly caused by taking certain medications like antipsychotics, which also affect dopamine in the body. Antipsychotics are commonly used in the treatment of schizophrenia and bipolar disorder. It is in these conditions that akathisia is most well studied.³

Risk factors for developing akathisia include:¹

• Increasing medication dosage or rapid dose adjustments
• Sudden discontinuation of medications used to treat schizophrenia or bipolar disorder
• Older age and potentially male gender (although individual variations exist)
• Use of first-generation antipsychotics
• Use of second-generation antipsychotics
• Rarely the use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants (TCAs)
• Use of medications that treat nausea and vomiting such as metoclopramide

Antipsychotic Medications Linked With Akathisia

Medications associated with akathisia primarily include antipsychotics. These medications are divided into two main categories: first-generation (typical) antipsychotics and second-generation (atypical) antipsychotics. First-generation antipsychotics were the initial medications developed to treat conditions like schizophrenia, and they primarily block dopamine receptors in the brain.

On the other hand, second-generation antipsychotics were developed later and targeted multiple systems. While both types of antipsychotics have been associated with akathisia, research suggests that first-generation antipsychotics may be more strongly linked to the development of akathisia compared to second-generation antipsychotics.⁴

First Generation Antipsychotics (FGAs)*:

• Haldol (haloperidol)
• Thorazine (chlorpromazine)
• Fluphenazine (Prolixin)
• Chlorpromazine (Thorazine)
• Loxapine (Loxitane)
• Molindone (Moban)
• Pimozide (Orap)
• Prochlorperazine (Compro, Compazine)
• Thioridazine (Mellaril)
• Thiothixene (Navane)
• Trifluoperazine (Stelazine)

*Akathisia is most commonly linked to this class of medications.

Second Generation Antipsychotics (SGAs):⁴

• Clozapine (Clozaril): Despite being a second-generation antipsychotic, this medication has a rate of akathisia much closer to first-generation antipsychotics.
• Paliperidone (Invega)
• Ziprasidone (Geodon)

Disclaimer: Antipsychotic medications have a risk of side effects, including serious side effects. You should talk with your healthcare professional about the benefits and risks of any medication before starting treatment.

Can Other Medications Cause Akathisia?

While akathisia is commonly associated with antipsychotic medications, other classes of medications can also potentially cause akathisia. These include certain antidepressants, antiemetics, and even some drugs used to treat Parkinson’s disease.

These medications share some common characteristics that may contribute to the development of akathisia. One commonality is their impact on the neurotransmitter dopamine, which plays a crucial role in movement and emotions. Medications that interfere with the dopamine system, such as by blocking dopamine receptors or altering dopamine levels, can disrupt the delicate balance and potentially trigger akathisia.³

Here are some other medications potentially linked with akathisia:⁵

• Antidepressants: Antidepressants, including SSRIs, MAOIs, and TCAs, can all cause akathisia. While possible, akathisia is much less common in antidepressants compared to other antipsychotics.
• Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs associated with akathisia include fluoxetine (Prozac) and paroxetine (Brisdelle, Paxil)
• Monoamine-Oxidase Inhibitors (MAOI): MAOIs associated with akathisia include isocarboxazid (Marplan) and phenelzine (Nardil).¹
• Tricyclic (TCA) antidepressants: TCAs associated with akathisia include amitriptyline (Elavil, Vanatrip) and clomipramine (Anafranil)
• Buspirone: While uncommon, it is possible for buspirone to also cause akathisia. Buspirone is a medication used for the treatment of anxiety disorders.
• Calcium-Channel Blockers (CCBs): While generally used for blood pressure, CCBs such as diltiazem can also rarely cause akathisia.
• Antiemetics: Used to treat nausea and vomiting, metoclopramide and prochlorperazine have been linked to akathisia.

Symptoms of Akathisia

Akathisia is characterized by a range of distressing symptoms primarily related to motor restlessness and an intense urge to move. The symptoms are caused by certain medications, particularly antipsychotics, although other medications can also cause it. The sensations experienced in akathisia often involve discomfort or unease within the body, creating a strong desire for constant movement. This may also lead to symptoms being improperly characterized as agitation or anxiety.¹

A person with akathisia may experience a persistent urge to pace, fidget, or shift positions frequently. Restlessness can be accompanied by sensations of discomfort, uneasiness, or an inability to sit still or relax. Akathisia can affect various areas of the body, but it is often concentrated in the legs and lower extremities, leading to constant leg movement or repetitive motions like crossing and uncrossing the legs.¹

What Does Akathisia Feel Like?

The physical and emotional experience of akathisia can be profoundly distressing for individuals who are affected by it. Physically, individuals may feel an intense restlessness, as if their body is constantly urging them to move. This can manifest as a strong need to pace, fidget, or engage in repetitive motions. The sensations can be described as a deep discomfort or unease within the body, which can be difficult to alleviate.

Akathisia can cause significant anxiety and distress. The restlessness and inability to find relief can lead to feelings of frustration, agitation, and irritability. The person may struggle to find words to explain their symptoms, leading to a sense of helplessness or difficulty in conveying their experience to others. This lack of understanding from others can exacerbate feelings of isolation and frustration. Akathisia has been associated with a higher risk of self-harm and suicidal thoughts and behaviors for this reason.¹

Symptoms of akathisia include:¹

• Rocking back and forth
• Pacing or marching in place
• Restlessness or an uncontrollable urge to move
• Fidgeting
• Tapping feet excessively
• Repeatedly wringing hands
• Inability to sit still
• Anxiety
• Agitation
• Nervousness
• Constantly shifting body weight
• Difficulty finding relief

How Is Akathisia Diagnosed?

The Barnes Akathisia Rating Scale may be used to assess patients with akathisia. However, most clinicians will rely on clinical observation. There are no relevant laboratory or radiographic tests involved in the diagnosis of akathisia.⁶ Patient medical history will also be taken into account.

This rating scale helps to provide an objective measure of the intensity and impact of akathisia, aiding healthcare professionals in monitoring the progression of symptoms, assessing treatment response, and making informed decisions about management strategies.

Physical Exam

When assessing a patient for akathisia it is important to consider that it is often underdiagnosed because its symptoms often mimic or overlap other psychiatric disorders like psychosis, mania, attention deficit hyperactivity disorder (ADHD), or agitated depression.

Medical History

Using the Barnes Akathisia Rating Scale, patients will be asked a series of questions regarding medical history including: if they have started an antipsychotic agent, increased the dose recently, or stopped taking the medication for any conditions. If they have a history of depression, anxiety, suicidal ideations, or psychological disorders. Or if the patient is experiencing a sense of restlessness or desire to move constantly. Each component of the scale is rated numerically from 0-3 or 0-5.⁷

Here are conditions with similar symptoms as akathisia:⁷

• Anxiety: Anxiety disorders, such as generalized anxiety disorder or panic disorder, can manifest with restlessness, irritability, and a sense of inner tension. However the restlessness is usually driven by excessive worry or fear, rather drug-induced.
• Tardive dyskinesia: While both tardive dyskinesia and akathisia can be associated with the use of antipsychotics, they differ in their timing of onset, symptoms, and course. Tardive dyskinesia is a delayed side effect that may emerge after prolonged use of antipsychotics and typically involves the face, mouth, and tongue.
• Restless leg syndrome (RLS): RLS is characterized by an uncontrollable urge to move the legs, often accompanied by uncomfortable sensations such as crawling or tingling. However, unlike akathisia, RLS typically occurs during periods of rest or inactivity, especially in the evening or at night.
• Hyperthyroidism: An overactive thyroid gland can cause symptoms similar to akathisia, including restlessness, nervousness, and increased activity levels. Additional symptoms of hyperthyroidism may include weight loss, rapid heartbeat, and heat intolerance.
• Substance withdrawal: Certain substances, such as alcohol or benzodiazepines, when abruptly discontinued, can lead to restlessness and agitation resembling akathisia. However, a careful assessment of substance use history is crucial in distinguishing withdrawal-induced symptoms from medication-induced akathisia.
• Parkinson’s disease: Parkinson’s disease can involve motor symptoms such as tremors and muscle stiffness, which may be mistaken for akathisia. However, these symptoms of Parkinson’s disease are usually more persistent and not solely driven by restlessness or an urge to move.

What Does the Prognosis Look Like for Akathisia?

Untreated akathisia can lead to significant distress and functional impairment. Constant restlessness and discomfort can cause extreme agitation and anxiety. This can make daily activities or social interactions challenging to maintain. The inability to find relief from the symptoms may also contribute to increased frustration and emotional turmoil.

Moreover, untreated akathisia has been associated with a higher risk of self-harm and suicidal thoughts and behaviors, underscoring the importance of early recognition and intervention. With proper care, individuals with akathisia can achieve better symptom control and regain their overall well-being.¹

Akathisia Treatments

While there is no standard treatment for akathisia, there are several ways to address symptoms. First, your provider may try to reduce the dose of your medication or change it to another to see if the symptoms improve. Antipsychotics like quetiapine have a lower chance of akathisia and may be a good option for some patients. If the regimen cannot be adjusted, an anti-akathisia agent may be added such as propranolol, mirtazapine, or benztropine.¹

Adjusting Medication or Dosage

The first strategy most providers choose involves a reduction in the dose of antipsychotic medication. Prescribers may also consider a potential switch to a lower potency first generation antipsychotic or a second generation antipsychotic with low potential to induce akathisia. These include medications such as chlorpromazine (low-potency FGA), or quetiapine (SGA). In cases of intractable or refractory akathisia, clozapine should be considered.¹

Treating Symptoms With Another Medication

The other option for patients experiencing akathisia is to add an anti-akathisia agent. These medications fall into two categories: first-line and second-line. First-line options include beta-blockers such as propranolol (40-80 mg/day), 5HT2a antagonists like mirtazapine or Remeron (15 mg/day), or (rarely) anticholinergic medications in the case of parkinsonism. Second line options include: amantadine (100 mg/day), benzodiazepines such as lorazepam, diazepam, clonazepam, or 5HT2a antagonists like Mianserin or cyproheptadine.¹

Here are some medications used to treat symptoms of akathisia:¹

• Beta-blockers: These medications work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta-blockers cause the heart to beat more slowly and with less force, which lowers blood pressure.
• Benzodiazepines: Benzodiazepines depress the central nervous system which induces feelings of calm, drowsiness, and sleep.
• Amantadine: This medication is used to treat Parkinson’s disease and its symptoms, including dyskinesia (sudden uncontrolled movements).
• Clonidine: This medication works by reducing sympathetic outflow from the central nervous system (CNS), which clinically causes a decrease in arterial blood pressure.
• 5-HT2A Antagonists: These medications block the 5HT2A receptor, leading to an increase in neurotransmitters.
• Anticholinergics: Anticholinergic drugs block the acetylcholine receptors thereby overcoming the excessive cholinergic activity.

Can Akathisia Be Prevented?

Preventing akathisia can be easier than treating it once it occurs. To reduce the risk of developing akathisia, it is important to carefully consider the potential side effects when taking medications, particularly those known to be closely associated with akathisia, such as antipsychotics.

Working closely with a healthcare professional is crucial to finding the right medication at the appropriate dosage, as well as never stopping the medication abruptly or taking more than prescribed.

Questions to Ask Your Healthcare Provider About Akathisia

When discussing akathisia and its potential treatments with your care team, you may want to ask specific questions to gain a better understanding and make informed decisions. Some questions to consider asking your doctor, psychiatrist, or therapist include: what signs and symptoms to be on the lookout for, what alternative options for treatment are available, what to do if symptoms worsen or become intolerable, etc.

Questions to ask your care team about akathisia may include:

• What helps calm akathisia?
• Does akathisia ever go away?
• Am I at risk for more severe symptoms if I am already taking medication for anxiety, depression, or other mental health conditions?
• How long does akathisia usually last?
• Does akathisia get worse at night?
• What is the best dosage to ensure fewer side effects?
• When should I reach out to you if I think I may have symptoms of akathisia, or if my symptoms get worse?
• Is there anything I should tell my therapist about akathisia?
• Are there any lifestyle changes or strategies to help minimize the impact of akathisia on my daily life?
• How quickly will I see improvement in symptoms with a treatment plan?
• If I take another medication to treat my akathisia, will it affect my other medications and what side effects should I be concerned about?
• How can I monitor and assess the severity of my symptoms over time?
• What medications are least likely to cause akathisia if I need to switch later?

In My Experience

In my experience, akathisia is a very significant side effect, that when left untreated, can strongly impact an individual’s life or even make doing basic tasks intolerable. It is for this reason that I think it is important to consult your doctor or psychiatrist when taking any antipsychotic medications for mental health disorders such as schizophrenia or bipolar disorder. They will be able to inform you of what to watch out for, and when to reach out if akathisia does begin to develop or worsen.

There are thankfully many treatment alternatives for this condition. If a certain antipsychotic is not working well for you that there are other options to consider that may be much better in the long run.

For Further Reading

• Bipolar Disorder Treatment: Medication & Therapy
• Treatment for Schizophrenia: Medications & Therapy
• Abilify Withdrawal Symptoms: All You Need to Know
• Mental Health First Aid: National Council for Mental Wellbeing
• CDC Mental Health Resources: Home
• What Are the Side Effects of Buspirone Sexually?