Imagine a feeling of inner restlessness so intense that your body is in constant, painful motion. You pace, you shuffle your feet, you fidget, but no position—sitting, standing, or lying down—offers relief. This agonizing experience is known as akathisia, a neurological movement disorder that is a common side effect of certain medications, particularly those used in psychiatry.

Despite being a frequent, and often profound, adverse effect, akathisia is also frequently misunderstood and misdiagnosed. It is often mistaken for anxiety or agitation associated with the very mental health conditions it’s being used to treat. This oversight can cause immense distress and lead to patients discontinuing their medication, worsening their underlying condition, or experiencing severe anxiety and depression.

What is akathisia?

Derived from the Greek word for “inability to sit still,” akathisia is characterized by a relentless and uncomfortable sensation of inner restlessness. This inner agitation manifests as a compelling, uncontrollable urge to move.

Common symptoms and behaviors include:

• Persistent fidgeting: Constantly shifting legs, crossing and uncrossing them, or swinging them while seated.
• Pacing and rocking: A compulsion to walk back and forth, or rock the body while sitting or standing.
• Subjective distress: An overwhelming feeling of anxiety, tension, and unease that worsens when trying to be still.

What causes akathisia?

The primary culprits behind akathisia are medications that block dopamine receptors in the brain, which are crucial for regulating movement. While the exact mechanism is not fully understood, it’s thought to be caused by an imbalance in the brain’s neurochemical pathways.

Medications most often associated with akathisia include:

• Antipsychotics (neuroleptics): Both first-generation (e.g., haloperidol) and second-generation (e.g., risperidone, aripiprazole) can cause akathisia, though the risk is higher with older drugs.
• Antidepressants: SSRIs and SNRIs, especially at higher doses, have been known to cause this side effect.
• Antiemetics: Medications for nausea, like metoclopramide, can also trigger akathisia.
• Other drugs: Calcium channel blockers, some antihypertensives, and cocaine have also been linked to the condition.

Akathisia can begin shortly after starting a new medication, increasing a dose, or, in some cases, after stopping a medication (withdrawal akathisia).

How is akathisia treated?

The first step in treating medication-induced akathisia is to address the offending drug. A healthcare provider may:

• Lower the dosage of the medication.
• Switch to a different medication with a lower risk of causing akathisia.

Additional treatments may include:

• Beta-blockers: Propranolol is often used to help reduce symptoms.
• Benzodiazepines: Anti-anxiety medications like clonazepam can offer relief.
• Anticholinergics: While effective, these are used with caution due to side effects.
• Low-dose mirtazapine: Some studies have found this antidepressant to be effective.
• Vitamin B6: High doses have been explored as a potential treatment.

What is the outlook for akathisia?

The prognosis for akathisia is generally good if it is identified and treated early. For many, symptoms resolve once the causative drug is discontinued or adjusted. However, if left untreated, the condition can become disabling, leading to severe anxiety, depression, and a poor quality of life.

In some cases, akathisia can become chronic or persist even after the medication is stopped, known as tardive akathisia. This requires careful, ongoing management. Prompt recognition and action by both patients and healthcare providers are essential for a positive outcome.

If you or someone you know is experiencing symptoms of akathisia, it is crucial to speak with a professional healthcare provider immediately. Do not stop or change a medication’s dose without consulting a healthcare professional.