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  • Updated 05.28.2021
  • Released 12.16.1994
  • Expires For CME 05.28.2024

Akathisia

Introduction

Overview

Akathisia is the abnormal state of motor restlessness that is most commonly caused by drugs that block dopamine receptors; it is sometimes perceived as anxiety. It can be an acute side effect that improves with withdrawal of medication, or it can be tardive, which occurs after chronic therapy and worsens with drug withdrawal. Literature demonstrates that it occurs with atypical antipsychotics although perhaps less commonly than is seen with typical agents. It can also be caused by antidepressants. The treatment is different for acute and tardive forms. For the acute form, withdrawal of the causative agent is the first step. This may be followed by the use of propranolol, mirtazapine, and trazodone, if necessary. These agents can be helpful for the tardive form, but other drugs for tardive dyskinesia may also be tried, including vesicular monoamine transporter type 2 (VMAT2) inhibitors.

Key points

• Akathisia is a sensorimotor syndrome.

• Motor symptoms appear to be in response to a variety of sensory symptoms and are stereotyped and suppressible; they decrease with distraction.

• Sensory symptoms are urges or other uncomfortable phenomena that partially improve with movement.

• Akathisia occurs acutely or subacutely with dopamine receptor-blocker therapies and improves with removal of the drug. It is chronic or tardive, occurring after chronic therapy, and worsens with removal of the drug.

• Mechanisms relate to impact of dopamine, serotonin, and noradrenergic systems on the somatosensory system in the brain.

• There should be a high index of suspicion as akathisia is frequently underrecognized.

• Akathisia is a complication of all atypical antipsychotics.

• First-line therapies include propranolol, mirtazapine, vitamin B6, or trazodone.

Historical note and terminology

The term “akathisia” is from the Greek “inability to sit,” but it generally refers to an aversion to being still that is relieved by movement. The term was first used medically by Haskovec (37) who thought the symptoms were the result of psychological disorders (01). A Czech neuropsychiatrist and a former student of Charcot, Haskovec obviously described this phenomenon in the pre-antipsychotic era (70). Akathisia was recognized as a complication of parkinsonism during the epidemic of encephalitis lethargica in the 1920s, and later, Parkinson disease. Dopamine receptor-blocking drugs for the treatment of psychosis were developed during the 1940s, and akathisia was recognized as a side effect of promethazine in 1947 (01). Tardive akathisia, occurring after chronic neuroleptic therapy and remaining and worsening after withdrawal of the drug, was first reported in 1960 (51) but was not labeled “chronic akathisia” until 1983 (08). Akathisia is one of the most troublesome aspects of tardive dyskinesia (111; 28; 94).

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