What is Akathisia: An Uncomfortable Medication Side Effect and Its Management

Akathisia is a distressing medication side effect characterized by extreme inner restlessness and an uncontrollable urge to move, stemming from the Greek term "not to sit." It can range from mild discomfort to severe distress, even inducing suicidality in some cases. This movement disorder is primarily associated with antipsychotics (e.g., aripiprazole, ziprasidone), antidepressants, and antiemetics (e.g., ondansetron, promethazine), particularly those antipsychotics with less sedating properties.

The core mechanism behind akathisia is believed to be a drop in dopamine levels in specific brain regions responsible for inhibiting movements, likened to a broken control valve. Antipsychotics directly block dopamine, while antidepressants can indirectly cause a dopamine decrease through a serotonin feedback mechanism. It can also manifest as a withdrawal effect from anticholinergic drugs. A key distinction is drawn between akathisia and anxiety: while both involve physical symptoms, akathisia is an involuntary physical inability to stay still, whereas anxiety is predominantly an emotional process where one can still force physical stillness.

Practical management strategies prioritize stopping or tapering off the causative medication, as symptoms typically do not improve with continued use or dose adjustment alone. If the medication is essential, adjunct treatments can be introduced, such as benztropine, propranolol, amantadine, or clonidine. While benzodiazepines like clonazepam can offer symptomatic relief, they are generally not recommended for long-term daily use due to the significant risk of dependence and tolerance.

The duration of akathisia varies, usually resolving weeks after discontinuing the medication, though it can persist for up to six months or, in rare chronic cases, evolve into a dyskinesia. It's crucial to differentiate akathisia from antidepressant-induced anxiety, as the latter typically subsides as the body adjusts, while akathisia often emerges later and persists. Effective identification and management are vital to alleviate patient distress and prevent severe outcomes like suicidality, highlighting the importance of careful medication monitoring and patient education.

"Akathisia is a Greek term that means not to sit and as such, akathisia a movement disorder that causes extreme restlessness and inability to stay still."

"In some people, it has even caused the onset of suicidality."

"I've had some patients tell me that they feel like they were coming out of their skin."

"Anxiety may start with physical symptoms like a rapid heart rate or shortness of breath but it's still connected to a mental component of fear, angst or worry."

"But with akathisia, you can't force yourself not to move."

"We don't have exact answers but the proposed mechanism is the medication causes a drop in dopamine in certain areas of the brain that are involved with inhibiting movements."

"Usually, akathisia goes away weeks after stopping the medication but sometimes it can take up to six months to resolve."

"The first thing is to stop the medication that's causing the problem and when I say stop, I mean taper off."

"Benzodiazepines like clonazepam can also help the symptoms but they're not the best choice in my opinion because akathisia is a daily problem and when you need to take a benzodiazepine daily, it's a setup for becoming dependent on a benzodiazepine and benzodiazepines cause tolerance as well."

"But the akathisia remains and often starts after you've been taking the medication for a little while."