Akathisia

For the album by Hovercraft, see Akathisia (album).

Akathisia
Other namesAcathisia
Common sign of akathisia
SpecialtyNeurology, psychiatry
SymptomsFeelings of restlessness, inability to stay still, uneasy[1]
ComplicationsViolence or suicidal thoughts[2]
DurationShort- or long-term[2]
CausesAntipsychotics, selective serotonin reuptake inhibitors, metoclopramide, reserpine[2]
Diagnostic methodBased on symptoms[2]
Differential diagnosisAnxiety, tic disorders, tardive dyskinesia, dystonia, medication-induced parkinsonism, restless leg syndrome[2][3]
TreatmentReduce or switch antipsychotics, correct iron deficiency[2]
MedicationDiphenhydramine, trazodone, benzodiazepines, benztropine, mirtazapine, beta blockers[4][2]
FrequencyRelatively common[4]

Akathisia (IPA: /æ.kə.ˈθɪ.si.ə/) is a movement disorder[5] characterized by a subjective feeling of inner restlessness accompanied by mental distress and/or an inability to sit still.[6][4] Usually, the legs are most prominently affected.[2] Those affected may fidget, rock back and forth, or pace,[7] while some may just have an uneasy feeling in their body.[2] The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts.[2] Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients.[8] However, the attempts to find potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series.[9] Apart from these few low-quality studies, there is another more recent and better quality study (a systematic review from 2021)[9] that concludes akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication.[9]

Antipsychotic medication, particularly the first generation antipsychotics, are a leading cause.[4][7] Other agents commonly responsible for this side-effect may also include selective serotonin reuptake inhibitors, metoclopramide, and reserpine, though any medication listing agitation as a side effect may trigger it.[2][10] It may also occur upon stopping antipsychotics.[2] The underlying mechanism is believed to involve dopamine.[2] When antidepressants are the cause, there is no agreement regarding the distinction between activation syndrome from akathisia.[11] Akathisia is often included as a component of activation syndrome.[11] However, the two phenomena are not the same since the former, namely antipsychotic-induced akathisia, suggests a known neuroreceptor mechanism (e.g., dopamine-receptor blockade).[11] Diagnosis is based on the symptoms.[2] It differs from restless leg syndrome in that akathisia is not associated with sleeping. However, despite a lack of historical association between restless leg syndrome and akathisia, this does not guarantee that the two conditions do not share symptoms in individual cases.[2]

If akathisia is caused by an antipsychotic, treatment may include switching to an antipsychotic with a lower risk of the condition.[2] The antidepressant mirtazapine, although paradoxically associated with the development of akathisia in some individuals, has demonstrated benefit,[5] as have diphenhydramine, trazodone, benzatropine, cyproheptadine, and beta blockers, particularly propranolol.[2][4][12]

The term was first used by Czech neuropsychiatrist Ladislav Haškovec, who described the phenomenon in 1901 long before the discovery of antipsychotics, with drug-induced akathisia first being described in 1960.[1] It is from Greek a-, meaning "not", and καθίζειν kathízein, meaning "to sit", or in other words an "inability to sit".[2]

  1. ^ a b Cite error: The named reference Salem2017 was invoked but never defined (see the help page).
  2. ^ a b c d e f g h i j k l m n o p q r Lohr, JB; Eidt, CA; Abdulrazzaq Alfaraj, A; Soliman, MA (December 2015). "The clinical challenges of akathisia". CNS Spectrums (Review). 20 (Suppl 1): 1–14, quiz 15–6. doi:10.1017/S1092852915000838. PMID 26683525. S2CID 4253429.
  3. ^ Kaufman, David Myland; Milstein, Mark J. (2012). Kaufman's Clinical Neurology for Psychiatrists E-Book. Elsevier Health Sciences. p. 429. ISBN 978-1455740048.
  4. ^ a b c d e Laoutidis, ZG; Luckhaus, C (May 2014). "5-HT2A receptor antagonists for the treatment of neuroleptic-induced akathisia: a systematic review and meta-analysis". The International Journal of Neuropsychopharmacology (Review). 17 (5): 823–32. doi:10.1017/S1461145713001417. PMID 24286228.
  5. ^ a b Cite error: The named reference Poyurovsky2020 was invoked but never defined (see the help page).
  6. ^ Forcen, FE; Matsoukas, K; Alici, Y (February 2016). "Antipsychotic-induced akathisia in delirium: A systematic review". Palliative & Supportive Care (Review). 14 (1): 77–84. doi:10.1017/S1478951515000784. PMC 5516628. PMID 26087817.
  7. ^ a b Thomas, JE; Caballero, J; Harrington, CA (2015). "The Incidence of Akathisia in the Treatment of Schizophrenia with Aripiprazole, Asenapine and Lurasidone: A Meta-Analysis". Current Neuropharmacology (Review). 13 (5): 681–91. doi:10.2174/1570159x13666150115220221. PMC 4761637. PMID 26467415.
  8. ^ Stubbs, J. H.; Hutchins, D. A.; Mountjoy, C. Q. (2000). "Relationship of akathisia to aggressive and self-injurious behaviour: A prevalence study in a UK tertiary referral centre". International Journal of Psychiatry in Clinical Practice. 4 (4): 319–325. doi:10.1080/13651500050517894. ISSN 1365-1501. PMID 24926584. S2CID 26486432.
  9. ^ a b c Kalniunas, Arturas; Chakrabarti, Ipsita; Mandalia, Rakhee; Munjiza, Jasna; Pappa, Sofia (3 December 2021). "The Relationship Between Antipsychotic-Induced Akathisia and Suicidal Behaviour: A Systematic Review". Neuropsychiatric Disease and Treatment. 17: 3489–3497. doi:10.2147/NDT.S337785. ISSN 1176-6328. PMC 8651045. PMID 34887662.
  10. ^ "MISSD - The Medication-Induced Suicide Prevention and Education Foundation in Memory of Stewart Dolin - Akathisia Support". missd.co. Retrieved 26 August 2022.
  11. ^ a b c Amitai, Maya; Chen, Alon; Weizman, Abraham; Apter, Alan (1 March 2015). "SSRI-Induced Activation Syndrome in Children and Adolescents—What Is Next?". Current Treatment Options in Psychiatry. 2 (1): 28–37. doi:10.1007/s40501-015-0034-9. ISSN 2196-3061.
  12. ^ Fischel, T.; Hermesh, H.; Aizenberg, D.; Zemishlany, Z.; Munitz, H.; Benjamini, Y.; Weizman, A. (December 2001). "Cyproheptadine versus propranolol for the treatment of acute neuroleptic-induced akathisia: a comparative double-blind study". Journal of Clinical Psychopharmacology. 21 (6): 612–615. doi:10.1097/00004714-200112000-00013. ISSN 0271-0749. PMID 11763011. S2CID 22663143.