What is Akathisia?

Types
Cause and symptoms
Epidemiology
Case report
Diagnosis and treatment
References
Further reading

Akathisia is a common movement disorder associated with the use of antipsychotic medications. Ladislav Hakovec, a neuropathology professor at the University of Prague, coined the word akathisia as a sign of hysteria or neurasthenia in 1901.

Although it is now considered a drug-induced syndrome, akathisia was unrelated to neuroleptic medicines until the 1950s. The foundation of this neuropsychiatric disorder is a subjective perception of mental uneasiness and dysphoria, along with a sense of restlessness that can occasionally drive impulsive behavior.

Types

Acute akathisia generally appears when antipsychotic medication is started. Chronic akathisia occurs when symptoms last longer than three months. Withdrawal akathisia can occur due to antipsychotic drug dosage reduction or discontinuation.

Persistent akathisia is particularly debilitating and frequently resistant to treatment. When a patient exhibits objective indicators of akathisia but is unaware of the typical subjective experience, this is called pseudo-akathisia.

If symptoms do not resolve within six weeks, or if a patient has a delayed onset of symptoms (1-3 months after starting treatment), it is known as tardive akathisia.

Cause and symptoms

Akathisia appears to be one of the most common and distressing drug-induced movement disorders, affecting approximately one in every four patients receiving first-generation antipsychotics (FGAs).

Risk factors for akathisia are age, ethnicity, and previous episodes of psychiatric conditions. There is an inverse link between age and antipsychotic-induced akathisia (AIA).

Children and adolescents are more vulnerable to akathisia than adults. Ethnicity is a potential risk factor for AIA, with Caucasians being less susceptible than other ethnic groups. Individuals experiencing their first episode of psychosis who have previously gone untreated with antipsychotic medications are most likely to develop akathisia.

Notably, patients with affective disorders, including bipolar depression, proved to be more vulnerable to AIA than people with schizophrenia. Patients with delirium, substance addiction, and those in palliative care settings were vulnerable to the development of AIA.

Patients usually experience a sense of restlessness and an urge to move. Patients will also experience objective pacing and rocking. Altering posture, indicating restlessness, is also common. Patients suffering from akathisia frequently experience distress and discomfort.

Epidemiology

The prevalence varies greatly. Akathisia is more common with first-generation, or typical, antipsychotics, particularly high-potency drugs like haloperidol, than with second-generation, or atypical, antipsychotics.

Case report

Salinas et al. described an unfavorable reaction following the second dosage of the COVID-19 vaccination. The patient is a 36-year-old Hispanic female who is right-handed and has a history of atopic dermatitis, allergic rhinitis, and anxiety. She tolerated the first dosage of the Pfizer-BioNTech vaccine well but had an unpleasant reaction to the second dose.

Approximately 12 hours after the injection, she began to experience what she called "restless body syndrome." There was no concomitant pain or sensory alteration. She developed a low-grade temperature, widespread myalgias, and nausea about five hours following the commencement of motor restlessness.

The remaining of her symptoms subsided about 24 hours after the vaccine was administered. This patient's motor restlessness and near-constant movement of the lower limbs and trunk are compatible with the phenomenology of akathisia.

This is the first report of transitory akathisia following the Pfizer/BioNTech COVID-19 vaccination at the time of submission.

Diagnosis and treatment

A comprehensive examination and diagnosis of akathisia might be difficult for various reasons. There is no universally accepted definition. There is no consensus on the importance of its subjective and objective components.

Furthermore, akathisia can have varying degrees of severity and a wide spectrum of non-specific motor characteristics. It can be commonly misdiagnosed. A minor case of akathisia can be misunderstood as psychotic agitation, leading to an increase in the dose of the offending medicine.

Other psychiatric diseases (acute psychosis, comorbid affective disorders, delirium) and psychotropic medicines, most commonly antidepressants, might co-occur or induce it.

AIA diagnosis is further complicated by daily fluctuations in its manifestation and its prevalent comorbidity with other extrapyramidal disorders (EPS), such as Parkinsonism and tardive dyskinesia.

The Barnes Akathisia Rating Scale (BARS) is now the most extensively used diagnostic instrument in clinical trials for diagnosing and assessing akathisia. This scale was developed 15 years ago due to research into the clinical aspects of antipsychotic-induced akathisia. Its validity and reliability were later proved, and it has been widely utilized in clinical research worldwide.

Acute akathisia is associated with several adverse clinical consequences, so early detection and treatment are critical. Substantial evidence shows that akathisia is related to poor treatment response and psychotic worsening. Acute akathisia is difficult to manage.

A main clinical goal is to adapt the antipsychotic drug regimen appropriately to avoid the development of akathisia. To reduce the risk of akathisia, a minimal effective dose of an antipsychotic, avoidance of rapid dose escalation, and polypharmacy are required.

To treat persistent akathisia, a gradual dose reduction or transition to an antipsychotic with a lesser propensity for causing akathisia is recommended.

Because of their non-specific anti-dysphoric and sedative actions, benzodiazepines may have some clinical usefulness in AIA. Nonetheless, clinical experience suggests that these benefits are insufficient to alleviate AIA. Adrenergic Agents like propranolol and clonidine can aid in relieving the symptoms.

Ritanserin has also been effective in patients with AIA who have failed to respond to standard anti-akathisia medicines (e.g., anticholinergics, benzodiazepines, and alpha-blockers). Mirtazapine at low doses was related to a quick and clinically significant improvement in akathisia ratings.

There are two basic therapeutic methods for acute AIA – changing the antipsychotic drug regimen and/or adding an anti-akathisia substance.

There are limited treatment options for akathisia. More large-scale, randomized controlled studies are required to assess prospective treatments for antipsychotic-induced akathisia, improving the evidence base and expanding therapy options.

References

• Patel J, Marwaha R. Akathisia. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519543/
• Salinas MR & Dieppa M (2021). Transient Akathisia after the SARS-Cov-2 vaccine. Clinical Parkinsonism & Related Disorders, 4, 100098. https://doi.org/10.1016/j.prdoa.2021.100098
• Chow CL, Kadouh NK, Bostwick, JR, & VandenBerg, AM (2020). Akathisia and Newer Second-Generation Antipsychotic Drugs: A Review of Current Evidence. Pharmacotherapy, 40(6), 565–574. https://doi.org/10.1002/phar.2404
• Poyurovsky M, & Weizman A (2020). Treatment of Antipsychotic-Induced Akathisia: Role of Serotonin 5-HT2a Receptor Antagonists. Drugs, 80(9), 871–882. https://doi.org/10.1007/s40265-020-01312-0
• Sienaert P, van Harten P & Rhebergen D (2019). The psychopharmacology of catatonia, neuroleptic malignant syndrome, Akathisia, tardive dyskinesia, and dystonia. Handbook of clinical neurology, 165, 415–428. https://doi.org/10.1016/B978-0-444-64012-3.00025-3
• Pringsheim T, Gardner D, Addington D, et al. (2018). The Assessment and Treatment of Antipsychotic-Induced Akathisia. Canadian journal of psychiatry. Revue Canadienne de Psychiatrie, 63(11), 719–729. https://doi.org/10.1177/0706743718760288
• Berna F, Misdrahi D, Boyer L, et al. … FACE-SZ (FondaMental Academic Centers of Expertise for Schizophrenia) group (2015). Akathisia: prevalence and risk factors in a community-dwelling sample of patients with schizophrenia. Results from the FACE-SZ dataset. Schizophrenia Research, 169(1-3), 255–261. https://doi.org/10.1016/j.schres.2015.10.04

Further Reading

• All Movement Disorder Content
• Movement disorders – What are movement disorders?
• Types of movement disorders
• Causes of movement disorders
• Symptoms of movement disorders