What Is Akathisia? Symptoms, Causes, Types, and Treatments for Feeling Restless

What Is Akathisia?

Akathisia, or acathisia, is a movement disorder in which patients experience inner restlessness, the urgent need to constantly move, and the inability to stand still or sit for a reasonable amount of time. This may cause the person to rock while sitting or standing, or lift their feet as if marching on the spot.

The name akathisia comes from the Greek word akathemi, which translates to “never sit down.”

Akathisia is a common side effect of antipsychotic drugs used to treat mental health conditions like schizophrenia and bipolar disorder. This is what is known as antipsychotic-induced acute akathisia, which affects 30% to 80% of those who take antipsychotic drugs. Akathisia also affects 20% of people on antidepressants.

In this article, we will delve deeper into the types, symptoms, and causes of akathisia. We will also discuss what medications may cause akathisia, how to diagnosis condition, and the conditions that some people often confuse with akathisia.

How do you treat akathisia? Read on to find out the conventional treatment for akathisia, as well as natural ways to manage the condition.

Are Restlessness and Akathisia the Same?

Feeling restless is not the same thing as having akathisia. What’s the difference?

Restlessness is simply the condition or state of being restless or the inability to be at peace, still, or quiet. Akathisia, on the other hand, is described as a torturous sensation of restlessness where the person is unable to be still or sit down, or remain seated or motionless.

As mentioned, this intense desire or need to move often involves muscle twitching, and is a common side effect of psychiatric or antipsychotic drugs.

Types of Akathisia

Akathisia can be classified into four different types. They all have the same causes and symptoms; however, the difference is when they begin. The following are the four types of akathisia:

• Acute akathisia: Acute akathisia, or antipsychotic-induced acute akathisia, will develop very soon after you start the antipsychotic drug, and it will last for less than a six-month period.
• Tardive akathisia: Tardive akathisia develops a few months or years after taking antipsychotics. Tardive means “something that appears late.”
• Chronic akathisia: This is any type of akathisia that lasts for more than six months.
• Withdrawal akathisia: This type usually sets in within six weeks of stopping or switching your antipsychotic medication. It is thought to be a withdrawal symptom of antipsychotics, antidepressants, or illegal drugs like opiates and cocaine.

What Are the Signs and Symptoms of Akathisia?

Akathisia affects cognitive function and motor control. This condition is most likely to affect movement of the hands, arms, legs, and trunk of the body. In general, there is a compulsive and uncontrollable urge to move the body, along with a sense of restlessness.

To find relief from this urge, the person will engage in particular repetitive movements, such as:

• Pacing
• Shifting weight from one leg to the other
• Rocking back and forth while sitting or standing
• Persistent fidgeting
• Walking in place
• Lifting the feet as if marching
• Shuffling while walking
• Uncrossing or crossing the legs or swinging one leg while sitting

On top of this, other akathisia symptoms include:

• Increased irritability
• Panic or tension
• Anxiety, depression, and even suicidal thoughts
• Impatience
• Restlessness and mental unease
• Rage, anger, and agitation
• Behavioral disturbances
• Fear and nervousness
• Trouble sleeping
• Appetite loss, nausea, and weight loss
• Slowed cognition
• Worsened psychotic symptoms and symptoms associated with insanity

What Causes Akathisia?

Akathisia is mainly a side effect caused by certain neurological medications. As noted, the condition can appear shortly after starting or switching to a new treatment, or when going through withdrawal from a prior drug. Certain other diseases like Parkinson’s or encephalitis, or having nutrient deficiencies, may also cause akathisia.

Akathisia is a drug-induced condition caused by:

• Antipsychotics (due to decreased dopamine signals)/antidepressants (due to increased serotonin signals): Akathisia is linked to decreased dopamine signals in the brain but can also be caused by increased serotonin signals. As a result, the condition sometimes appears as a side effect when taking antipsychotic or antidepressant medications, or during periods of drug withdrawal.
• Anti-nausea or anti-migraine medications: Certain migraine or anti-nausea medicines work similarly to these drugs and can also cause akathisia, though this is rare. It does not necessarily require the change or start of a drug to be a recent event in order for akathisia to manifest. Some cases arise shortly afterwards but others can take months to make themselves apparent.
• Drug withdrawal (cocaine, benzodiazepine, barbiturates, or opioids): When caused by withdrawal, symptoms appear in a matter of weeks.
• Selective serotonin reuptake inhibitors (SSRIs): Although not strictly a cause, SSRIs are known to aggravate existing akathisia cases.
• Other drugs: Can “Benadryl” cause akathisia? In extremely rare cases, it is possible, but most of those who have it were bipolar and taking the medication “Ativan.” Outside of these circumstances, it is very unlikely for “Benadryl” to cause the condition. Other drugs that may cause akathisia include calcium channel blockers, vertigo medications, and pre-surgical sedatives.
• Other causes: Other causes of akathisia include Parkinson’s disease, traumatic brain injury (TBI), and a type of brain inflammation called encephalitis. You are also at risk if you have a genetic predisposition to or family history of akathisia, as well as if you have a nutrient deficiency like vitamin D or iron.

List of Medications that Can Cause Akathisia

What specific drugs can lead to akathisia? It is thought that antipsychotic drugs block dopamine receptors in the brain, and dopamine is a chemical messenger that helps control movement.

At the same time, other neurotransmitters like serotonin, acetylcholine, and GABA (gamma-aminobutyric acid) may also play a role in akathisia.

First-generation antipsychotics linked with akathisia include:

• Flupenthixol (“Fluanxol”)
• Lurasidone (“Latuda”)
• Chlorpromazine (“Thorazine”)
• Loxapine (“Loxitane”)
• Haloperidol (“Haldol”)
• Fluphenazine (“Prolixin”)
• Molindone (“Moban”)
• Perphenazine (“Trilafon”)
• Thioridazine (“Mellaril”)
• Pimozide (“Orap”)
• Prochlorperazine (“Compazine,” “Compro”)
• Trifluoperazine (“Stelazine”)
• Thiothixene (“Navane”)

Neuroleptic drugs that may also cause akathisia include:

• Clozapine (“Clozaril”)
• Quetiapine (“Seroquel”)
• Ziprasidone (“Geodon”)
• Aripiprazole (“Abilify”)
• Olanzapine (“Zyprexa”)
• Risperidone (“Risperdal”)

Antidepressants can also cause akathisia, including:

• Fluoxetine (“Prozac”)
• Fluvoxamine (“Luvox”)
• Escitalopram (“Cipralex,” “Lexapro”)
• Citalopram (“Celexa”)
• Paroxetine (“Seroxat,” “Paxil”)
• Desvenlafaxine (“Pristiq”)
• Levomilnacipran (“Fetzima”)
• Sertraline (“Lustral,” “Zoloft”)
• Duloxetine (“Cymbalta”)
• Milnacipran (“Savella,” “Ixel”)
• Tofenacin (“Tofacine,” “Elamol”)
• Venlafaxine (“Effexor”)

Diagnosing Akathisia

It is important to consult your doctor if you suspect any of the akathisia symptoms listed above. The key in identifying drug-induced akathisia is to be on high alert for certain movements.

During your doctor’s visit, they will look for symptoms such as shuffling your legs, rocking back and forth while sitting, fidgeting, or tapping your feet.

The physical exam will also have you reveal what medications you take and details about your medical history. The doctor may also have you fill out a rating scale like the Barnes Akathisia Rating Scale, which serves as a tool for measuring the severity of your symptoms. This also tracks your progression during your akathisia treatment.

Your doctor will diagnose akathisia based on the different types. As mentioned, if your symptoms have lasted fewer than six months, your doctor will diagnose your condition as acute akathisia.

When they last more than six months, you’re looking at chronic akathisia. If symptoms arise a few months or years after you’ve begun taking a drug, this is tardive akathisia. Withdrawal akathisia will develop within six weeks after switching or stopping your antipsychotic.

Conditions Often Confused with Akathisia

You may also need further testing so your doctor doesn’t confuse akathisia with another condition. Dyskinesia, akathisia, tardive dystonia, and “parkinsonism” are all conditions classified as extrapyramidal syndromes (EPS). They are all similar and can appear together in the same patient.

People with akathisia may have a predisposition toward developing tardive dyskinesia. In other words, akathisia may sometimes evolve into tardive dyskinesia.

The most common condition your doctor may confuse with akathisia is tardive dyskinesia. Like akathisia, tardive dyskinesia is a side effect of antipsychotic drugs and it will cause repetitive movements.

What are the differences? Akathisia will involve voluntary movements, which means you are in control of them and you make the choice to relieve an urge with movement. But tardive dyskinesia is involuntary, characterized by repetitive, purposeless movements like grimacing and blinking.

Akathisia mostly involves your trunk or legs, while tardive dyskinesia will most often affect the arms and face.

Akathisia can also be masked by akinesia—a reduction of movement most often seen in Parkinson’s disease and sometimes with neuro-affective drugs.

Other conditions that can cause similar symptoms to akathisia include restless legs syndrome, insomnia, sleep deprivation, anxiety, agitated depression, mania, psychosis, ADHD (attention deficit hyperactivity disorder), sepsis, hyperthyroidism, hypoxia, head trauma, delirium, acute coronary event, hyponatremia, tics and Tourette syndrome, and alcohol or sedative withdrawal.

Treatments for Akathisia

With Akathisia being a drug-induced condition, treatment normally involves lowering the dose of an existing treatment, abandoning the drug entirely, or trying to switch to a new drug.

Unfortunately, if you are on an antipsychotic or an antidepressant, there is usually a reason for it and tinkering too much with the dosages can either result in further side effects or allow symptoms of the underlying psychiatric condition to become stronger.

If you have developed akathisia and are discussing possible treatments with your doctor, consult them on some of the following options:

• Dose adjustment: Scaling back any increase in dosages may alleviate the symptoms of akathisia. In the case of opioids or benzodiazepine withdrawal, raising the dose may help instead. Since there is likely a medical reason why your dose has been adjusted, care and consultation will be important to not only make sure that your symptoms are being reduced, but also that the drugs are having their intended effect.
• Switching prescriptions: Second-generation antipsychotic and antidepressants are still capable of causing akathisia, but seem to induce it more slowly than other treatments. You could consider asking your doctor about alternative drugs as a way to slow progression.
• Drug holidays: Going off your medication is never something you should do without your doctor’s express permission. Having said that, talk to your doctor about the possibility of skipping the drugs for a certain period to see if this helps ease symptoms. Ideally, time the “holiday” period for when this would cause the least disruption.
• Diet changes: Vitamin B6 is known to ease the symptoms of akathisia. The nutrient is found in most foods but is more prevalent in both meat and starches. Try eating more potatoes, turkey, or beef and see if your symptoms improve.
• Anticholinergics: These drugs are normally used to block certain neurotransmitters. They are usually employed to address digestive, respiratory, or sleep-related ailments, but have been known to help in some cases of akathisia. Anticholinergics can have side effects of their own, so you should ideally try at least one other treatment first before resorting to them.

Natural Ways to Manage Akathisia

How can you naturally manage akathisia? It can be as simple as making sure you get enough sleep; getting regular exercise; eating a healthy diet; managing stress, anxiety, or depression; or changing your medication or drug dosage when necessary.

The following is a deeper explanation of how to manage akathisia:

Keep your doctor informed

Your doctor should be aware of your medications, especially any you suspect may have caused your akathisia. If you experience suicidal thoughts or depression, you will want to get help right away. Monitoring your symptoms will help you avoid any sudden side effects associated with stopping your medications.

If your medication cannot be discontinued or your symptoms linger even after making dosage changes, your doctor may prescribe a different drug, such as Parkinson’s disease medications like amantadine, benzodiazepines, propranolol or other lipophilic beta-blockers, or antidepressants like trazodone or mirtazapine.

These drugs will help reduce akathisia symptoms, control blood pressure, and limit side effects that other mood-altering drugs may cause.

Manage stress

Is it possible to reduce your need for psychotic drugs, and therefore prevent akathisia? Try implementing a stress-reduction routine. This can include acupuncture, massage therapy, meditation, yoga, stretching, breathing exercises, regular exercise, reading or journaling, and taking a magnesium supplement or an adaptogenic herb like rhodiola and ashwagandha. You can also take essential oils such as chamomile, ylang ylang, bergamot, and lavender.

Prevent anxiety and depression

Depression and anxiety can increase your risk of akathisia. To prevent these mood-related conditions, it is a good idea to work with a doctor or counselor who offers cognitive behavioral therapy (CBT). This can help identify and alter troubling thoughts that lead to destructive behavior. Research shows that therapy and behavioral interventions can help reduce akathisia risk factors and symptoms once they have begun.

Joining a support group or group therapy class can also help prevent anxiety and depression. Furthermore, you will want to avoid recreational drugs or abusing prescription drugs, and be sure to get help from a therapist or counselor if you have a substance or drug abuse problem.

A healthy diet can also go a long way. Include healthy fats like wild-caught fish or coconut oil, high-fiber vegetables and fruits, and protein-rich foods like organic eggs and grass-fed poultry and meat. Also, limit your consumption of processed grains, sugar, refined vegetable oils, caffeine, and alcohol.

Treat restlessness and nausea

You should also address akathisia symptoms like restlessness, muscle spasms, appetite loss, and nausea. Vitamin B6 can help ease akathisia symptoms through its ability to affect neurotransmitter systems. Vitamin D and iron deficiencies are common with akathisia; therefore, getting more sunshine and iron-rich foods will be helpful. A magnesium supplement can also reduce twitching or other symptoms similar to restless legs syndrome.

Final Thoughts on Akathisia

Once diagnosed with akathisia, be sure to educate yourself on everything associated with the condition, including the symptoms. This will allow you to report them to your doctor immediately. Also, if you’ve experienced akathisia symptoms once, it is likely you will experience symptoms again.

Once you stop taking the medication that caused akathisia, your symptoms should disappear. However, others may still exhibit signs of akathisia despite stopping the medication.

It is always important to treat akathisia quickly because when untreated, psychotic behavior may worsen. Akathisia may also prevent you from taking certain drugs used for mental illness. Any new medication prescribed should be taken slowly, and always continue to update your doctor about your symptoms.