Akathisia: General Information

This is Akathisia

Akathisia is an extremely distressing neurological disorder characterized by severe agitation, an inability to remain still, and an overwhelming sense of terror. It is well known to cause suicide. Additionally, akathisia can cause aggression with violent and homicidal impulses, and is suspected to have played a role in certain mass shootings (Lucire, Crotty, 2011; Spingola, 2015).1,2

Although akathisia can occur in Parkinson’s disease, traumatic brain injury, and other neurological disorders, it is primarily medication induced. The most frequent offenders are antipsychotics, antidepressants, antibiotics, and anti-nausea medications; however, the list of medications and supplements that can cause it is very long. Akathisia is also common in benzodiazepine withdrawal, especially when discontinued too quickly after long-term use. It can also result from the withdrawal of opioids and drugs such as cocaine and amphetamines.

Akathisia most commonly occurs when starting, stopping, adjusting dosages, or changing medications. It is very likely to occur with abrupt discontinuation of any psychotropic medication after long-term use.

“There are two sides to akathisia. One is an outer, visible restlessness that you can observe, but the other, much more important one, is an extraordinary state of terror inside a person.” Joseph Glenmullen, MD

Signs and Symptoms

The following symptoms have been reported universally (regardless of whether it was caused by long-term use of a psychiatric medication or by one dose of a non-psychiatric medication in a person with no history of mental illness):

The most common symptoms are:

  • Intense physical restlessness with a need for constant movement. This may include pacing, rocking, leg swinging, foot tapping, hand wringing, shifting weight from one leg to the other, and general fidgeting.
  • An overwhelming sense of terror that may be described as a “chemical terror” much worse than any pre-existing anxiety
  • Extreme agitation, impatience, and irritability
  • A feeling of being “out of control”
  • A feeling often described as wanting to “jump out of my skin”
  • Racing thoughts with pressured speech
  • Suicidal and/or violent impulses

Other common symptoms include, but are not limited to:

  • Separation anxiety/monophobia and agoraphobia (a need to be near safe people and places at all times) (Forrest, Fahn, 1979; Atbasoglu, Schultz, Andreasen, 2001)3,4
  • Subjective physical sensations such as electrical zaps or an electrical current coursing through the body, buzzing or vibrating feeling, bugs crawling under the skin, burning sensation, etc.
  • Depersonalization-derealization – Feeling disconnected from the body, as if observing it from the outside, or a sense that the world is unreal, similar to living in a dream/nightmare (Glenmullen, 2006; Atbasoglu, Schultz, Andreasen, 2001)5,6
  • Vocal tics (throat clearing, sniffing, grunting, etc.)
  • Nonsuicidal self-harm (e.g., hitting, cutting)
  • Insomnia
  • Hypersensitivity to light and sound

Akathisia is often misdiagnosed as:

  • Worsening of a pre-existing mental illness
  • Emergence of a new mental illness
  • Functional neurological disorder (conversion, somatization, psychogenic, etc.)
  • Acute psychosis
  • Agitated depression
  • Psychomotor agitation
  • Generalized anxiety disorder
  • Panic disorder
  • Restless legs syndrome
  • Borderline personality disorder
  • Bipolar disorder
  • ADD/ADHD
In his book, Born to Run, Bruce Springsteen accurately describes the symptoms of akathisia, although he had been diagnosed instead with “agitated depression” (Springsteen, 2016)7:
“I had an attack of what was called an ‘agitated depression.’ During this period, I was so profoundly uncomfortable in my own skin that I just wanted OUT. It feels dangerous and brings plenty of unwanted thoughts. I was uncomfortable doing anything. Standing…walking…sitting down…everything brought waves of an agitated anxiety that I’d spend every waking minute trying to dispel. Demise and foreboding were all that awaited and sleep was the only respite.”

Akathisia Types

Akathisia can be classified with respect to duration:
  • Acute akathisia – lasts less than six months
  • Chronic akathisia – symptoms present for longer than six months, though they may be milder than at onset
And according to the nature of onset (Salem, Nagpal, et al., 2017)8:
  • Acute akathisia – develops within hours or days of starting, stopping, or changing the dose of a medication
  • Tardive akathisia – symptoms develop more than three months after starting, stopping, or changing the dose of a medication
  • Withdrawal or rebound akathisia – symptoms arise with discontinuation or a decrease in dosage, usually within six weeks (Qureshi, Cervantes, 2007; Sachdev, 1995).9,10
  • Interdose or end-of-dose akathisia – symptoms occur when a medication dose wears off and resolve with the next dose

Cause / Pathophysiology

One of Akathisia Alliance’s central goals is to help uncover the exact cause or pathophysiology of the condition – until this is better understood, treatment and prevention will remain problematic.Although researchers do not know the exact biological cause of akathisia, one current hypothesis explains it in terms of dysregulation within dopaminergic, cholinergic and/or serotonergic systems (Salem, Nagpal, et al., 2017).11We are currently setting up a website at journalofakathisia.com where a much more detailed discussion regarding the pathophysiology of akathisia and potential avenues for future research will take place.

Understanding Akathisia

Josh describes akathisia in a nutshell —

Anxiety vs. "Terror"

It would be difficult for anyone who has not had akathisia to understand the difference between anxiety and the “terror” of akathisia. Jennifer explains it well —

Descriptions

When asked to describe akathisia, patients gave the following very similar analogies —

“Take every horrific feeling you’ve ever had in your life, all at once. Now, times them by 200, right in your gut. The ‘my- mother- just- died- and- so- did- my- cat- and- my- wife- left- me- for- my- best- friend’ feeling. On top of those? A feeling of terror, panic, fear, as if you LIVE in a horror movie, and you must do something, or everyone you love will die, YOU will die — and you’ve no clue what that ‘something’ is. So sick with this pain, caused by this neurological condition… so sick from it you can barely eat. That is how akathisia pain feels. It’s how it feels to me, and countless others who are experiencing it, or who have.” ~ J.A. Carter-Winward

“I am incredibly anxious and almost completely consumed by a sense of terrified foreboding and/or danger. Even that feels physical, which I know doesn’t make any sense, but I don’t know how else to put it. I want to scream and shout and bang my head off the wall and stab myself and cry. Earlier, I considered going to the petrol station with a view to purchasing flammable liquid to set myself on fire. Extreme perhaps, but in a way I cannot explain, even the indescribable agony of burning seems preferable to the indescribable ‘somethingness’ of this.” ~ Anonymous

“It’s sheer terror, like I’ve been lit on fire or thrown out of an airplane without a parachute” – Laurie U

“An endless desire to die (often in the most savage manner imaginable), [a need] to escape the endless feeling of suffocation in your body and the depraved need to spontaneously combust that might stop you from using a knife to peel the skin from your body.” – Robert B

“…like being buried alive” – Jackie R

“…like the skin is being peeled off my body if my skin were inside me. It’s virtually impossible to describe, but there is no other feeling like it and there is no feeling worse than it.” – Alexandra

“…like being held up at gunpoint and watching my children being dangled off the Grand Canyon” – Jill S

“…like being trapped in a box and I can’t get out as I hear my babies crying for help while being tortured and killed.” – Cate K

Suicide in Akathisia vs. Depression

Although he did not have an official diagnosis of akathisia, author David Foster Wallace describes the difference between suicide due to akathisia and suicide due to depression in his book, “Infinite Jest” 12:

“The so-called ‘psychotically depressed’ person who tries to kill herself doesn’t do so out of quote ‘hopelessness’ or any abstract conviction that life’s assets and debits do not square. And surely not because death seems suddenly appealing. The person in whom its invisible agony reaches a certain unendurable level will kill herself the same way a trapped person will eventually jump from the window of a burning high-rise. Make no mistake about people who leap from burning windows. Their terror of falling from a great height is still just as great as it would be for you or me standing speculatively at the same window just checking out the view; i.e. the fear of falling remains a constant. The variable here is the other terror, the fire’s flames: when the flames get close enough, falling to death becomes the slightly less terrible of two terrors. It’s not desiring the fall; it’s terror of the flames. And yet nobody down on the sidewalk, looking up and yelling ‘Don’t!’ and ‘Hang on!’ can understand the jump. Not really. You’ d have to have personally been trapped and felt flames to really understand a terror way beyond falling.”

According to his widow, Karen Green, Wallace had been taking the antidepressant Nardil (phenelzine) for 20 years at the time this was written in 1996. He stopped taking it in 2007, as advised by his doctor, and quickly became very unstable. She recalls that “He was scared out of his mind” prior to his suicide in 2008.13

References

1. Lucire, & Crotty, C. (2011). Antidepressant-induced akathisia-related homicides associated with diminishing mutations in metabolizing genes of the CYP450 family. Pharmacogenomics and Personalized Medicine, 65. doi: 10.2147/pgpm.s17445

2. Spingola, D. (2015). Screening Sandy Hook: causes and consequences. Bloomington, IN: Trafford Publishing.

3. Forrest, D. V., Fahn, S. (1979) Tardive Dysphrenia and Subjective Akathisia. Journal of Clinical Psychiatry, 40(4):206

4.  Atbasoglu, E. C., Schultz, S. K., Andreasen, N. C. (2001) The Relationship of Akathisia with Suicidality and Depersonalization Among Patients with Schizophrenia. Journal of Neuropsychiatry and Clinical Neurosciences, 2001;13(3):336-41

5.  Glenmullen, J. (2006). The antidepressant solution: A step-by-step guide to safely overcoming antidepressant withdrawal, dependence, and “addiction”. New York, NY: Free Press.

6.  Atbasoglu, E. C., Schultz, S. K., Andreasen, N. C. (2001) The Relationship of Akathisia with Suicidality and Depersonalization Among Patients with Schizophrenia. Journal of Neuropsychiatry and Clinical Neurosciences, 2001;13(3):336-41

7. Springsteen, B. (2017). Born to Run. New York: Simon and Schuster

8. Salem, H., Nagpal, C., Pigott, T., & Teixeira, A. L. (2017). Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges. Current neuropharmacology, 15(5), 789–798. https://doi.org/10.2174/1570159X14666161208153644

9. Qureshi, S., Cervantes, L. (2007). Unhappy feet: one woman’s severe akathisia. Current Psychiatry, 6(10). Retrieved from https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/Document/September-2017/0610CP_Cases.pdf

10. Sachdev, P. (1995). The Epidemiology of Drug-induced Akathisia: Part II. Chronic, Tardive, and Withdrawal Akathisias. Schizophrenia Bulletin, 21(3), 451–461. doi: 10.1093/schbul/21.3.451

11. Salem, H., Nagpal, C., Pigott, T., & Teixeira, A. L. (2017). Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges. Current neuropharmacology, 15(5), 789–798.

12. Wallace, D. F. (1996). Infinite jest: a novel. Boston: Little, Brown

13. Adams, T. (2011). Karen Green: ‘David Foster Wallace’s suicide turned him into a “celebrity writer dude”, which would have made him wince.’ The Observer. Retrieved from https://www.theguardian.com/books/2011/apr/10/karen-green-david-foster-wallace-interview