Akathisia – A Quick Reference

About Akathisia

Akathisia is an extremely distressing neurological disorder that is most often a medication side effect or withdrawal syndrome. It is characterized by severe agitation, an inability to remain still, and an overwhelming sense of terror, and it is so torturous that it can lead to impulsive suicide and violence.

Please watch this 1-minute video to better understand the severity of akathisia.1

Key Points

  • “Akathisia is generally either underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as poor adherence to medications, exacerbation of psychiatric symptoms, and, in some cases, aggression, violence, and suicide” (Lohr, et al., 2015).2
  • “Akathisia is likely underdiagnosed because its symptoms often mimic or overlap psychiatric disorders like psychosis, mania, attention deficit hyperactivity disorder, or agitated depression” (Patel, Marwaha, 2022).3
  • “Psychiatric drugs were used by the Soviet Union in the Gulag to induce akathisia as a form of torture” (Glenmullen, Akathisia Alliance, 2019).4
  • Dismissal of a self-diagnosis with subsequent administration of a contraindicated medication, acceleration of a tapering rate, or abrupt discontinuation of a psychotropic medication could severely exacerbate akathisia.

Medications That Can Cause or Worsen Akathisia

The list below should not be used as a means of ruling out akathisia on the basis that a patient is not taking, or has not recently taken, any of these medications. There are published and anecdotal reports of akathisia due to many other pharmacological and non-pharmacological agents, and akathisia can persist for many years after an offending medication is discontinued.5
The medications that most commonly cause or exacerbate akathisia are listed below, including all antipsychotics and antiemetics that deplete dopamine as well as most classes of antidepressants as they can indirectly do this as well.6,7Although low-dose mirtazapine is often listed as a potential treatment for akathisia, it is included because there are several published cases of mirtazapine-induced akathisia.8As there are published cases of akathisia induced by calcium channel blockers,9 certain antibiotics (fluoroquinolones,10 macrolides,11 and tetracyclines12), lithium,13 gabapentin,14 and pregabalin,15 they are also included.
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Benzodiazepines and Akathisia

Although there is little peer-reviewed literature regarding akathisia in benzodiazepine withdrawal, there are thousands of support group members with akathisia due abrupt discontinuation or rapid tapering, the majority of whom had taken the medication as prescribed.

It is well known in the support groups that benzodiazepine interdose or end-of-dose akathisia is very common in dependent individuals. In this case, patients taking benzodiazepines who appear agitated while demanding this medication may only appear to be drug-seeking because they are attempting to ward off escalating akathisia.

Treating Akathisia

Please review the literature below for more information about akathisia and how to treat it.16

Full Text PDF:  https://sci-hub.se/10.1017/S1092852915000838

References

1. Akathisia Alliance for Education and Research. (2022, December 7). Drug-Induced Akathisia is a Suicide-Prevention Emergency [Video]. YouTube. https://www.youtube.com/watch?v=dDpr-FRRdFA

2. Lohr JB, Eidt CA, Abdulrazzaq Alfaraj A, Soliman MA. The clinical challenges of akathisia. CNS Spectr. 2015 Dec;20 Suppl 1:1-14; quiz 15-6. doi: 10.1017/S1092852915000838. PMID: 26683525.

3. Patel J, Marwaha R. Akathisia. 2022 Jul 25. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 30137828.

4. Akathisia Alliance for Education and Research. (2019e, August 26). Akathisia is Torture [Video]. YouTube. https://www.youtube.com/watch?v=_6eix3cdwoU

5. Burke RE, Kang UJ, Jankovic J., Miller LG, Fahn S. Tardive akathisia: an analysis of clinical features and response to open therapeutic trials. Mov Disord. 1989;4(2):157-75. doi: 10.1002/mds.870040208. PMID: 2567492.

6. Zubenko GS, Cohen BM, Lipinski JF Jr. Antidepressant-related akathisia. J Clin Psychopharmacol. 1987 Aug;7(4):254-7. PMID: 3624508.

7. Ak, S., & Anıl Yağcıoğlu, A. E. (2014). Escitalopram-induced Parkinsonism. General hospital psychiatry, 36(1), 126.e1–126.e1262. https://doi.org/10.1016/j.genhosppsych.2013.09.010

8. Rissardo JP, Caprara ALF. Mirtazapine-associated movement disorders: A literature review. Tzu Chi Med J. 2020 Jul 13;32(4):318-330. doi: 10.4103/tcmj.tcmj_13_20. PMID: 33163376; PMCID: PMC7605300

9. Jacobs MB. Diltiazem and akathisia. Ann Intern Med. 1983 Dec;99(6):794-5. doi: 10.7326/0003-4819-99-6-794. PMID: 6651024.

10. Owusu Aboagye G, Ankrah D. Drug-Drug-Induced Akathisia: Two Case Reports. Case Rep Psychiatry. 2020 Apr 23;2020:9649483. doi: 10.1155/2020/9649483. PMID: 32373382; PMCID: PMC7196143.

11. Riesselman A, El-Mallakh RS. Akathisia with azithromycin. Ann Pharmacother. 2015 May;49(5):609. doi: 10.1177/1060028015570728. PMID: 25870444.

12. Healy, D. (2021, November 22). Mentally Hijacked by Doxycycline RxISK. https://rxisk.org/mentally-hijacked-by-doxycyline/

13. Demir B, Sancaktar M, Altindag A. Lithium-Induced Treatment-Resistant Akathisia: A Case Report and Literature Overview. Clin Neuropharmacol. 2021 May-Jun 01;44(3):112-113. doi: 10.1097/WNF.0000000000000453. PMID: 33811193.

14. Tuccori M, Lombardo G, Lapi F, Vannacci A, Blandizzi C, Del Tacca M. Gabapentin-induced severe myopathy. Ann Pharmacother. 2007 Jul;41(7):1301-5. doi: 10.1345/aph.1K077. Epub 2007 Jun 12. PMID: 17565043.

15. Rissardo JP, Caprara ALF. Pregabalin-associated movement disorders: A literature review. Brain Circ. 2020 Jun 26;6(2):96-106. doi: 10.4103/bc.bc_57_19. PMID: 33033779; PMCID: PMC7511912

16. Lohr JB, Eidt CA, Abdulrazzaq Alfaraj A, Soliman MA. The clinical challenges of akathisia. CNS Spectr. 2015 Dec;20 Suppl 1:1-14; quiz 15-6. doi: 10.1017/S1092852915000838. PMID: 26683525.