Akathisia - A Medical Alert

Key Points

Akathisia is a life-threatening neurological disorder characterized by extreme agitation, an inability to remain still, and an overwhelming sense of terror.

Akathisia is so torturous that there is a well-documented high risk of impulsive suicide.

Akathisia is NOT a mental illness. It is most often a side effect of psychotropic medications or withdrawal syndrome. This is a crucial distinction because diagnosing akathisia as a mental illness instead and treating the patient with an antipsychotic, antidepressant, or any dopamine-depleting agent would likely cause severe exacerbation of the patient’s condition.

Akathisia has been misdiagnosed for many decades (Lohr, et al., 2015)1: 

Akathisia is generally underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as exacerbation of psychiatric symptoms, aggression, violence, and suicide.

How you can help

Listen and believe. Whether or not this patient has a recorded diagnosis of akathisia, they may be wearing a medical alert bracelet because they have been misdiagnosed and subsequently mistreated in the past. If they feel threatened that they will be involuntarily hospitalized and force-drugged with a psychotropic medication, they could become significantly more agitated.

Do not ignore the medical alert warnings. With the high risk of suicide, please do not dismiss a self-diagnosis, administer a dopamine-depleting medication, such as those listed below, abruptly discontinue a medication, or accelerate a tapering schedule.

Remain calm and reassuring. As akathisia itself causes an overwhelming sense of terror, it is important that the patient feels safe. By calmly reassuring that you believe them and will heed the warnings on their medical alert bracelet, they will become much less agitated and easier to manage.

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.2

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.3,4

Although 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.5

As there are published cases of akathisia induced by calcium channel blockers,6 certain antibiotics (fluoroquinolones,7 macrolides,8 and tetracyclines9), lithium,10 gabapentin,11 and pregabalin,12 they are also included.

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 to 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 increasing akathisia. Treating this patient with their current dose of the benzodiazepine and resuming a tapering schedule will de-escalate the situation.

Treating Akathisia

For more information, click here to read the full-text of “The Clinical Challenges of Akathisia” 


1. 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.

2. 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.

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

4. 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

5. 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

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

7. 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.

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

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

10. 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.

11. 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.

12. 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

13. 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.