The Problem

Although akathisia is a true neuropsychiatric disorder and an ideal model for collaboration between neurology and psychiatry, to date there has been very limited joint research in its regard. The disconnection between the two in the clinical setting is perhaps even more troubling. 

When patients with sudden-onset akathisia present to neurology, they may be distraught, pleading for help, and adamant their condition is neurological. Due to their anxious appearance and distractible/suppressible movements, however, they are most often diagnosed as psychogenic and referred to psychiatry. If they are unwilling to accept the diagnosis, this scenario can recur repeatedly and ultimately lead to hopelessness, loss of family support and significantly worsened suicidality. It is, however, a practice that can be challenged scientifically, as noted by Ellenstein, Kranick, and Hallett in “An Update on Psychogenic Movement Disorders” (2011) [1]:

Psychogenic movement disorders (PMD) and other conversion disorders (CD) with apparent neurologic signs (neurologic CD) plague patients and perplex physicians. Due to a lack of objective evidence of underlying brain lesions, CD were largely abandoned by neurologists and remained poorly understood psychiatric diagnoses throughout most of the 20th century. Modern neuroscience now supports increasingly comprehensive biological models for these complex disorders, definitively establishing their place in both neurology and psychiatry.  Although it is often clinically useful to distinguish a movement disorder as either “organic” or “psychogenic,” this dichotomy is difficult to defend scientifically.    

This was also addressed by Wilshire and Ward in “Psychogenic Explanations of Physical Illness, Time to Examine the Evidence” (2016) [2]: 

Clearly, psychological causation cannot be demonstrated by the mere absence of a confirmed disease diagnosis (argument from ignorance). Medical practitioners simply cannot assume that the current knowledge of disease and its markers is 100% perfect or that all complaints not otherwise accounted for must have a psychological origin. It is commonly assumed that any physical complaint without a medical explanation must reflect somatization. Given our current incomplete understanding of disease, this assumption is difficult to justify….We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In the future, researchers need to take a wider view concerning the etiology of these illnesses. 

The Solution - Collaborative Research

As stated by Joseph Glenmullen, MD, “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” (2019) [3]. Many published case reports support this statement. Consequently, collaboration between neurology and psychiatry may be necessary to significantly advance research regarding akathisia. Considering it has been reported in up to 68% of Parkinson’s patients (Lang, Johnson, 1987) [4], this collaborative effort may advance Parkinson’s research as well.  

How the Akathisia Alliance Can Help

The Akathisia Alliance has a database of patients who are willing to participate in studies that do not involve a drug trial. This database includes patients who got akathisia from one dose of a non-psychiatric medication, had no history of mental illness, had never taken a psychiatric medication, and were not taking any other medications at the onset of akathisia. Because akathisia is often misdiagnosed as exacerbation of a preexisting mental illness, research involving these specific patients may eliminate this confounding factor and help define akathisia, determine its pathophysiology, uncover a genetic predisposition, and identify potential treatments.

Coming soon - Journal of Akathisia

The Journal of Akathisia will contain peer-reviewed case reports, reviews of literature, and informal data obtained through patient questionnaires and diagnostic studies. We will solicit and publish peer reviews in a transparent process and welcome letters to the editor.

References

1. Ellenstein, A., Kranick, S. M., & Hallett, M. (2011). An Update on Psychogenic Movement Disorders. Current Neurology and Neuroscience Reports, 11(4), 396–403. doi: 10.1007/s11910-011-0205-z

2. Wilshire, C. E., & Ward, T. (2016). Psychogenic Explanations of Physical Illness. Perspectives on Psychological Science, 11(5), 606–631. doi: 10.1177/1745691616645540

3. Akathisia Alliance for Education and Research (2019, August 26). Akathisia is torture. [Video]. YouTube. https://youtu.be/_6eix3cdwoU

4. Lang, A. E., & Johnson, K. (1987). Akathisia in idiopathic Parkinson’s disease. Neurology, 37(3), 477-477. doi: 10.1212/wnl.37.3.477