Akathisia can be caused by antipsychotics but also by other medications such as antidepressants. Of all of the drug-induced movement disorders, akathisia causes the most hindrance. The feeling of restlessness  can  be  very unpleasant  and  is  sometimes  underestimated by practitioners or loved ones. Akathisia usually begins within two weeks after starting or increasing antipsychotics and regularly as early as a few hours to a few days.

Akathisia

Akathisia literally means ‘not being able to sit still.’

The central symptom is the inner restlessness (the subjective symptom). The (leg) movements (the objective symptoms) are a consequence of this. The inner restlessness  is often experienced in the legs.

Patients describe this in many ways: ‘restless’, ‘tense’, ‘cannot sit still’, ‘nervous’, ‘must move’, or ‘can no longer concentrate’. Sometimes the patients complain of irritability or dysphoria. Dysphoria refers to a mood of general unwellness, an angry, irritable, restless feeling and severe akathisia is almost always accompanied by dysphoria. Dysphoria that occurs after the  onset of antipsychotics can  precede akathisia but can also occur without akathisia.

Two sensitive questions are: “Do you feel restless?” And “Is it difficult for you to sit still?”. A negative answer to both questions makes akathisia unlikely (For further research on akathisia see the movement disorders research).

The severity of the akathisia often changes during the day.

Certain movements indicate akathisia.

For example, in a seated position you can see:

  • repeatedlystriking one leg over the other at the ankles or knees;
  • repeatedly moving a crossed leg over the other leg;
  • wobbling of the legs, kicking with the feet;
  • turning the foot downwards or upwards;turn the ankles inwards and outwards.

In a standing position you can see:

  • walking in place;
  • kicking with the legs;
  • repeatedly shifting weight from one leg to the other, or in a lighter form alternately contracting the calf muscles.

Lying down reduces the restlessness as well as leg movements.

Publications

Chow CL, Kadouh NK, Bostwick JR, VandenBerg AM. Akathisia and Newer Second-Generation Antipsychotic Drugs: A Review of Current Evidence. Pharmacotherapy 2020.

Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. Handb Clin Neurol 2019; 165: 415-28.

Yoshimura B, Sato K, Sakamoto S, Tsukahara M, Yoshimura Y, So R. Incidence and predictors of acute akathisia in severely ill patients with first-episode schizophrenia treated with aripiprazole or risperidone: secondary analysis of an observational study. Psychopharmacology (Berl) 2019; 236(2): 723-30.

Harten PN. Acathisie als bijwerking van geneesmiddelen. Ned Tijdschr Geneeskd 2002; 146: 110-4.