Akathisia

Akathisia (IPA: /æ.kə.ˈθɪ.si.ə/) is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their body. The most severe cases may result in poor adherence to medications, exacerbation of psychiatric symptoms, and, because of this, aggression, violence, and/or suicidal thoughts. Akathisia is also associated with threatening behaviour and physical aggression in mentally disordered patients. However, the attempts to found potential links between akathisia and emerging suicidal or homicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. Apart from these few low-quality studies, there is another more recent and better quality study (a systematic review from 2021) that concludes «akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication».

Antipsychotic medication, particularly the first generation antipsychotics, are a leading cause. Other agents commonly responsible for this side-effect may also include selective serotonin reuptake inhibitors, metoclopramide, and reserpine, though any medication listing agitation as a side effect may trigger it. It may also occur upon stopping antipsychotics. The underlying mechanism is believed to involve dopamine. When antidepressants are the cause, there is no agreement regarding the distinction between activation syndrome from akathisia. Akathisia is often included as a component of activation syndrome. However, the two phenomena are not the same since the former, namely antipsychotic-induced akathisia, suggests a known neuroreceptor mechanism (e.g., dopamine-receptor blockade). Diagnosis is based on the symptoms. It differs from restless leg syndrome in that akathisia is not associated with sleeping. However, despite a lack of historical association between restless leg syndrome and akathisia, this does not guarantee that the two conditions do not share symptoms in individual cases.

Treatment may include switching to an antipsychotic with a lower risk of the condition, if the akathisia was caused by an antipsychotic. The antidepressant mirtazapine has demonstrated benefit, as well as diphenhydramine, trazodone, benzatropine, cyproheptadine, and beta blockers, particularly propranolol.

The term was first used by Czech neuropsychiatrist Ladislav Haškovec, who described the phenomenon in 1901 long before the discovery of antipsychotics, with drug-induced akathisia first being described in 1960. It is from Greek a-, meaning "not", and καθίζειν kathízein, meaning "to sit", or in other words an "inability to sit".