Akathisia [Antipsychotic induced movement disorder]

Akathisia is a neuropsychiatric syndrome that can occur as an adverse effect of antipsychotic medications and manifests as psychomotor restlessness. In recent years, akathisia has additionally been found to occur in certain individuals as an adverse effect of with calcium channel blockers, antiemetics, anti-vertigo drugs, cocaine, and sedatives used in anesthesia. Akathisia is defined as an inability to remain still. It is a neuropsychiatric syndrome that is associated with psychomotor restlessness. The individual with akathisia will generally experience an intense sensation of unease or an inner restlessness that usually involves the lower extremities. This results in a compulsion to move. In most cases the movement is repetitive. The individual may cross, uncross, swing, or shift from one foot to the other. To the observer, this may appear as a persistent fidget.

Akathisia is frequently associated with the use of antipsychotics (neuroleptics), but it can also complicate the use of selective serotonin reuptake inhibitors (SSRIs). Other causes of akathisia include anxiety disorders, drug withdrawal or discontinuation states, early serotonin syndrome, restless legs syndrome, iron deficiency anemia and endocrinopathies. It is therefore important to find the underlying cause by identifying drug precipitants and associated psychopathology and excluding general medical causes. The pathophysiology of akathisia is not fully understood, but a combination of hypodopaminergic and hyperserotonergic neurotransmission may be implicated. This hypothesis is supported by the emergence of akathisia following the initiation of antipsychotics or SSRIs, but also from the observation that dopamine agonists can alleviate psychomotor agitation associated with restless legs syndrome

Akathisia can have a significant negative impact on quality of life and is associated with increased suicidality. Treatment of this distressing condition is difficult and treatment options are limited.

Antipsychotic-induced akathisia may be managed by reducing the dose of the offending agent or switching to an alternative antipsychotic agent. Beta-blockers such as propranolol and benzodiazepines have historically been used for the treatment of akathisia although the amount of high-quality data supporting their use is limited. Anticholinergic agents such as benztropine may be utilized if concomitant pseudoparkinsonism is present. Mirtazapine may also be utilized for the management of akathisia. Low-dose mirtazapine has been found to be as effective as beta-blockers and may be considered first-line therapy.

When using beta-blockers, clinicians should be aware of the risk of bradycardia and hypotension. Many other agents, including vitamin B6, have been used to treat akathisia, but there are no randomized controlled trials to determine their efficacy

Antipsychotic-induced akathisia may be managed by reducing the dose of the offending agent or switching to an alternative antipsychotic agent.

Beta-blockers such as propranolol and benzodiazepines have historically been used for the treatment of akathisia although the amount of high-quality data supporting their use is limited.

Anticholinergic agents such as benztropine may be utilized if concomitant pseudoparkinsonism is present.

Unfortunately, once akathisia has developed it can take months for the disorder to subside. Case reports exist indicating that this movement disorder also increases the risk of suicidality. Hence, all patients with akathisia need to be closely monitored and the family should be educated about the impact of akathisia

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