Akathisia is a neurological condition characterized by an intense, inner sense of restlessness and a compulsion to move. This subjective feeling of unease is often accompanied by objective signs of motor restlessness, such as pacing, rocking while sitting, or constantly shifting weight from one foot to the other.
Understanding the Types and Causes of Akathisia
Akathisia is primarily categorized by when it appears in relation to medication use, which helps predict its duration. It is most commonly induced by medications that block dopamine receptors in the brain, often used to treat mental health conditions. While antipsychotics are the most frequent cause, certain antidepressants, anti-nausea drugs, and calcium channel blockers can also trigger the syndrome.
Acute akathisia begins soon after a drug is started or the dose is increased, typically within the first few weeks, and lasts for less than six months. Chronic akathisia is diagnosed when symptoms persist for six months or longer.
Withdrawal-emergent akathisia appears when a causative drug is suddenly stopped or its dose is significantly reduced, often emerging within six weeks of the change. Tardive akathisia is a late-onset form that develops after months or years of medication exposure.
The Expected Duration Based on Classification
Acute akathisia generally has the most favorable outlook, with symptoms often resolving within hours to days once the drug dose is lowered or the medication is stopped entirely.
If symptoms continue past the six-month mark, the condition is classified as chronic akathisia. Tardive akathisia and withdrawal-emergent akathisia represent the most persistent forms.
Tardive akathisia, in particular, can be highly stubborn, sometimes lasting for years even after the causative medication has been discontinued. The average duration reported for this late-onset form can be around 2.7 years, with some cases persisting even longer.
What Influences the Severity and Persistence
The dosage of the causative medication is a major factor, with higher doses and rapid increases significantly predisposing a person to developing more severe and potentially chronic symptoms. High-potency first-generation antipsychotics also carry a greater risk of inducing persistent akathisia compared to many newer agents.
The time it takes for a healthcare provider to recognize and intervene is a strong predictor of the condition’s trajectory. Delayed recognition or misdiagnosis as anxiety or agitation can lead to the inappropriate escalation of the causative drug, which intensifies the symptoms and increases the risk of the condition becoming chronic or tardive.
Older adults, for instance, are more susceptible to developing akathisia as a side effect of certain medications. Underlying neurological conditions or the simultaneous presence of other drug-induced movement disorders can also complicate the presentation and management, increasing the likelihood of long-term symptoms.
Managing Akathisia Through Treatment
The first step in managing medication-induced akathisia is to reduce the dose of the offending drug or, if medically appropriate, switch to an alternative medication with a lower risk profile. This must be done carefully and only under the supervision of a healthcare provider to avoid withdrawal-emergent symptoms or relapse of the underlying condition.
When dose reduction or switching is not possible, specific pharmacological interventions are used to control the motor symptoms and subjective distress. Beta-blockers, such as propranolol, are commonly prescribed to reduce the motor restlessness. Low-dose mirtazapine, a type of antidepressant, has also shown effectiveness in reducing the severity of akathisia.
Other classes of medications used include benzodiazepines, which may help reduce anxiety and agitation, and anticholinergic agents, which are sometimes added, particularly when other movement symptoms are present. For the most challenging and persistent forms, such as tardive akathisia, specialized approaches may be necessary. Supportive care, including managing the extreme anxiety and dysphoria that often accompany the inner restlessness, is important for overall management.