The word “akathisia” comes from Greek and means inability to sit. This condition, consists of a set of both objective and subjective symptoms of motor restlessness. The disease makes remaining motionless almost impossible. The need to constantly move becomes so strong that it makes it difficult to focus on basic activities. It often causes anxiety as well as restlessness.
Find out more about akathisia, learn about the causes of this condition and treatments for akathisia.
Unusual symptom. What is akathisia?
Akathisia is a set of symptoms of motor restlessness, accompanied by an unpleasant feeling in the muscles. It is characterized by aimless movement of the upper and lower limbs, changes in position, and walking and standing up. A person who is affected by akathisia is unable to sit still, stands up and sits down, transgresses from foot to foot, straightens his legs, bends them, sways his feet. It is often combined with a condition such as tazkinesia, which manifests as a compulsion to walk. Akathisia is recognized as an adverse symptom of therapy with various types of drugs, most commonly neuroleptics, or antipsychotics. It is often confused with restless legs syndrome.
The concept of akathisia was introduced in 1901 by Ladislav Haškovec, a Czech neuropathologist and neuropsychiatrist at Prague University. At that time, however, akathisia was linked to neurological diseases such as Parkinson’s disease. Only later, with the advent of new first-generation psychiatric drugs, did akathisia also begin to be defined as a side effect of taking them. Akathisia is one of the most commonly observed extrapyramidal side effects occurring after taking antipsychotics and antidepressants. The International Classification of Diseases IDC-10 does not list akathisia as a separate disease entity. It is in the group of other drug-induced secondary parkinsonism.
Akathisia – symptoms
The symptoms of akathisia are due to disturbances in neurotransmission. It is also believed that akathisia may be associated with iron deficiency and craniocerebral trauma. Akathisia is not only associated with distressing motor symptoms. Motor restlessness can also be associated with other bothersome symptoms from the body.
Akathisia symptoms:
- Various types of leg movements while sitting.
- Swinging movement of the leg when one is placed on top of the other.
- Constant restless walking, often on the spot.
- Stepping from one leg to the other while standing.
- While sitting, frequent rocking in a chair.
- Difficulty or complete inability to stand still in one place for a minimum of several minutes.
- Anxiety often severe, feelings of restlessness, anxiety attacks, panic attacks.
- Nervousness, irritability, emotional unsteadiness.
- A feeling of movement described as crawling, worm-like, inside the limbs.
- Problems falling asleep.
- A feeling of itchy skin on the legs.
- A feeling of tingling in the limbs; see paresthesias
- Tension is sometimes also localized outside the limbs, for example: neck, abdomen, chest.
- Lack of concentration, especially when reading books, studying, or even watching TV.
Diagnosis of akathisia
The diagnosis of akathisia is quite a diagnostic challenge. To diagnose akathisia, at least one of the following symptoms must be confirmed:
- Inability to sit or stand in one place for a period of several minutes,
- Restless or swinging leg movements that occur while sitting,
- Walking in place to relieve tension,
- Stepping from one leg to the other while standing or walking, putting leg over leg, bending legs, moving feet.
There is a Barnes Akathisia Scale through which a doctor can assess the severity of akathisia. Various extrapyramidal symptom scales are also used to assess the symptoms of akathisia. Crucial in the diagnosis of akathisia is the recognition of the relationship between the symptoms and the drug treatment being used. It is also important for the doctor to be aware that akathisia can be confused with the severity of the symptoms of the primary psychiatric disorder, which can lead to an inappropriate increase in the dose of the drug causing the akathisia.
Drug-induced akathisia
Drug-induced akathisia is often confused with other types of disorders such as psychomotor agitation, restless legs syndrome, or irritability. It can lead to inappropriate therapy decisions and difficulties with the sufferer’s rapid recovery. It is most often a side effect of antipsychotic drugs . It can also occur after antidepressants, especially those in the SSRI group
The mechanism of drug-induced akathisia probably, related to an imbalance of neurotransmitters, mainly dopamine and serotonin.Taking a particular group of drugs by a patient should be an indication of the doctor’s diagnosis of akathisia.
What are the types of akathisia?
Due to the time of use of the drug, in which drug-induced akathisia manifests itself most often, we can distinguish it into several types.
- Early-onset akathisia – occurs most quickly, just a few hours to a few days after taking medication. However, it most often appears between the second and sixth weeks of treatment.
- Acute akathisia – lasts as long as the patient takes the drugs that cause it.
- Late akathisia – appears after at least three months of treatment. It does not involve raising the dose of the drug. It is the most difficult to diagnose.
- Chronic akathisia – this is the form in which the symptoms of akathisia persist for at least three months and longer.
There is also pseudo akathisia, which is characterized by the occurrence of only objective motor symptoms, without subjective sensations.
Akathisia – the causes of the development of this condition. Drugs that potentially cause akathisia.
Akathisias are most often diagnosed in the course of treatment of schizophrenia with neuroleptic drugs. Drug-induced akathisia occurs in as many as 20-50% of people who take neuroleptic drugs. The occurrence of akathisia is closely related to the dose of the drug, taking classic drugs with high potency, and occurs much less frequently with atypical drugs. The risk of akathisia increases as the dose of a neuroleptic drug increases rapidly. It most often affects middle-aged women, and the elderly.
Akathisia can also occur after discontinuing a neuroleptic. So-called withdrawal akathisia often occurs. It results from the withdrawal or reduction of the dose of the drug that serves to control extrapyramidal symptoms during neuroleptic therapy. Such akathisia can manifest itself up to six weeks after the reduction of such a drug. Akathisia most often occurs in a person treated with first-generation neuroleptic drugs for a long time. Sometimes, however, akathisia can also appear in a person who is treated with serotonin reuptake inhibitors – used, for example, for depression. Other conditions that are treated with drugs whose side effect can be akathisia are: neurosis, bipolar disorder and other affective disorders such as psychotic depression. There are other chemical groups of drugs besides neuroleptics and serotonin reuptake inhibitors that can lead to akathisia. These include:
- metoclopramide – used, for example, for nausea and vomiting,
- reserpine – prescribed for the treatment of hypertension,
- calcium channel antagonists – drugs that slow down heart action ora reduce blood pressure,
- pemoline – a drug for ADHD and narcolepsy,
- dopamine agonists – used to treat Parkinson’s and Restless Legs Syndrome,
- buspirone – used to treat anxiety disorders and depression,
- apomorphine – aids in the treatment of alcohol addiction, reduces Parkinson’s symptoms, and sedates,
- amphetamine – a substance with stimulating, intoxicating and euphoric effects,
- ethosuximide – used as an antiepileptic drug with anticonvulsant effects.
The symptoms associated with akathisia are due to disturbances in relaying:
- serotonergic – is responsible for the regulation of sleep and various emotions.
- noradrenergic – is responsible for accelerating information processing in memory.
- dopaminergic – this system is responsible for regulating emotions and motor skills, among other things.
Akathisia – treatment of motor anxiety
Implementation of therapy that will be appropriate, requires a thorough physical examination of the affected person, and diagnosis with differential diagnosis. The most common treatment for drug-induced akathisia, is to reduce the dose of the drug that caused it. It is also used to completely discontinue treatment with this drug for one or several days, after which time a drug from another chemical group is introduced. Another option is to gradually wean off the dose of the drug, since abruptly stopping treatment in some people can exacerbate symptoms. Anticholinergic drugs were once thought to be effective in treating akathisia, but today’s research indicates they have little efficacy. Their use is indicated only when other extrapyramidal symptoms are present. In emergencies, benzodiazepines can be used for a short period of time. However, they cause short-term improvement and can lead to addiction. In the chronic treatment of akathisia, betablockers such as propranolol, metoprolol and others are often used. They have been observed to have as much as a 75% success rate in treating akathisia. Currently, betablockers are most often the first-line treatment for akathisia. However, they are discouraged in patients who have naturally low blood pressure, suffer from drug-induced parkinsonism, or have unstable diabetes. Some studies indicate that dopaminergic drugs from the MAO inhibitor group are highly effective in treating akathisia. These include selegiline particularly credited with treating persistent akathisia, and moclobemide. Other known medications effective in treating akathisia are bromocriptine, zolmitriptan, mianserin, diphenhydramine, amantidine, cyproheptadine, mirtazapine, amitriptyline, ritanserin and trazodone. When treating akathisia that is persistent and the patient has anxiety and agitation, clonidine is recommended. Some point to the effectiveness of iron supplementation and vitamins C, E and B6 in treating akathisia. There is a distinguished several-step process for treating akathisia, it looks like this:
- Changing the drug that caused the akathisia to clozapine or quetiapine,
- Trial treatment with an antimuscarinic drug,
- Trial treatment with propranolol,
- Trial treatment with cyproheptidine,
- Trial treatment with benzodiazepine,
- Trial therapy with clonidine.
According to the algorithm, in case of ineffective treatment with a particular group of drugs, they should be discontinued and treatment should be started with drugs from the next listed stage. The effectiveness of therapy with a particular drug should be judged only after a month of therapy. Unfortunately, there is currently no single effective drug that will cure akathisia. Therefore, further research and the search for a suitable drug is desirable.
Does akathisia pass?
It should be noted that the prognosis for akathisia is nevertheless rather good. With proper and well-chosen therapy, the symptoms, or part of them, can disappear even after a few days. However, it happens that akathisia will take on a chronic form, and this can persist even for months. A drug that works for one person may show no effect on another. Sometimes therapy can be prolonged, as it can take several months to match a drug that works. Therefore, it is not easy to concretely answer the question of how long akathisia lasts, because each case is different and should be considered individually. It all depends on prompt recognition and the initiation of appropriate therapy. A special problem is that in some patients, complete withdrawal of antipsychotic drugs is out of the question. In this case, the doctor must effectively replace the drug that caused akathisia with another drug that will not cause it. It is important to do any modification of treatment under the doctor’s supervision, changing treatment without the doctor’s knowledge can carry the danger of other side effects and even loss of health and life. Therefore, if you suspect akathisia, report it to your doctor as soon as possible.
Summary
Akathisia, or the compulsion to move, is one of the more troublesome side effects of the medications used. It sometimes makes it difficult to function normally or even to perform basic activities. It is also associated with other unpleasant discomforts such as anxiety, restlessness and sleep problems. It can affect not only people who are taking antipsychotic drugs, but also those being treated for depression or affective disorders. When treating psychotic symptoms, cognitive-behavioral therapy can be supportive. It is worth noting that CBT in the treatment of psychotic symptoms is usually used as an adjunct to, rather than an alternative to, pharmacotherapy. The best results are achieved by combining different treatment methods.
Quickly diagnosed, it usually passes within a short time of appropriate pharmacotherapy. Sometimes the chosen therapy can be ineffective and it happens that it is necessary to start again. As a result, treatment may be prolonged. If drug-induced akathisia occurs, it is important that the affected person be under constant medical supervision.
Source:
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