Restlessness and anxiety are common symptoms of using and withdrawing from some medications and drugs. Akathisia is a particular case of psychomotor agitation that causes feelings of emotional dysphoria, as well as physical discomfort and pain.

In this article we will describe what akathisia is and what are the most common symptoms and causes of this syndrome, considered a disorder by some professionals and more a consequence of medical malpractice by others.

What is Akathisia?

Akathisia is a syndrome that is characterized by a feeling of constant restlessness, both physiologically and mentally . This term is mainly used to describe adverse reactions to certain psychoactive substances or symptoms resulting from the cessation of their use.

It manifests itself as an anxious type of emotional state that can include only cognitive symptoms or also physical signs, mainly related to the need to stay in motion .

The word “akathisia” comes from the Greek and can be translated as “inability to sit”. It was coined by the Czech neuropsychiatrist Ladislav Hakovec, who first described this disorder in the article entitled L’akathisie , in 1901.

Although akathisia is usually associated with the use of typical antipsychotics such as haloperidol or with drug withdrawal, it can also be caused by other medications and substances, as well as by some types of brain injury.

Physical signs and clinical picture

Continued feelings of agitation are the cardinal symptom of akathisia. Depending on the intensity of the syndrome, this anxiety may manifest itself as psychological restlessness or may lead to extreme discomfort in the body . In particular, a large number of patients with akathisia describe discomfort and pain in the knees.

In many cases the agitation causes the person to perform movements of different types. Some behaviors characteristic of akathisia are walking without stopping, repeated standing and sitting, tapping fingers, swinging the trunk, crossing the legs, or making grunting sounds.

These signs occur in reaction to feelings of physical tension and diffuse pain . Other neuropathic disorders, such as restless leg syndrome and some cases of fibromyalgia, cause symptoms similar to those of akathisia and are therefore sometimes misdiagnosed.

As patients report, constant movement helps relieve some of the physical discomfort and pain; for example, walking and crossing or stretching the legs reduces some of the uncomfortable feelings in the knees.

Psychological symptoms of akathisia

On a cognitive and emotional level , symptoms such as dysphoria (unpleasant feelings as opposed to euphoria), worry, irritability, emotional instability and the presence of gloomy thoughts stand out.

The sensations become so uncomfortable that many patients claim that they make them want to get out of their skin and even tear it off. People with drug-induced akathisia tend to reject them and strongly assert that they are the cause of the discomfort, comparable to chemical torture .

Other anxious symptoms associated with restlessness are also common; in people with akathisia the likelihood of insomnia and sleep difficulties increases, as well as anxiety crises as a result of intense psychophysiological activation.

Causes and risk factors

Akathisia is usually related to an alteration in the levels of dopamine , a neurotransmitter involved in movement and many other functions, such as pleasure, learning and motivation.

Therefore, the substances that cause this syndrome are mainly those that block the action of dopamine in the central nervous system, i.e. dopaminergic antagonists. However, akathisia can also be due to other causes.

1. Antipsychotic drugs

Akathisia has been described very often in people undergoing long term treatment with antipsychotics, especially the typical or first generation ones , which block the D2 dopamine receptors. It can occur as a side effect of drug potency, overdose or withdrawal.

Some of the antipsychotics that carry an increased risk of developing akathisia and other extrapyramidal symptoms are haloperidol, chlorpromazine, thiotixene, zuclopenthixol, olanzapine and risperidone.

2. Antidepressant drugs

Not only can the reduction of dopamine cause akathisia, but so can the increase in serotonin levels . Thus, some serotonergic drugs that are mainly used to treat depression are related to the development of this syndrome.

Antidepressants that cause akathisia include SSRIs or selective serotonin reuptake inhibitors , such as paroxetine, fluoxetine and sertraline, and tricyclics, such as clomipramine and amitriptyline. Venlafaxine, which inhibits the reuptake of serotonin and noradrenaline, has also been associated with symptoms of akathisia.

3. Drug and Substance Abstinence

When there is physical dependence on drugs or dopaminergic drugs, discontinuation of use often leads to akathisia in the context of withdrawal.

This happens with antipsychotics and antidepressants, described in the previous sections, but also with alcohol, cannabis, cocaine and opiates such as heroin. Amphetamine stimulants have similar effects to those of cocaine, and barbiturates and benzodiazepines to those of alcohol.

4. Other medications

Other medications that can cause akathisia to occur are antiemetics, antihistamines and painkillers used to treat migraine. In general, the higher the potency of the drug, the greater the likelihood of adverse reactions.

5. Parkinson’s Disease

Akathisia has also been associated with Parkinson’s disease, which progressively deteriorates the central nervous system and is mainly characterized by motor, cognitive and emotional symptoms.

However, in these cases it is not always clear whether the akathisia is due to the disorder itself or to the medicines used to treat it, as they often alter the action of dopamine. Levodopa is the most common drug in the management of Parkinson’s disease.