What Is Akathisia? Symptoms and How To Manage It

If you are experiencing restlessness and an inability to sit still, you may have akathisia. Akathisia can happen as a side effect of certain medications, especially antipsychotic medications, many of which are commonly prescribed for schizophrenia.

So what is akathisia? Akathisia is a condition that causes you to feel an intense and uncontrollable need to move. Akathisia is not something that a doctor can test your blood work for; it’s something that you feel and experience yourself (like pain).

It most often shows up as a need or desire to move your legs. It can involve pacing, crossing and uncrossing your legs, rocking from foot to foot, or fidgeting with your legs.

Akathisia is often very distressing and can increase the risk of medication nonadherence (not taking medication as prescribed), and in severe cases, impulsive behavior and suicidal ideation.

Note: If you or someone you know needs help, you can contact the 988 Suicide & Crisis Lifeline by calling or texting 988 or chatting online.

Types of Akathisia

Akathisia can appear in several forms and is classified based on when it happens and how long it lasts.

Akathisia Symptoms

Akathisia causes an intense feeling of restlessness and need to move the body. It can appear as fidgeting, pacing, rocking, and other repetitive movements. Akathisia often causes a strong need to constantly move the legs and sometimes other parts of the body, like the arms or torso. With akathisia, it can be very difficult to hold the same position for more than a few minutes.

Having an uncontrollable need to move can cause extreme discomfort and distress. It often creates an inner sense of tension. It can cause anxiety, panic, irritability, mood swings, and inability to sleep.

Akathisia, Anxiety, and Misdiagnosis

Among people with schizophrenia who are taking more than one psychotropic medication, akathisia can be fairly common. One study estimated a rate of 15 percent to 35 percent.

Unfortunately, akathisia is often misdiagnosed or not recognized. The behaviors of akathisia that a doctor can observe, like pacing, agitation, and repetitive movement, can also be common with other conditions, like anxiety and mood disorders. Although akathisia often causes distress and anxiety, it is not the same as anxiety.

And because some of the signs of akathisia may look like symptoms of schizophrenia as well, your doctor may assume that your schizophrenia medication isn’t working rather than that you could be experiencing a medication side effect. Clinicians also sometimes mistake akathisia for general agitation, restless legs syndrome, or substance withdrawal disorder.

Talk to Your Doctor

What sets akathisia apart from these other conditions is how it feels to the person who is experiencing it. Early recognition and treatment are very important with akathisia.

If you’re experiencing feelings of uncontrollable restlessness, especially after starting or changing the dose of any medication, it is important to talk to your doctor right away.

Be aware that akathisia may be difficult for your doctor to recognize, so it’s important to describe in detail what you are feeling and tell your provider what medications you’re taking.

In addition to a change in medication, the key symptoms that your doctor needs to know about in order to diagnose and treat akathisia may include:

• A feeling of inner restlessness or tension, especially in the lower limbs
• An urge to constantly move
• Difficulty holding a position for more than a few minutes

Doctors may use the Barnes Akathisia Rating Scale but often rely on clinical observation to make a diagnosis. There are no lab or imaging tests that are used to diagnose akathisia.

Even if you suspect akathisia, it is very important not to stop or change an antipsychotic medication without guidance from a healthcare provider.

What Causes Akathisia?

Doctors aren’t entirely sure why akathisia happens, but they know it has something to do with dopamine, a brain chemical that acts as a neurotransmitter. Dopamine communicates messages between nerve cells in your brain and the rest of your body, playing a role in memory, mood, movement, and attention.

Antipsychotic medications that block dopamine receptors are most likely to cause akathisia. Dopamine’s normal role in controlling movement includes helping put the brakes on unnecessary movement.

The current theory of how akathisia happens says that when a medication reduces dopamine activity, those “brakes” on unneeded movement can stop working properly, resulting in a restless, uncontrollable urge to move.

Another theory that has also been proposed says that increases in serotonin and norepinephrine (two other brain chemicals) can indirectly dial down dopamine activity, leading to the same problem through a different route.

Antipsychotics and Akathisia

Certain drugs are more likely to cause akathisia than others. Akathisia is more common in first-generation antipsychotics but can also occur with second generation antipsychotics.

In first generation antipsychotics, the rate of developing akathisia is estimated to be between 25 percent and 30 percent or higher. In a recent study of second-generation antipsychotics, the rate was estimated to be 17 percent, depending on the type of medication. In second-generation antipsychotics, the higher the dose, the greater the risk of akathisia.

Antipsychotic drugs which are considered more likely to cause akathisia include:

• Aripiprazole
• Cariprazine
• Haloperidol
• Lurasidone
• Paliperidone
• Risperidone

Antipsychotic drugs which are considered to have lower likelihood of causing akathisia include:

• Clozapine
• Iloperidone
• Quetiapine

Some other drugs that are not antipsychotics can also cause akathisia. These may include:

• Selective serotonin reuptake inhibitors (SSRIs)
• Monoamine oxidase inhibitors (MAOIs)
• Tricyclic (TCA) antidepressants
• Antiemetics (nausea medicines)
• Some high blood pressure medicines
• Azithromycin (an antibiotic)
• Buspirone (an anxiety medication)
• Calcium channel blockers
• Anti-vertigo drugs
• Sedatives used in anesthesia
• Some illicit drugs

How Is Akathisia Managed?

Once you are diagnosed with akathisia, your healthcare team will come up with a plan to manage the condition.

Options for managing akathisia include switching schizophrenia medications, stopping or reducing the dose of your current medication, or introducing another medication which may help to treat akathisia.

Medications which may help with akathisia include:

• Beta-blockers
• Benzodiazepines
• Anticholinergics
• Mirtazapine
• Vitamin B6

Remember to talk to your doctor before starting, stopping, or changing any medication, including an antipsychotic medication.

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On MySchizophreniaTeam, people share their experiences with schizophrenia, get advice, and find support from others who understand.

Have you ever experienced akathisia? If so, what was it like for you? Let others know in the comments below.