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This is my sandbox. There are many others like it but this one is mine.

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Middlebury College web site

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Description[edit]

Akathisia may range in intensity from a sense of disquiet or anxiety, to severe discomfort, particularly in the knees. Patients typically pace for hours because the pressure on the knees reduces the discomfort somewhat; once their knees and legs become fatigued and they are unable to continue pacing, they sit or lie down, although this does not relieve the akathisia. At high doses or with potent drugs such as haloperidol (Haldol) or chlorpromazine (Thorazine/Largactil), the feeling can last all day from awakening to sleep. The anticholinergic medication procyclidine reduces neuroleptic-induced akathisia to a certain degree, in addition to preventing and sometimes eliminating the muscle stiffness that can occur alongside akathisia. When misdiagnosis occurs in antipsychotic neuroleptic-induced akathisia, more antipsychotic neuroleptics may be prescribed, potentially worsening the symptoms.[1] High-functioning patients have described the feeling as a sense of inner tension and torment or chemical torture. Many patients describe symptoms of neuropathic pain akin to fibromyalgia and Restless Legs Syndrome.[2] In Han et al. (2013), the authors describe Restless Leg Syndrome’s relation to akathisia, "Some researchers regard RLS as a ‘focal akathisia’ [in the legs].”[3] Although these side effects disappear quickly and remarkably when the medication is stopped, tardive, or late-persisting akathisia may go on long after the offending drug is discontinued, sometimes for a period of years—unlike the related tardive dyskinesia, which can be permanent.

Healy, et al. (2006), described the following regarding akathisia: tension, insomnia, a sense of discomfort, motor restlessness, and marked anxiety and panic. Increased labile affect can result, such as weepiness. Interestingly, in some people the opposite response to SSRIs occurs, in the form of emotional blunting; but sufficient clinical research has not yet been made in this area.[4]

Severe akathisia can become a very harrowing experience. Jack Henry Abbot (1981) describes the sensation:

...[It comes] from so deep inside you, you cannot locate the source of the pain ... The muscles of your jawbone go berserk, so that you bite the inside of your mouth and your jaw locks and the pain throbs. ... Your spinal column stiffens so that you can hardly move your head or your neck and sometimes your back bends like a bow and you cannot stand up. ... You ache with restlessness, so you feel you have to walk, to pace. And then as soon as you start pacing, the opposite occurs to you; you must sit and rest. Back and forth, up and down you go ... you cannot get relief ...

— Jack Henry Abbot, In the Belly of the Beast (1981/1991). Vintage Books, 35–36. Quoted in Robert Whitaker, Mad in America (2002, ISBN 0-7382-0799-3), 187.

In a psychiatric setting, patients who suffer from neuroleptic-induced akathisia often react by refusing treatment.[5]

Diagnosis[edit]

Despite the intensive research surrounding Akathisia, it is important to note the difficulty of diagnosis due to the complex nature of the disorder. Precise assessment of akathisia is problematic as it is difficult to differentiate from a multitude of disorders with similar symptoms. In a study of movement disorders induced by neuroleptics, akathisia was diagnosed in only 26% of patients who actually had it.[5] The primary distinguishing features of akathisia in comparison with other syndromes are primarily subjective characteristics, such as the feeling of inner restlessness.[6] Akathisia can commonly be mistaken for agitation secondary to psychotic symptoms or mood disorder, antipsychotic dysphoria, restless legs syndrome, anxiety, insomnia, drug withdrawal states, tardive dyskinesia, or other neurologic and medical conditions.[7]

Causes[edit]

Pathophysiological[edit]

Han et al. (2013)[3] reported that upon examination of three patients who experienced abrupt onset of restlessness characteristic of akathisia and Restless Leg Syndrome, magnetic resonance imaging of the brain revealed pontine infarction (lack of blood to the Pons area of the brain). Han et al. wrote, “The features of our three patients suggest that RLS and akathisia may have a common pathophysiological mechanism related to the pontine region of the brain.”[3]

Drug-Induced[edit]

Akathisia is frequently associated with the use of antipsychotic drugs that are dopamine receptor antagonists.[8] There is still limited understanding on the pathophysiology of akathisia, but it is seen to be associated with medications which block dopaminergic transmission in the brain. Additionally, drugs with successful therapeutic effects in the treatment of medication-induced akathisia have provided additional insight into the involvement of other transmitter systems. These include benzodiazepines, ß-adrenergic blockers, and serotonin antagonists.[8] Another major cause of the syndrome is the withdrawal of various addictive drugs in dependent individuals.[9]

It has been correlated with Parkinson's disease and related syndromes.[1] It is unclear, however, whether this is due more to Parkinson's or the drugs used to treat it, such as carbidopa/levodopa (levocarb).[10]

Antidepressants can also induce the appearance of akathisia.[11][12][13][14] The 2006 UK study by Healy et al. observed that akathisia is often miscoded in antidepressant clinical trials as "agitation, emotional lability, and hyperkinesis (overactivity)".[4] The study further points out that misdiagnosis of akathisia as simple motor restlessness occurs, but that this is more properly classed as dyskinesia. Moreover, it shows links between antidepressant-induced akathisia and violence, including suicide, since akathisia can "exacerbate psychopathology", going on to state that there is extensive clinical evidence correlating akathisia with SSRI use—approximately ten times as many patients on SSRIs compared to placebo (5.0% versus 0.5%) showed symptoms severe enough to drop out of a trial.[4]

It was discovered that akathisia involves increased levels of the neurotransmitter norepinephrine, which is associated with mechanisms that regulate aggression, alertness, and arousal.[15] Though no further research has been done yet, it may also be involved with disrupted NMDA channels in the brain, which have both synergistic and regulatory effects on norepinephrine.

A single study observed that methylphenidate (Ritalin) appeared to cause akathisia in a single patient.[16]

The table below summarizes factors that can induce akathisia, grouped by type, with examples or brief explanations for each:

Category Examples
Antipsychotics[17] Haloperidol (Haldol), droperidol, pimozide, trifluoperazine, amisulpride, risperidone, aripiprazole (Abilify), ziprasidone and asenapine (Saphris)
SSRIs[18] Fluoxetine (Prozac),[18] paroxetine (Paxil)[4]
Antidepressants Venlafaxine (Effexor), tricyclics, and trazodone (Desyrel)
Anti-emetics Metoclopramide (Reglan), prochlorperazine (Compazine), and promethazine
Antihistamines Cyproheptadine (Periactin) or diphenhydramine (Benadryl) — this is more commonly seen at very high doses
Drug withdrawal Opioid withdrawal, barbiturates withdrawal, cocaine withdrawal
Serotonin Syndrome Harmful combinations of psychotropic drugs

Epidemiology[edit]

Published epidemiological data for akathisia is mostly limited to treatment periods preceding the arrival of second-generation antipsychotics (SGAs).[19] Sachdev (1995)[20] reported an incidence rate of acute akathisia of 31% for 100 patients treated for 2 weeks with antipsychotic medications. Sachdev (1995) reported a prevalence range from 0.1% to 41%.[20] In all likelihood, rates of prevalence are lower for current treatment as second generation antipsychotics carry a lower risk of akathisia.[19]

Treatment[edit]

Case reports and small randomized studies suggest that benzodiazepines, propranolol, and anticholinergics may help treat to a degree acute akathisia.[19] These treatments are even less effective in chronic akathisia.[19] If it is possible to reduce the dosage of the offending antipsychotic, it should be done gradually.[19]

If the patient is experiencing akathisia due to opioid withdrawal, a moderate dose of any opioid (e.g.morphine, fentanyl, methadone, oxycodone) will relieve it all together. Also many patients get relief with pregabalin, which is a GABA-analogue related to gabapentin.[citation needed]

One study showed that vitamin B6 is effective for the treatment of neuroleptic-induced akathisia.[21]

N-acetyl cysteine also showed a positive effect on akathisia in an RCT.[22]

Paragraph 5[edit]

Schizophrenia commonly begins in adulthood.[23]

References[edit]

  1. ^ a b Cite error: The named reference szabadi was invoked but never defined (see the help page).
  2. ^ Perminder Sachdev (2006). Akathisia and Restless Legs Page 299. Cambridge University Press. p. 299. ISBN 9780521031486.[dead link]
  3. ^ a b c Han, Su-Hyun (March 2013). "Restless legs syndrome and akathisia as manifestations of acute pontine infarction". Journal of Clinical Neuroscience. 224 (1): 156, 755. Retrieved 8 December 2013. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: date and year (link)
  4. ^ a b c d Healy D, Herxheimer A, Menkes DB (September 2006). "Antidepressants and Violence: Problems at the Interface of Medicine and Law". Public Library of Science Medicine. 3 (9): e372. doi:10.1371/journal.pmed.0030372. PMC 1564177. PMID 16968128.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
  5. ^ a b Akagi H, Kumar TM (June 2002). "Akathisia: overlooked at a cost". British Medical Journal. 324 (7352): 1506–07. doi:10.1136/bmj.324.7352.1506. PMC 1123446. PMID 12077042.(subscription only, offers a 14-day free trial with registration) Cite error: The named reference "Akagi" was defined multiple times with different content (see the help page).
  6. ^ Kim, J. H.; Byun, H. J. (2003 Nov-Dec). "Prevalence and characteristics of subjective akathisia, objective akathisia, and mixed akathisia in chronic schizophrenic subjects". Clinical Neuropharmacology. 26 (6): 312–6. doi:10.1097/00002826-200311000-00010. PMID 14646611. S2CID 23393707. {{cite journal}}: Check date values in: |date= (help)
  7. ^ Kane, John M.; Fleischhacker, Wolfgang W.; Hansen, Lars; Perlis, Roy; Pikalov, Andrei; Assunção-Talbott, Sheila (2009 Apr 21). "Akathisia: an updated review focusing on second-generation antipsychotics". The Journal of Clinical Psychiatry. 70 (5): 627–43. doi:10.4088/JCP.08r04210. PMID 19389331. {{cite journal}}: Check date values in: |date= (help)CS1 maint: date and year (link)
  8. ^ a b Cite error: The named reference JM Kane was invoked but never defined (see the help page).
  9. ^ Cite error: The named reference NS Kaye was invoked but never defined (see the help page).
  10. ^ Tack, E., De Cuypere, G., Jannes, C. and Remouchamps, A. (September 1988) [First published online 23 August 2007]. "Levodopa addiction: a case study". Acta Psychiatrica Scandinavica. 78 (3): 356–60. doi:10.1111/j.1600-0447.1988.tb06347.x. PMID 2973725. S2CID 30339509.{{cite journal}}: CS1 maint: multiple names: authors list (link)(subscription required)
  11. ^ Stahl SM, Lonnen AJ (January 2011). "The Mechanism of Drug-induced Akathsia". CNS Spectrums. PMID 21406165.
  12. ^ Lane RM (1998). "SSRI-induced extrapyramidal side-effects and akathisia: implications for treatment". Journal of Psychopharmacology. 12 (2): 192–214. doi:10.1177/026988119801200212. PMID 9694033. S2CID 20944428.
  13. ^ Koliscak LP, Makela EH (March–April 2009) [2003]. "Selective serotonin reuptake inhibitor-induced akathisia". Journal of American Pharmacists Association. 49 (2): e28–36. doi:10.1331/JAPhA.2009.08083. PMID 19289334.
  14. ^ Leo RJ (October 1996). "Movement disorders associated with the serotonin selective reuptake inhibitors". Journal of Clinical Psychiatry. 57 (10): 449–54. doi:10.4088/jcp.v57n1002. PMID 8909330.(abstract only)
  15. ^ Marc E. Agronin, Gabe J. Maletta (2006). "Chapter 14: Pharmacotherapy in the Elderly". Principles and Practice of Geriatric Psychiatry (illustrated ed.). Lippincott Williams & Wilkins. p. 215. ISBN 9780781748100. Retrieved 2013-11-23.
  16. ^ Almeida MS, Padala PR, Bhatia S (2006). "Methylphenidate-induced akathisia in a patient with multiple sclerosis". Primary Care Companion to the Journal of Clinical Psychiatry. 8 (6): 379–380. doi:10.4088/pcc.v08n0611d. PMC 1764510. PMID 17245465.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Diaz, Jaime (1996). How Drugs Influence Behavior. Englewood Cliffs: Prentice Hall.[page needed]
  18. ^ a b Hansen L (December 2003). "Fluoxetine dose-increment related akathisia in depression: implications for clinical care, recognition and management of selective serotonin reuptake inhibitor-induced akathisia". Journal of Psychopharmacology (Oxford). 17 (4): 451–52. doi:10.1177/0269881103174003. PMID 14870959. S2CID 40974047.
  19. ^ a b c d e Bratti, IM (November 2007). "Chronic Restlessness With Antipsychotics". American Journal of Psychiatry. 164 (11): 1648–1654. doi:10.1176/appi.ajp.2007.07071150. PMID 17974927. S2CID 35725021. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: date and year (link)
  20. ^ a b Sachdev, P (1995). Akathisia and Restless Legs. New York: Cambridge University Press.
  21. ^ Lerner V, Bergman J, Statsenko N, Miodownik C (2004). "Vitamin B6 treatment in acute neuroleptic-induced akathisia: a randomized, double-blind, placebo-controlled study". The Journal of Clinical Psychiatry. 65 (11): 1550–4. doi:10.4088/JCP.v65n1118. PMID 15554771.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Berk M, Copolov D, Dean O, Lu K, Jeavons S, Schapkaitz I, Anderson-Hunt M, Judd F, Katz F, Katz P, Ording-Jespersen S, Little J, Conus P, Cuenod M, Do KQ, Bush AI. (2008). "N-acetyl cysteine as a glutathione precursor for schizophrenia--a double-blind, randomized, placebo-controlled trial.(2008 Sep 1;64(5):361-8. Epub 2008 Apr 23.)". Biol Psychiatry. 64 (5): 361–8. doi:10.1016/j.biopsych.2008.03.004. PMID 18436195. S2CID 10321144.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ Schneider, C.; Corrigall, R.; Hayes, D.; Kyriakopoulos, M.; Frangou, S. (Oct 9). "Systematic review of the efficacy and tolerability of Clozapine in the treatment of youth with early onset schizophrenia". European Psychiatry : The Journal of the Association of European Psychiatrists. 29 (1): 1–10. doi:10.1016/j.eurpsy.2013.08.001. PMID 24119631. S2CID 42072027. {{cite journal}}: Check date values in: |date= and |year= / |date= mismatch (help)
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