AKATHISIA

'Akathisia', or 'acathisia', is an unpleasant subjective sensation of "inner" restlessness that manifests itself with an inability to sit still or remain motionless, hence its origin [ Ancient Greek 'α' (a), without, not + 'κάθισις' (káthisis), sitting]. Its most common cause is as a side effect of medications, mainly neuroleptic antipsychotics especially the phenothiazines (such as perphenazine and chlorpromazine), thioxanthenes (such as flupenthixol and zuclopenthixol) and butyrophenones (such as haloperidol (Haldol)), and rarely, antidepressants. Akathisia can also, to a lesser extent, be caused by Parkinson disease-related syndromes.^[1]
Akathisia may range in intensity from a mild sense of disquiet or anxiety (which may be easily overlooked) to a total inability to sit still, accompanied by overwhelming anxiety, malaise, and severe dysphoria (manifesting as an almost indescribable sense of terror and doom).
Partly because the condition is difficult for the patient to describe, it is often misdiagnosed. When misdiagnosis occurs in antipsychotic neuroleptic-induced akathisia, more antipsychotic neuroleptics may be prescribed, potentially worsening the symptoms. High functioning patients have described the feeling as a sense of inner tension and torment or chemical torture from the inside out.
Akathisia makes some patients act out in violent fits of rage throwing and breaking things or harming others. Ironically antipsychotic drugs are many times prescribed as “mood stabilizers” but then have the opposite intended effect, which often leads to increased doses further escalating the symptoms when the intent was to ameliorate the symptoms.
The presence and severity of akathisia can be measured using the Barnes Akathisia Scale.^[2][3][4]

Contents

Description

Causes

Treatment

See also

References

External links

Description

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.^[5]
Jack Henry Abbot (1981) described the effects of akathisia produced by neuroleptic drugs:
In the most severe cases, dysphoria can be so severe that the patient is compelled to take action, leading, possibly, to suicide attempts.
Treatment non-compliance is a common consequence of neuroleptic-induced akathisia. At the extreme end of non-compliance, patients who have been treated with neuroleptic antipsychotics for psychotic episodes or prochlorperazine for nausea may rarely run away from hospitals or emergency rooms due to this disconcerting sensation.^[6]

Causes

Akathisia is most often seen as a side effect of certain drugs. It is by far most commonly seen in the use of antipsychotic medications, as well as other neuroleptic drugs.

★ Non-sedating antipsychotics such as haloperidol (Haldol), droperidol, pimozide, trifluoperazine, amisulpride, risperidone, and aripiprazole (Abilify). Much less common in sedating antipsychotics such as olanzapine (Zyprexa®) or chlorpromazine where anticholinergic and antihistaminergic effects counteract akathisia to a degree.

★ SSRIs, such as fluoxetine (Prozac). It has also been documented with the use of paroxetine (Paxil). Akathisia has been studied as the mechanism by which SSRI-induced suicidality occurs.^[7]

★ Other antidepressants, such as the tricyclics and trazodone (Desyrel).

★ Certain anti-emetic drugs, particularly the dopamine blockers, such as metoclopramide (Reglan) and prochlorperazine (Compazine).

★ Certain drugs of abuse, such as GHB, methamphetamine and MDMA when administered in excessive doses.
The 2006 U.K. study by Healy, Herxheimer, and Menkes observed that akathisia is often miscoded in antidepressant clinical trials as "agitation, emotional lability, and hyperkinesis (overactivity)". The study further points out that misdiagnosis of akathisia as simple motor restlessness occurs, but that this is more properly classed as dyskinesia. Healy, et. al., further show links between antidepressant-induced akathisia and violence, including suicide, as akathisia can "exacerbate psychopathology." The study goes on to state that there is extensive clinical evidence correlating akathisia with SSRI use, showing that approximately ten times as many patients on SSRIs as those on placebos showed symptoms severe enough to drop out of a trial (5.0% compared to 0.5%).

Treatment

Treatment includes the discontinuation or reduction of dose of the causative agent.
The most common treatment for antipsychotic akathisia is the anticholinegic medication benztropine (Cogentin). But since benztropine is for extrapyramidal side effects such as muscle spasms and tremors it is not effective in treating akathisia which is not a true extrapyramidal side effect.
Akathisia can be reduced by administering other drugs, though effectiveness can vary with more severe cases resistant to most drug treatment. Benzodiazepines like clonazepam (Klonopin) are effective. Some consider the drug of choice for the treatment of akathisia to be beta-blockers such as propranolol (Inderal) or metoprolol. The antihistamine cyproheptadine is also effective, though with shorter effect than beta blockers.
One study showed that vitamin B₆ is effective for the treatment of neuroleptic-induced akathisia.^[8]

See also

★ Agitation (emotion)

★ Anxiety

★ Psychomotor agitation

References

1. Akathisia--or not sitting, Szabadi E, , , British medical journal (Clinical research ed.), 1986
2. Scale can be found online at:Barnes Akathisia Scale
3. A rating scale for drug-induced akathisia, Barnes TR, , , The British journal of psychiatry : the journal of mental science, 1989
4. The Barnes Akathisia Rating Scale--revisited, Barnes TR, , , J. Psychopharmacol. (Oxford), 2003
5. Antidepressants and violence: problems at the interface of medicine and law, Healy D, Herxheimer A, Menkes DB, , , PLoS Med., 2006
6. Lesson of the week: Akathisia: overlooked at a cost, Akagi H, Kumar TM, , , BMJ, 2002
7. Fluoxetine dose-increment related akathisia in depression: implications for clinical care, recognition and management of selective serotonin reuptake inhibitor-induced akathisia, Hansen L, , , J. Psychopharmacol. (Oxford), 2003
8. Vitamin B6 treatment in acute neuroleptic-induced akathisia: a randomized, double-blind, placebo-controlled study, Lerner V, Bergman J, Statsenko N, Miodownik C, , , The Journal of clinical psychiatry, 2004

External links

★ DSM-IV: Neuroleptic Induced Acute Akathisia at behavenet.com

★ Information on treating this condition and copies of original research papers at akathisiasupport.org

★ Placebo-level incidence of extrapyramidal symptoms (EPS) with quetiapine in controlled studies of patients with bipolar mania, Nasrallah H, Brecher M, Paulsson B, , , Bipolar Disord, 2006