Akathisia

Akathisia
Specialty	Neurology

Akathisia (or "acathisia") is an often extremely unpleasant subjective sensation of "inner" restlessness that manifests itself with an inability to sit still or remain motionless, hence the origin of its name: Greek a (without) + kathesis (sitting). Its most common cause is as a side effect of medications, mainly neuroleptic antipsychotics especially the phenothiazines and haloperidol (Haldol®), and rarely, antidepressants.

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 with overwhelming anxiety and severe dysphoria (manifesting as an almost indescribable sense of terror and doom). In the most severe cases, dysphoria can be so severe that the patient is literally compelled to take action, leading, possibly, to suicide attempts. There have been cases of patients who have attempted to jump out of moving vehicles because they were unable to remain motionless in the seat.

It is not unknown to have patients (who have been treated most often with neuroleptic antipsychotics for psychotic episodes or prochlorperazine for nausea) to bolt out of hospitals or emergency rooms due to this odd and disconcerting emotion and feelings.

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 decribed the feeling as a sense of inner tension and torment or chemical torture from the inside out.

Akathisia makes many 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.

In an institutionalized setting such behavior will get the person tied to the bed in four point restraints and injected with more antipsychotics. After which the person is unable to relieve their need to constantly move about so they struggle on the bed in sheer agony unable to move while making attempts to free themselves of the restraints. Some patients may shout at the staff, accusing them of torturing them while the staff can't understand how they can possibly be tortured when they are simply just laying flat on their back.

Patients often beg the staff to let them get up to relieve a need to urinate when the need is not so urgent just so they can have a moment to stand on their legs. They will prolong the urinating experience, which may result in the staff becoming irritable, which then results in the patient reciprocating by shouting back or even acting out in further violence which is caused by the akathisia.

Often the staff will close the door to the isolation room - sometimes called a quietroom or observation room - so they can stop being annoyed by the patient and then when the real need to urinate arrives the patient is forced to urinate on their selves while laying restrained to the bed. In many countries the orderlies will get angry at the patient and abuse them while they lay restrained on the bed in attempts to silence them or force them to stop making attempts to free themselves.

The presence and severity of akathisia can be measured using the Barnes Akathisia Scale .

Causes

Akathisia is most often the side effect of certain drugs - commonly seen in the antipsychotics, and less so in the others listed below:

• typical or atypical antipsychotics, such as haloperidol (Haldol®) and droperidol, olanzapine (Zyprexa®), aripiprazole (Abilify®); Pimozide is especially infamous for causing akathisia;
• SSRIs, such as paroxetine (Paxil®); see Healy (2006) reference, below, which focuses primarily on SSRIs and specifically paroxetine.
• Other antidepressants, such as the tricyclics and trazodone
• certain antihistamines, such as promethazine and diphenhydramine (Benadryl®);
• certain anti-emetic drugs, particularly the dopamine blockers (e.g. metoclopramide (Reglan®) and prochlorperazine (Compazine®)).
• certain drugs of abuse, such as GHB, methamphetamine and MDMA when administered in excessive doses.

A 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 misuse 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%).

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. Sufficient clinical research has not yet been made in this area.)

Jack Henry Abbot (1981) described the effects of akathisia produced by neuroleptic drugs:

These drugs, in this family, do not calm or sedate the nerves. They attack. They attack 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. For hours every day this will occur. 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. The pain grinds into your fiber ... 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 in pain you cannot locate, in such wretched anxiety you are overwhelmed, because you cannot get relief even in breathing.

— Jack Henry Abbot, In the Belly of the Beast (1981/1991). Vintage Books, 35-36. Quoted in Robert Whitaker, Mad in America (2002, ISBN 0738207993), 187.

Treatment

Treatment includes the discontinuation or reduction of dose of the causative agent and the use of typical or atypical antipsychotics (also called major tranquilizers) to reduce the agitation and anxiety. Unfortunately, these neuroleptic antipsyhoctics are often the cause of the condition and are known to cause irreversible akathisia in some cases. While the administration of these drugs may temporarily ameliorate the symptoms, there is a serious risk of worsening the condition over the longterm.

Therefore, some consider the drug of choice for the treatment of akathisia to be propranolol, along with other beta blockers such as metoprolol. The antihistamine cyproheptadine is also effective, though with shorter effect than beta blockers. Second-line treatments include benztropine and benadryl, though excess use of Benadryl may worsen symptoms. Most of the clinical cases of akathisia can be prevented by not administering the drugs that cause the condition.

Recent studies have shown that Vitamin B₆ is effective for the treatment of neuroleptic induced akathisia. Many also claim marijuana can ease symptoms of akathisia.

External links

• DSM-IV: Neuroleptic Induced Acute Akathisia at behavenet.com
• Information on treating this condition at akathisiasupport.org
• Healy D, Herxheimer A, Menkes DB (2006). "Antidepressants and Violence: Problems at the Interface of Medicine and Law". PLoS Med. 3 (9).{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Nasrallah H, Brecher M, Paulsson B (2006). "Placebo-level incidence of extrapyramidal symptoms (EPS) with quetiapine in controlled studies of patients with bipolar mania". Bipolar Disord. 8 (5 Pt 1): 467–74. PMID 17042884.{{cite journal}}: CS1 maint: multiple names: authors list (link)