Can’t sit still? It may just be nervous energy or it could be something more serious like akathisia. Akathisia is a somewhat common problem that can contribute to behavioral problems in psychiatric settings/hospital wards, issues with drug compliance, and side effects in patients being treated for cancer. It can even be an underlying cause of suicidal thoughts, since it tends to worsen depression and anxiety.
Symptoms of akathisia usually include intense inner feelings of distress and sometimes the complete inability to sit still due to “psychomotor restlessness.” Even though most people with akathisia experience similar feelings of intense unease, the condition is still believed to be overlooked or under-diagnosed by many doctors, in addition to being underreported by many patients.
When the underlying cause of someone’s akathisia is not identified — such as the use of certain drugs or withdrawing from medications — this only exacerbates the condition because the offending drug is usually continued or even increased.
What Is Akathisia?
Akathisia is a type of movement disorder consisting of “difficulty staying still and a subjective sense of restlessness.” The word akathisia (pronounced ak-uh–thizh–uh) has Greek origins and translates to “not to sit” or “inability to sit.” (1) This condition is most commonly a side effect of taking certain neuroleptic, psychotic and psychotropic drugs, although a number of other drugs can cause akathisia too.
It can be hard to diagnose akathisia because symptoms resemble and can overlap with symptoms caused by many other psychiatric disorders — such as depression, bipolar disorder (manic depression), psychosis and ADHD.
How long does akathisia usually last? It can be either acute or chronic. It usually lasts for less than six months, although some people who don’t get treatment for the underlying cause can experience akathisia symptoms for longer.
Signs and Symptoms
Akathisia affects motor control and cognitive functions. It is most likely to affect movement of the trunk, hands, legs and arms. The most common signs and symptoms of akathisia include: (2)
- Restlessness and “mental unease”
- Inability to stay still, pacing, compulsions, and desire for constant movement (especially of the legs, which may be mistaken for restless leg syndrome)
- Repetitive movements, such as swinging or crossing the legs, shifting, rocking, shuffling, continuously pacing, or persistently fidgeting
- Anger, rage and agitation
- Behavioral disturbances (sometimes referred to as akathisia-induced impulsivity)
- Symptoms of depression and anxiety and in severe cases suicidal thoughts/behaviors
- Nervousness, fear, and a general “sense of dread”
- Trouble sleeping
- Nausea, loss of appetite and sometimes weight loss
- Slowed cognition
- Worsening of psychotic symptoms and symptoms associated with “insanity” (in some cases, akathisia has been the basis for an insanity defense by people who have been accused of committing a violent crime or act)
Tardive dyskinesia (sometimes called tardive akathisia) is a similar condition to akathisia, although the two have some slight differences. While akathisia involves voluntary movements (meaning you are in control of them and choose to move to relieve an urge you have), tardive dyskinesia is an “involuntary movement disorder characterized by repetitive purposeless movements,” especially movement of the face, mouth and limbs. (3) If you have akathisia you may be predisposed to developing tardive dyskinesia. In other words, akathisia may evolve into tardive dyskinesia, although not always. (4)
Causes and Risk Factors
There are several different theories regarding the underlying cause of akathisia. Some experts believe it is caused by disturbances in serotonin and/or dopamine levels. This is tied to an imbalance between the dopaminergic/cholinergic and dopaminergic/serotonergic systems. Others believe it results from overstimulation of certain parts of the brain, especially the locus ceruleus.
Akathisia risk factors can include:
- Taking certain non-neuroleptic medications, especially antipsychotic or antiemetic drugs. Akathisia is most likely to occur when a new medication is taken or the dosage is increased. Other medications can also trigger akathisia (more on these below).
- Having a history of previous akathisia episodes.
- History of depression, anxiety or other mood disorders.
- Experiencing withdrawal after taking antipsychotic drugs.
- Discontinuing use of stimulants, such as those used to treat attention-deficit/hyperactivity disorder (ADHD).
- Having a substance use disorder, especially involving cocaine.
- Undergoing chemotherapy, especially involving the use of metoclopramide or prochlorperazine.
- Trauma or injury to the brain, potentially including suffering from a concussion.
- Having a genetic predisposition or family history of akathisia.
- Having nutrient deficiencies, such as iron and vitamin D deficiency. (5)
- Being a young adult, since younger people are affected more by akathisia than older adults. (6)
Which Medications Can Cause Akathisia?
Akathisia can be a side effect of taking various antipsychotic, antiemetic and anti-depressant drugs. It is also commonly seen in people undergoing cancer treatments including chemotherapy; one report published in the American Journal of Psychiatry stated that in cancer patients undergoing chemotherapy, about 50 percent of patients meet the diagnostic threshold of akathisia. (7)
The list of drugs reported to cause akathisia has been growing over the past several decades. Medications/drugs reported to cause it now include: (8)
- Antiemetics: Metoclopramide, prochlorperazine, domperidone. Reported prevalence rates vary widely, but suggest that between 5 and 36 percent of people using these drugs will experience akathisia symptoms. (9)
- Antidepressants: Tricyclics, selective serotonin reuptake inhibitors (SSRIs; including fluoxetine, paroxetine, sertraline), venlafaxine and nefazodone. Suicidal thoughts and suicide attempts have been reported in some patients using fluoxetine, droperidol, and metoclopramide, which is why patients are warned to speak with their doctor right away if they experience depression and intense anxiety.
- Calcium channel blockers: Cinnarizine, flunarizine (H1 antagonists), diltiazem.
- Antivertigo agents.
- Preoperative sedatives and drugs (used before surgery).
- Drugs, used to control Parkinson’s symptoms like loss of motor control and depression.
- Anticonvulsant drugs.
- Other drugs including: Methyldopa, levodopa and dopamine agonists, orthopramides and benzamides, lithium carbonate and buspirone.
- Withdrawal following use of cocaine.
Some of these drugs, especially antidepressants, are widely prescribed and capable of causing many adverse effects — like changes in appetite, sleep, energy levels and body weight. Not only can taking some mood-altering medications cause unwanted physical and/or mental side effects like akathisia, but once it is experienced it then becomes a cause of poor drug compliance in the future. Because someone may want to discontinue use of any medication that makes them feel unwell, many patients with drug-induced akathisia will stop taking their medications even once they feel better, potentially leaving them in a bad situation.
- Prompt diagnosis and management of akathisia in its earliest stages are important for preventing it from worsening. Many doctors use the Barnes Akathisia Rating Scale to aid in detection and assessment of akathisia.
- If akathisia is caused by certain medications, then the first thing a doctor will do is adjust the patient’s dosage or medication type.
- It’s recommended that if a patient seems to be experiencing akathisia symptoms that their doctor first check for a recent introduction of a new medication or an increase in the dose of drugs being used.
- Drug-induced akathisia can be confirmed if the patient stops taking their medication and then immediately feels better.
Is akathisia reversible? Yes, it usually is with treatment and should decrease within several months. But one problem is that many people experiencing akathisia do not report their symptoms to their doctor. For example, the same American Journal of Psychiatry report mentioned above found that 75 percent of cancer patients with akathisia stated they would not have reported their symptoms to their medical provider had they not been involved in the study.
The reason that akathisia may go unmentioned is because patients seem to have a hard time recognizing and explaining how they feel, especially if they have a mental illness, are battling a chronic health condition, or are recovering from surgery, illness or trauma. In these situations the patient might think it’s normal to feel very anxious, restless and uneasy.
How to Help Manage Akathisia
1. Discuss Your Medications With Your Doctor and Report Symptoms ASAP
Talk to your doctor about all medications you currently use, especially any drugs you recently started or suspect are contributing to your problem. If you experience any symptoms of akathisia, especially depression or suicidal thoughts, then don’t wait to get help. Any offending drug should be stopped or reduced as soon as possible. However, it’s best to be monitored in the process to prevent sudden side effects associated with stopping your medication.
If a particular medication you’re taking cannot be stopped, or your symptoms persist after making dosage changes, your doctor might describe other medications to help. These can include propranolol, other lipophilic beta blockers, benzodiazepines, Parkinson’s disease medications including amantadine, or antidepressants like mirtazapine or trazodone. The goal is to use these medications to help control blood pressure, reduce akathisia symptoms, and limit side effects that other mood-altering drugs tend to cause.
2. Help Prevent Depression & Anxiety
To help prevent or manage mood-related conditions that can increase your risk for akathisia, especially anxiety and depression, try these natural remedies:
- Meet with a counselor or doctor who offers cognitive behavioral therapy (CBT). CBT is useful for identifying and altering troubling thoughts that can lead to destructive behaviors. Studies have shown that therapy and behavioral interventions can be helpful for reducing risk factors for akathisia and symptoms once they’ve started. (10) You can get the most from therapy by staying open-minded to suggestions from your therapist; being open and honest about your feelings; keeping a journal about your feelings; and gaining support from your family and friends (possibly even including them in therapy sessions).
- Exercise regularly, especially outdoors. Try taking a walk outdoors every day, regardless of the weather or time of year, to stay in touch with nature, the seasons and the elements around you. Aim to do 30–90 minutes daily of any exercise you enjoy to boost your mood naturally.
- Get enough sleep and open up time in your day to rest and unwind.
- Make time for play and relaxation by keeping up with hobbies that increase happiness.
- Eat a healthy diet. Your diet can greatly affect hormone production, neurotransmitter functions, energy and other processes that influence your overall mood. Some of the best foods for fighting anxiety, depression and inflammation include: healthy fats (like coconut, raw dairy and grass-fed meats), protein foods (cage-free eggs, wild fish, grass-fed meat and pasture-raised poultry), vegetables and fruit, high-fiber foods (nuts and seeds, such as flax, chia, hemp and pumpkin seeds, ancient grains and beans/legumes).
- Limit your intake of sugar, processed grains, refined vegetable oils, alcohol and caffeine.
- Join a support group or group therapy class to connect with other people going through the same thing and receive valuable advice from others who have recovered.
- Don’t use recreational drugs, including cocaine or alcohol, or abuse prescription drugs. Get help from a counselor or therapist if you have a drug/substance abuse problem.
- Take omega-3 fatty acids or fish oil, which may help lower depression symptoms and inflammation. St. John’s wort (Hypericum perforatum) is another natural antidepressant that can be helpful for feeling calmer and getting good sleep.
3. Practice Stress Management
Prevention is really the best akathisia natural treatment there is. Not needing to take any risky medications in the first place is the best way to prevent adverse effects. This might not always be within your control, but you can lower the chances that you’ll need to take mood-altering drugs by taking steps to manage stress in your life. Some stress-relieving practices that might help include:
- Make it a priority to get enough sleep and rest each night, about seven to nine hours. If you find it hard to sleep due to stress or anxiety, try using natural sleep aids such as taking a magnesium supplement, reading or journaling, exercising during the day time, and using essential oils such as lavender, bergamot, ylang ylang and chamomile. Essential oils can be used in the shower, inhaled/used for aromatherapy, or applied to the skin as a way of bringing on relaxation and reducing muscle tension.
- Take natural plant-based adaptogenic herbs, including ginseng, holy basil, ashwagandha and rhodiola, which help control the body’s stress response, lower cortisol, improve energy/focus and balance hormones in various ways. Kava is always helpful for fighting anxiety.
- Keep yourself calm and organized throughout the day by creating a daily planner to help manage stress.
- Try meditation, stretching, yoga and breathing exercises.
- Take a nap if you’re feeling overwhelmed or fatigued.
- Visit an acupuncturist or massage therapist.
4. Treat Symptoms Like Nausea & Restlessness
Below are some tips that can be helpful for dealing with akathisia symptoms like nausea, loss of appetite, restlessness or muscle spasms:
- Take a vitamin B6 supplement. When taken in high doses, vitamin B6 can help to naturally ease symptoms of akathisia because of how it affects neurotransmitter systems. One clinical study found that when adults with acute akathisia were treated with 600 milligrams daily of vitamin B6 they showed a significant improvement on subjective-awareness of restlessness and distress compared to a placebo group. (11)
- Take a magnesium supplement, which can help to make you calmer and reduce twitching or other symptoms similar to those caused by restless leg syndrome.
- Make sure you are not deficient in iron or vitamin D. Eat iron-rich foods and get exposure to sunlight outdoors to boost your vitamin D levels.
- Get fresh air by walking outdoors and keeping your windows open. Try to keep your home cool, clean and organized.
- Make sure your bedroom is dark and cool so you get can quality sleep.
- Eat regular meals and don’t skip meals, which can lead to more nervousness. Drink fluids throughout the day to prevent dehydration.
If you’ve been diagnosed with akathisia, educate yourself about the condition and be aware of all symptoms that it may cause so you can report future episodes to your doctor right away. If you’ve had it once, there is a higher chance you’ll experience similar problems in the future. Start new medications slowly, discuss symptoms you’re experiencing with your doctor, and don’t be shy about asking for help when you need it.
- Akathisia is a type of movement disorder consisting of “difficulty staying still and a subjective sense of restlessness.”
- It is a side effect sometimes experienced by patients prescribed antipsychotic, antiemetic, or antidepressant drugs. It can also be caused by other medications, chemotherapy, Parkinson’s disease, withdrawal, drug use and trauma to the head/brain.
- Symptoms may include: anxiety, pacing, repetitive movements, anger and rage, unusual behaviors, trouble sleeping, loss of appetite and depression.