What Is Akathisia? Symptoms, Causes, and Treatments

Akathisia is a condition that can be deeply uncomfortable and often misunderstood. It causes intense inner restlessness and an inability to stay still—symptoms that can significantly impact a person’s quality of life. Although it often occurs as a side effect of medications, akathisia can also be mistaken for anxiety or agitation, leading to misdiagnosis and frustration. 

Understanding this condition is the first step toward better management and recovery.This article comprehensively guides readers through the symptoms, causes, and treatments of akathisia.

[signup]

Understanding Akathisia

To recognize and treat akathisia effectively, it’s essential to understand what it is and how it differs from other movement or mental health conditions.

What Is Akathisia?

Akathisia is a neuropsychiatric syndrome characterized by:

• A powerful sense of inner restlessness
• A compulsion to move, such as constant pacing, shifting, or fidgeting

Unlike anxiety, which is driven by worry or emotional distress, the discomfort in akathisia is physical and neurological in origin. People with akathisia often feel like they “can't sit still” and are driven to move—even when doing so offers no relief.

Types of Akathisia

There are several forms of akathisia, each with different timelines and causes:

• Acute Akathisia: Develops within days or weeks of starting or increasing a medication (usually antipsychotics).
• Chronic Akathisia: Persists for months, even after stopping the triggering medication.
• Tardive Akathisia: Occurs after long-term use of certain drugs and is often harder to treat.
• Withdrawal-Related Akathisia: Appears after reducing or stopping medications, particularly if done too quickly.

Identifying the specific type can guide treatment decisions and help predict recovery time.

Symptoms and Causes

Akathisia symptoms can be both physical and emotional, making it a challenge to recognize, especially in people already coping with mental health conditions.

Causes of Akathisia

While medications, typically antipsychotics that cause an imbalance in neurotransmitters (e.g., dopamine), are the most common cause, other factors can also contribute.

Medication-Related Causes

• Antipsychotics (especially first-generation types like haloperidol)
• Antidepressants, particularly SSRIs and SNRIs
• Anti-nausea medications, such as metoclopramide or prochlorperazine

Non-Pharmacological Triggers

• Iron deficiency, which affects dopamine regulation
• Metabolic changes or systemic illness
• Sudden medication withdrawal, especially if done without medical guidance

Recognizing the root cause is vital for managing symptoms effectively.

Recognizing Symptoms of Akathisia

Symptoms of akathisia can be divided into subjective experiences and observable behaviors:

Subjective symptoms include:

• An intense, internal sense of restlessness
• A feeling of being “on edge” or uncomfortable in one’s body
  

Objective signs include:

• Constant pacing or walking in place
• Fidgeting, rocking, or shifting weight between feet
• Inability to remain seated

This restlessness can lead to emotional distress, such as:

• Increased anxiety
• Irritability
• Depression
• Trouble sleeping

Diagnosis

Diagnosing akathisia requires careful evaluation because its symptoms overlap with other mental health and movement disorders.

How Is Akathisia Diagnosed?

Healthcare providers may use clinical interviews, observations, and standardized tools like the Barnes Akathisia Rating Scale (BARS). This scale assesses:

• The patient’s self-reported feelings of restlessness
• Observable physical movements
• Emotional distress associated with the condition

Differential Diagnosis

A correct diagnosis helps avoid unnecessary changes in psychiatric medications and ensures timely treatment. Conditions with overlapping symptoms include:

• Anxiety disorders may cause restlessness, but not the compulsive need to move
• Restless Leg Syndrome (RLS) involves discomfort in the legs and occurs mostly at night
• Parkinsonism or other movement disorders involve stiffness or tremors, which are different from the pacing and agitation seen in akathisia.

Treatment and Management

Managing akathisia involves a combination of medication adjustments, symptom relief, and emotional support. Treatment plans should be individualized and closely monitored.

Treatment Options for Akathisia

Adjusting Medications

• Lowering the dose of the triggering medication
• Switching to a drug with a lower risk of akathisia (e.g., changing antipsychotics)
• Gradual tapering instead of sudden withdrawal when stopping medications

Pharmacological Interventions

• Propranolol (a beta-blocker) is often the first-line treatment
• Benzodiazepines (like lorazepam) may provide short-term relief
• Mirtazapine or clonidine may be considered when first-line treatments fail

Non-Pharmacological Strategies

• Iron supplementation, if levels are low
• Regular movement or light exercise can temporarily reduce restlessness
• Mindfulness techniques or breathing exercises to help manage emotional discomfort

Treatment often involves trial and error and should always be supervised by a qualified healthcare provider.

Coping Strategies for Patients

Living with akathisia can be challenging. Supportive strategies may include:

• Creating a safe, calm environment with room to move if needed
• Setting realistic goals and pacing daily activities
• Using weighted blankets or fidget tools to ease restlessness in mild cases
• Seeking mental health support through counseling or peer groups

Because akathisia can increase the risk of suicidal thoughts, it’s important that patients receive compassionate care and frequent follow-up.

Prevention and Prognosis

In addition to understanding how to manage akathisia, exploring how it may be prevented and what patients can expect over time is key. Although not every case can be avoided, early recognition and careful prescribing practices can reduce the risk of developing this condition.

Can Akathisia Be Prevented?

While not all cases of akathisia are preventable, certain strategies can significantly lower the likelihood of its occurrence:

• Judicious use of medications: Using the lowest effective dose of antipsychotics, antidepressants, or anti-nausea medications—and avoiding unnecessary polypharmacy—can reduce the risk.
• Gradual dose adjustments: Tapering medications slowly rather than stopping them abruptly allows the brain to adjust to changes in neurotransmitter levels.
• Early monitoring: Clinicians should assess for symptoms of restlessness within days to weeks of starting or adjusting medications, especially in high-risk individuals.
• Patient education: Informing patients about the early warning signs of akathisia empowers them to report symptoms before they become severe or disabling.

Healthcare providers should especially monitor elderly patients, those with iron deficiency, or individuals with a history of extrapyramidal side effects, as these groups may be more vulnerable.

Outlook for Patients with Akathisia

The long-term outlook varies depending on the type and severity of akathisia:

• Acute akathisia often resolves within days to a few weeks after adjusting or stopping the offending medication, especially with early intervention.
• Withdrawal-related akathisia may improve gradually with time, but symptoms can persist for weeks during the tapering process.
• Chronic or tardive akathisia can last for months or even years, and may require a multi-modal treatment approach. Sometimes, symptoms may become less intense over time, even if they do not fully resolve.

Importance of Early Intervention

The sooner akathisia is recognized and treated, the better the outcomes. Early intervention can:

• Shorten symptom duration
• Prevent progression to chronic forms
• Reduce the risk of emotional complications such as depression or suicidal ideation
• Preserve trust in psychiatric treatment and reduce non-adherence

[signup]

Key Takeaways

Akathisia is a serious and distressing condition that often stems from necessary medical treatments. However, with early recognition, appropriate adjustments to medications, and supportive coping strategies, many patients can find relief. Comprehensive care—including medical, emotional, and social support—helps manage symptoms and restore a sense of control and hope in recovery.

• Akathisia is a neuropsychiatric condition marked by severe inner restlessness and an uncontrollable need to move, often triggered by certain medications such as antipsychotics or antidepressants.
• Symptoms include both internal and visible signs, such as anxiety, pacing, fidgeting, and an inability to remain still—making it easy to mistake for anxiety or agitation.
• There are multiple forms of akathisia, including acute, chronic, tardive, and withdrawal-related types, each with different timelines and treatment responses.
• Diagnosis is clinical and often supported by tools like the Barnes Akathisia Rating Scale (BARS), with careful evaluation to rule out similar conditions like anxiety disorders or restless leg syndrome.
• Effective treatment may include dose adjustments, switching medications, or using targeted drugs such as propranolol, benzodiazepines, or iron supplements, alongside supportive lifestyle strategies.
• Early recognition and careful medication management can prevent many cases, and outcomes are most favorable when akathisia is addressed quickly—especially for acute cases.