Akathisia is a symptom that is defined by the urge to move or to trample on the spot in an irresistible and incessant way. This sensorimotor disorder is mainly located in the lower limbs. Akathisia can be accompanied by mood disorders, anxiety. The cause of akathisia must first and foremost be identified and the initial treatment must be aimed at this cause.

What is it ?

Akathisia is a symptom that is defined by the urge to move or to trample on the spot in an irresistible and incessant way. This sensorimotor disorder – which must be differentiated from psychomotor agitation – is mainly located in the lower limbs. It occurs mostly when sitting or lying down. Discomfort, secondary insomnia, even distress in major forms are often observed. Akathisia can be accompanied by mood disorders, anxiety.

The differential diagnosis between akathisia and restless leg syndrome remains debated given the high degree of clinical overlap between the two. Some researchers believe that the two symptoms are similar but that they are considered to be different due to the different inheritance of these concepts: studies on restless legs syndrome come more from the neurological literature and on sleep and Akathisia of the psychiatric and psychopharmacological literature.

How to recognize akathisia

Currently, akathisia is only diagnosed on clinical observation and patient report, as there is no confirmatory blood test, imaging assessment, or neurophysiological study.

The essential features of acute neuroleptic-induced akathisia are subjective complaints of impatience and at least one of the following observed movements:

• Restless movements or swaying of the legs when sitting;
• Swinging from one foot to the other or stomping while standing;
• Need to walk to relieve impatience;
• Inability to sit or stand without moving for several minutes.

The most commonly used assessment tool is the Barnes Akathisia Rating Scale (BARS), which is a four-point scale in which the subjective and objective components of disease are rated separately and then combined. Each item is rated on a four-point scale, from zero to three:

• The objective component: there is a movement disorder. When the severity is mild to moderate, the lower extremities are primarily affected, usually from the hips to the ankles, and movements take the form of changes in position while standing, rocking, or movement of the feet while sitting. When severe, however, akathisia can affect the entire body, causing almost incessant twisting and swaying movements, often accompanied by jumps, runs and, on occasion, throws from a chair or kick. a bed.
• The subjective component: the severity of subjective discomfort varies from “slightly annoying” and easily relieved by moving a limb or changing position, to “absolutely intolerable”. In the most severe form, the subject may be unable to maintain any position for more than a few seconds. Subjective complaints include a feeling of inner restlessness – most often in the legs – a compulsion to move the legs and pain if the subject is asked not to move their legs.

Risk factors

Although acute antipsychotic-induced akathisia is often associated with schizophrenia, it appears that patients with mood disorders, especially bipolar disorder, are actually at greater risk.

Other risk factors can be identified:

• Head trauma;
• Cancer ;
• Iron deficiency.

Chronic or late akathisia can also be associated with old age and female sex.

Antipsychotics

Akathisia is commonly seen after treatment with first generation antipsychotics, with prevalence ratios ranging from 8 to 76% of patients treated, making it arguably the most common side effect of these drugs. . Although the prevalence of akathisia is lower with second generation antipsychotic drugs, it is far from zero;

Antidepressants

Akathisia can occur during treatment with antidepressants.

Other medicinal origins

The antibiotic azithromycin 55, calcium channel blockers, lithium, and drugs often used recreationally such as gamma-hydroxybutyrate, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) and cocaine.

Parkinsonian conditions

Akathisia has been described in conjunction with a variety of disorders associated with Parkinson’s disease.

Spontaneous Akathisia

Akathisia has been reported in some cases of untreated schizophrenia, where it has been referred to as “spontaneous akathisia”.

Poor adherence to treatment

The suffering caused by akathisia is significant and may be the cause of non-compliance with the neuroleptic treatment responsible for this symptom.

Exacerbation of psychiatric symptoms

The presence of akathisia also exacerbates psychiatric symptoms, often causing clinicians to inappropriately increase offending agents, such as selective serotonin reuptake inhibitors (SSRIs) or antipsychotics.

Suicide

Akathisia can be associated with irritability, aggression, violence, or suicide attempts.

The cause of akathisia must first and foremost be identified and the initial treatment must be aimed at this cause.

As Akathisia develops mainly as a result of taking psychotropic drugs, the initial recommendation is to reduce or change the drug if possible. In patients taking first generation drugs, an attempt should be made to switch to second generation agents that appear to cause less akathisia, including quetiapine and iloperidone.

If an iron deficiency exists, it may be helpful to correct the situation.

It should also be noted that a “withdrawal akathisia” can occur – following a change in treatment, a temporary exacerbation can occur: it is therefore not necessary to judge the effectiveness of a reduction in dose or ” a change of medication before six weeks or more.

However, akathisia can remain very difficult to treat. A multitude of different are reported to be useful, but the evidence is yet to be confirmed.