Hi, I'm Dr. Tracey Marks, a psychiatrist
and I make mental health education videos.
I've gotten several requests to talk about akathisia
and I'm going to talk about what it is,
why it happens and what we do about it.
Akathisia is a side effect of some medications,
mostly antipsychotics, antidepressants and antiemetics
which are medications
that are prescribed for nausea and vomiting.
Some of these medicines are things like odansetron,
brand name Zofran and promethazine, brand name Phenergan.
Akathisia is a Greek term that means not to sit
and as such, akathisia a movement disorder
that causes extreme restlessness
and inability to stay still.
It can vary from mild to severe and cause a lot of distress.
In some people, it has even caused the onset of suicidality.
On the surface, it may seem like you feel restless.
Well, just get up and walk but it's much more than that.
Here are some of the ways that it can manifest.
Feeling inner tension or discomfort.
I've had some patients tell me
that they feel like they were coming out of their skin.
An urge to constantly move the legs or parts of the body
such as the arms or trunk.
The trunk movement can look like this
like just someone who's restless
and the person can't suppress the movement.
There's a buildup of tension and then you just have to move.
Another way that it can look as needing to shift your weight
from one foot to another or pace
and these are all physical sensations
but it can cause a lot of anxiety and distress
and it's much different from anxiety.
Anxiety may start with physical symptoms
like a rapid heart rate or shortness of breath
but it's still connected to a mental component
of fear, angst or worry.
Another difference between akathisia and anxiety
is because anxiety is predominantly an emotional process,
you can force yourself to keep your body still
if you had to.
You can keep your trunk still while you fret in your mind
but with akathisia, you can't force yourself not to move.
So a good test for akathisia
that involves moving the limbs or trunk
is to see if you're able to maintain a normal posture
or refrain from moving your legs for several minutes.
You can't really use this test though
if your akathisia manifests as internal sensations.
Why does this happen?
We don't have exact answers but the proposed mechanism
is the medication causes a drop in dopamine
in certain areas of the brain
that are involved with inhibiting movements.
It's like a control valve is broken
and you just can't control your movements.
It's not a big surprise though
that the antipsychotics tend to do this
because of the way that they work is by blocking dopamine.
Any of the antipsychotics can do this
but the ones that have less weight gain and less sedation
tend to be the ones that do it more
and some of these are aripiprazole, brexpiprazole,
ziprasidone and lurasidone.
The sedating medications like quetiapine and olanzapine
don't do it as much
because these drugs have antihistamine properties
that offset this problem.
This can also happen with the antidepressants
because of a feedback mechanism of increased serotonin
causing the decrease in dopamine
in other parts of the brain.
Another scenario where you can see this
is a withdrawal effect of stopping an anticholinergic drug.
Anticholinergics block acetylcholine in the nerve synapse
which is the space between the nerves.
Dextromethorphan which is a cough suppressant
found in over the counter remedies,
is an example of an anticholinergic medication.
Now, you would have to take a lot of it though
on a regular basis to experience rebound akathisia
from stopping it but I just wanted to give you an example
or an everyday example of an anticholinergic medication.
How long does it last?
Usually, akathisia goes away
weeks after stopping the medication
but sometimes it can take up to six months to resolve
and there are less frequent instances
of people having chronic symptoms
well after the medication has been stopped.
In this case, we consider it more of a dyskinesia
like tardive dyskinesia
that is a long-standing movement problem.
What do we do about this?
The first thing is to stop the medication
that's causing the problem
and when I say stop, I mean taper off.
How fast you taper off
is something that you would work out with your doctor.
Some symptoms can get better by decreasing the dose
and not necessarily getting completely off the medication
but in general, this is not a symptom
that gets better as your body gets used to the medicine.
You have to make some kind of adjustment.
If you need to stay on the medication
because it's the only one that works for you,
another approach is to take another medication
to address the akathisia.
Some of these medications are benztropine,
propranolol which is a blood pressure medicine,
amantadine and clonidine.
Benzodiazepines like clonazepam can also help the symptoms
but they're not the best choice in my opinion
because akathisia is a daily problem
and when you need to take a benzodiazepine daily,
it's a setup for becoming dependent on a benzodiazepine
and benzodiazepines cause tolerance as well
and then you may need increasing doses of that.
In my experience, these medications work well for akathisia
and some people's symptoms can completely go away
allowing them to stay on the original medication
that was helping but it does mean taking a second medicine
on top of the original one.
And the medications have their own set of side effects.
For example, benztropine can cause dry mouth
which can affect your breath and your oral health.
It can also cause constipation
in which case you may need something else to overcome that.
Akathisia that comes from antidepressants
can be mistaken for increased anxiety from antidepressants
and you can have both.
But one way to tell the difference between the two
is the anxiety that you can get
when you first start an antidepressant usually goes away
after your body adjusts to the medication.
But the akathisia remains
and often starts after you've been taking the medication
for a little while.
I talk about feeling worse on antidepressants in this video.
See you next time.