The typical patient who comes in my office with akathisia hands me a business sized card that tells me about the condition. It pulls at my heartstrings because I instantly know I’m not even close to the first person they have shown this to. The diagnosis is often made by the individual and they often know more about it than most doctors. The first line treatment is not strong the way Augmentin is for strep throat. But I'm jumping ahead; before we talk about the treatment and where I think it needs to go, I want to discuss exactly what Akathisia is and why doctors and patients can’t get on the same page about it.
Akathisia is the inability to sit still. There’s the first problem; the definition. Akathisia is a movement disorder in a group of other movement disorders like tardive dyskinesia. More specifically, akathisia is characterized by a subjective feeling of inner restlessness or jitteriness with a compelling urge to move. As you can see, these symptoms resemble what might manifest from Parkison’s disease, anxiety, tic disorder or schizophrenia. This inner restlessness can be quite severe, causing anxiety, insomnia, skin crawling sensations and inability to calm down. The word “move” is in the definition, but the person affected by akathisia may not physically always move in the repetitive way that those with tardive dyskinesia do. The clinical diagnosis, as you can see, can be challenging to correctly make. The cause can be a helpful clue. Antipsychotics and SSRIs are established enough in the literature at this point to be a known cause, particularly during a taper that was not quite slow enough. Do I think this potential withdrawal akathisia is limited to these two drug classes? No. Will everyone tapering go on to develop akathisia? Definitely not.
If akathisia can be caused by a med taper, then what’s the difference between akathisia and severe withdrawal or drug discontinuation syndrome? I wish I had a diagram here, because of the symptoms that apply to both akathisia and withdrawal, which include
Anxiety
Agitation
Aggression
Insomnia
Itching
Restlessness
Sweating
Lightheadedness
Ok the list is gonna go on for days, but you get the gist.
Now, let’s say someone develops akathisia with symptomatic physical movement expression, such as hand rolling, restless legs or pacing. That will typically be an easier diagnosis for a doctor to make, but the problem at this point might be the treatment. It’s thought dopamine signaling is involved with akathisia which is also the case with other movement disorders like Parkinsons. Dopamine agonists may help certain movement disorders, but it’s not recommended as first line for withdrawal akathisia.
So where does this leave us? Are beta blockers the answer? Is the research on vitamin B6 that good?
I’ve seen both of these be somewhat helpful and also not do much. It truly depends on the person. I’ve found more effective therapies in my practice, and each is dependent on the person’s unique situation and symptoms. Just like someone might be more adept at basketball and someone else likes hiking. The same thing might apply here. Not everyone can tolerate a specific therapy, so there’s no one size fits all protocol. The treatment must be individualized. The truth is, that psychiatric medication withdrawal or akathisia can feel so severe that at times, it seems like it’s going to swallow you whole. It might seem like it is the new normal, but that doesn’t have to be the case. The first step is getting a correct diagnosis, the second is to work with someone whom you trust and knows what they are doing and the third is to believe that you can get better. The third one is crucial. <3
Please reach out to me if you need medical guidance and remember, you are not alone.