Akathisia Diagnosis and Management
Clinical Presentation
- The physical exam finding of a patient moving as if stretching their muscles or dancing is characteristic of akathisia, a drug-induced movement disorder most commonly caused by antipsychotic medications 1, 2
- Pacing or restless walking is an objective motor finding of akathisia 1, 2
- Repetitive foot tapping and rubbing feet together are also characteristic of akathisia 3
- Physical agitation that resembles stretching or dancing movements is a key feature of akathisia 1
Differential Diagnosis
- The American Academy of Child and Adolescent Psychiatry emphasizes distinguishing akathisia from Restless Legs Syndrome (RLS), which improves with movement and worsens at night 3, 4
- Tardive Dyskinesia is distinguished from akathisia by its involuntary, rhythmic movements primarily affecting the orofacial region that develop after prolonged antipsychotic use 1
- Drug-induced Parkinsonism is characterized by bradykinesia, tremors, and rigidity without the subjective restlessness 1
- Acute Dystonia is marked by sudden spastic muscle contractions of neck, eyes, and torso 1
Causative Medications
- High-potency typical antipsychotics have the highest risk of causing akathisia 1
- Atypical antipsychotics have a lower but still present risk of causing akathisia 1
- SSRIs, particularly fluoxetine, are associated with an increased risk of akathisia and suicidality 2
Assessment Approach
- The American Academy of Child and Adolescent Psychiatry recommends systematically inquiring about the subjective feeling of inner restlessness and observing for characteristic repetitive movements when akathisia is suspected 2
- The diagnosis of akathisia is primarily clinical and does not require polysomnography or other objective testing in most cases 3