Clinical Psychopharmacology · Paper A
Akathisia
AkathisiaAn inner restlessness and urge to keep moving, a common side effect of antipsychotic drugs.Read more → matters because it is easily mistaken for anxiety or worsening psychosis, yet treating it as either can make the restlessness worse. It is a subjective inner restlessness with an outward inability to stay still, pacing, rocking, shifting weight, that appears early after starting or raising an antipsychotic. E.g. a patient who cannot stop shifting their legs and paces the ward corridor within days of a dose increase shows this classic presentation.
AkathisiaAn inner restlessness and urge to keep moving, a common side effect of antipsychotic drugs.Read more → is dose-related and driven by dopamine blockade, but unlike dystoniaInvoluntary muscle contractions causing abnormal, sometimes painful, postures or movements.Read more → (sustained abnormal muscle spasms forcing the body into twisted postures) or drug-induced parkinsonism it does not respond to anticholinergicBlocking the action of acetylcholine, a nerve chemical, causing effects like a dry mouth and blurred vision.Read more → drugs, a key discriminator. Giving an anticholinergic to a patient with akathisia, expecting the same improvement seen in drug-induced parkinsonism, will not settle it, because the underlying mechanism differs. The fix is reducing the antipsychotic dose or switching agents, not adding an anticholinergic.
A fresh doctor might see a restless, pacing patient on an antipsychotic and assume the underlying psychosis is simply worsening, prompting a higher dose. That assumption can backfire badly: is itself a drug side effect that increasing the antipsychotic dose will worsen, not improve, and it carries a genuine link to suicidality. Hold the phrase INNER RESTLESSNESS through every section below, because the subjective feeling, not just the visible movement, is what actually defines akathisia.
Akathisia is a movement side effect of dopamine-blocking drugs (most often antipsychotics) combining a subjective, internal feeling of restlessness and an urge to move with objective, outward motor restlessness: pacing, rocking from foot to foot, shifting weight while seated, or being unable to keep the legs still. It typically appears within days to weeks of starting a dopamine-blocking drug or raising its dose, placing it earlier in onset than tardive dyskinesia (a late, often irreversible movement disorder from the same drug class).
A common and dangerous mistake is treating as worsening psychotic agitation and increasing the causative antipsychotic dose. This escalates the restlessness rather than resolving it, and delays the correct management. Akathisia carries a documented association with increased suicidality, so recognising and correctly labelling it, rather than misreading it as anxiety or psychosis, matters as a genuine safety issue, not only an academic distinction.
is thought to be driven by dopamine blockade, in the same broad family of mechanisms as other extrapyramidal side effects (EPSE, movement problems caused by drugs that block dopamine in the brain's motor circuits). It is dose-related: the more completely and potently a drug blocks dopamine , the more likely akathisia becomes. Unlike acute (sudden muscle spasm) or drug-induced parkinsonism (tremor and stiffness), however, akathisia does not respond to drugs (medications that block acetylcholine, used successfully for those other movement side effects): giving one will not settle it, because the underlying circuitry driving the restless urge differs from the pathway those other conditions sit on. This non-response is itself a useful bedside discriminator when the diagnosis is uncertain.
A patient with will often describe the sensation directly if asked (an inner urge or need to move, distinct from ordinary anxiety or agitation) even before an observer notices obvious pacing. For example, a patient started on haloperidol who begins constantly shifting their weight from foot to foot and reports feeling unable to sit still is showing a classic combination of the subjective and objective features together, and asking "do you feel a pulling, restless urge inside, or is it more that your mind is racing with worry?" is often what separates the two.
Restless legs syndrome causes an urge localised to the legs, characteristically worse at night and relieved by movement, rather than constant, drug-linked, whole-body restlessness. agitation is driven by the underlying mood or psychotic disorder itself, not tied to a specific dopamine-blocking drug or its dose. Tardive dyskinesia is a late-onset, involuntary movement disorder (typically orofacial: around the mouth and jaw) that the patient is often unaware of, unlike akathisia's early onset and clearly felt subjective urge to move. Anxiety produces pervasive worry and autonomic arousal (racing heart, sweating) without the specific drug-linked motor restlessness of akathisia.
is a clinical diagnosis, made by combining history and observation rather than any blood test or scan. The key history question is whether the patient feels an inner urge to move, not simply whether they look restless. Severity and the presence of the syndrome are formally rated using the Barnes Akathisia Rating Scale (BARS), a structured instrument that scores both the observed objective restlessness (pacing, foot-shifting) and the patient's subjective distress about it, then combines these into a global severity rating. Timing is a diagnostic clue in itself: symptoms emerging within days to weeks of starting or increasing a dopamine-blocking drug, and easing when that drug is reduced, support the diagnosis. A trial of an that fails to help is a further supportive (though not definitive) clue, since work for other EPSEs but not for akathisia.
The first management step is reducing the dose of the causative dopamine-blocking drug or switching to a lower-propensity agent: this is the single most effective intervention and should always be considered before adding a new drug. Propranolol (a beta-blocker) is the best-evidenced adjunct treatment for persistent once dose reduction alone is insufficient. Benzodiazepines can offer short-term symptomatic relief while the causative drug is being adjusted. are not an effective treatment here, unlike their role in acute and parkinsonism, so reaching for one is a recognised prescribing error. Maudsley Prescribing Guidelines-informed practice emphasises reviewing dose and agent choice first, reserving propranolol or a short benzodiazepine course for cases where that alone does not settle things, and always asking a restless patient directly whether they feel an inner urge to move rather than only observing their behaviour from across the room.
A vignette describing a patient whose "worsening agitation" after an antipsychotic dose increase is treated with yet another dose increase, with symptoms escalating further, is testing recognition of being mistaken for psychosis. Another trap offers an as the answer for a restless, pacing patient: the correct discriminator is that help and parkinsonism but do not help akathisia, so picking one here is the wrong answer even though it looks like a plausible EPSE treatment.
combines subjective inner restlessness with objective motor restlessness, appearing within days to weeks of starting or raising a dopamine-blocking drug, diagnosed clinically and rated with the Barnes Akathisia Rating Scale; management is to reduce the dose or switch agent, with propranolol as the best-evidenced adjunct, never an . If a patient on an antipsychotic feels an inner need to move, don't raise the dose: lower it, or add propranolol.