Akathisia diagnosis: An objective test

Abstract

Dr. Malthie is head of the ps.vchiatry consultation liaison service at the Veterans Administration Ho.~pital. Durham. N.C. and assistant professor of pS.l'chiatr.l' at Duke Universit.l' Medical Center. Dr. Cavenar is chief of the p.I}'<·hiatr.l' serrice at the Veterans Administration Hospital and a.Hociate professor o( pS.l'chiatr.l' at Duke. Akathisia has received considerable attention in the psychiatric literature lately as a frequently overlooked or misdiagnosed complication of neuroleptic therapy.1 Some of our patients have complained bitterly of this drug-induced complication and we may easily confuse the patient's distress with a worsening of his primary illness. Akathisia. like most drug-induced extrapyramidal side effects. is readily reversible and usually easily managed by appropriate use of antiparkinsonian agents or thoughtful adjustment of neuroleptic treatment. Therefore, the accurate diagnosis of this therapeutic complication is of utmost importance to maintaining the patient's well-being. Akathisia has variously been described as restless legs, 2.3 an inability to sit still,1 or a need or desire to move.u It is generally accompanied by complaints such as restlessness. impatience. vague feelings of discomfort. jitters. nervousness. or panic. Patients usually report a worsening of their discomfort with physical inactivity. Consequently. such a patient may fidget, tap his feet. pace. rock forward and backward. or stand shifting his weight continuously from side to side. In a survey of 3.775 patients receiving phenothiazines. Ayd reported that 1,472 (39%) developed drug-induced extrapyramidal reactions. More than half of the 1,472 (21 %) had akathisia. Marsden and associates confirmed Ayd's general incidence of about 20% and noted other reports ranging from 5% to 50% for akathisia following potent piperazine-phenothiazine use. They note that. as with other drug-induced syndromes. the incidence varies with the potency of the phenothiazine. Onset of akathisia usually does not occur within the first 48 hours of drug treatment; thereafter. the incidence continually increases, with 50% occurring within a month and 90% within two or three months.3.6 Akathisia favors no age group; it occurs almost equally in people from 12 to 65 years of age.3.6 Raskin I notes that the subjective experience of discomfort and restlessness in akathisia is easily confused with anxiety. He warns that any anxiety-like symptoms. uneasiness. or restlessness associated with antipsychotic drug use should lead to a consideration of a diagnosis of akathisia. Van Putten and associates~ recently reported that. in a systematic study of 80 schizophrenic patients receiving phenothiazines in conventional doses. nine experienced dramatic exacerbations of their psychosis while on phenothiazines. This was associated with subtle akathisia. and intramuscular biperiden promptly