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Wikipedia Workshop

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Middlebury College web site

Middlebury Wikipedia page

I am from Harrison, Maine

Akathisia

Now I will draft my Akathisia article

Description

Akathisia may range in intensity from a sense of disquiet or anxiety, to severe discomfort, particularly in the knees. Patients typically pace for hours because the pressure on the knees reduces the discomfort somewhat; once their knees and legs become fatigued and they are unable to continue pacing, they sit or lie down, although this does not relieve the akathisia. At high doses or with potent drugs such as haloperidol (Haldol) or chlorpromazine (Thorazine/Largactil), the feeling can last all day from awakening to sleep. The anticholinergic procyclidine reduces neuroleptic-induced akathisia to a certain degree, in addition to preventing and sometimes eliminating the muscle stiffness that can occur alongside akathisia. When misdiagnosis occurs in antipsychotic neuroleptic-induced akathisia, more antipsychotic neuroleptics may be prescribed, potentially worsening the symptoms. High-functioning patients have described the feeling as a sense of inner tension and torment or chemical torture. Many patients describe symptoms of neuropathic pain akin to fibromyalgia and restless legs syndrome. Although these side effects disappear quickly and remarkably when the medication is stopped, tardive, or late-persisting akathisia may go on long after the offending drug is discontinued, sometimes for a period of years—unlike the related tardive dyskinesia, which can be permanent.

The presence and severity of akathisia can be measured using the Barnes Akathisia Scale, which assesses both objective and subjective criteria.

The term was coined before the introduction of antipsychotics by the Czech neuropsychiatrist Ladislav Haskovec (1866–1944) who described the phenomenon in 1901. Reports of akathisic states can be found in the medical literature before the advent of neuroleptics. Healy, et al. (2006), described the following regarding akathisia: tension, insomnia, a sense of discomfort, motor restlessness, and marked anxiety and panic. Increased labile affect can result, such as weepiness. Interestingly, in some people the opposite response to SSRIs occurs, in the form of emotional blunting; but sufficient clinical research has not yet been made in this area.

Jack Henry Abbot (1981), a convicted murderer and author, described the effects of akathisia produced by antipsychotic drugs when given without the necessary medication for side effects (e.g. procyclidine) as may occur in prison and even sometimes hospitals:

These drugs, in this family, do not calm or sedate the nerves. They attack. They attack from so deep inside you, you cannot locate the source of the pain ... The muscles of your jawbone go berserk, so that you bite the inside of your mouth and your jaw locks and the pain throbs. For hours every day this will occur. Your spinal column stiffens so that you can hardly move your head or your neck and sometimes your back bends like a bow and you cannot stand up. The pain grinds into your fiber ... You ache with restlessness, so you feel you have to walk, to pace. And then as soon as you start pacing, the opposite occurs to you; you must sit and rest. Back and forth, up and down you go in pain you cannot locate, in such wretched anxiety you are overwhelmed, because you cannot get relief even in breathing.

— Jack Henry Abbot, In the Belly of the Beast (1981/1991). Vintage Books, 35–36. Quoted in Robert Whitaker, Mad in America (2002, ISBN 0-7382-0799-3), 187.

In a psychiatric setting, patients who suffer from neuroleptic-induced akathisia often react by refusing treatment.

Diagnosis

Despite the intensive research surrounding Akathisia, it is important to note the difficulty of diagnosis due to the complex nature of the disorder. Precise assessment of akathisia is problematic as it is difficult to differentiate from a multitude of disorders with similar symptoms. In a study of movement disorders induced by neuroleptics, akathisia was diagnosed in only 26% of patients who actually had it.The primary distinguishing features of akathisia in comparison with other syndromes are primarily subjective characteristics, such as the feeling of inner restlessness. Akathisia can commonly be mistaken for agitation secondary to psychotic symptoms or mood disorder, antipsychotic dysphoria, restless legs syndrome, anxiety, insomnia, drug withdrawal states, tardive dyskinesia, or other neurologic and medical conditions .

Additionally, there is the controversial diagnosis of pseudoakathisia, as discussed by Mark J. Garcia in his article discussing akathisia in adults with severe and profound intellectual disability. He describes pseudoakathisia as “comprising all the symptoms of abnormal movements seen with akathisia, but without a sense of restlessness”. It is difficult to arrive at an accurate diagnosis of akathisia as it is easily misdiagnosed as a psychiatric disorder. Even an experienced clinician may have difficulty distinguishing akathisia from the symptoms of similar disorders.

Classification

Acute akathisia

• Duration of less than 6 months
• Develops soon after starting antipsychotic medication or following dose increase, switch to high-potency antipsychotic, withdrawal of anticholinergic
• Intense dysphoria
• Awareness of restlessness
• Complex and semipurposeful motor fidgetiness

Chronic akathisia

• Persists for over 6 months after last dosage increment
• Subjective sense of restlessness may be less marked
• Mild dysphoria
• Awareness of restlessness
• Motor fidgetiness with stereotyped movement
• Limb and orofacial dyskinesia often present

Pseudoakathisia

• Motor manifestations without subjective component
• Predominantly in men
• Possibly late stage of chronic akathisia
• No dysphoria
• No awareness of restlessness
• Motor fidgetiness with stereotyped movement
• Great overlap with limb and orofacial dyskinesia

Tardive akathisia

• Delayed onset (usually 3 months)
• Not related to a recent change in druge or dose
• Significantly associated with tardive dyskinesia

Withdrawal or “rebound” akathisia

• Associated with switching antipsychotic medications
• Onset usually within 6 weeks of discontinuation or dose decrease
• Anticholinergic discontinuation reaction

Causes

Drug-related Akathisia is frequently associated with the use of antipsychotic drugs that are dopamine-receptor antagonists. There is still limited understanding on the pathophysiology of akathisia, but it is seen to be associated with medications which block dopaminergic transmission in the brain. Additionally, drugs with successful therapeutic effects in the treatment of medication-induced akathisia have provided additional insight into the involvement of other transmitter systems. These include benzodiazepines, ß-adrenergic blockers, and serotonin antagonists.

Treatment

If the patient is experiencing akathisia due to opioid withdrawal, a moderate dose of any opioid (e.g.morphine, fentanyl, methadone, oxycodone) will relieve it all together. Also many patients get relief with pregabalin, which is a GABA-analogue related togabapentin.[citation needed] One study showed that vitamin B6 is effective for the treatment of neuroleptic-induced akathisia.[16] N-acetyl cysteine also showed a positive effect on akathisia in an RCT.[17] Additional pharmacologic interventions found to have anti-akathisia effects include B-adrenergic antagonists (eg. propranolol), benzodiazepines (eg. lorazepam), anticholinergics (eg. benztropine) as well as serotonin antagonists (eg. cyproheptadine) as an alternative. Taylor et al. found success in lowering the dose of antipsychotic medication as an initial response if the akathisia is drug-induced The clinician is advised to take a conservative approach when planning an adjustment in medication to minimize the risk of akathisia.