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    I believe the following are all part of the akathisia syndrome -- all of which are quite, to very, uncomfortable, if not worse. I see the first 2 as its most important features, yet they have hardly been recognized. Importantly, akathisia is intermittent and comes and goes as it will.  

1. Exacerbation, persistence, or return of underlying psychotic symptoms, especially paranoia, nightmares, and hallucinations which turn on and off rapidly, closely tracking with other waxing and waning akathisial features.  

2. Exacerbation, persistence, or return of underlying depressive symptoms from major depression, bipolar, or schizoaffective disorder. These also come and go rapidly, again tracking closely with other akathisial symptoms. 

3. On and off day or night restlessness/antsiness that derives from uncomfortable muscle and other body sensations and can be somewhat relieved by movement. (Seen as marché à pieds, tapping or flexing and extending hands, feet, or toes, rocking, abducting, adducting, swinging, crossing, and uncrossing the legs and arms, twirling the ankle, tossing in bed, feeling a need to take a long walk, etc.) Can be confused with ADHD. 

4. On and off nervous/anxious or “edgy” feelings. Can precipitate panic attacks. 

5. On and off irritability, anger, and/or agitation. (I believe these are just secondary to the increased anxiety and restlessness of akathisia or its exacerbation of depression and/or psychosis.)

6. On and off headaches. (Often felt as sudden sharp stabs, blows, aching, or strange feelings in head.) Strange or weird physical feelings commonly go with akathisia.

7. On and off muscle cramps, spasms, stiffness, and tightenings (including in larynx which can be confused with an anticholinergic-responsive dystonia). My patients often call them Charley horses. 

8. Spontaneous tremors or shaking of legs or hands typically starting while at rest (vs. a lithium intention tremor resulting from a muscle action). Feeling tremulous or “shaky” internally.

9. On and off twitches and myoclonic jerks. (Could lead to dropping objects or the leg suddenly giving out which could be mistaken for a dizziness due to an orthostasis from clonidine or guanfacine.)

10. Muscle, joint, bone, or other areas of aching that can be felt deep down. These may be more continuous, i.e. less intermittent than the other symptoms. Again, can be labeled as a Charley horse.                                     11. Bruxism or feeling need to “click” the teeth.                                                                                                                     12. Dizziness or lightheadedness. Can be confounded with orthostasis from clonidine and guanfacine, but akathisial dizziness often occurs when sitting or lying down. 

13. Feeling an urgency to breathe, a restlessness in breathing, or feeling unable to “breathe in a leisurely relaxed manner”. (84) Can cause grunting, gasping, sighing, snorting, dyspnea, etc.

14. A tardive dyskinesia-like picture (such as tongue protrusions or eyebrow movements I’ve seen in 2-3 patients). Perhaps TD is related to, or part of, akathisia. 

15. Paresthesias: (These are very common.)       

     On and off unusual itchiness on or deep under skin or scalp, under the skull, in brain, or in back of throat and often difficult to get at.        

     On and off crawling (formication) on or under the skin, or as if you’ve run into a spider web.             

     On and off hot or burning feelings on or under the skin, or in some part of the body. (can be quite intense)   Hot and/or cold flashes and feelings, hot and cold sweats and chills. (can be confused with menopause) 

     On and off numbness or tingling occurring most anywhere but most commonly in the hands and feet

(can be confused with diabetic neuropathy) 

     Sudden needle sticks, bee stings, or bites on the surface or penetrating deep into the body. (can be  mistakenly attributed to bed bugs)

     Touch sensations as if pushed on by a thumb or being gripped or suddenly punched.  

     On and off sudden electric shocks in part of or throughout the body. 

     On and off shooting pains that could be attributed to disc problems and arthritis. 

     Feeling pressure or aching, especially in the head. (can be confused with a headache or migraine)  

     On and off stabbing pains, especially in head, joints, sides, back, and chest (including precordium,  confusing it with angina, but is often while at rest). 

     ‘Icky’ feelings on or under skin. (can make one feel need to shower, dig at, rip off, or crawl out of skin) 

     Weird sensations such as water running down neck, blood flowing in the veins, tingles or tickling in brain  or that the head might explode, pulling or drawing sensations on a part of the body, strange sensations in  muscles and joints that can make one want to crack the knuckles, strange feelings in viscera. (“My stomach  feels strange. It’s like I’m churning inside.”) (76)

16. Dysesthesias: A touch or gentle brushing feels as if sandpaper were abrading the skin.



      Numerous other seemingly forgotten akathisia symptoms have been noted in the literature over the 

 years that I constantly see in my patients and which further substantiate my discoveries.

      As I have stated, anxiety is a major and very frequent symptom of akathisia which I think is too often ignored. The Barnes Scale gives weight to “distress” that is “related to restlessness”. I see this ‘distress’ as just anxiety due directly to akathisia and not to its restlessness.  Hirose (33) gives some variation to my idea that anxiety is an inherent symptom of akathisia. He says akathisia’s anxiety is, “the most common variant expression of [the] inner restlessness of akathisia,” -- i.e., it is just another expression of the restlessness. Sachdev states, “tension was described by 52.5% of our patients [with akathisia]… in the mind and (or) body”.(99) Van Putten writes of akathisia bringing on “strong affects of fright, terror, [and] anxiety.”(76)  Numerous others in the past, such as I noted above with the Sarwer-Foner and Ogle article, (86) have described anxiety as a symptom of akathisia and that it can reach to panic levels and even terror. More recently, Nelson (104) ascribes “tension [and] panic” to it. And again, as per Van Putten (89) citing Fouks et al., (90) akathisia is “often associated with severe anxiety…”. (translated from the French) 

     I rank the intermittent, usually out of the blue rapid onset of anxiety (Its quick onset supports my view it is an inherent symptom of akathisia.) as one of akathisia’s major features that can help me increase my index of suspicion that akathisia is occurring. My patients will, at times, describe this as a feeling of “desperation”.

     Sachdev and Kruk (105) found “coarse tremors” and “myoclonic jerks” in the legs to be due to a

neuroleptic-induced akathisia in about 5-10% of 100 inpatients as did Braude et al. (78) and Ritchie et al. (28) who observed myoclonus and akathisia from buspirone. I see these same symptoms from all my causative meds, but likely because of my early recognition and treatment, they are often limited to much milder, but, nevertheless, irritating muscle twitches, especially in the eyelids, cheeks, arms, and thighs. Other forms of muscle involvement such as cramps, (also noted by Fouks) spasms, and stiffenings are quite common with the akathisia I see.

     Sachdev and Kruk (105) saw “a feeling of pins and needles” from akathisia in 12.5% of 100 inpatients, and Fouks et al., (90) noted “fourmillements” (tingling). 

     Sachdev states, (99) 12.5% of his patients “experienced paraesthesiae” from akathisia. To me, this rate is quite low. In 1992, before the SGAs, Decina et al. (100) reported 23% of 60 consecutively admitted psychiatric inpatients on neuroleptics suffered “subjective painful sensory symptoms” who did not have them at admission which they attributed to the treatment and which I would specifically attribute to akathisia. My estimate for paresthesias is 30-40%. They are sudden, usually sharp, stinging, or like electric shocks (as felt in “Garden State”). I typically ask my patient about bee stings, bites, shocks, or pinpricks. In the present national concern over bedbug infestations, many of my patients claim they are being bitten, but generally this stops after I begin treatment for akathisia. With so many people on our meds, I can wonder how much of our bedbug problem is only this!  

     There are various other paresthesias I commonly see with akathisia that have been described before.  Astra Zenica, in a pamphlet on quetiapine (Seroquel) entitled “Recognize Akathisia”, (pamphlet #237575, June 2006) mentions the “sensation of skin crawling or jumping out of one’s skin” (i.e., wanting to). I find feeling bugs crawling on or under the skin, along with itching, to be one of the most common symptoms of akathisia, and again, not only due to the antipsychotics but from almost all the psychotropics. Burke et al. (101) saw rubbing of the face and hair and scratching from akathisia, which they thought of as an expression of “stereotyped movements” but which I suspect is just part of its paresthetic itching and crawling. In the same way, Barnes attributed scratching and face and thigh rubbing to “complex hand movements” (94) due to akathisia. Kim et al. (102) write of “paresthesias and various unpleasant sensations”. Fouks et al.,(90) as translated in Van Putten, (89) write of “peculiar bodily sensations”, Van Putten and Marder,(88) of a patient who felt “worms crawling on my bones”, and Van Putten, of “vague somatic complaints”, all due to akathisia.(76) The vague somatic complaints I see usually entail weird or strange sensations such as being touched or pulled on, including internally, feeling water running down a part of the body, blood coursing through the veins, an inflated balloon inside, tingles, or numbness within the head, the brain being pulled on or ‘tickled’, etc. Freyhan (85) described “pulling and drawing sensations in the extremities” as did Barnes. (94) I see them occurring most anywhere on the body. Though many of these unpleasant sensations might be diagnosed as tactile hallucinations, I am quite sure they are more likely to be symptoms of akathisia because when I treat them as part of it, they typically resolve. 

     Head-banging has been seen with identified akathisia (76), (84) and sometimes where it was not mentioned (106) but which I suspect was present. I haven’t seen head-banging with my patients, but my guess is it’s from the itching, pulling, and other very uncomfortable feelings from akathisia inside the head of which they would complain and which I think I was able to deal with before injury occurred. I did have a couple patients who slashed their arms due to akathisia which I was then able to stop. (I can only wonder if akathisia is behind many of these self-mutilations and head-bangings.)        

     Breathing can be affected by akathisia. Kruk et al. (107) write of “irregular respirations, dyspnea, grunting or gasping, and abnormal chest and esophageal movements” from TA and dyskinesia. Hirose, (84) in 5 patients, noted a restlessness in breathing and difficulty “breath[ing] in a leisurely relaxed manner”, with gasping, sighing, and dyspnea, and Kim et al. (102) noted “difficulty breathing”. Similar problems are reported by others. (101), (94), (103) I suspect these symptoms reflect the spasms, cramps, and tightenings I see from akathisia but have seen only a couple patients with such breathing difficulties. I’ve had a couple to a few with laryngospasm who responded to my akathisia medications and not so well to an anticholinergic, the usual therapy for this dystonia.

     These papers reveal that some of the numerous symptoms I saw from akathisia have been recognized by others but were then apparently forgotten. I believe they are very much a part of this syndrome and can help us recognize just how frequent and important akathisia is to our patients’ comforts and our medication efforts. I think the field has only caught glimpses of what I have seen, leaving major gaps in our understanding of its overall significance and how to better treat it. And of course, there is the apparent deletion I noted above by the DSM-5 of the DSM-IV and -IV-TR assertion that akathisia can cause a psychotic relapse, but no mention made in either that it can frequently do the same with depression.  (but restored in the 5-TR)

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