Akathisia is a complex phenomenon that combines a feeling of inner disturbing discomfort and a constant need for movement, realized through rocking, shifting from foot to foot, marching in place. Patients with this disorder are unable to stand still, cannot sit still, and sometimes this kind of activity occurs even during sleep.
Causes of illness
Most doctors agree that akathisia is the result of taking antipsychotics (drugs that affect the synthesis and transmission of dopamine) and antidepressants. In addition, recent studies (for 2013) have shown that pathology can also develop due to pathophysiological causes.
Researchers have noted some connection between the appearance of akathisia and Parkinson's disease, but whether the disease is a consequence of Parkinson's disease or is associated with the use of anti-Parkinsonian drugs ("Levodopa") is not completely clear.
So, the most common "causative" factor of akathisia is long-term usepsychotropic (usually neuroleptics) and other drugs from the following pharmaceutical groups:
- lithium preparations;
- antiemetic;
- neuroleptics;
- some antihistamines;
- antidepressants;
- SSRIs;
- certain antibiotics, antiarrhythmics, interferons, antituberculous and antiviral drugs;
- barbiturates, opiates, cocaine, benzodiazepines (for withdrawal);
- antipsychotic combinations (if serotonin syndrome is present).
Risk factors
A high risk of developing akathisias caused by neuroleptics or other antipsychotic therapy is present in elderly or young patients with dementia, a history of neurological, anxiety or affective disorders, oncological pathologies, brain injuries, during pregnancy, the presence of a genetic predisposition, lack of magnesium and iron, high dosages of medications taken, or a combination of them.
In addition, other factors and conditions can cause the appearance of the syndrome:
- stroke, TBI, extrapyramidal and neurological disorders;
- certain mental illnesses: hysterical, anxiety, affective, conversion disorders and schizophrenia;
- very rare when coming out of general anesthesia or after electroconvulsive treatment.
Pathogenesis
Doctors attribute akathisia to Parkinson-like conditions associated with exposure to the patient's dopaminergic system of psychotropic drugs. And if in cases of applicationneuroleptics the picture is quite clear (direct antagonism to type 2 dopamine receptors), then when taking antidepressants, the mechanism of akathisia is more complex. It is realized, probably, due to the antagonism of dopamine and serotonin in the brain, which leads to some lack of dopamine, in particular in the nigrostriatal pathway responsible for motor skills.
It is worth noting that there are no disorders in the peripheral nervous system in this pathology, and the disease is purely psychological.
Main classification
With akathisia, neurologists most often use the division of pathology into the following forms:
- Spicy. Duration less than six months. Occurs almost immediately after starting treatment with antipsychotics (for example, Paroxetine, Paxil). Akathisia is one of the side effects of these drugs. Also, the disease may be the result of a transition to more powerful means or an increase in the dosage of those already mentioned, with withdrawal syndrome or severe dysphoria. This form is accompanied by a feeling and awareness of anxiety and other pronounced classic symptoms.
- Chronic. Duration more than six months. The feeling of anxiety is not expressed intensely, but is realized by the patient. There are orofacial and limbal dyskinesias, motor fussiness with repetitive movements, mild dysphoria.
- Late. It appears with some delay (up to three months) after abrupt withdrawal or change in the dosage of antipsychotics, but may not be associated with changes in therapy.
- Pseudoakathisia. It occurs mainly among men. There are motor symptoms (including fussiness) and orofacial dyskinesia, with no sensation or awareness of anxiety. No dysphoria.
Clinical systematization
Also, akathisias are classified according to the predominance of certain symptoms into the following types:
- Classic. Sensations and objective symptoms are approximately the same.
- Mostly psychic. There is marked tension, anxiety, restlessness.
- With a predominance of motor symptoms. The patient cannot sit still, restless, fussy.
- With a predominance of sensory manifestations. The patient complains of discomfort in the muscles of the legs and arms, while motor changes appear slightly.
Symptoms of akathisia
The clinical picture of the disease includes a wide variety of symptoms, but irritability and anxiety almost always come to the fore.
The entire clinic of akathisia can be divided into 2 symptom complexes: sensory and motor.
Sensory component implies the presence of an internal acute anxiety that prompts the patient to consciously perform certain actions. Changeable mood, indefinite inner fear, irritability serve as manifestations of the sensory symptom complex.
There is often pain in the legs.
Motorthe symptom complex consists in the constant repetition of a certain movement (for each patient his own). For example, it can be rocking the torso, bouncing on a chair, constant walking, and so on. Often such movements are combined with lowing or screaming, however, when the activity fades, the sounds disappear.
Internal extremely uncomfortable sensations force the patient to constantly change positions and do something. At the same time, the actions carried out by the patient are fully conscious, and for a short time the patient can suppress them by an effort of will and remain motionless. However, when switching attention or fatigue, stereotyped movements return again.
Insomnia with akathisia
A frequent companion of akathisia is insomnia. Due to pathological processes in the brain, the patient does not control his own actions and is forced to constantly move due to internal restlessness, which is present even at night.
In addition, the colossal expenditure of energy that is not replenished in a dream leads to a deterioration in the general condition and aggravation of the disease. The patient contemplates suicide. The disease enters an advanced stage.
This is why early diagnosis and adequate treatment of akathisia is essential.
Diagnostic measures
Diagnosis and treatment of akathisia is the task of a neurologist. To make a diagnosis, no instrumental studies are needed, the doctor only needs a visual examination (that is, external motor manifestations), an anamnesis (antipsychotic therapy) andpatient complaints.
However, the diagnosis of pathology is significantly hampered by the fact that the patient is not able to explain what is happening to him. To accurately describe the condition of the patient, doctors use the Burns scale.
Burns Scale
The patient during the study sits, and then takes arbitrary positions, in each of which he needs to stay for about two minutes. At the same time, the doctor carefully records the emerging symptoms and subjective feelings of the patient.
The data obtained is evaluated on a special scale and conclusions are drawn.
So, joint movements: 0 - normal, 1 - there is a slight motor restlessness (shuffling feet, stamping), 2 - symptoms are quite pronounced, 3 - vivid manifestations, the patient cannot remain motionless.
Awareness by the patient of the presence of motor restlessness: 0 - normal, 1 - no awareness, 2 - inability to hold the legs at rest, 3 - constant need to move.
How the patient evaluates motor restlessness: 0 - normal, 1 - weak, 2 - moderate, 3 - severe.
Determination of the general condition of the patient: 5 - pronounced, 4 - distinct, 3 - average, 2 - weak, 1 - doubtful.
Condition Therapy
Methods of treatment of akathisia are individual and are prescribed only after examination. The most optimal way can be considered the complete abolition or lowering of the dosage of the drug that caused the problem. But such therapy is not always acceptable, and therefore antiparkinsonian drugs are more often used.or other means that are used in parallel with antipsychotics, due to which the dosages of the latter can be safely reduced.
So, in the treatment of akathisia caused by antidepressants and other drugs, use:
- Antiparkinsonian drugs ("Trihexyphenidyl", "Biperiden").
- Tranquilizers. Reduce the intensity of symptoms: reduce anxiety and eliminate insomnia.
- Beta blockers. Reduces the negative effects of antipsychotics and anxiety ("Propranolol").
- Cholinolytics and antihistamines. They have a sedative effect and fight insomnia ("Dimedrol", "Amitriptyline").
- Light opioids. Considered the most effective ("Hydrocodone", "Codeine").
- Anticonvulsants. Have a pronounced anti-anxiety effect ("Pregabalin", "Valproate");
- Therapy for tardive akathisia is reduced to the abolition of the base drug and the appointment of an atypical neuroleptic (for example, Olanzapine).
Preventive measures
Prophylaxis of the disease implies limiting the use of typical antipsychotics, in particular in the presence of contraindications (for example, patients with severe affective disorders).
Before prescribing antipsychotics, the patient should be carefully examined, since inadequate therapy can cause extrapyramidal disorders. When a patient takes antipsychotics, he should not only be examined, but also beunder the constant supervision of a doctor, because even a slight increase in dose can lead to akathisia. Both the patient and his relatives can prevent this process, and at the slightest manifestation of the disease, visit a specialist in order to exclude the development of akathisia.
Neuroleptics quite often lead to changes in consciousness, that is, they cause the opposite effect (increase excitability), and therefore treatment with such drugs should be controlled, and the dosage should be as accurate as possible.
Forecasts
The prognosis of the disease corresponds to its form and cause. In the presence of a dosage form, it is difficult to determine it, since the course of therapy averages more than six months, and the patient must be under constant control.
Withdrawal form has a positive prognosis, since the duration of treatment is only about 20 days.
In the vast majority of cases, the disease has a favorable prognosis and responds well to treatment, however, any form of akathisia requires maximum monitoring of the patient's condition.
