Akathisia prognosis What is akathisia Akathisia is defined as an inability to remain still. Akathisia is a subjective disorder characterized by feeling of inner restlessness and the urge to move, to be in constant motion resulting in an inability to sit still and a compulsion to move; as well as objective components rocking while standing or sitting, lifting feet as if marching on the spot and crossing and uncrossing the legs while sitting. The individual with akathisia will generally experience an intense sensation of unease or an inner restlessness that usually involves the lower extremities 1. This results in a compulsion to move. In most cases the movement is repetitive. The individual may cross, uncross, swing, or shift from one foot to the other.
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Abstract The authors describe the case of a year-old man with a history of schizoaffective disorder, who attempted suicide following the recent starting of a neuroleptic agent that resulted in the development of intolerable akathisia.
He survived the attempt, and following changes in his medications the akathisia resolved with no further suicidal ideation. Background Akathisia is an under-recognised side effect of antipsychotic neuroleptic agents that can lead to fatal outcomes when missed. The amount of distress that it can cause is often overlooked and clinicians should be active in eliciting this symptom especially when adjusting medication regimes. This case highlights a potential life-threatening complication of a neuroleptic agent.
Case presentation A year-old man with schizoaffective disorder was brought to an inner-city hospital after a self-inflicted gunshot wound into his oral cavity.
This man was usually well supported in the community by his family, a counsellor and community psychiatrist. He achieved average grades at school and had worked in several semiskilled and unskilled jobs after graduating from high school.
He had never been in a relationship nor convicted of any crimes. His medical history was significant for a mild traumatic head injury from a motor vehicle accident at the age of 24 with no lasting complications and previous amphetamine use.
Last amphetamine use was more than 6 months prior to presentation. He was diagnosed at the age of 25 with BAD, which was typically episodic with full inter-episodic recovery. At the age of 30, he was diagnosed with schizoaffective disorder with the development of negative and psychotic symptoms, most prominently paranoid delusions.
He has not had any history of suicidal thoughts or behaviour. His suicidal ideation began a few days prior to the attempt. On the day of the presentation, he left a note, went to a shooting gallery, hired a gun and shot himself in the mouth.
The shot was not fatal and the gun jammed on his second attempt. He was then brought to the emergency department ED by ambulance. He revealed that he had been frustrated with the new onset of an unpleasant sensation of restlessness after being put on depot pipothiazine.
He describes low mood secondary to this, otherwise denied further symptoms of depression. He denied any persecutory and referential ideation or command hallucinations. He stated that he attempted suicide to rid himself of the restlessness. Previously on chlorpromazine, olanzapine and sodium valproate, he was initiated on pipothiazine depot following a recent manic relapse with psychotic symptoms secondary to non-adherence.
He had brought up his concern of the side effects of his medication to his psychiatrist but owing to his lack of insight and complex compliance issues, he was continued on the depot. The primary survey did not show compromises in airway, breathing and circulation. The secondary survey demonstrated haemotympanum in the left ear and a House-Brackmann grade V palsy of the left facial nerve. There was no facial bone instability.
The oral examination showed an intact postpharyngeal wall with visible entry point in the left retromolar trigone. The left parotid region was tender and full to palpate. Mental state examination revealed a young man with visible psychomotor agitation. His mood was frustrated and his affect was restricted and angry, but stable. Thought process was grossly linear and thought content involved suicidal ideation and frustration at medication side effect.
There were no perceptual disturbances. Insight and judgement were poor. Investigations Radiological investigations included CT head, face, temporal bones, cervical spine and CT angiogram of the head and neck.
Debris and air locules were noted along the trajectory tract, extending from the left oropharynx to the left mastoid tip region, para-pharyngeal space, masticator space and the parotid space. The anterior and posterior walls of the left external auditory canal were fractured with possible involvement of the tympanic membrane. Blood tests, including full blood picture, electrolytes, iron studies and thyroid function test, were unremarkable.
Differential diagnosis The presentation of akathisia and self-harm attracts several differential diagnoses. Iron deficiency and hyperthyroidism were also ruled out on blood panels. Given the history of previous head trauma, neurological conditions would also have to be considered and a likely predisposition to akathisia should be noted.
However, this patient did not have any other neurological signs and this was the first onset of akathisia. However, he did not meet the criteria for depression as he denied most symptoms of depression and did not present depressed. He displayed negative symptoms and the lack of psychotic symptoms may be owing to an early relapse. Although patients with schizophrenia can sometimes experience significant anxiety, which can present as physical restlessness, this patient denied anxiety symptoms.
Coupled with a lack of social stressors, stable living circumstances and good community support, an anxiety disorder was unlikely. Taking into account the temporal sequence of events leading up to his suicide attempt and his mood and affect, his presentation was more consistent with a drug-induced akathisia and dysphoria. Treatment The patient was admitted to the hospital under the care of the head and neck surgery team.
His injuries including the facial nerve palsy was treated conservatively with intravenous steroids and prophylactic antibiotics. He was started on regular risperidone and PRN lorazepam for agitation and akathisia. His usual antipsychotic medications were withheld owing to the potential of exacerbating his dysphoria, akathisia and suicidality.
Outcome and follow-up Three months after his hospitalisation, the patient continues to be managed in the community with stable control of his schizophrenia on risperidone. He denies any suicidal ideation and no longer suffers from akathisia. His facial nerve palsy showed little improvement over the past 3 months and is still graded as House-Brackmann IV.
He is scheduled for a facial reanimation surgery that will provide him with symptomatic and cosmetic improvement of his facial nerve palsy. Coupled with the difficulty in describing the subjective feelings, akathisia is frequently underdetected, and direct questioning by the clinician is often required to elicit this symptom. Its association with self-harm is not unsurprising and has been previously reported in the literature.
Clinicians should have this diagnosis as a consideration whenever changes are made to neuroleptic medications. Akathisia as a side effect of neuroleptic medication should be forewarned; when diagnosed, patients should be reassured that it is an effect of medication rather than their illness. If these are ineffective, or if the patient exhibits Parkinsonism symptoms, anticholinergic medications can then be tried.
Recognition and treatment of drug-induced akathisia usually leads to favourable prognosis evidenced by previous case reports and the current case. It is a modifiable risk factor of suicidal behaviour in patients with schizophrenia and should be actively managed in this group of patients. Learning points Akathisia is a common side effect of neuroleptic medication which is under-recognised and has been associated with suicide. Screening of neuroleptic-induced akathisia should be routine.
Neuroleptic-induced akathisia is easily treatable and generally has good outcomes when treated. Footnotes Contributors: The authors declare that they have all made substantial contributions to conception, design, drafting and final approval of this paper.
Competing interests: None. Provenance and peer review: Not commissioned; externally peer reviewed. References 1. Akathisia: problem of history or concern of today. Hansen L. A critical review of akathisia, and its possible association with suicidal behaviour. Barnes TR. A rating scale for drug-induced akathisia. Suicide associated with akathisia and depot fluphenazine treatment.
A case of suicidal and homicidal ideation and akathisia in a double-blind neuroleptic crossover study. Drake RE, Ehrlich J. Suicide attempts associated with akathisia. The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia.
No association between akathisia or Parkinsonism and suicidality in treatment-resistant schizophrenia.
A rating scale for drug-induced akathisia.
Mikatilar Consult your doctor before doing any of these things. Psychiatry— Extrapyramidal symptoms topic Extrapyramidal symptoms EPSalso known as extrapyramidal side effects EPSEare drug-induced movement disorders that include acute and tardive symptoms. Actigraphic monitoring With appropriate cut-off, actometry is very sensitive in actigraphy of circadian locomotor activity in schizophrenic patients finding akathisia cases, but asking about subjective symp- with acute neuroleptic-induced akathisia. Akathisia is a movement disorder characterized by a feeling of inner restlessness and inability to stay still. Once identified, akathisia is straightforward to treat.
Barnes Akathisia Rating Scale
Kristian Wahlbeck European Neuropsychopharmacology 15 39 — 41 www. The results of this methodological study provide BARS with objective validation through movement measuring, that it has been suggested to need. D Elsevier B. All rights reserved. Standardized actometry may Neuroleptic-induced akathisia NIA is a common ad- be suitable in finding mild or hypokinetic NIA cases Tuisku verse effect of traditional antipsychotics Barnes and Mc- et al.