Akathisia – Pathophysiology, Diagnosis and Management Strategies

Posted on: January 9, 2021
Last Updated: November 9, 2021

Dr Sanil Rege is a Consultant psychiatrist, founder of Psychscene.com and Vita Healthcare.

In this video, Dr Sanil Rege discusses the following:

  • Clinical features of akathisia
  • Types of akathisia
  • Differentiating akathisia from agitation and restless legs syndrome
  • Clinical cases
  • Medications (non-psychotropic) associated with akathisia
  • Pathophysiology of akathisia
  • Management algorithm for akathisia

What Is Akathisia? 

  • Akathisia is defined as subjective complaints of restlessness, often accompanied by observed excessive movements (e.g. fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit or stand still), developing within a few weeks of starting or raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a medication used to treat extrapyramidal symptoms. [DSM-5]

Pathophysiology of Akathisia: 

  • The pathophysiology of akathisia appears to be complex involving several neurotransmitters including dopamine, acetylcholine, y-aminobutyric acid (GABA), norepinephrine, serotonin, and neuropeptides.
  • The neurotransmitters most specifically linked to akathisia are gamma-aminobutyric acid (GABA) and serotonin.
  • GABA (mainly via GABAA receptor interactions) exerts an influence on dopamine-dependent signalling, thus, increasing or reducing locomotor activity Akathisia may result from efforts to compensate for dopaminergic underactivity in the nucleus accumbens

Management Strategies: 

  1. Reduce dose
  2. Switch to low risk antipsychotic
  3. Adjunctive approaches:
  • Propranolol 40-80 mg/day
  • 5HT2A receptor antagonists (e.g. mirtazapine 15 mg PO daily, cyproheptadine 8-16 mg PO daily)
  • Benzodiazepines (e.g. clonazepam 0.5-1 mg PO daily, diazepam 5-15 mg PO daily)
  • Anticholinergics (e.g. benztropine 1-4 mg PO daily) should be used mainly for patients who have concurrent Parkinsonism

We cover an algorithm for the management of akathisia based on evidence-based guidelines.



1.American Psychiatric Association, 2013. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

2. Salem, Haitham, et al. “Revisiting antipsychotic-induced akathisia: current issues and prospective challenges.” Current Neuropharmacology 15.5 (2017): 789-798.