Akathisia is a complex phenomenon that combines a feeling of internal disturbing discomfort and a constant need for movement, which is realized through swaying, shifting from one foot to another, and marching in place. Patients with this disorder are not able to stand still, cannot sit still, sometimes this kind of activity is manifested even during sleep.
The causes of the disease
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 reasons.
Researchers also note some connection between the appearance of akathisia and Parkinson's disease, however, it is not clear whether the disease is a consequence of Parkinson's disease or is associated with the use of antiparkinsonian drugs (Levodopa).
So, the most common "causal" factor of akathisia is the long-term use of psychotropic (usually antipsychotics) and other drugs from the following pharmaceutical groups:
- lithium preparations;
- antiemetic;
- antipsychotics;
- some antihistamines;
- antidepressants;
- SSRIs;
- some antibiotics, antiarrhythmics, interferons, anti-tuberculosis and antiviral drugs;
- barbiturates, opiates, cocaine, benzodiazepines (with withdrawal syndrome);
- combination of antipsychotics (in the presence of serotonin syndrome).
Risk factors
A high risk of the formation of akathisia caused by antipsychotics or therapy with other antipsychotic drugs is present in elderly or young patients with dementia, neurological, anxious or affective history, cancer pathologies, brain injuries, pregnancy, a genetic predisposition, lack of magnesium and iron high dosages of medications or a combination thereof.
In addition, other factors and conditions can cause the appearance of the syndrome:
- strokes, head injury, extrapyramidal and neurological disorders;
- some mental illnesses: hysterical, anxious, affective, conversion disorders and schizophrenia;
- extremely rarely when exiting 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 the use of antipsychotics 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 a certain lack of dopamine, in particular in the nigrostriatal pathway, which is responsible for motility.
It is worth noting that there are no violations in the peripheral nervous system with this pathology, and the disease is purely psychological in nature.
Main classification
With akathisia, neurologists most often use the division of pathology into the following forms:
- Sharp. Duration less than six months. It occurs almost immediately after the start of treatment with antipsychotics (for example, Paroxetine, Paxil). Akatisia is one of the side effects of these drugs. Also, the ailment may be the result of switching to more powerful means or increasing the dosage of the already mentioned, with withdrawal syndrome or severe dysphoria. This form is accompanied by a sensation and awareness of anxiety and other pronounced classic symptoms.
- Chronic Duration is more than six months. The feeling of anxiety is not expressed intensely, but is recognized by the patient. There are orofacial and limbal dyskinesias, motor fussiness with repeated movements, mild dysphoria.
- Late. It appears with a certain delay (up to three months) after a sharp cancellation or change in the dosage of antipsychotics, however, it may not be associated with changes in therapy.
- Pseudo-akathisia It occurs mainly among men. There are motor symptoms (including fussiness) and orofacial dyskinesia, without sensations and awareness of anxiety. Dysphoria is absent.
Clinical systematization
Also, akathisia is classified in accordance with the predominance of certain symptoms into the following types:
- Classical. Sensations and objective symptoms are expressed approximately the same.
- Mostly mental. There is a pronounced tension, anxiety, anxiety.
- With a predominance of motor symptoms. The patient can not 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 many different 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.
The sensory component implies the presence of internal acute anxiety, prompting the patient to consciously perform certain actions. Manifestations of the sensory symptom complex are fickle mood, vague internal fear, irritability.
Often there is pain in the legs.
The motor symptom complex consists in the constant repetition of a certain movement (for each patient its own). For example, it can be rocking the body, bouncing on a chair, constant walking and so on. Often such movements are combined with mooing or screaming, however, when the activity fades, the sounds disappear.
Internal extremely uncomfortable sensations cause the patient to constantly change postures 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 with a willpower and remain motionless. However, when switching attention or fatigue, stereotypical 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 anxiety, which is present even at night.
In addition, the enormous energy expenditures that are not replenished in a dream lead to a deterioration in the general condition and aggravation of the disease. The patient thinks about suicide. The disease goes into an advanced stage.
That is why early diagnosis and adequate treatment of akathisia are necessary.
Diagnostic measures
Diagnosis and treatment of akathisia is the task of a neurologist. For the diagnosis, no instrumental studies are needed, the doctor needs a visual examination (that is, external motor manifestations), a medical history (antipsychotic therapy) and patient complaints.
However, the diagnosis of pathology is significantly complicated by the fact that the patient is not able to explain what is happening with him. To accurately describe the condition of the patient, the doctor uses the Burns scale.
Burns Scale
During the study, the patient sits and then occupies arbitrary positions, in each of which he needs to stay for about two minutes. In this case, the doctor carefully fixes the symptoms and subjective sensations of the patient.
The data obtained are evaluated on a special scale and draw conclusions.
So, articular movements: 0 - normal, 1 - there is a slight motor anxiety (shuffling, drowning), 2 - symptoms are quite pronounced, 3 - bright manifestations, the patient cannot remain motionless.
The patient’s awareness of the presence of motor anxiety: 0 - normal, 1 - no awareness, 2 - the inability to restrain his legs at rest, 3 - a constant need for movement.
How the patient assesses motor anxiety: 0 - normal, 1 - weak, 2 - medium strength, 3 - pronounced.
Determination of the general condition of the patient: 5 - pronounced, 4 - distinct, 3 - medium, 2 - weak, 1 - doubtful.
Condition therapy
Methods of treatment of akathisia are individual and are prescribed exclusively after examination. The most optimal way can be considered a complete cancellation or lowering of the dosage of the medicine that caused the problem. But such therapy is not always acceptable, and therefore they often use antiparkinsonian or other drugs, which 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, apply:
- Antiparkinsonian drugs ("Trihexyphenidyl", "Biperiden").
- Tranquilizers. Reduce the intensity of symptoms: reduce anxiety and eliminate insomnia.
- Beta blockers. Reduce the negative effects of antipsychotics and anxiety ("Propranolol").
- Anticholinergics and antihistamines. They have a sedative effect and fight insomnia ("Diphenhydramine", "Amitriptyline").
- Light opioids. They are considered the most effective ("Hydrocodone", "Codeine").
- Anticonvulsants. Have a pronounced anti-anxiety effect ("Pregabalin", "Valproate");
- Therapy of late akathisia boils down to the abolition of the base drug and the appointment of an atypical antipsychotic (for example, Olanzapine).
Preventative measures
Prevention of the disease involves 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 under the constant supervision of a doctor, because even a slight increase in the dose can lead to akathisia. To prevent this process, both the patient and his relatives can, and at the slightest manifestations 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 agents 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, since the course of therapy on average is more than six months, and the patient should be constantly monitored.
The 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 is well treatable, however, any form of akathisia requires maximum control over the patient's condition.