Neuroleptic-induced akathisia: a review

Comparative efficacy of akathisia treatments: A network meta-analysis

OBJECTIVE

Akathisia, a common side effect of psychotropic medications, poses a significant challenge in neuropsychiatry, affecting up to 30% of patients on antipsychotics. Despite its prevalence, akathisia remains poorly understood, with difficulties in diagnosis, patient reporting, and treatment efficacy. This research aimed to shed light on effective interventions to improve akathisia management.

METHODS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted, encompassing controlled trials in English and Italian languages. Databases, such asPubMed, Scopus, and EMBASE, were searched until July 9, 2023. Treatment effectiveness was assessed using standardized mean differences (SMDs) in post-treatment akathisia scores.

RESULTS

Thirteen studies involving 446 individuals met the inclusion criteria. Benzodiazepines, beta-blockers, and NaSSA demonstrated significant efficacy as compared with placebo. Anticholinergic, anticonvulsant, triptan, and other treatments did not show significant differences. Benzodiazepines ranked highest in P-scores (0.8186), followed by beta-blockers and NaSSA.

CONCLUSIONS

Effective management of akathisia is crucial, with benzodiazepines, beta-blockers, and NaSSA offering evidence-based options. Treatment rankings provide guidance for clinicians. Future research should prioritize larger, more robust studies to address limitations associated with small sample sizes and publication bias. This research enhances our understanding of interventions for akathisia, offering promising options to improve patient quality of life and prevent complications related to non-adherence and mismanagement.

Treatment of Antipsychotic-Induced Akathisia: Role of Serotonin 5-HT2a Receptor Antagonists

Akathisia is one of the most prevalent and distressing adverse effects associated with antipsychotic drug treatment. Propranolol, a non-selective beta-adrenergic receptor antagonist, is currently considered a first-line treatment for antipsychotic-induced akathisia (AIA). Surprisingly, the evidence for its anti-akathisia effect is modest. Propranolol's side effects (e.g. orthostatic hypotension, bradycardia), contraindications (e.g. asthma) and increased complexity in titration schedules limit its use in some patients. Anticholinergic agents and benzodiazepines merely provide symptomatic relief in patients with AIA. Effective and well-tolerated treatment remains a major unmet need in akathisia and warrants a search for new anti-akathisia agents. Accumulating evidence during the last two decades indicates that agents with marked postsynaptic serotonin 5-HT_2a receptor antagonism (ritanserin, cyproheptadine, trazodone, mianserin, mirtazapine) may represent a new class of potential anti-akathisia remedies. Among these agents, low-dose mirtazapine (7.5 mg or 15 mg once daily) has demonstrated the most compelling evidence for therapeutic efficacy. In this narrative review we highlight the clinical significance of AIA, outline major approaches for its management and propose a practical algorithm for its treatment.

Use of serotonin antagonists in the treatment of neuroleptic-induced akathisia

Akathisia is a distressing movement disorder associated with neuroleptic medication. Patients complain of a feeling of inner restlessness (Barnes, 1989). The characteristic signs include constant moving when seated, rocking from foot to foot and pacing (Adler et al, 1989). Neuroleptic-induced akathisia (NIA) is usually an acute reaction, but a chronic akathisia can occur after prolonged treatment with neuroleptics (Fleischhacker et al, 1990). It has been suggested that chronic NIA is related to tardive dyskinesia, and that like tardive dyskinesia it is difficult to treat (Blaisdell, 1994). Reducing the neuroleptic dose may ease the symptoms (Barnes, 1989). Other options include using an atypical neuroleptic, which may cause lower rates of akathisia (Poyurovsky et al, 1999). Biochemical and pharmacological evidence has indicated the importance of serotonin in controlling movement (Bersani et al, 1986). Serotonin antagonists, particularly mianserin, ritanserin and cyproheptadine, have been used to treat NIA. This article reviews the published trials and case reports retrieved by a Medline search from January 1985 to August 1999.

Assessment of drug-related movement disorders in schizophrenia

Conventional antipsychotic drugs remain one of the mainstays of treatment of schizophrenia and related psychotic disorders. The therapeutic efficacy of these drugs is well established, both for treatment of acute symptoms and in relapse prevention. Unfortunately, they are associated with a broad range of side-effects, the most prominent of which is the development of a variety of movement disorders (see Box 1). Compared with the conventional antipsychotic agents, the newer, atypical antipsychotics have a lower liability for the acute extrapyramidal side-effects (EPS) and, for a few of the new drugs, there is some evidence of a lower risk of tardive dyskinesia (Barnes & McPhillips, 1999). Nevertheless, even with these newer agents, movement disorders are seen in a significant proportion of patients.

Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges

BACKGROUND

Akathisia continues to be a significant challenge in current neurological and psychiatric practice. Prompt and accurate detection is often difficult and there is a lack of consensus concerning the neurobiological basis of akathisia. No definitive treatment has been established for akathisia despite numerous preclinical and clinical studies.] Method: We reviewed antipsychotic-induced akathisia including its clinical presentation, proposed underlying pathophysiology, current and under investigation therapeutic strategies.

CONCLUSION

Despite the initial promise that second generation antipsychotics would be devoid of akathisia effects, this has not been confirmed. Currently, there are limited therapeutic options for the clinical practice and the evidence supporting the most widely used treatments (beta blockers, anticholinergic drugs) is still absent or inconsistent.

Association of subjective cognitive dysfunction with akathisia in patients receiving stable doses of risperidone or haloperidol

BACKGROUND AND OBJECTIVE

Antipsychotic-induced akathisia leads to poor compliance with medication and is still a source of concern in the treatment with antipsychotic drugs. Regarding clinical characteristics, the distinguishing features of akathisia in comparison with other extrapyramidal syndromes are prominent subjective symptoms. The purpose of the present study was to examine the subjective cognitive dysfunction associated with antipsychotic-induced akathisia.

METHODS

Sixty-seven outpatients with schizophrenia receiving stable doses of risperidone or haloperidol were evaluated for akathisia and other extrapyramidal side effects. Subjective cognitive dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). The severity of subjective cognitive deficits was compared between the groups with and without akathisia using analysis of covariance with relevant variables as covariates.

RESULTS

The akathisia group (n = 25) scored significantly higher on the total FCQ score than the non-akathisia group (n = 42) (P < 0.05). In phenomenological subscale scores, the akathisia group had significantly higher scores on various subscales, i.e. 'anxiety', 'disorder of selective attention', 'deterioration of discrimination', 'perceptual disorder' and 'disorder of coping responses' than the non-akathisia group (P < 0.05).

CONCLUSIONS

These results suggest that akathisia is significantly associated with a variety of subjective cognitive-perceptual deficits. Early therapeutic interventions for akathisia should be performed considering its significant association with the subjective cognitive dysfunction and the impairment of coping responses.

Practical prescribing with aripiprazole in schizophrenia: consensus recommendations of a UK multidisciplinary panel

BACKGROUND

The atypical antipsychotic, aripiprazole, differs from other antipsychotics in its pharmacology and clinical outcomes. Aripiprazole's clinical outcomes include beneficial effects on mood, quality of life and cognition; favourable tolerability with low potential for sedation; and a favourable physical health profile, with low potential for weight change, sexual dysfunction or adverse metabolic effects. Such outcomes, particularly cognitive improvements, may allow for greater psychosocial intervention and improved social inclusion. In accordance with the UK NICE guidance on the use of antipsychotic treatment for schizophrenia (2002), aripiprazole may be an appropriate therapeutic option for patients with schizophrenia who are newly diagnosed, in acute relapse or experiencing tolerability problems, adverse metabolic effects or dissatisfaction with their current medication.

SCOPE

A multidisciplinary panel was convened in the UK in October 2006 to discuss and provide practical guidance regarding the potential benefits and risks of prescribing aripiprazole. This report describes the consensus recommendations agreed during the meeting and includes practical guidance on the optimal approach to prescribing aripiprazole, which patients might benefit from aripiprazole and how best to approach initiation of and switching to treatment with aripiprazole. A PubMed/MEDLINE literature search was conducted to support these recommendations.

FINDINGS

To support antipsychotic therapy, a therapeutic partnership should be established between the patient and a well-informed, multidisciplinary care team. Aripiprazole should be initiated at the minimal efficacious dose (10 mg/day) and titrated as required (usually to 15 mg/day) after a minimum of 2 weeks. The primary goal during aripiprazole initiation is to ensure the patient completes the first few days of treatment, with support from concomitant medications if required. Nausea, insomnia and agitation may occur in 10-20% of patients, but are manageable and typically resolve during the first 3-7 days of therapy. The dose of any prior antipsychotic should remain stable until the response to aripiprazole is satisfactory and then the previous antipsychotic should be tapered off slowly over several weeks or more.

CONCLUSION

Patients are more likely to adhere to treatment with aripiprazole--and indeed any other antipsychotic--and derive long-term therapeutic benefits if they and a well-informed care team are involved in the treatment decision, establish a therapeutic partnership, are aware of the transient nature of any adverse events and understand what the potential long-term benefits are.

Low-dose mirtazapine: a new option in the treatment of antipsychotic-induced akathisia. A randomized, double-blind, placebo- and propranolol-controlled trial

BACKGROUND

Preliminary evidence indicates a beneficial effect of serotonin 2A (5-HT(2A)) receptor antagonists in antipsychotic-induced akathisia (AIA). We investigated the antiakathisia effect, safety, and tolerability of low-dose mirtazapine, an agent with marked 5-HT(2A) antagonism.

METHODS

In a 7-day double-blind trial, 90 antipsychotic-treated patients meeting DSM-IV criteria for AIA were randomly assigned to mirtazapine (n = 30; 15 mg), propranolol (n = 30; 80 mg), or placebo (n = 30). Primary outcome measures were between-group differences in Barnes Akathisia Scale (BAS) global scores and in the proportion of responders (reduction of > or = 2 points on BAS). Analysis was by intention to treat.

RESULTS

Twenty-four patients (26.6%) who were assigned treatment did not complete the study (7 mirtazapine, 8 propranolol, 9 placebo), due to lack of response (n = 19) and adverse events (n = 5). Both mirtazapine and propranolol significantly reduced AIA severity (BAS: -34% mirtazapine and -29% propranolol vs. placebo -11%; p = .012 and p = .023, respectively). Thirteen (43.3%) mirtazapine and 9 (30.0%) propranolol-treated patients versus 2 (6.7%) placebo-treated patients responded (the corresponding odds ratios 10.7 [95% confidence interval (CI), 2.1-53.3] and 6.0 [95% CI, 1.1-30.7]). Five (16.7%) of 30 propranolol-treated patients and none in the mirtazapine and placebo groups (p = .0195 for both) prematurely discontinued the study due to clinically significant hypotension or bradycardia.

CONCLUSIONS

The comparable efficacy and better tolerability of low-dose mirtazapine versus propranolol, the current first-line treatment for AIA, position mirtazapine as a favorable candidate for the treatment of acute AIA and may improve current therapeutic practices.

Vitamin B6 versus mianserin and placebo in acute neuroleptic-induced akathisia: a randomized, double-blind, controlled study

Treatment strategies against acute neuroleptic-induced akathisia (NIA) include anticholinergic (antimuscarinic) agents, dopamine agonists, GABAergic agents, beta-blockers, benzodiazepines, and serotonin antagonists. However, many patients who have acute akathisia fail to respond. In previous studies, mianserin and vitamin B6 were found to be effective in the treatment of acute akathisia. The purpose of this study was to compare the efficacy of B(6), mianserin and placebo in the treatment of acute NIA. Sixty schizophrenia and schizoaffective inpatients who have NIA were randomly divided to receive vitamin B(6) 1,200 mg/d, mianserin 15 mg/d, or placebo for 5 days, in a double-blind design. The Barnes Akathisia Rating Scale, Brief Psychiatric Rating Scale, and Clinical Global Impression were used to assess the severity of NIA and psychotic symptoms. The assessment was made at baseline and daily for the duration of the study. Compared with the placebo group, the vitamin B(6)-treated and mianserin-treated patients showed a significant improvement in the subjective (P < 0.0001), subjective distress (P < 0.0001), and global (P < 0.0001) subscales. The objective subscale did not show significant positive results (P = 0.056), but there was a trend toward symptom amelioration in both groups. A reduction of at least 2 points on the Barnes Akathisia Rating Scale global subscale was noted in the vitamin B(6) group (13/23, 56%) as well as in the mianserin groups (13/20, 65%), and in only one patient in the placebo group (1/17, 6%; P < 0.0005). Our results indicate that high doses of B(6) and a low dose of mianserin may be a useful addition to current treatments of NIA. The efficacy of vitamin B(6) and mianserin suggests that the pathophysiology of acute NIA is heterogeneous with the various subtypes of acute NIA responding differently to the various pharmacological approaches.

Pharmacological management of akathisia in combination with psychological interventions by a mental health nurse consultant

The article describes the management of akathisia by a mental health nurse (MHN) prescriber, working in partnership with the patient. A single-case design was used to evaluate this. It highlights three features: first, MHN can safely prescribe psychiatric medication in combination with concordance therapy. Second, the value base underpinning prescribing practice is partnership, honesty and choice for the patient. Finally, the pharmacological mechanism of antipsychotic medication, which contributes towards akathisia, requires further analysis.

Multidimensional sensory phenomena in antipsychotic-induced akathisia

The primary distinguishing features of akathisia in comparison with other extrapyramidal syndromes are the prominent subjective manifestations, which include various sensory symptoms. The sensory symptoms are multidimensional in nature and encompass various forms of bodily and mental sensations. The purpose of the present study was to elucidate the multidimensional aspects of the sensory phenomena associated with antipsychotic-induced akathisia. Seventy stable and chronic schizophrenic subjects receiving maintenance antipsychotic treatment were evaluated for akathisia and other extrapyramidal side effects. Subjective sensory phenomena were evaluated in 3 dimensions (ie, bodily sensations, mental sensations, and autonomic sensations). The frequency of each dimension of these sensory phenomena was compared between the groups with and without akathisia using chi test with Bonferroni correction. The akathisia group (n = 29) reported significantly more frequent focal or generalized bodily sensations than the non-akathisia group (n = 41) (P < 0.001). The akathisia group also showed significantly more frequent mental sensations such as mental urge and a feeling of inner tension/pressure (P < 0.001). In autonomic phenomena, there was a trend for the akathisia group to show more frequent autonomic sensations. The most common autonomic phenomena associated with akathisia were palpitation and difficulty breathing. The results of the present study suggest that the sensory phenomena of antipsychotic-induced akathisia are characterized by multidimensional features such as bodily sensations, mental sensations, and several autonomic sensations. The assessment of these multidimensional sensory phenomena would be useful in evaluating the important phenotypic features of akathisia.

The Barnes Akathisia Rating Scale--revisited

Akathisia is a syndrome of motor restlessness, principally seen in association with antipsychotic medication. It is characterized by a subjective experience of mental unease and the urge to move, and manifests physically as particular patterns of restless movement. This review focuses on the signs and symptoms of the condition, and its diagnosis and assessment using the Barnes Akathisia Rating Scale. This scale was generated 15 years ago, and was derived from the findings of studies exploring the clinical features of antipsychotic-induced akathisia. Subsequently, its validity and reliability have been established, and it has been used extensively in clinical studies worldwide.

Subjective emotional experience and cognitive impairment in drug-induced akathisia

The purpose of this study was to characterize the subjectively experienced symptoms and cognitive impairment associated with akathisia, which is among the most disabling adverse effects associated with antipsychotic drugs. While subjective experience is considered to be an integral part of akathisia, only a few studies have comprehensively investigated the specific contents of the subjective experiences or of the discomforts of patients with drug-induced akathisia. In addition, the precise relationship of akathisia to cognitive impairment, one of the main constituents of subjective experiences, is largely unknown. Forty-one stable and chronic schizophrenic patients, who were receiving maintenance antipsychotic treatment, were rated using the Barnes Akathisia Rating Scale (BARS) for drug-induced akathisia. Subjective experiences were evaluated using the Symptom Checklist-90-Revised (SCL-90-R), and cognitive function was assessed using the Wechsler Memory Scale (WMS). Analysis of covariance (ANCOVA) with relevant variables as covariates revealed that patients with akathisia (n = 17) had significantly higher scores on the depression subscale of the SCL-90-R than those without akathisia (n = 24). Patients with akathisia also had significantly lower scores on the mental control subtest of the WMS. Further analysis using ordinal logistic regression revealed that the depression subscale of SCL-90-R and the mental control subtest of WMS were significantly associated with the severity of akathisia. These results suggest that akathisia is significantly associated with depressive symptoms and attentional impairment, which reflects the complex nature of akathisia that includes motor, emotional, and cognitive aspects. Several methodological considerations and future directions are discussed.

Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics

Recent studies suggest that the risk of relapse in patients with schizophrenia is approximately 3.5% per month. Predictors of more frequent relapses include poor compliance with antipsychotic drug treatment, severe residual psychopathology, poor insight into the illness and the need for treatment, comorbid substance abuse, and poor relationships between patients, families and care providers. Although conventional antipsychotic drugs, such as haloperidol and fluphenazine, are effective in preventing relapse, second generation antipsychotic drugs, such as clozapine, risperidone and olanzapine, appear to be superior in preventing relapse and improving the patient's quality of life. The development of adverse events can undermine treatment response and relapse prevention. Minimising adverse effects thus helps to improve treatment compliance and prevent relapse. Second generation antipsychotic drugs tend to have fewer adverse effects than conventional agents, especially pseudoparkinsonism and akathisia. The societal costs of treating patients with schizophrenia can be lessened by employing strategies that decrease relapse and the need for rehospitalisation, the most costly treatment alternative.

A current review of olanzapine's safety in the geriatric patient: from pre-clinical pharmacology to clinical data

OBJECTIVE

Olanzapine (OLZ) is unique among currently available antipsychotic medications in its antagonism of a range of receptor systems including dopamine, norepinephrine, serotonin, acetylcholine, and histamine. Olanzapine's mechanistic complexity provides a broad efficacy profile in patients with schizophrenia and acute, pure or mixed mania. Patients experience symptomatic relief of mania, anxiety, hallucinations, delusions, and agitation/aggression and reduced depressive, negative, and some cognitive symptoms. This paper will review the safety profile of OLZ, focusing on the elderly, where data are available.

METHOD

Preclinical and clinical studies of OLZ are reviewed, with emphasis on its possible effects on the cholinergic system and the histamine H(1) receptor. Weight change and related metabolic considerations, cardiac and cardiovascular safety, and motor function during treatment with OLZ are also reviewed.

RESULTS AND CONCLUSION

In vitro receptor characterization methods, when done using physiologically relevant conditions allow accurate prediction of the relatively low rate of anticholinergic-like adverse events, extrapyramidal symptoms, and cardiovascular adverse events during treatment with OLZ. Currently available clinical data suggest olanzapine is predictably safe in treating adult patients of any age with schizophrenia and acute bipolar mania, as well as in treatment of patients with some types of neurodegenerative disorders.

Chronic, but not acute, dosing of antipsychotic drugs alters neurotensin binding in rat brain regions

The present study compared high affinity neurotensin (NT) binding in rat brain following acute or chronic treatment with the classical antipsychotic, haloperidol, and the newer antipsychotic drugs, clozapine and zotepine. Drugs were given orally, as an acute treatment (1 dose) or chronically (21 day dosing) and binding to the NT high affinity receptor was examined in three brain regions; striatum, nucleus accumbens/olfactory tubercle and frontal cortex. Acute dosing with either vehicle, haloperidol, clozapine or zotepine produced no significant changes in NT binding from controls (naïve rats). Chronic (21 day) dosing resulted in an increase in the K:(D:) and B(max) of high affinity receptors in the striatum following haloperidol, but not clozapine, zotepine or vehicles. In contrast, the newer antipsychotics, clozapine and zotepine but not haloperidol or vehicles, significantly altered NT binding in the nucleus accumbens/olfactory tubercle by decreasing the K:(D:) and B(max). Further differentiation between the two newer antipsychotic drugs occurred in the frontal cortex. Clozapine had no significant effect on NT binding, whereas zotepine significantly reduced the K:(D:) of the high affinity receptor with no alteration in B(max). The antipsychotic drugs tested did not interact directly with the NT high affinity receptor. Therefore, they must be acting indirectly via an alternative receptor mechanism to alter NT high affinity binding. In accordance with previously reported NT/dopamine receptor interactions, this would suggest cross-talk between these systems. Overall, these data demonstrate that chronic, but not acute, administration of antipsychotic drugs alters NT binding in the rat brain. In addition, anatomical differences in NT binding arise according to the antipsychotic drug under test. This may be predictive of drug side-effect profile, antipsychotic efficacy or atypicality.

Antipsychotic-Induced movement disorders in the elderly: epidemiology and treatment recommendations

We reviewed the epidemiological aspects of antipsychotic-induced movement disorders as they pertain to older patients. The incidence and prevalence of drug-induced parkinsonism and tardive dyskinesia (TD) are significantly greater in the older patient than in the younger patient whereas akathisia seems to occur evenly across the age spectrum and dystonia is uncommon among older patients. The literature on risk factors associated with treatment-emergent movement disorders is highly variable. Treatment practices vary across the age range and the interaction between age and antipsychotic dosage confounds our understanding of the relative importance of treatment-related risk factors. However, there is general agreement that pre-existing extrapyramidal signs (EPS) increase the vulnerability of the patient to developing significant drug-induced movement disorders. Elderly patients with dementia are at greater risk than patients without dementia for persistent drug-induced EPS. Management of drug-induced movement disorders in the older patient requires careful consideration of the contraindications imposed by such agents as anticholinergics and beta-blockers. At present, well-controlled double-blind studies of second-generation antipsychotics such as clozapine, risperidone. olanzapine or quetiapine for reducing the risk of treatment-emergent movement disorders in the elderly have not been published. However, open-label studies of atypical antipsychotics demonstrate a markedly lower incidence of both EPS and TD compared with conventional antipsychotic treatment in the elderly. There is emerging literature in support of atypical antipsychotics for the treatment of existing drug-induced movement disorders. More controversial is the use of adjunctive antioxidants in newly treated patients who are vulnerable to drug-induced movement disorders. While the evidence is mixed in support of antioxidants for the treatment of TD, the possibility remains that prophylactic use of antioxidants may help reduce the incidence of TD. The development of a drug-induced movement disorder often reduces the quality of life in an elderly patient. Effective pharmacological management requires cooperation from the patient and family, which can be fostered early in the patient's care through proper informed consent. The risks and benefits of antipsychotic treatment in the elderly patient need to be communicated to the patient and family. At the present time, there is no consistently effective treatment for patients with TD once it develops. Therefore, attention should focus on its prevention and close monitoring.

What can we do about acute extrapyramidal symptoms?

Antipsychotic drugs are the most effective treatment for psychotic disorders such as schizophrenia. However, they are known to cause a range of side-effects including acute extrapyramidal symptoms (EPS) that are both distressing and disabling. Mental health nurses play a critical role in both the detection and the management of these symptoms. A review of the literature was conducted to identify strategies for managing acute EPS. Despite a widely held belief that EPS are associated with noncompliance with medication, the data to support this hypothesis are weak. Although akathisia may negatively affect the treatment outcome, there was little evidence to suggest that parkinsonism or dystonia do. Whilst the use of anticholinergic medication may be helpful in treating acute parkinsonism and dystonia they were associated with their own side-effects and the benefit of long-term prophylactic treatment is doubtful. The literature suggests that logical prescribing and rapid detection and management of acute EPS will result in a substantial reduction in the incidence of these disabling side-effects.

Akathisia and exacerbation of psychopathology: a preliminary report

Akathisia has previously been reported to exacerbate psychopathology and to be associated with noncompliance, suicidality, and violence. One previous study found brisk decrements in psychopathology after acute treatment of akathisia with intramuscular biperiden. This study assessed changes in akathisia and psychopathology in 19 patients after separate one-day treatments with intramuscular benztropine and oral propranolol. Benztropine and propranolol led to clinically meaningful and statistically significant decrements in ratings of subjective and objective measures of akathisia and in psychopathology scores. Changes in psychopathology correlated significantly with changes in subjective measures of akathisia after benztropine and with subjective and objective measures of akathisia after propranolol. Changes in akathisia accounted for 9%-42% of the variance in changes in psychopathology. After treatment, statistically significant decrements in Brief Psychiatric Rating Scale (BPRS) positive symptoms were noted, and individual items not directly related to the akathisia syndrome, such as conceptual disorganization, hallucinatory behavior, and unusual thought content declined, although not significantly. These findings, taken together with the results of a similar previous study, indicate that the effect of akathisia in exacerbating psychopathology is large. If suspected, akathisia should be treated promptly.

Measuring neuroleptic-induced akathisia by three-channel actometry

Three-channel actometry was used to study neuroleptic-induced akathisia (NIA), a common and often serious disorder in association of traditional neuroleptic therapy. The aim was to explore the diagnostic possibilities of actometry in NIA and to examine in detail the motor phenomenology of the disorder in detail. The actometers were attached to the ankles and waists of ten patients, suffering from NIA, and to ten matched healthy controls. Five of the patients were changed to olanzapine treatment, and these patients were re-examined during the no-NIA condition. NIA was associated with manyfold movement activity during controlled rest (sitting) but not with increased daily overall motor activity. Movement frequencies in NIA seemed to be pathognomonic. Actometry is promising for investigation and clinical assessment of NIA. Olanzapine proved to be an adequate treatment choice for NIA patients.

Prochlorperazine induces akathisia in emergency patients

STUDY OBJECTIVE

Prochlorperazine (PCZ), a commonly used antiemetic and analgesic agent, is known to cause akathisia. The incidence of akathisia after a single 10-mg dose of intravenous PCZ has not been prospectively evaluated. We determined the incidence and severity of PCZ-induced akathisia at 1 hour and the incidence of delayed akathisic symptoms at 48 hours.

METHODS

This prospective controlled study evaluated a convenience sample of 140 adult patients at a 400-bed, academic, tertiary-care medical center with an annual emergency department census of 95,000 patient visits. One hundred patients who received intravenous PCZ for the treatment of severe headache or vomiting constituted the PCZ group. Forty patients receiving nonakathisic intravenous therapy (eg, saline solution or antibiotics) served as control subjects. Patients were excluded if they had preexisting motor disorders (eg, restless-leg syndrome or Parkinson's disease) or if they recently had received any medication with extrapyramidal, anticholinergic, sedative, or antiakathisic properties. All patients underwent an akathisia assessment before and 1 hour after receiving their respective intravenous medications. An established scale was used to detect the presence of akathisia and grade its severity as mild, moderate, or severe. The delayed development of akathisic symptoms within 48 hours also was measured in the PCZ group.

RESULTS

Akathisia developed in 44 (44%) of the patients receiving PCZ within 1 hour (95% confidence interval, 34% to 54%). The akathisia was graded as mild, moderate, and severe in 14, 22, and 8 subjects, respectively. Delayed symptoms suggestive of akathisia developed in 3 other patients within 48 hours. None of the 40 control subjects developed akathisia.

CONCLUSION

Single-dose intravenous PCZ frequently induced akathisia within 1 hour of administration. Acute akathisia was not observed in patients receiving intravenous saline solution or antibiotics. The delayed development of akathisia symptoms 48 hours after a single dose of intravenous PCZ was uncommon.

Propranolol attenuates haloperidol-induced Fos expression in discrete regions of rat brain: possible brain regions responsible for akathisia

Neuroleptics induce several extra-pyramidal side effects, such as akathisia, acute dystonia and parkinsonism. Although recently developed atypical neuroleptics ameliorate some of these side effects, akathisia remains a common and severely distressing adverse reaction. Several drugs are reported to be of clinical use for the pharmacological treatment of akathisia. In particular, the beta-adrenoceptor blocker, propranolol, has been widely used for the treatment of akathisia, but it does not ameliorate other extra-pyramidal side effects. To identify the neural substrates of akathisia, we investigated the effects of propranolol on haloperidol-induced Fos expression in rat brain. Haloperidol (1 mg/kg) induced Fos-positive nuclei in several regions of the brain, including the cingulate cortex area 3, piriform cortex nucleus accumbens, caudate-putamen, ventral lateral septum and parietal cortex. Pretreatment with propranolol (5 mg/kg) reduced the number of Fos-positive nuclei in the cingulate cortex area 3, the piriform cortex and area 1 of the parietal cortex. Injection of vehicle by itself tended to increase Fos expression in the cingulate cortex area 3 and the piriform cortex. Considering the functions of these brain regions, we speculate that the most plausible neural framework for haloperidol-induced akathisia involves area I of the parietal cortex, but possible roles for the cingulate cortex area 3 and the piriform cortex cannot be ruled out.

Emerging roles for novel antipsychotic medications in the treatment of schizophrenia

Antipsychotic medications are the mainstay of treatment for schizophrenia. The recent advent of atypical antipsychotics has provided new clinical options and set higher expectations for the treatment of schizophrenia. It is not yet clear how each different drug will fit within the therapeutic armamentarium and this lack is most evident with considering patients with treatment refractory schizophrenia. On the other hand, the expectation of superior efficacy, more benign side effect profile and potential to impact the longitudinal course of schizophrenia provide a rationale for the use of novel antipsychotics as a first-line treatment of schizophrenia.

The effects of beta-adrenoceptor antagonists on a rat model of neuroleptic-induced akathisia

Neuroleptic-induced defecation in rats in a well-habituated environment has been proposed as a model of the subjective component of akathisia. In this study, we examined the effects of two lipophilic beta-adrenoceptor antagonists - the non-selective drug propranolol and the relatively beta1-selective metoprolol - and one non-selective hydrophilic drug nadolol in this model. Young male Wistar rats were randomly assigned to one of eight groups (n = 12 in each group) and treated with haloperidol or vehicle, with or without one of the beta-antagonists. Haloperidol-treated rats had higher bolus counts than vehicle-treated rats, and this increase was significantly reversed by the lipophilic but not the hydrophilic beta-antagonists. This finding is consistent with the reported anti-akathisia effects of these drugs in humans, suggesting that this effect is central in origin and achievable with relatively selective beta1-antagonism. The B-antagonist drugs significantly reduced the cataleptic effect of haloperidol and this effect warrants further examination.

Hyperkinesias in a prepubertal boy with autistic disorder treated with haloperidol and valproic acid

A 7-yr.-old Bangladeshi boy with autistic disorder, unspecified mental retardation, asthma, pica, and generalized tonic seizures, presented for hyperactivity, aggression, and disruptive behaviors. He had a history of an elevated blood lead level. He was being treated with haloperidol and valproic acid. He was assessed in an unstimulated state for the occurrence of adventitious movements. He exhibited hand flapping, jumping, running, and spinning as well as other motor and phonic stereotypes typical of autistic disorder. Although the presence of subjective distress and a sensation of inner restlessness could not be ascertained given his cognitive impairments, the objective picture of constant leg movement and inability to sit still was consistent with akathisia. The hyperkinesias may be due to autistic disorder, multiple comorbid conditions, and medications. Further studies with large populations of medicated and unmedicated children with autistic disorder are needed to characterize further the associated movement disorders which may result from neurological disorders and pharmacological treatments.

Beta 2-receptor density on mononuclear blood cells in patients suffering from neuroleptic-induced akathisia (NIA)

The effectiveness of beta-blockers in the treatment of neuroleptic-induced akathisia (NIA) suggests that beta-adrenergic overactivity is involved in the manifestation of NIA. As an approach to understanding this postulated overactivity, we investigated the beta 2-receptor density on mononuclear blood cells in 21 patients suffering from NIA as well as in 12 patients without NIA. The beta 2-receptor density in NIA-positive patients was significantly higher than that in NIA-negative patients (t = 2.84; p = .008). The NIA-positive patients were treated with 20 mg propranolol t.i.d. for 5 days. The beta 2-receptor density in treatment responders did not differ significantly from that in non-responders. Our results indicate that beta 2-receptors on mononuclear cells in patients with NIA may be of a certain degree of importance. With the prerequisites of replicability as well as correlation of this parameter with therapeutic success of beta-blockers, it may be considered as a predictor for treatment response.

Akathisia following low-dose droperidol for antiemesis in day-case patients

Akathisia has been described following the use of droperidol for antiemetic prophylaxis. In a double-blind, placebo-controlled study, we investigated both the incidence of akathisia and its relationship to the dose of droperidol (0.5 or 1 mg). One hundred and twenty healthy women undergoing day-case gynaecological surgery were anaesthetised with propofol, fentanyl, isoflurane and droperidol according to group. Patients were assessed by structured telephone interview at 24 h. There was an increasing incidence of both restlessness (p = 0.01) and unpleasant restlessness (p = 0.02) between the groups on Chi-squared testing. Compared to the control group, those women given droperidol 1 mg suffered more restlessness (p = 0.001) and unpleasant restlessness (p < 0.01). No statistical difference could be demonstrated between the two droperidol groups. We conclude that droperidol may commonly cause akathisia and may not, therefore, be an appropriate prophylactic antiemetic for day-case anaesthesia.

A retrospective study of risk factors of akathisia in terminally ill patients

Akathisia is a distressing disorder that manifests as a state of restlessness and motor agitation. We aim to highlight the problem of akathisia to the palliative care physician by identifying and quantifying risk factors in the terminally ill. A retrospective case-control study was utilized to investigate risk factors for akathisia. Medical records of cases (N = 100) and controls (N = 365) archived in a computerized database were downloaded and risk factors determined using conditional logistic regression analyses. Exposure to pharmacologically similar drugs, such as haloperidol [odds ratio (OR), 18.4; 95% confidence interval (CI), 8.2-41.4], prochlorperazine (OR, 8.1; 95% CI, 3.0-21.8), and promethazine (OR, 3.3; 95% CI, 1.3-8.0), conferred an increased risk. Other significant variables were exposure to morphine (OR, 5.3; 95% CI, 1.9-14.2), sodium valproate (OR, 2.5; 95% CI, 1.0-6.4), and sodium bicarbonate/tartrate (Ural) (OR, 4.2; 95% CI, 1.2-15.3). Highlighting factors that predispose patients to akathisia emphasizes that this syndrome should not be forgotten when treating the terminally ill. It is recommended that those drugs identified should be judicially used and carefully monitored.

Tourette's syndrome associated with restless legs syndrome and akathisia in a family

A family with coincidence of a restless leg syndrome (RLS) in the mother and a Gilles de la Tourette syndrome (GTS) in the son who also shows increased vulnerability to neuroleptic induced akathisia (NIA) is presented. Since these diseases show parallels from a genetic, pathogenetic and clinical point of view, the familiar coincidence is discussed under these aspects with respect to suggested disturbances of the dopamine and the opiate systems in RLS, GTS, and NIA.

Motor and mental aspects of acute extrapyramidal syndromes

Acute extrapyramidal syndromes (EPS) are one of the major limitations to effective neuroleptic treatment. These disorders have both motor (objective) and mental (subjective) aspects, which must be considered in any evaluation and differential diagnosis of treatment-related side effects. The disorders of akathisia, acute dystonia and parkinsonism have unique features that are best understood in the context of a careful assessment of patient characteristics, drug factors and temporal aspects. Though acute EPS are commonly explained on the basis of dopamine D2 receptor antagonism, data from several lines of study raise important questions about this hypothesis. The roles of receptor subtype specificity, brain region selectivity and ratios of different receptor subtype antagonism are discussed. New and novel antipsychotic drugs with low rates of EPS are important clinical advancements that will increase patients' ability to participate in therapy and rehabilitation and thus improve their quality of life.

Influence of rate of administration of raclopride on akathisia and prolactin response

The D2-dopamine receptor antagonist raclopride was administered to eight healthy male subjects, who had previously experienced akathisia following antipsychotic drugs. The influence of administration rate on onset, severity and duration of akathisia and on prolactin response was studied. Raclopride 3, 5 or 9 mg or placebo (P) was administered as single IV infusions during 10 min (R10 min/3 mg), 1 h (R1h/5 mg) or 4 h (R4h/9 mg) according to a randomized double-blind design. Despite a 24-fold difference in administration rate a similar peak raclopride concentration of about 350 nmol/l was obtained after all three infusions. Three of the eight subjects experienced akathisia following R10 min/3 mg and R1h/5 mg, respectively. After R4h/9 mg seven subjects experienced akathisia of longer duration but not more severe than after the short infusions. The incidence and duration of akathisia seem to be mainly related to the plasma raclopride concentrations over time, whereas the rate of administration might be more important for the severity. A maximal prolactin response was induced which was not markedly affected by the rate of administration.

A rating scale for acute drug-induced akathisia: development, reliability, and validity

This paper describes the process of developing a new rating scale for acute neuroleptic-induced akathisia. Previously reported clinical characteristics of akathisia were used to construct the initial version of the scale. This was administered to 100 consecutively admitted psychiatric patients treated with neuroleptic medication. The scale was then subjected to a reliability analysis, and the number of items reduced. A factor analysis of the ratings supported the decision to rate subjective and objective items separately. The new version of the scale (The Prince Henry Hospital Akathisia Rating Scale) was further standardized in its administration. A preliminary examination of its construct validity was performed by calculating the correlations with the ratings on the analogue and global scales, as well as those of depression, anxiety, and hyperactivity. The new scale was administered to 50 new subjects to examine its interrater reliability and concurrent validity with respect to the Barnes Akathisia Rating Scale.

Research diagnostic criteria for drug-induced akathisia: conceptualization, rationale and proposal

This paper argues for consistency in the conceptualization and definition of drug-induced akathisia (DIA), something found lacking in published research reports. It suggests the adoption of a common set of provisional categories with operationally defined diagnostic criteria. The categories proposed are acute, tardive, withdrawal and chronic DIA, with overlap of chronic DIA with the other three. The prerequisites for diagnosis are drug exposure, the presence of characteristic clinical features and the exclusion of non-drug causes. The frequency of the clinical features, and their nature, determine the level of certainty. A decision regarding severity is made independently of diagnostic certainty. Some ways of testing the usefulness and validity of these definitions are discussed.

Placebo response in refractory tardive akathisia

A double-blind, crossover drug trial with a patient with treatment-resistant tardive akathisia is described. The finding of a placebo response was unexpected, but emphasizes the value of such an approach in refractory cases.

The suppressing effect of chlorpromazine treatment on alimentary-social differentiation in amygdala dogs

Experiments were performed on dogs with bilateral electrolytic damage of dorso-medial amygdala. Before the operation dogs were trained in alimentary-social reward differentiation. It consisted in conditioning of instrumental responses of either right or left foreleg to two different tones respectively. Chlorpromazine was injected intramuscularly in 1.5 mg/kg dose during four consecutive days, beginning at third to fifth week after the operation. Amygdala damage produced significant deterioration of the instrumental performance both reinforced by food and by social-sensory rewards. Chlorpromazine produced further dramatic decrease of performance of both responses. It was concluded that chlorpromazine exerts a suppressing effect on motivated behavior reinforced by positive rewards in amygdala dogs. As the effect of chlorpromazine and medial amygdalar damage are summated it may be suggested that the deficit of medial amygdala neurons impairs similar neurochemical mechanisms, (probably dopaminergic and alpha-adrenergic transmission) as does chlorpromazine.

Neuroleptic-induced defecation in rats as a model for neuroleptic dysphoria

Two groups of 32 rats were challenged in a well-habituated environment with haloperidol (0.5 mg/kg), haloperidol (0.1 mg/kg), domperidone (0.1 mg/kg), or saline to study the effect of these drugs on defecation--an index of emotionality--and voluntary movements in the 2 hours after the injection. The haloperidol-treated rats in the high-dose condition had significantly more bolus counts in the 2 hours after the injection than were observed in the groups treated with domperidone (a peripheral dopamine D2 receptor antagonist) or placebo. All movements were greatly reduced in the haloperidol-treated rats and, in this group, the ones with more bolus counts did not differ in their activity levels from those with fewer bolus counts. There was a trend for the rats that were less mobile at 10 minutes after the injection to produce more boli in the 2-hour period. Our study, therefore, replicates the findings of Sanberg (1980) and Russell et al. (1987a, 1987b) that haloperidol increases "emotional" defecation in rats in well-habituated environments, but the same model does not replicate the motor component of neuroleptic-induced akathisia seen in human subjects.

Phenomenology and Prevalence of Neuroleptic-Induced Akathisia in Late Life

The authors examined 115 patients totaling 127 admissions to an acute care geriatric psychiatry inpatient unit using the Barnes Akathisia Scale. Subjective complaints of akathisia were associated with a diagnosis of major depression and correlated with Hamilton Rating Scale for Depression scores but were not associated with current neuroleptic treatment. Objective evidence of akathisia was strongly associated with current neuroleptic use. Patients from 45 admissions were receiving neuroleptics at the time of assessment. By using the presence of objective akathisia to define the syndrome, the authors identified 8 patients from these 45 (17.8%) as having neurolepticinduced akathisia (NIA). The presence of MA was associated with a lower rate of antiparkinsonian agent use. NIA contributed to the presenting complaints on admission in 7 patients, comprising 5.5% of all 127 admissions.

Differentiation of haloperidol and clozapine using a complex operant schedule in the dog

This study aimed to differentiate chronically administered typical (haloperidol) and atypical (clozapine) neuroleptics in the dog using a complex temporal regulation schedule combining operant, voluntary, and involuntary motor parameters. Although clozapine and haloperidol showed some characteristics of neuroleptics, justifying their adherence to the same class of compounds, differences have also been highlighted and compared to the clinical observations. Haloperidol induced catalepsy, tremor, dystony, hyperkinesia, and stereotypy. Subjects produced anticipated responses before any stimulus. Incomplete and delayed responses were also produced. An interpretation in terms of akathisia and anhedonia has been suggested. Clozapine induced tremor, exploration, dystony, and hypersalivation. Subjects produced disinhibitory responses to the negative stimulus and incomplete responses but these latter were submitted to tolerance. The simultaneous presence of tranquilizing and disinhibitory effects has been reported on the clinical potential of clozapine both in cases of positive and negative schizophrenic symptomatologies.

Intravenous benztropine and propranolol challenges in tardive akathisia

We challenged five patients suffering from tardive akathisia (TA) with intravenous benztropine (2 mg), propranolol (1 mg) and placebo (saline) using a random, double-blind cross-over design to examine the effects of the drugs on the subjective, objective and global manifestations of neuroleptic-induced akathisia. Benztropine produced a marginally significant, and propranolol a significant improvement in the overall manifestations of the disorder. The patients demonstrated a considerable placebo effect and marked variation in their responses to the drugs. The implications of these findings for the pathophysiology of TA in relation to acute akathisia and tardive dyskinesia are discussed.