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Clinical characteristics of akathisia. A systematic investigation of acute

psychiatric inpatient admissions

Article in The British Journal of Psychiatry · September 1983

DOI: 10.1192/bjp.143.2.139 · Source: PubMed

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Clinical characteristics of akathisia. A systematic investigation of
acute psychiatric inpatient admissions.
W M Braude, T R Barnes and S M Gore
BJP 1983, 143:139-150.
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Brit. J. Psychiat. (1983), 143, 139—150

Clinical Characteristics of Akathisia

A SystematicInvestigationof AcutePsychiatricInpatientAdmissions
WALTER M. BRAUDE,THOMAS R.E. BARNESand SHEILAM. GORE

Summary: Assessment of drug-induced movement disorders was carried out

regularly on 104 psychiatricpatients requiring antipsychoticmedication on
admissionto hospital.The data relevantto motor restlessnesswere subjected
to a principal components' analysis. Accordingto their component scores,
patientswere then classifiedinto two main groups: an akathisiagroup and an
illness-related-movementgroup, the former group showing the clinical and
pharmacological characteristics expected of akathisia. Clinical features which
distinguished between the two groups, and between grades of akathisia
severity, were identified, so an objective, phenomenological description of the
akathisia syndrome was possible. Our observations suggested two distinct
types of acute akathisia;one relatedto severe parkinsonismand one not. The
implications ofthesefindings arediscussed.

Akathisia is a syndrome of motor restlessness
associated with the administration of antipsychotic
drugs. It is both a common and a distressing symptom
and may lead to poor drug compliance (Ayd, 1961;
Raskin, 1972; Marsden eta!, 1975; Van Putten, 1975,
1978). However, despite the clinical importance of this
syndrome, phenomenological descriptions are incon
sistent and a generally accepted clinical definition has
not been established. This may explain the variations
in prevalence and treatment response reported. The
lackofprecise diagnosticcriteria may be related tothe
composite nature of the syndrome, which includes
both a subjective sense of restlessness and observable
motor signs. Clinicians have differed in their opinion
regarding the relative importance of these two aspects
of the condition. Delay and Deniker (1968) have
referred to it as an extrapyramidal motor disorder,
while Sovner and DiMascio (1978) considered it to be
basically a sensory phenomenon. Alternatively, Crane
eta! (1971) and Van Putten (1975) have described the
syndrome as primarily emotional, and a wide range of
behavioural syndromes have been documented as
presentations of akathisia (Van Putten; 1978, Kekich,
1978; Kumar, 1979). Whether all these reports de
scribe a genuine manifestation of the condition, or
whether some of them merely reflect the lack of
distinction between akathisia and symptoms of a
psychotic illness, remains unclear.
The main aims of this investigation were, firstly, to
identify the characteristic phenomena of the syndrome
in acute psychiatric inpatients receiving antipsychotic
139
medication and, secondly, to study the clinical behav
iour of the condition during these patients' hospital
stay.
Method
Patients
Over a six-month period, consecutive admissions to
two acute admission wards were monitored through
out their hospital stay. All the patients who required
antipsychotic medication following admission during
this period were considered suitable for the study.
Initially, 106 patients were assessed. Only two were
subsequently excluded; one because of idiopathic
Parkinson's disease, and the other as he was dis
charged within the first week. The remaining 104
patients (30 males, 74 females) were all in hospital for
at least one week (mean duration of hospital stay 23.1
±17.2 days). The age range of the sample was 19—72
years (mean 40.6 ±15.0). Primary diagnoses of the
patients were schizophrenia (n = 28), manic depres
sive illness (25), endogenous depression (19), neurotic
depression (14), personality disorder (7), schizo
affective psychosis (5), toxic or unspecified psychosis
(3), other neurotic conditions (2), and alcoholism and
related problems (1).
Procedure
This investigation was intended as a ‘¿naturalistic'
study; all inpatients at the risk of developing akathisia
by virtue of their antipsychotic drug treatment were
monitored throughout their hospital admission and no
140 CLINICAL CHARACTERISTICS OF AKATHISIA
attempt was made to influence the clinical manage were seen by both investigators using the question
ment of these patients. However, the ward doctor with naire and standard examination, and satisfactory
clinical responsibility was asked to record the case agreement on procedure was reached. On completion
note diagnosis as well as details of each patient's recent of the data collection both investigators reviewed all
drug history and all medication administered through the data directly referrable to akathisia. A global
out the admission period. In addition, the ward doctor clinical assessment of each case was made. A joint
completed the Brief Psychiatric Rating Scale (BPR5) decision was reached regarding the presence or
(Overall and Gorham, 1962) at weekly intervals. All absence of akathisia and, if present, a grading of mild,
other assessments were carried out by investigators moderate or severe was agreed upon.
blind to this clinical information, including all details of
drug treatment. Data analysis
Patients were assessed as soon after admission as The main aim of the study was to identify the
was practicable, usually within thefirst48 hours,and constituent signs and symptoms of the akathisia
subsequently at at least weekly intervals throughout syndrome. A multivariate statistical method was
their stay in hospital. Parkinsonism was evaluated considered an appropriate technique for objective
using the Simpson and Angus (1970) rating scale for classification in such a context, where a large number
extrapyramidal sideeffects. Tardivedyskinesia wasof clinical phenomena are involved and the weight to
scored using the videotape rating technique described be attached to the different features in diagnosis is
byBarnesandTrauer(1982). Inaddition, astructured uncertain (Garside and Roth, 1978). In this study the
interview and standard examination procedure were technique was to be used to indicate whether, in our
included, which had been designed to identify subjec patient sample, certain of the patient variables re
tive symptoms of restlessness and determine the corded tended to occur together i.e. would emerge as
presence of motor restlessness and other purposeless correlated items in distinct clusters of symptoms.
movements. The interview began with open questions, However, should symptom groupings emerge from
such as whether the medication was suiting the patient such a procedure, it had then to be established whether
or whether the patient had been aware of any adverse one or more of these groupings would allow a more
effects overtheprevious week.Subsequently, specific precise delineation of akathisia, as a clinical entity.
enquiry was made about particular symptoms, as listed The statistical method chosen was a principal
inTableIV,derivedfrom a widevariety ofclinical components' analysis. For each patient only one set of
descriptions of akathisia in the literature (Hedge, ratings from a single assessment occasion was included
1959; Sigwald and Raymondeaud, 1968; Sigwald and in this multivariate analysis. In each case the set of
Solgnac, 1968; Raskin, 1972; Van Putten, 1975; ratings used was from the occasion on which the
Marsden eta!, 1975). maximum number of items were scored on the
Before the examination, patients were asked to questionnaire and examination schedule..
remove their shoes and socks and also any clothing that
might obscure limb movements. The examination was Results
conducted with the patient sitting, standing and lying Principal components' analysis
and being observed in each position for at least four Eighteen items (listed in Table Ia), derived only
minutes. Semi-purposeful and purposeless movements from the “¿restlessness―questionnaire and examina
of the upper limbs, trunk, and lower limbs were tion schedule, were subjected to a principal compo
assessed in each of the three positions while the patient nents' analysis. Oblique rotation revealed four
was engaged in informal conversation on neutral components which jointly accounted for 68 per cent of
topics. The site and type of movements that were the total variance; Component 1 accounted for 44 per
puposeless were recorded. Such movements were cent, Component 2 for 11 percent, Component 3 for 8
rated according to a simple scale: 0 = absent, 1 = per cent and Component 4 for 5 per cent. Table I
movement present less than half the observation indicates the loadings of the individual items on each of
period, 2 = movement present for more than half the the four components. Item loadings indicating a major
time, 3 = continuous movement. The criterion of contribution to a component are marked with an
severity was thus based on the proportion of the asterisk.
observation period during which the movement was The main items making a positive contribution to
present. Abnormal movements (dyskinesias) were Component 1 were a complaint of an inability to keep
classified according to the definitions proposed by the the legs still, semipurposeful leg and foot movements
ResearchGroup on Extrapyramidal Disorders ofthe while sitting, shifting body weight from foot to foot and
World Federation of Neurology (1981). walking-on-the-spot, and other normal purposeless leg
Before beginning the study, a number of patients and foot movements, (e.g. lateral kicking movements)
 WALTER M. BRAUDE, THOMAS R. E. BARNES AND SHEILA M. GORE 141
TABLE I
Component loadings on 18 items from restlessness questionnaire and examination. Major contributions are starred
Components1
23 4
Questionnaire
itemsLimb
sensations.27—.17.36*—
39*Inner

restlessness—.08.12•79*—.14Inability
to remain still.22.03.51*—
@54*Inability

.48*Examination to keep legs still.67*.02.06—

items(1)
SittingSemipurposeful
movements.71*—.04.27.09Shifting
or purposelessnormal leg/feet
chair.15.30*.10....46*Inability
body position in
seated.20@49*.11.09Semipurposeful
to remain
.07.03•57*.09Purposeless, hand/arm movements-
movements.13.02.31*.36*(2) normal hand/arm

StandingShifting
spot'.67*.22—.06Other
weightfrom foot to foot and/or ‘¿walking
on the
movements.63*.04.07.19Inability
purposeless(normal) foot
.11(3) to remain standingon one spot (walkedor paced).19•44*.11—

LyingCoarse
tremor of legs/feet77*.03—
.07—.17Myoclonic

jerks of the feet.83*.06—

.12Semipurposeful .13—

or purposelessleg/feetmovements74*.12—
.09.09Shiftingpositionof

legs33*.50.10.03Shifting
.05—.02Inability positionof trunk/buttocks— .09.85*—

to remain lyingdown—
.07•99*.00.03Intercorrelations

componentsComponents
betweenthefour

2 0.44
3 0.38 0.19

4 —¿0.26 —¿0.09 —¿0.05

2 3 4
Components

while standing. A few of these items, such as rocking
from foot to foot while standing, have been specifically
mentioned in some previous descriptions of the
akathisia syndrome (Raskin, 1972; Marsden et a!,
1975). In addition, several items, apparent on lying,
made a significant positive contribution; coarse tremor
and myoclomc jerks of the feet, and semipurposeful/
purposeless movements and shifting of the legs. The
myoclonus appeared as intermittent, jerky activity in
the feet, consistent with Halliday's (1967) description
of extrapyramidal myoclonus, i.e. “¿broken-upbeats of
extrapyramidal
tremor―.
Component 2 was noted for small positive loadings
for many of the items which made a major contribution
to Component 1 (see Table I). This implied an affinity
between Components 1 and 2 which was reflected in a
0.44 correlation between them. In addition, the
following items made a marked positive contribution
to Component 2: shifting body position while seated:
inability to remain sitting down: inability to remain
standing on one spot: shifting the position of legs while
lying: shifting the trunk while lying and inability to
remainlying down.Alloftheseitemsrepresent gross
body movements. Overall, Component 2 appeared to
correspond to a severity variant of Component 1.
Component 3 received major positive contributions
142 CUNICAL CHARACTERISTICS OF AKATHISIA
from three of the four questionnaire items, the item By this method two main patient groupings emerged.
with the highest loading being a patient report of inner Table II lists the group of patients characterised by
restlessness. Also, semipurposeful and purposeless relatively high Components 1 and 2 scores and
hand and arm movements while seated had high negative Component 4 scores. Based on the item
positive loadings. This component was interpreted as loadings for these components, this group of patients
representing non-specific emotional unease with asso appeared to manifest a specific syndrome of motor
ciated fidgety movements of the upper limbs. restlessness, particularly referable to the legs and feet.
Component 4 was characterised by strong negative The phenomena present were considered to be
loadings for many of the items that made a positive consistent witha clarification and refinement of the
contribution toComponent 1.Thiswas reflected ina akathisia syndrome. This hypothesis is tested below.
—¿0.26
correlation between these two components. Table Ill presents the second main patient grouping.
This group of patients was characterized by relatively
high Components 3 and 4 scores and negative Compo
Class4fication of patients nents 1 and 2 scores. The component scores in this
Component scores were calculated for each patient. group would appear to correspond to the non-specific
These scores were then simplified, being expressed in movements observed in psychiatric illness Although
terms of a simple 0-3 grading, which was based on the diagnostically heterogenous this group contained a
distribution of scores in the patient sample for each significant excess of depressive patients (@ = 4.74, df
component. Cases were then grouped together accord =1, P <.05). Clinically, the movements present in this
ing to the similarity of their component score proffles. group were manifestations of agitated depression,

TABLE II
Componentxores of27patientswith
akathisiaComponent
scoresAkathisia
3419
diagnosisPatient
number- gradingClinical
12

0.7
21 2.4 0.9 0.3 —¿1.9 Manicdepressivedisorder
26 2.1 7.1 0.7 1.1 Schizo-affective psychosis
77 3.0 6.5 1.5 0.5 Manicdepressivedic*@
91 1.5 0.2 1.0 —¿2.4 Schizophrenia
Schizophrenia5 1.70.1
951.7 0.3 0.8—2.2 —¿1.2severeSchizophrenia

0.5 depressive disorder

15 2.0 0.0 —¿0.4 —¿2.0 Schizophrenia
18 2.1 —¿0.1 —¿0.7 —¿0.4 Schizophrenia
28 2.1 0.3 —¿0.5 —¿0.4 Schizophrenia
31 1.4 0.1 —¿0.2 —¿0.6 Manic depressive disorder
38 1.2 —¿0.1 0.9 —¿1.1 Manicdepressivedisorder
42 2.2 —¿0.1 0.1 —¿0.2 Manic depressive disorder
50 0.1 0.1 —¿0.1 —¿1.9 Schizophrenia
58 2.5 04 2.1 0.7 Neurotic depression
64 1.8 0.1 —¿1.1 —¿0.8 Schizophrenia
66 1.5 0.5 0.2 —¿0.1 Manic depressive disorder
71 1.7 —¿1.0 1.7 0.1 Schizophrenia
1012.4
disorder8 0.9—0.2 0.1 1.2—1.0 —¿1.0moderateManic Manicdepressive

0.9
46 —¿0.2 —¿0.4 0.1 —¿1.5 Schizophrenia
63 0.4 0.3 -0.4 -0.7 Schizophrenia
92 0.1 —¿0.2 0.7 —¿1.8 Endogeeomreano.
93 0.1 —¿0.2 0.2 0.5 Schizophrenia
97 0.4 —¿0.3 1.4 —¿1.2 Schizophrenia
99 0.1 —¿0.1 0.6 —¿0.4 Marncdepressivediaorder
1040.1 0.3—0.1 —¿0.5 1.5—0.2 —¿0.9@dSchizophrenia Schizophrenia
Note high scores on 1 and 2 and negatives on 4.
 WALTER M. BRAUDE, THOMAS R. E. BARNES AND SHEILA M. GORE 143
T@nu@Ill
withpsychiatric-illness-relatedmovementsPatient
Componentscores of 35 patients
scoresClinical
number 1Component diagnosis2 34
6
10 1.3 —¿0.5 2.2 1.5
22 —¿0.3 —¿0.1 0.1 0.9
27 —¿0.4 —¿0.2 0.3 0.7
55 —¿0.4 —¿0.3 —¿0.3 0.6 Endogenous depression
65 —¿0.5 —¿0.1 —¿0.4 0.6
79 —¿0.1 —¿0.1 1.2 1.2
94 —¿0.1 —¿0.1 0.9 —¿1.1
103—0.4
0.54 —¿0.1—0.30.2—0.5 —¿0.70.5

20 —¿0.4 —¿0.3 —¿0.3 0.6

53 —¿0.5 —¿0.1 0.8 0.8
54 —¿0.3 —¿0.4 1.0 —¿1.5
—¿0.1 0.8 0.8 Neuroticdepression
81 —¿0.5
88 —¿0.2 —¿0.2 1.0 0.5
1.085—0.50.00.79
90—0.3 —¿0.3—0.2 —¿0.10.2 1.00.9
0.8 Anxiety neurosis

49 0.0 —¿0.4 0.2 1.3

57 —¿0.4 0.1 1.8 0.3
72 —¿0.6 0.8 1.5 —¿0.4 Schizophrenia
78 —¿0.4 —¿0.1 —¿0.4 0.8
—¿3.07
800.1 —¿0.50.1 —¿0.21.2 2.01.0

60 —¿0.4 —¿0.3 0.6 —¿1.5

75 —¿0.1 —¿0.2 0.3 1.2 Schizoaffective psychosis
25 0.1 0.2 1.5 1.8
0.673
52—0.7 —¿0.40.0 —¿0.20.8 —¿0.1—0.4

86 0.3 —¿0.2 —¿0.1 1.1

87 —¿0.1 —¿0.2 0.1 0.8 Manicdepressivedisorder
89 —¿0.3 —¿0.2 1.1 —¿0.2
102—0.2 —¿01—0.3
—¿0.712—0.6—0.183—0.2—0.2 0.20.6 —¿0.30.8
0.3 0.7 Toxic psychosis
—¿0.4 0.7 Personality disorder
Note highscoreson 3 and4aad negativevaluesin columns 1and 2 (contrast Table II).
psychotic excitement and overactivity, stereotypies akathisia group, that were derived from the principal
and mannerisms, andcatatonic posturing. Total BPRS components analysis (see Table II), represented a
scores and the scores for meaningful groupings of more precise delineation of akathisia it was necessary
BPRS items were compared between this group, the todemonstrate thatthesyndromeidentified inthese
akathisia group and the rest of the sample. No patients showed the conventional clinical and pharma
statistically significant differences were revealed. cological characteristics of the akathisia syndrome.
Clinical validation of the putative akathisia group (i) Clinical diagnosis
In order to support the contention that the specific As previously mentioned, global clinical assess
features of motor restlessness present in the putative ment ofeachcasewas carried outfollowing the
 144 CLINICAL CHARACTERISTICS OF AKATHISIA
completion of data collection. A diagnosis of
akathisia was made in 28 out of the 104 patients.
Subsequently, all cases were classified into groups
according to their component score profiles, as 100@
described above. All 27 of the cases allocated to the
group listed in Table II had received a clinical
diagnosis of akathisia. Thus, only one patient
(number 94) clinically diagnosed akathisia was not
classified within this putative akathisia group. 80.
(ii) Incidence
Out of the 104 patients in our sample 27 were 70.
included in the putative akathisia group. How 0

ever, when akathisia incidence was calculated, one

patient (number 28) in this group had to be 60.
excluded as his signs and symptoms of motor
restlessness had been present prior to admission.
50.
Thus, the incidence figure in our sample was 25 per
cent which is in accord with an incidence reported
in the literature of approximately 20 per cent 40.
(Ayd, 1961; Marsden eta!, 1975).

(iii) Antipsychotic drug treatment 30@

The first 10 days of drug treatment were found to
be the period of maximum drug dose increase for
all patients in the study. Within this period the 20.
maximum antipsychotic drug dose was noted for
the 26 cases of acute akathisia in this group (Table
II). In 22(85 per cent) of these patients, signs and 10'
symptoms appeared within seven days after
reaching this maximum dose. Three of these
0.
patients developed akathisia within 12 hours of 0 0.1-1 1.1-2 2.1-3 @3.
1
the administration of their first dose and all 26 (n-li) (n-20) (n-li) (n-41) (n-21)
cases had developed it within 14 days of starting
on the maximum dose. Index of antipsychotic drug dose increase
FIG 1.—Proportion of patients with akathisia according to
@ In order to compare the groups that had been index of antipsychotic drug dose increase, log ( ).
derived from the principal components' analysis
in terms of antipsychotic drug treatment, an index
of dose change over the first 10 days of treatment putative akathisia group had experienced an in
was calculated. As the patients had received a crease in antipsychotic drug dosage during the
variety of antipsychotic drugs, all drug doses in first 10 days of drug treatment. Furthermore, the
this period (including the dose each patient was proportion of akathisia patients increased sharply
receiving immediately prior to hospital admis at log, ratio levels greater than 3.1, a figure
sion) were converted into chlorpromazine equiv indicative of a large increase in dosage. For
alents per day (Davis, 1974; Wyatt and Togrow, example, an increase in drug dosage from 0—1000
1976; Ezrin-Waters eta!, 1981). The index of dose chlorpromazine equivalents per day would give a
change was expressed as algorithmic ratio, log log, ratio of 3.0.
@ ), whereCPZmaxandCPZmmwere These results show that for patients in the
respectively the maximum and minimum antipsy putative akathisia group, the specific signs and
chotic drug doses administered during this period symptoms of motor restlessness developed rap
expressed in chlorpromazine equivalents. In no idly following a relatively large initial increase in
case did this index represent a decrease in medi drug dosage. This is entirely in accord with
cation. Fig 1 reveals that all patients in the descriptions of akathisia as an acute, dose
 WALTER M. BRAUDE, THOMAS R. E. BARNES AND SHEILA M. GORE 145
related, antipsychotic drug side-effect (Ayd, was found to conform@closely to the conventional
1961; Marsden eta!, 1975). In addition, akathisia clinical and pharmacological criteria for diagnosis of
usually improves following drug reduction or akathisia.
withdrawal (Hodge, 1959; Raskin, 1972; Van
Putten, 1974). Only 10 patients in the akathisia Clinical characteristics of akathisia
group had a significant reduction in antipsychotic The patients in the akathisia group were significantly
drug dosage (decreased by at least one-third of younger than the rest of the patient sample (t = 2.4,
their maximum) early enough for the subsequent dl = 102, P <0.02). However, a second comparison
effects to be assessed during their hospital stay. was carried out on only those patients who were at risk
Relief of akathisia signs and symptoms occurred of developing akathisia by virtue of a recent marked
in eight of these cases within seven days, and in drug increase (log, ratio over 2.5). There was no
the remaining two cases within three weeks of this significant difference in age or sex distribution
dose reduction. between such patients in the akathisia group (n = 24)
In summary, the akathisia group listed in Table II and those in the rest of the sample (n = 23).
TABLE IV
Symptomsandsigns
inakathisia
andillness-related
movementgroupscompared
Akathisiaillness-relatedMildModerateSevereAllAll(n=8)(n=13)(n=6)(n=27)(n=35)Symptoms

report)Limbsensations66315@_____7Inner
(patient
restlessness7962223Inabilitytoremainstill712625——11Inability
still713626-@-@7Symptoms
to keep legs
whilestanding2——9516—Associated
worse

moderate/severe
distress29516Signs(1)SittingSemipurposeful

feetmovements
thanhalf for more
thetime23___**_510——4Shiftingpositioninchair15511—s—1Inabilitytoremainseated01—@—-453Semipurposeful

hand/arm
formore
movements
time2316—@——18Purposeless
than half the
hand!arm normal
movements221510(2)StandingRocking

etc.(morethanhalfthetime)0—@—9615——0Other
from foot to foot

purposelessfoot
normal
movements17210—s—1Inabilitytoremainstanding12_***__51(3)LyingCoarse

tremor0.—@—86l4—@—1Myoclonicjerksofthefeet0—@@—-11516—@—0Semipurposeful
feetmovements04_*_52Shifting
—¿--——595Trunk
positionof legs04
—¿s-—---—222Inabilitytoremainlying00—s--——220P<.05;
movements00

<.02**; <.01***;<.001gw (chi-squared test)

146 CLINICAL CHARACTERISTICS
TABLE V
Varieties of abnormal movements and akathisia
Akathisia group
(N=42)Acute (N=27)Illness-related
dystonias111Oro-facial
dyskinesia2611Choreiform
tardive
limb and trunk movements100
The patients in the akathisia group were further
subdivided into severity gradings of mild, moderate
and severe akathisia, based on their component score
profiles and the clinical global ratings (from Table II).
In Table IV starred items show inability to keep still
and abnormal limb sensations, together with coarse
tremor, myoclonic jerking and the other specific
patterns of restless movements as characteristics of
akathisia while'the presence of semi-purposeful hand
and arm movements for more than half the observation
period while sitting characterised the illness-related
movement group. There was no significant difference
between the two groups in inner restlessness, a
relatively common phenomenon present in almost half
the patients.
In more detailed clinical analysis of akathisia,
several items were found to be significant discrimina
tors (see Table IV). Symptoms in the mild group were
predominantly subjective items from the question
naire and relatively few observable signs were present.
In the moderate group significantly more patients
found the condition worse on standing, and more were
distressed by the symptoms. In addition, they had
more—myoclonus, coarse tremor, and shifting of
weight from foot to foot, or walking-on the-spot while
standing. The severe group had a greater inability to
remain lying down; movement of the trunk and shifting
the position of the legs while lying; inability to remain
standing still or to remain seated, and semipurposeful
foot movements while sitting and lying.
Table V gives the incidence of oro-facial dyskinesia,
acute dystonias and choreiform trunk and limb move
ments within the subgroups of the study sample. There
was no significant relationship between akathisia and
oro-facial dyskinesia.
There was no association between severity of
akathisia and peak Simpson and Angus Scale (parkin
sonism) score. Two-thirds (n = 18) of patients with
akathisia had parkinsonism scores of 1.5 or less (see
Fig 2). Of these cases 12 were administered anticholin
ergic medication for at least 14 days but their akathisia
failed to respond (see Fig 3). The anticholinergic drugs
prescribed were procycidine (minimum daily dose 10
mg), orphenadrine (minimum daily dose 150 mg) and
benzhexol (minimum daily dose 6 mg).
OF AKATHISIA
movementgroup of sample
(N=35)Rest
One third (n =9) of the patients with akathisia had a
peak parkinsonian score of 1.6 or over, of whom eight
received anticholinergic medication. Of these drug
treated patients, one severe and one moderate case of
akathisia did not respond but the other six showed
marked improvement, the symptoms disappearing in
all but one patient. Fig 3 demonstrates that the six
responders were characterised by a parallel response in
their severe parkinsonism. However, the signs and
symptoms of akathisia in this small group of respond
ers were not distinctive.
During the study four patients with akathisia
received diazepam in doses between 15 and 40 mg per
day. None showed any change in the condition.
Discussion
Clinical features
In this study objective methods were used to identify
and delineate the clinical features of akathisia and its
grades of severity, as mild, moderate and severe.
Mild akathisia presents principally subjectively,
with very few observable signs. Van Putten (1975) and
Gagrat et a! (1978) have referred to feelings of unease,
and in particular inner restlessness, as being typical of
mild akathisia. But our results showed inner restless
ness to be a common, non-specific symptom. In
addition, it has been suggested that mild akathisia may
be difficult to differentiate from generalised anxiety
(Raskin, 1972; Van Putten, 1975, 1978). However, we
found complaints specifically referable to the legs
discriminated most effectively between mild akathisia
and restlessness due to underlying psychiatric illness.
Patients with moderate akathisia expressed similar
complaints but in addition would typically rock from
foot to foot or walk-on-the-spot while standing and
showed both coarse tremor and myoclonic jerks in
their feet. Myoclonic jerks in the legs have been
described in association with the restless legs syn
drome, a condition phenomenologically similar to
akathisia (Behrman, 1958; Boghen and Peyronnard,
1976; Hussey, 1976). Myoclonus has also been re
ported as accompanying acute dystonias (Marsden et
a!, 1975) and tardive dyskinesia (Degwitz and
Wentzel, 1967; Marsden et a!, 1975), a syndrome that
 WALTER M. BRAUDE, THOMAS R. E. BARNES AND SHEILA M. GORE
100'
90
80
70@
60.
C sive illness (see Table II), which presumably reflects
@50,
@40.
30
20
0-0.5 0.6-1 1.1-1.5 1.6-2 2.1-3
Peakparkinsonism
scorebands
(AngusandSimpsonratingscale)
FIG 2.—Frequency distribution of parkinsonism scores in
total sample.The number of akathisiacasesineachsub-group
is indicated by the shaded area.
may include signs and symptoms of akathisia (Ayd,
1961; Brandon et a!, 1971; Kennedy et a!, 1971;
Simpson, 1977; Forrest and Fahn, 1979).
Patients suffering from severe akathisia also exhib
ited difficulty in maintaining their position. For
example, when seated they would stand up from the
chair, when standing they would begin to walk or pace
or, when lying, would feel compelled to leave the
couch to take a few steps. These features are consistent
with the descriptions of ‘¿tasikinesia',
which has been
regarded as indicative of severe akathisia (Delay and
Deniker, 1968; Raskin, 1972; Sovner and DiMascio,
1978). Most cases with moderate or severe akathisia
were markedly distressed by their symptoms (see
Table IV). Although akathisia literally means inability
147
to remain seated, most of these patients described the
condition as being worse when they were required to
stand still.
In contrast, patients with movements related to their
underlying psychiatric illness (among whom there
were more with a diagnosis of depressive illness) had a
significant excess of semipurposeful hand and arm
movements. This would suggest that much of the
movement recorded in this group represented the
typical hand-wringing and fidgety movements of
agitated depressive patients. Other movements in this
group were related to psychotic excitement, over
activity, stereotypies, mannerisms, and catatonia.
Within the akathisia group 25 out of the 27 patients
were admitted with a schizophrenic or manic depres
the likelihood of such patients receiving intensive drug
therapy. They were significantly younger, probably
simply because younger patients get bigger doses of
drugs, as this age effect was not significant when only
those patients receiving a rapid rise in antipsychotic
dosage were considered. In the majority of cases, aka
thisia developed soon alter a large increase in antipsy
chotic drug dose; in 85 per cent within a week of being
prescribed their maximum dose, three patients within
12 hours of their first drug administration. Such an
early onset is consistent with akathisia occurring within
90 minutes of the administration of the oral dopamine
antagonists, metoclopramide and droperidol (Barnes
et a!, 1982) and within 15—30
minutes of intravenous
metoclopramide (Jungmann and SchOfffing, 1982).
Drug treatment
In all 10 akathisia patients whose antipsychotic
medication was significantly reduced, the condition
improved. However, this was the only pharmacologi
cal manipulation which proved to be invariably
beneficial. A benzodiazepine drug was not helpful,
despite previous encouraging reports (Donlon, 1973;
Gagrat eta!, 1978; Director and Muniz, 1982). Out of
20 patients treated with anticholinergic agents only six
improved. Akathisia was an invariable accompani
ment of severe parkinsonism and in this context only
responded to anticholinergic drugs, suggesting there
may be two distinct types characterized by concomi
tant severe parkinsonism of early-onset akathisia, one
related to severe parkinsonism and one not, possibly
reflecting different pathophysiological mechanisms.
This may help to explain the variable response of
akathisia to anticholinergic treatment (Marsden et a!,
1975; Sovner and DiMascio, 1978).
Pathophysio!ogy
Response of both akathisia and severe parkinsonism
to anticholinergic medication is compatible with an
148 CLINICAL CHARACTERISTICS OF AKATHISIA

1.0

0.8

0.6
.
E
0.4
S .
.
0.2 .
C

a.
C 0
‘¿a •¿
0.5 1:5 2:0 2:5 3:0
Parkinsonismscore
-0.2 e
(pre-antkholinerqictreatment)

-0.4

-0.6

FIG 3.—Parkinsonism score of 20 akathisia patients before anticholinergic treatment (horizontal) and their index of
improvement in parkinsonismwith treatment (vertical). Patients whoseakathisiaalso improvedshownby stars, others by dots.

overwhelming blockade of post-synaptic dopamine provided invaluable advice and encouragement throughout
receptors in the nigrostriatal system by the the study and constructivecriticismof the manuscript.
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* Walter M. Braude, MB., Ch.B., M.R.C.PSYCh., Weilcome Research Fellow and Honorary Senior Registrar

Thomas R. E. Barnes, M.B.B.S.,

M.R.C.Psych.,
Senior Welkome Research Fellow and Honorary Senior Registrar,
Psychiatric Research Unit, University of Cambridge Clinical School, Addenbrooke's Hospital, Cambridge CB2
2QE
Sheila M. Gore, MA., Ph.D.,Statistician, MRC Biostatistics Unit, MRC Centre, Hills Road, Cambridge

Present appointment: Senior Registrar, Department of Psychiatry, Manchester Royal Infirmary, Manchester M13 0EV.
(Received 23 September1982)

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