Differential Diagnosis for Restlessness, Balance Problems, and Constant Walking

The patient's symptoms of restlessness, balance problems, and a compulsion to constantly walk to and fro can be attributed to various conditions. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Akathisia: This condition is characterized by a subjective feeling of restlessness and an urge to move, often seen in patients taking antipsychotic medications or experiencing withdrawal from certain substances. The constant walking to and fro is a classic presentation of akathisia.

• Other Likely Diagnoses

  • Anxiety Disorders: Conditions like generalized anxiety disorder or panic disorder can cause restlessness and an inability to stay still, which might manifest as constant walking.
  • Attention Deficit Hyperactivity Disorder (ADHD): Adults with ADHD can exhibit restlessness and an inability to engage in activities quietly, which could include pacing back and forth.
  • Substance Withdrawal: Withdrawal from substances like alcohol, benzodiazepines, or opioids can cause restlessness and agitation.

• Do Not Miss Diagnoses

  • Thyroid Storm: Although less common, thyroid storm (a life-threatening complication of untreated or undertreated hyperthyroidism) can present with agitation, restlessness, and confusion. Normal vital signs do not rule out this condition entirely, as it can sometimes present atypically.
  • Neuroleptic Malignant Syndrome (NMS): A rare but life-threatening side effect of neuroleptic medications, NMS can cause altered mental status, rigidity, and agitation. Early recognition is crucial.
  • Serotonin Syndrome: Another potentially life-threatening condition caused by excessive serotonin levels, often due to medication interactions. It can present with agitation, confusion, and changes in mental status.

• Rare Diagnoses

  • Huntington's Disease: A genetic disorder that causes progressive damage to the brain, leading to physical, cognitive, and psychiatric problems. Chorea (involuntary, abrupt movements) and restlessness can be part of the presentation.
  • Pantothenate Kinase-Associated Neurodegeneration (PKAN): A rare genetic disorder characterized by progressive damage to the brain, which can cause dystonia, parkinsonism, and other movement disorders, potentially leading to restlessness and gait disturbances.

Each of these diagnoses requires careful consideration of the patient's full clinical picture, including medical history, medication use, and thorough physical and neurological examination.