Can a Patient Have Both Akathisia and Tardive Dyskinesia?
Yes, a patient can absolutely experience both akathisia and tardive dyskinesia simultaneously, and this co-occurrence is well-documented in clinical practice. 1
Evidence for Co-occurrence
Both conditions can occur together in the same patient, with research demonstrating that 33 chronic schizophrenic patients presented with concurrent signs of akathisia and tardive dyskinesia when withdrawn from antipsychotic medications. 2
The American Academy of Child and Adolescent Psychiatry explicitly recognizes that akathisia may occur alongside other acute extrapyramidal symptoms, and patients can develop multiple movement disorders from antipsychotic exposure. 1
Clinical studies confirm that tardive akathisia tends to be associated with signs of tardive dyskinesia, suggesting these conditions share some pathophysiological characteristics and can coexist. 3
Understanding the Two Distinct Conditions
Akathisia Characteristics:
- Subjective inner restlessness with severe tension and compulsion to move 1
- Semi-voluntary movements including pacing, inability to sit still, marching in place, crossing/uncrossing legs, and trunk rocking 1
- Predominantly affects legs and trunk with whole-body restlessness 1
- Often misinterpreted as psychotic agitation or anxiety, leading to inappropriate dose increases 1
Tardive Dyskinesia Characteristics:
- Involuntary and rhythmic movements that are choreiform or athetoid 1
- Primarily affects the orofacial region with rapid involuntary facial movements including blinking, grimacing, chewing, or tongue movements 1, 4
- Can also involve choreiform limb movements 1
- Movements are truly involuntary, not driven by subjective distress 1
Clinical Assessment Algorithm
When evaluating a patient on antipsychotics with movement abnormalities:
Step 1: Observe location and quality of movements
- Predominantly leg/trunk movements with pacing → suggests akathisia 1
- Orofacial movements (tongue, jaw, facial grimacing) → suggests tardive dyskinesia 1
- Both patterns present simultaneously → patient has both conditions 1, 2
Step 2: Assess subjective component
- Inner sense of restlessness and compulsion to move → akathisia component 1
- No subjective distress with movements → pure TD 1
Step 3: Document baseline movements
- Essential before antipsychotic initiation to avoid mislabeling pre-existing movements as drug-induced 1
Important Clinical Pitfalls
Do not assume a patient can only have one movement disorder – the co-occurrence of akathisia and TD is common, particularly in patients with prolonged antipsychotic exposure. 2, 3
Misinterpreting akathisia as worsening psychosis leads to inappropriate antipsychotic dose increases, which paradoxically worsens the akathisia. 1
Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia, highlighting the high prevalence of these conditions. 1
Treatment Implications When Both Are Present
Lowering the antipsychotic dose may help akathisia but could initially worsen TD (though this is controversial). 1
β-blockers or benzodiazepines can provide relief for akathisia specifically. 1
VMAT2 inhibitors (valbenazine or deutetrabenazine) are first-line for moderate-to-severe TD and do not worsen akathisia. 1, 5
Anticholinergics should be avoided – they do not help akathisia consistently and may worsen TD. 1, 5
Switching to atypical antipsychotics with lower D2 affinity (such as clozapine) reduces risk of both conditions if continued antipsychotic treatment is necessary. 1
Pathophysiological Relationship
Research suggests that TD and tardive akathisia may share common pathophysiological mechanisms, involving dopamine receptor hypersensitivity and GABA receptor changes in different striatal regions. 6, 3
The heterogeneous nature of TD depends on a subtle balance between several neurotransmitters, which explains why multiple movement disorders can coexist. 6