How to Recognize Akathisia
Akathisia is diagnosed by identifying both subjective feelings of inner restlessness and objective motor restlessness, particularly when these symptoms emerge or worsen after starting or increasing doses of antipsychotic medications or SSRIs.
Core Diagnostic Features
You can tell if you have akathisia by recognizing this characteristic combination 1:
Subjective Symptoms (What You Feel)
- Inner tension and emotional unease - a feeling of restlessness from within
- Constant need to move - inability to tolerate sitting still or remaining inactive
- Anxiety-like sensations that are specifically tied to the urge to move
Objective Signs (What Can Be Observed)
The most discriminating physical signs include 2:
- Shifting weight from foot to foot or walking on the spot
- Inability to keep legs still
- Shifting body position repeatedly while sitting in a chair
- Pacing or constant movement
Critical Diagnostic Clues
Timing is essential: Akathisia typically develops after 1, 2:
- Starting an antipsychotic medication or SSRI
- Increasing the dose of these medications
- Frequent use of "as needed" antipsychotic medications
The symptoms worsen with dose increases - this is a key distinguishing feature from primary anxiety or psychiatric agitation 1.
Common Pitfalls Leading to Missed Diagnosis
Akathisia is frequently misdiagnosed because 3:
- Mild cases may present with subtle restlessness
- Some patients cannot articulate the inner restlessness clearly
- Restlessness may occur in body parts other than legs (arms, trunk)
- Clinicians may focus only on visible motor restlessness and miss the subjective component
- It gets mistaken for psychiatric anxiety or agitation, leading to inappropriate dose increases that worsen the condition 1
Validated Assessment Tools
For clinical confirmation, the Barnes Akathisia Rating Scale (BARS) is the standard assessment tool 4. A simplified approach uses 5:
- Presence of subjective inner restlessness (patient report)
- Presence of objective motor restlessness (clinical observation)
- Both components should be present for definitive diagnosis
Key Distinguishing Features from Anxiety
Unlike primary anxiety 2:
- Akathisia has low correlation with standard anxiety scales
- The restlessness is specifically motor-driven rather than worry-driven
- There is a clear temporal relationship with medication initiation or dose changes
- The urge to move provides temporary relief, whereas in anxiety, movement doesn't specifically address the core symptom
Risk Factors That Increase Suspicion
You are more likely to have akathisia if 4, 2:
- Using multiple medications that can cause akathisia
- Recent dose increases of antipsychotics or SSRIs
- Previous history of akathisia
- Presence of other extrapyramidal side effects
- Higher current medication doses
If you experience inner restlessness and an irresistible urge to move that started or worsened after beginning or increasing psychiatric medications, particularly antipsychotics or SSRIs, you should report this immediately to your prescriber 6. The condition requires prompt recognition because it is highly distressing, can lead to medication non-adherence, and has been associated with suicidal ideation 4.