Tardive Akathisia

The anguish associated with both acute and persistent akathisia should not be minimized. Consider Van Putten s (1974) description of a mild, temporary akathisia or hyperkinesia Patient feels all nerved up, squirmy inside, uptight, nervous, tense, uncomfortable, impatient. ... Subjective feeling of ill-being may be accompanied by restless changes in posture.  

One reason that so little attention has been given to the mental disruption associated with the dyskinesias is the tendency to blame the mental component on preexisting emotional problems attributed to the 

It takes no great imagination to grasp the suffering of a patient condemned to even a relatively mild tardive akathisia for a lifetime. I have seen cases of this kind that were previously mistaken for severe anxiety or agitated depression. Chapter 3 reviewed research indicating that acute akathisia can drive a patient into psychosis and to violence and/or suicide. Considering the millions of patients subjected to this torment, the problem takes on epidemic proportions. 

Her hospital and clinic charts disclosed that 2 years earlier, she had been treated for approximately 6 months with neuroleptics. The sensation she was describing had first been noted while she was taking the medication. I concluded that she probably had tardive akathisia, a subtle case that did not force her to move about. However, because she did not show external signs of the disorder, other physicians were reluctant to make the diagnosis. The patient felt driven to distraction and even to suicide, but after my diagnosis, she felt somewhat relieved. At last, a physician was taking her seriously and talking honestly to her. 

In terms of clinical treatment and the public health, howevep TDAK [tardive akathisia] is a fact, not a question. It is one more serious side effect of neuroleptic treatment, like TD and the Neuroleptic Malignant Syndrome. Taken together, they define neuroleptic treatment as a necessary evil, a treatment that should be administered with care and caution, and reserved for patients who have no other recourse. 

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Akathisia is a drug-induced reaction characterized by compelling feelings of restlessness, tension, or anxiety that drive a person to move his or her body (Jeste et al., 1986 Weiner et al., 1983). People with akathisia find it difficult to sit or to keep their feet still. Some will walk in place, pace frantically, or search out activities that keep them on the move. I have evaluated patients with permanent akathisia (tardive akathisia see chapter 4) who, for their entire lives, are trapped in perpetual suffering. The neurological distress produced by this drug-induced condition can become so extreme that even the most spellbound, relatively indifferent patient will feel tortured. 

There are at least two relatively common variants of TD tardive dystonia and tardive akathisia. According to Burke et al. (1982), tardive dystonia involves sustained involuntary twisting movements, generally slow, which may affect the limbs, trunk, neck, or face (p. 1335). The face and neck are by far the most frequently affected areas of the body. Severe deformities of the neck (torticollis) can cause extreme pain and disability. I have seen several cases affecting the orbital muscles of the eyes (blepharospasm) to the degree that the individual s vision was impaired, requiring botulinum (Botox) injections to paralyze the muscles. I have also seen respiratory and abdominal muscles affected in a painful and debilitating manner. 

Fatigue to the point of exhaustion almost always accompanies tardive disorders of any severity. Patients often become exhausted by the movements, by the effort to hide them, and by increased difficulty associated with carrying out daily activities. The primary impact on the brain itself may also produce fatigue. Although the disorders tend to disappear in sleep, they can make it difficult to fall asleep, adding to the exhaustion. Having to contend with the physical pain associated with tardive akathisia (inner torment) and with tardive dystonia (muscle spasms) can also wear a person down. 

Gualtieri (1993) observed that the anxiety and emotional tension suffered by tardive akathisia patients are primary emotional and cognitive components of the disease. After reviewing the functional neuroanatomy, Gualtieri concluded,... 

One is entitled to surmise, therefore, that affective instability and intellectual impairment may be the consequence of neuropathology at the level of the basal ganglia TDAK [tardive akathisia] is one manifes-... 

In other words, the existence of the syndrome of tardive akathisia demonstrates that the neuroleptics can produce irreversible damage to the mental life of the individual. 

Gualtieri, C. (1993). The problem of tardive akathisia. Brain and Cognition, 23, 102-109. 

Gualtieri, C., Sovner, R. (1989). Akathisia and tardive akathisia. Psychiatric Aspects of Mental Retardation Reviews, 8, 83—87. 

Weiner, W., Luby, E. (1983). Tardive akathisia. Journal of Clinical Psychiatry, 44, 417-419. 

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