When Doctors Misread the Signals
A patient paces the hall, shifts from foot to foot, complains of anxiety, and can’t sleep. It’s easy to assume worsening psychosis, mania, or simple agitation. But if the real culprit is akathisia, the wrong response can deepen their torment.
The Misdiagnosis Trap
Akathisia’s visible signs – fidgeting, pacing, rocking – are easy to mistake for other problems:
- Mania or agitated depression
- Anxiety disorders
- Psychotic agitation
- Attention deficit hyperactivity disorder
- Restless legs syndrome
- Drug withdrawal or other neurological conditions
Yet the defining feature of akathisia is subjective: an inner restlessness and tension that makes stillness almost impossible. Without asking carefully about this internal experience, clinicians can miss the diagnosis entirely.
When Treatment Makes Things Worse
If akathisia is triggered by an antipsychotic, misreading it as worsening psychiatric illness can lead to a dangerous response: prescribing more antipsychotic medication.
Instead of easing symptoms, the increased dose can intensify the very side effect causing the distress. The person becomes more restless, more desperate, and less likely to trust their treatment team.
Escalating Distress and Risk
Unrecognized and untreated, akathisia can escalate. The grinding discomfort may produce severe anxiety, dysphoria, and insomnia. Over time, some individuals develop suicidal thoughts, aggression, or violent behavior.
Studies have discussed links between akathisia and suicidal or homicidal acts, though most of this research rests on small case reports and limited series. A more robust systematic review in 2021 concluded that akathisia could not be reliably tied to suicidal behavior in patients on antipsychotics. Still, the clinical picture is clear: the condition can be emotionally unbearable.
Measuring the Unbearable
To bring some structure to assessment, clinicians can use the Barnes Akathisia Scale, which evaluates both visible movements and the person’s subjective feelings. Even with such tools, diagnosis remains challenging because akathisia comes in various forms and overlaps with many other movement and mood disorders.
A controversial label, “pseudoakathisia,” is sometimes used when patients show typical movements but report little or no inner restlessness, adding another layer of complexity.
The Takeaway
Misdiagnosing akathisia is not a minor error; it can turn a treatable side effect into a spiraling crisis. Careful listening to the patient’s inner experience – not just watching how they move – is crucial to preventing needless suffering and dangerous treatment decisions.