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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 24 of 24. This is the beginning of the thread.
Posted by SLS on November 14, 2013, at 0:16:31
How do you know when you have akathisia?
- Scott
Posted by Christ_empowered on November 14, 2013, at 5:03:52
In reply to Akathisia question., posted by SLS on November 14, 2013, at 0:16:31
For me, its happened twice, due to neuroleptics. The first was relatively low-dose Zyprexa, and it popped up despite clonazepam. I couldn't sit still or think clearly.The second was Risperdal (hate the stuff!). Lots of pacing, inability to be still and rest, that sort of thing. It was co-administered with Depakote. I have no idea if the Depakote made things better or worse, lol.
Posted by g_g_g_unit on November 14, 2013, at 7:25:19
In reply to Re: Akathisia question., posted by Christ_empowered on November 14, 2013, at 5:03:52
When I experience akathisia, the anticipation of any kind of activity which would involve sitting still and concentrating (watching TV, writing an e-mail etc.) induces unspeakable dread. It's also accompanied by dysphoria and an inability to enjoy any kind of stimuli. My sole aim becomes to end the sensation as soon as possible.
At its worst, I'll lie in bed writhing and squeezing a pillow for hours on end.
Posted by Phillipa on November 14, 2013, at 8:36:41
In reply to Re: Akathisia question., posted by g_g_g_unit on November 14, 2013, at 7:25:19
Is it really true that any med at all can cause this? Seriously seems like meds are started to be reported as causing more problems than they fix. or control maybe a better word? Phillipa
Posted by ihatedrugs on November 14, 2013, at 16:22:51
In reply to Re: Akathisia question., posted by g_g_g_unit on November 14, 2013, at 7:25:19
> When I experience akathisia, the anticipation of any kind of activity which would involve sitting still and concentrating (watching TV, writing an e-mail etc.) induces unspeakable dread. It's also accompanied by dysphoria and an inability to enjoy any kind of stimuli. My sole aim becomes to end the sensation as soon as possible.
>
> At its worst, I'll lie in bed writhing and squeezing a pillow for hours on end.
>Wow, you hit the nail right on the head. Especially watching tv. That is what I felt while on Abilify. Hate it the feeling.
Posted by johnLA on November 14, 2013, at 16:26:18
In reply to Akathisia question., posted by SLS on November 14, 2013, at 0:16:31
scott did you know you speak ancient greek? ;)
akathisia. another word from my culture that i never even knew about until i got it...
i didn't know it at the time, but my very first psyche drug; zoloft had me pacing between two bedrooms for weeks. i knew nothing of psychiatry at the time. had a very poor first pdoc who simply kept upping my dosage.
besides the pacing i lost about 20 pounds and my skin felt like it was on fire.
i remember when i first came here i read a post of yours about what to treat first; anxiety or depression. you said treat the anxiety first. i wonder if somebody took the time to say 'hey, you are having severe akathisia; a reaction to a med' if that would not have led me to my first hospitalization and eventual ect. i can only wonder now.
it's been 3 plus years now for me since those first days of taking meds. i am still in depression, but relative to those first months i am better. ironically i am on the least amount of medication since this whole nightmare started.
i am in the process (hopefully) of getting off klonopin. my last med. curious to see how i feel med-free. hoping something magical happens...
john
Posted by baseball55 on November 14, 2013, at 19:43:57
In reply to Re: Akathisia question. » SLS, posted by johnLA on November 14, 2013, at 16:26:18
I was in a locked ward waiting out a two-week washout to start parnate. AAPs had all worked for me for severe depression, but all made me gain weight. The p-doc decided to try perphenizine while I was washing out. She had me on 36mg - a very high dose. After a few days, I couldn't be still. If I sat down, I kept moving my legs, feet. Trying to sit and talk to someone made me feel like I would jump out of my skin. It wasn't like anxiety. It was an entirely physical sensation. A combination of cutting the perphenazine dose and taking benadryl made it stop.
Have never had any akathesia except at high dose of perphenazine.
Posted by sigismund on November 14, 2013, at 22:01:59
In reply to Akathisia question., posted by SLS on November 14, 2013, at 0:13:51
The end result (I guess) a dystonic reaction is obvious.
Because it is subjective it is (in its essence if not in its result) unmeasureable.
You mean something like that?
Posted by Phillipa on November 14, 2013, at 22:02:00
In reply to Re: Akathisia question. » SLS, posted by sigismund on November 14, 2013, at 4:28:49
Sigi have you had it if so what does it feel like for you? PJ
Posted by SLS on November 14, 2013, at 22:02:00
In reply to Re: Akathisia question. » SLS, posted by sigismund on November 14, 2013, at 4:28:49
> The end result (I guess) a dystonic reaction is obvious.
>
> Because it is subjective it is (in its essence if not in its result) unmeasureable.
>
> You mean something like that?I asked the question in order for the community to understand better what akathisia is. I know it when I see it, but I don't know what it is like to experience it. I hope my post becomes a learning tool. It appears to me that some people mistake various kinds of anxiety for akathisia. I would also like to get an impression for how often akathisia appears in people who have taken only SRIs.
- Scott
Posted by Angela2 on November 14, 2013, at 22:02:00
In reply to Re: Akathisia question. » sigismund, posted by SLS on November 14, 2013, at 12:58:36
http://en.wikipedia.org/wiki/Akathisia
I've had it in the past as a reaction to medication I was on. It doesn't hurt. But it's like I wanted to keep pacing, felt like I had to keep moving. Fun times!
Posted by phidippus on November 16, 2013, at 13:59:33
In reply to Akathisia question., posted by SLS on November 14, 2013, at 0:16:31
It really manifests as a inner restlessness that can range from mild to severe. You literally can't sit still if its bad enough. Some older typical antipsychotics induced akithisia so severe, patients would commit suicide.
ERIC
Posted by psychobot5000 on November 23, 2013, at 18:51:27
In reply to Re: Akathisia question., posted by Angela2 on November 14, 2013, at 22:02:00
> http://en.wikipedia.org/wiki/Akathisia
>
> I've had it in the past as a reaction to medication I was on. It doesn't hurt. But it's like I wanted to keep pacing, felt like I had to keep moving. Fun times!I have to respond to this, if only to STRONGLY object to the sign-off 'Fun times!' I realize this was meant ironically, but I don't think it's helpful in helping understand the drug-induced symptoms. I've undergone a lot of pain and a lot of depression, and, that said, akathisia--even moderate akathisia that's not yet bad enough to force me to move--is one of the most horrible experiences I've ever endured; what's more, I'm coming around to the view that it's very likely that many SSRI-startup related suicides (that strange bump in mortality over the first few weeks which, to my knowledge has never been adequately explained) is probably due to akathisia. Antidepressants, SSRIs in particular, give you akathisia with reasonable frequency (I had it with most SSRIs given to me--when I looked up side-effects at some point, I hadn't to read much: 'a subjective feeling of inner restlessness' to immediately recognize what I'd experienced before. Even mild akathisia is pretty intolerable, in my experience, even compared to fighting depression. The only thing that textbook quote I just gave left out was the negativity of the experience: it's a true horror to live through. I can't say whether it directly affects your mood, but in a more recent bout of akathisia due presumably to AAP blood levels getting to high because of drug-interactions, I seriously considered dying because I couldn't figure out how to get through a night and morning to the point where I could fill a prescription to partially suppress the symptom.
Takeaway, simply: akathisia is, in my experience, profoundly unpleasant as well as poorly understood, and it's important to learn to distinguish it from standard anxiety (or from anxiety at all if one doesn't consider it a form of physical anxiety; whatever, it's just semantics. All that matters is the reality).
I don't base this entirely on my own experience. I was in a writer's group in which someone submitted a story in which someone is given a recreational dose of an SSRI, which made the character feel absolutely horrible in a way that sounded like, well, akathisia (in the story, the character becomes very angry at the person who gave her the dose of...zoloft, I think it was). It was a workshop, so I questioned the accuracy of this portrayal, and a number of people jumped in to defend it based either on first or second-hand knowledge of the way SSRIs had made them, or someone they'd spoken to, feel, and...it was a little hard to tell, but I pressed a bit and there was a lot of resistance to my questioning of the accuracy of this fictional bit (keep in mind that creative writers and their relatives manifest psychiatric illnesses at a substantially higher rate than the normal population). Clearly, this akathisia-like description of the first feelings an SSRI might give you rang true to a lot of people in this room of twelve or so writers, and while I doubt a single dose of zoloft would give many people a significant portion of akathisia...this, combined with my horrible-beyond-words-to-describe-it 24-48 hour recent bout with akathisia recently leads me to believe that the UNPLEASANTNESS, or, better, HELL of akathisia (see the web-based urban dictionary's second definition), subjectively, should not be ignored. It's a much better explanation for antidepressant-onset-induced suicide than anything else I've ever heard suggested.
Akathisia. Is. Horrible. (at least in my experience and, in among a very significant portion of those talking about it on the web, and among that writers' group). Sorry to belabor this, but I feel it's a very important point; I think it's idiocy to give a potentially depressive person a beta blocker that crosses the BBB, but in the case of akathisia, you may have to (in addition to, say discontinuing the offending medication) just suck it up and take that propanolol for a couple days and hope you have a loved one nearby reminding you for the next few days after that you have things to live for, and it won't always feel like this.
There are several excellent antidepressants which I currently refuse to take because I sadly know they give me acute akathisia. Also: great story! I know of an otherwise intelligent depressive patient with good judgment who very rapidly escalated her dose of klonopin in a desperate (I would say) attempt to suppress the onset of akathisia. Normally, I would trust her judgment immensely, but the evident horror of the side-effect (she felt she needed the causative antidepressant in order to function...a very bad choice IMO) made her pop those pills like candy (she'd typically underdosed the stuff, it seems, so fortunately or unfortunately had a modest stockpile) until I saw with some shock what was going on. I was unable to convince her to change anything (by that point her judgment was probably impaired), but at least was on-hand to convince her FINALLY to stop taking the akathisia-causing agent when she realized something was seriously wrong...and that she was running out of dangerous pills to 'fix' the situation (a few days later she admitted to acting like a crazy person). ...I think she had enough remaining clonazepam to cushion the benzo withdrawal, but the full-blown akathisia--now unconcealed by absurd doses of the minor tranquilizer--seemed horror enough. I didn't entirely understand her experience because, at this point, it had been a while since I'd been through any serious akathisia, but the distress (and her very uncharacteristic and irresponsible use of controlled medication) was evident enough that I considered her a suicide risk for a day or so. She's probably lucky she had the days built up to call in sick for 48 hours, get to the weekend, and have me watching her. Again, I didn't fully understand at the time, but it seemed to me that whatever had her pacing (and I did have enough memory of akathisia from years earlier to 'get it' to some extent) was probably a lot worse than the benzo withdrawal she was also dealing with. Jesus. She was clearly afraid, which freaked me out a little, since she normally is a lot healthier than I am. Rrrh. When something gives you akathisia, STOP, people.
Sorry for the length of this post. But my point is simple. I think I can say pretty broadly that it can be dangerous, even as a casual throwaway comment, to dismiss akathisia as 'Fun times.' I know probably very little was meant by that. Rather, I just hope to help a person or two who might stumble across this thread to make sure they take this drug-induced side-effect very seriously, and do what they can to avoid the experience. To wit: akathisia is (or can be) a true horror, even if it's not precisely pain. Respect and avoid! Take the antidepressant that makes you fat, instead. Whatever you have to do. Oh, and benzodiazepines probably aren't a good 'solution' for the problem, even if they work temporarily.
Posted by sigismund on November 24, 2013, at 20:33:50
In reply to Re: Akathisia question. » sigismund, posted by Phillipa on November 14, 2013, at 22:02:00
Yes, I have had it, when I was taking Anatensol (perphenazine?).
Horrible feeling, couldn't sit still (which was true but does not contain the essence of it).
I guess the end point is a dystonic reaction. I had one of those too. Not fun.
Posted by sigismund on November 24, 2013, at 20:36:37
In reply to Re: Akathisia question. » SLS, posted by phidippus on November 16, 2013, at 13:59:33
> Some older typical antipsychotics induced akithisia so severe, patients would commit suicide.
The ordinary doses with which we are familiar were used on uncooperative Soviet scientists and citizens to break them down and it was effective.
Posted by sigismund on November 24, 2013, at 20:40:37
In reply to Re: Akathisia question., posted by psychobot5000 on November 23, 2013, at 18:51:27
I would never have confused it with anxiety and this had never occurred to me, that it might be.
I had always been somewhat anxious, but never had that akathisia feeling ever or indeed since because I avoided those drugs forever and always.
Posted by ed_uk2010 on November 25, 2013, at 9:07:45
In reply to Re: Akathisia question., posted by sigismund on November 24, 2013, at 20:33:50
> Yes, I have had it, when I was taking Anatensol (perphenazine?).
>
> Horrible feeling, couldn't sit still (which was true but does not contain the essence of it).
>
> I guess the end point is a dystonic reaction. I had one of those too. Not fun.Hi Sigi,
Absolutely not fun.
My worst akathisia (neuroleptic induced) felt like thrashing around in a coffin while someone tried to ram the lid shut and bury me. Total terror and horror + immense physical restlessness. It felt evil, like being possessed.
Posted by sigismund on November 27, 2013, at 0:56:53
In reply to Re: Akathisia question. » sigismund, posted by ed_uk2010 on November 25, 2013, at 9:07:45
G'day Eddy
I imagine a dystonic is like the beginning of strychine poisoning.
I knew what was happening and took straight off the bat something like 100mg Valium which proved to be helpful but not enough, so I took cogentin as well and that was OK.
Posted by ed_uk2010 on November 28, 2013, at 12:54:28
In reply to Re: Akathisia question. » ed_uk2010, posted by sigismund on November 27, 2013, at 0:56:53
>I knew what was happening and took straight off the bat something like 100mg Valium which proved to be helpful but not enough, so I took cogentin as well and that was OK.
Evening Sigi,
Well that's it. Akathisia is so difficult to get rid of, the best thing you can do is reduce or (if possible) discontinue the offending drug. In the mean time, benzos and anticholinergics may help some.
Propranolol has been suggested for those who need to stay on the antipsychotic but it seems far better to me to reduce the dose or change the med to something less akathisia-inducing eg. in schizophrenia, crossing over from risperidone to quetiapine. Clozapine, the 'king' of the antipsychotics can cause tonnes of side effects but at least it rarely causes akathisia.
Naturally, the distress of akathisia can aggravate psychosis. A dose reduction may therefore improve psychosis - but will anyone think of this? Someone crawling the walls on haloperidol 15mg/day might be a lot better on 5mg. Akathisia has many faces and can be mistaken for psychotic agitation (which of course can accompany it). But since the pt is 'agitated', they risk getting even more APs and becoming even more agitated. Horrifying thought, especially when the pts in question are often in little position to express themselves easily. Everyone is so focused on their 'underlying condition' that other causes of agitation can easily be missed (and mishandled).
Make sure your doctor's computer records are up-to-date with your drug intolerances. A message will pop up if they try to prescribe.
Some antipsychotics are primarily used to relieve nausea/vomiting so it's important that your prescribers are aware if you cannot tolerate them. Prochlorperazine (Stemetil, Compazine) is one of the most widely used antipsychotic/antinauseants. Other examples are haloperidol and droperidol. Metoclopramide (Reglan, Maxolon) can also cause akathisia and dystonia. You may be able to tolerate low doses well. Personally, I would rather take something else than risk it. There are various options.
In the treatment of depressive or anxiety disorders, I cannot envisage any situation where adding additional long-term meds to counter akathisia would be acceptable. The solution should be to reduce the AP dose, switch drugs, or if the akathisia is mild (with Abilify only) wait to see whether it passes. Of course, additional meds can be used briefly to relieve akathisia in any of the above situations but it should not be for more than a couple of weeks. The fact that akathisia is occurring at all points to something being wrong with the med regimen. It's a bit like when you've accidently added too much spice to a curry; adding more of something else to try and mask it rarely makes it better. You may have to start over! At least with APs you can just reduce the dose, and so starting over isn't always needed.
On another note, I'm not sure how I feel about the increasing tendency of using the term akathisia to refer to nasty restless feelings created by non-antipsychotic psych meds, esp. SSRIs and suchlike. My impression is that AP-induced akathisia is on a level of its own, and may not be the same condition at all, at least not in most cases.
:)
Posted by ed_uk2010 on November 28, 2013, at 13:04:57
In reply to Re: Akathisia question., posted by g_g_g_unit on November 14, 2013, at 7:25:19
> When I experience akathisia, the anticipation of any kind of activity which would involve sitting still and concentrating (watching TV, writing an e-mail etc.) induces unspeakable dread. It's also accompanied by dysphoria and an inability to enjoy any kind of stimuli. My sole aim becomes to end the sensation as soon as possible.
>
> At its worst, I'll lie in bed writhing and squeezing a pillow for hours on end.
>That was a very good description. And like you say, with severe akathisia you may not be pacing at all. It's gone beyond that. There is literally no relief. Extreme discomfort in every position.
Intense anxiety can be similar, but akathisia has a stronger muscle-related element, and a less definable psychological element eg. in severe anxiety, it is normally possible to remain still briefly, whereas in akathisia, your muscles feel like they could literally explode. Anxiety is also more 'explainable' eg. I feared than I was dying/choking/insert awful experience. Explaining akathisia is a bit like explaining severe pain to someone who has never felt it. To me, it feels like torture.
I've only ever experienced akathisia with neuroleptics. Other psych drugs have produced a variety of nasty reactions, including restlessness (mirtazapine) but it wasn't the same.
Posted by ed_uk2010 on November 28, 2013, at 13:09:28
In reply to Re: Akathisia question. » sigismund, posted by ed_uk2010 on November 28, 2013, at 12:54:28
>On another note, I'm not sure how I feel about the increasing tendency of using the term akathisia to refer to nasty restless feelings created by non-antipsychotic psych meds, esp. SSRIs and suchlike.
Just wanted to clarify. Some people have VERY severe reactions to SSRIs, which may include restlessness. What I meant is that it may not be biochemically the same as AP akathisia. The course of the condition may be different, pt experience may be different and the tx may be different.
Thanks.
Posted by sigismund on November 30, 2013, at 17:29:23
In reply to Re: Akathisia question. » sigismund, posted by ed_uk2010 on November 25, 2013, at 9:07:45
When I had the dystonic, I actually felt that my jaw might be ripped off its hinges, it was that bad. Seemed to be mainly there, but perhaps I had taken SO much Valium that I could not notice any other feelings of restlessness? It was alarming to go through and must have been difficult to watch.
Posted by sigismund on November 30, 2013, at 17:29:55
In reply to Re: Akathisia question. » ed_uk2010, posted by sigismund on November 30, 2013, at 17:29:23
That was with Torecan.
Posted by ed_uk2010 on December 1, 2013, at 6:24:31
In reply to Re: Akathisia question. » ed_uk2010, posted by sigismund on November 30, 2013, at 17:29:23
Hi Sigi,
> When I had the dystonic, I actually felt that my jaw might be ripped off its hinges, it was that bad. Seemed to be mainly there, but perhaps I had taken SO much Valium that I could not notice any other feelings of restlessness? It was alarming to go through and must have been difficult to watch.
It is horrific. I expect you would have been very restless without the Valium. But Cogentin (or similar) is usually needed for dystonia.
Although Torecan isn't used anymore in most countries, very similar dopamine antagonists are used extremely widely for nausea and vomiting. They are prescribed almost reflexively by some doctors eg. prochlorperazine, metoclopramide. Check out any anti-sickness med you ever get in future. If it's a potent dopamine antagonist, ask for something else. Domperidone (Motilium etc) is the only DA antagonist which almost never causes dystonia or akathisia, but it's not available in some countries (the reason for this is that when it originally came as an IV formulation, it caused cardiac arrhythmias. The tablets seem OK though, for short-term use only).
Antiemetics which *almost never* cause dystonia/akathisia:
Ondansetron (Zofran etc). Very useful for chemo nausea/vomiting, post-op vomiting and severe gastro-enteritis. Increasingly popular for multiple uses.
Granisetron (Kytril etc). Similar to ondansetron.
Palonosetron - a bit like a very potent long acting version of ondansetron, using to great benefit during chemo.
Aprepitant (Emend) - used mainly during chemo.
Dexamethasone (normally used as an add-on to ondansetron during chemo, not so much for other types of nausea).
Cyclizine, meclizine, diphenhydramine, dimenhydrinate (Dramamine) and similar anticholinergic antihistamine antiemetics. Useful for travel sickness but cyclizine is used for pretty much all types of vomiting over here.
Cinnarizine (Stugeron etc). Uses for inner ear disorders (eg. labyrinthitis) and motion sickness.
Betahistine (Serc, Betaserc). Not so much an antiemetic, but used to speed improvement of inner ear disorders causing vertigo and vomiting.
Hyoscine hydrobromide (eg. Kwells). Useful for severe travel sickness.
.............................................................................................................
Antiemetics which occasionally cause akathisia:
Promethazine (Phenergan) - but almost never dystonia. Very sedating.
.............................................................................................................
Antiemetics which should be *avoided* by pts prone to dystonia or akathisia:
Prochlorperazine (Stemetil, Compazine etc)
Metoclopramide (Reglan, Maxolon etc)
Haloperidol (Haldol, Serenace)
Droperidol
Perphenazine
Trifluoperazine (Stelazine)
Chlorpromazine
Thiethylperazine (Torecan - discontinued most places).Some of the above drugs may be perfectly tolerable at very low doses, but beware, seriously. Anyone who has had bad reactions before is at risk of having one again. Akathisia is dose-dependent so large doses are to be approached with special care.
This is the end of the thread.
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