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Contributed by 

Siti Nor Fadhlina binti Misron

Akathisia is one of the known extrapyramidal side effect from the administration of antipsychotic. The person affected will experience the feeling of inner reslessness and/or motor restlessness.

During cross-tapering between 2 antipsychotics, the risk increases as the former antipsychotic has not completely eliminated yet the next antipsychotic already introduced.

Pathophysiology

The pathophysiology still remains at hypothesis level. The symptoms are real but the medical advancement and knowledge till this date has not yet able to decipher this puzzle. Based on the current stage of evidence, it can be hypothesised that  akathisia resulted from the imbalance of both dopaminergic and noradrenergic pathway (1). These two pathways are interconnected as they share same precursor which is tyrosine. Dopamine in the presynaptic neuron can be converted to norepinephrine by the act of dopamine beta-hydroxylase (2). 

Management

The Maudsley Prescribing Guideline has beautifully illustrates it in diagram under the topic 'Akathisia' (3). 

Listed are several options for management of akathisia. However, a clinician has to keep in mind that the management chosen should be specifically individualized to the patient's condition.

1. Reduce the dose of the offending antipsychotic

2. Switch to antipsychotic with lower risk of akathisia

3. Pharmacological intervention:

· Propranolol 

· Mirtazapine

· Trazodone

· Mianserin

· Animuscarinic drugs e.g. Benzhexol

· Cyproheptadine

· Benzodiazepine e.g. Clonazepam

· Clonidine

References

1. Zareifopoulos, N., Katsaraki, M., Stratos, P., Villiotou, V., Skaltsa, M., Dimitriou, A., Karveli, M., Efthimiou, P., Lagadinou, M., & Velissaris, D. (2021). Pathophysiology and management of akathisia 70 years after the introduction of the chlorpromazine, the first antipsychotic. European Review for Medical and Pharmacological Sciences, 25, 4746–4756.

2. Malhi, G. S., Malhi, S., & Mitchell, A. J. (2005). Examination notes in psychiatry: Basic sciences (2nd ed.). CRC Press.

3. Taylor, D. M., Barnes, T. R. E., & Young, A. H. (Eds.). (2025). The Maudsley prescribing guidelines in psychiatry (15th ed.). Wiley Blackwell.

PUBLISHED ON 01/12/2025