Akathisia is one of the most distressing side effects in psychiatry and one of the most missed. The word comes from the Greek for "inability to sit." A person with akathisia feels a relentless inner need to move — pacing, shifting, jiggling a leg, standing up and sitting down, walking out of the room because the chair is unbearable. The inner experience is often worse than the outward movement: a sense of internal pressure or torment that is hard to put into words.
Akathisia is a movement-related side effect of dopamine-blocking medications, often misread as anxiety or worsening psychosis, and it has well-evidenced treatments.
What it actually feels like
Patients describe akathisia in striking ways: "ants under my skin," "needing to crawl out of my body," "if I sit still I'll explode." The discomfort is constant, hard to localise, and not relieved by the usual things people do for anxiety. It is often worse in the evening. Sleep can be very disturbed. Severe akathisia is one of the most painful experiences in mental health care, and untreated severe akathisia is associated with suicidal thinking.
How common
Rates depend heavily on which medication and which dose. Across studies, akathisia affects:
- Aripiprazole: 10–25% of patients
- Lurasidone: 13–22% (often dose-related)
- Cariprazine, brexpiprazole: 5–20%
- Risperidone, paliperidone, haloperidol: 10–30%
- Olanzapine, quetiapine, clozapine: generally lower (3–8%)
The CATIE trial documented akathisia across all the antipsychotics studied; lower rates with olanzapine were one of its more notable findings, though the trade-offs are real (see olanzapine weight gain).
Why it happens
Akathisia is part of the family of extrapyramidal symptoms (EPS). The mechanism is not fully understood. The leading theory involves dopamine D2 blockade in the mesocortical pathway and possibly imbalance between dopamine and other neurotransmitters such as noradrenaline. With partial agonists like aripiprazole, akathisia may relate to varying degrees of dopamine activation rather than pure blockade.
When it shows up
Akathisia typically appears within hours to days of starting the drug or after a dose increase. A long-acting injection can produce delayed akathisia that emerges over weeks. There is also a tardive form (tardive akathisia) that develops after long-term treatment — it is less common but harder to treat.
Why it gets missed
This is the central problem. Akathisia is regularly mistaken for:
- Anxiety — and treated with more medication that doesn't help
- Worsening psychosis — and treated with a higher antipsychotic dose, which makes the akathisia worse
- "Agitation" — and the patient is restrained or sedated rather than recognising the cause
One of the simplest screening questions is: "Is the restlessness coming from inside you, or from your thoughts?" Akathisia is body-centred. Anxiety is more cognitive. Either can coexist.
The Barnes Akathisia Rating Scale
Clinicians use the Barnes Akathisia Rating Scale (BARS) to rate the severity. It looks at observed movements, the patient's subjective awareness, and the distress caused. Anyone on a new antipsychotic or a recent dose change should ideally be screened for akathisia at follow-up appointments. If your prescriber doesn't ask, raise it.
What helps
1. Lower the dose
Akathisia is often dose-related. Even a modest reduction can resolve it. This is usually the first step if symptom control allows.
2. Switch the medication
Moving to a less akathisia-prone medication (often olanzapine or quetiapine) is reasonable if dose reduction isn't enough.
3. Add a beta-blocker
Propranolol (a non-selective beta-blocker) at low doses has decades of evidence for treating akathisia. It is often the first-line addition. Standard practice is checking blood pressure and heart rate before starting and during treatment.
4. Consider mirtazapine or mianserin
Low-dose mirtazapine has growing evidence as an effective and well-tolerated treatment for akathisia, particularly when beta-blockers are not tolerated.
5. Benzodiazepines short-term
Short courses of clonazepam or lorazepam can help acutely while other interventions take effect, but are not a long-term solution.
6. Anticholinergics
Benztropine and similar agents help less with akathisia than with other forms of EPS, but may help in some cases — particularly when other movement symptoms coexist.
When to call your prescriber
New restlessness, inability to sit still, or escalating anxiety in the days or weeks after starting or increasing an antipsychotic — especially if accompanied by thoughts of self-harm. Severe akathisia is a recognised risk factor for suicide and warrants prompt clinical attention. Don't wait for the next routine appointment.
What patients sometimes try
Many people independently try movement to ease akathisia — walking, pacing, exercise. Movement helps temporarily but doesn't treat the underlying problem. Caffeine often makes akathisia worse. Alcohol may dampen it briefly but rebounds badly. The real solution is usually pharmacological adjustment.
The bottom line
Akathisia is treatable. The main barrier is recognition. If you are starting an antipsychotic, learn what akathisia feels like before you need to know. If you are a family member of someone on antipsychotics, ask about restlessness. And if your clinician is not familiar with its treatment, it is reasonable to seek a second opinion.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.