Home | Help | Search/Archive | Feedback | Table of Contents |
|
||||||||||
Collections under which this article
appears: Other Psychiatry Adverse drug reactions |
Hiroko Akagi Department of Liaison Psychiatry, St James's University Hospital, Leeds LS9
7TF Correspondence to: H Akagi hakagi@doctors.org.uk
Akathisia (Greek "not to sit") is an extrapyramidal movement disorder
consisting of difficulty in staying still and a subjective sense of
restlessness. It is a recognised side effect of antipsychotic and
antiemetic drugs but may also be caused by other widely prescribed
drugs such as antidepressants. It is a difficult condition to
detect reliably and may present unexpectedly in a variety of clinical
settings. The patient's behaviour may be disturbed, treatment
may be refused, or the patient may be suicidal and be mistaken
for a psychiatric problem. We report three cases seen in the
psycho-oncology service which improved when the offending drug
was discontinued. Case 1 At the time of referral, she was awaiting surgery for a colonic stricture
resulting from a recurrence of carcinoma of the colon. She had
started taking haloperidol and metoclopramide for nausea and vomiting
just before the onset of the agitation. At her insistence the
previous day, these drugs had been stopped and she had begun to feel
better. At assessment she gave a history of previous depression and
overdoses, but there was no evidence of a current depressive illness
or excessive anxiety. She reported a "bad reaction to tablets for
nerves" in the past and had suspected that haloperidol and
metoclopramide had been causing the agitation but was aggrieved that
she had not been listened to until the previous day. Akathisia was
diagnosed as the cause of her behavioural disturbance. Further review
of her notes indicated that she had previously been given low dose
trifluoperazine on the surgical ward, resulting in premature self
discharge. On another occasion she had been given haloperidol and
metoclopramide; her course of chemotherapy was interrupted and she
was referred to psychiatrists for "bizzare behaviour," which had
settled by the time she was seen. Case 2 Case 3 Akathisia due to the higher dose of fluoxetine was diagnosed. Fluoxetine was
stopped and he was given diazepam 2 mg twice a day for a week.
He was monitored by his community psychiatric nurse, who reported
rapid improvement in his mental state, and when seen in clinic five
weeks later he was well with no anxiety, agitation, or suicidal ideas
and without evidence of depression. The psychiatrist advised the
patient and general practitioner about caution in the future use of
antiemetics, selective serotonin reuptake inhibitors, and
neuroleptics. Akathisia has been well documented as a common and distressing side effect of
antipsychotic drugs and an important cause of poor drug compliance.
However, even in psychiatric settings, it is not recognised readily.
In one study of movement disorders induced by neuroleptics, akathisia
was diagnosed in only 26% of patients who had it.1
Akathisia is common in general medical settings, especially when patients are
taking antiemetics. In cancer patients undergoing chemotherapy, 50%
of patients met the diagnostic threshold of akathisia,2
yet 75% stated they would not have reported the symptoms of
akathisia. Therefore, diagnosis can easily be missed if it relies on
patients' reports. Antidepressants are another group of drugs known to cause akathisia 3-5
but are not as well recognised. The list of drugs reported to cause
akathisia has been growing (box) and the disturbance of the serotonin
or dopamine system has been postulated in the aetiology of the
disorder. Antiemetics: Metoclopramide, prochlorperazine, [domperidone] Antidepressants: Tricyclics, selective serotonin reuptake
inhibitors (fluoxetine, paroxetine, sertraline), venlafaxine,
[nefazodone] Calcium channel blockers: Cinnarizine, flunarizine (also
H1 antagonists), [diltiazem] Others: Methyldopa, levodopa and dopamine agonists, [lithium
carbonate], [buspirone], [anticonvulsants], [pethidine], [interferon
alfa], [sumatriptan] [ ]=anecdotal or not well
established As our cases illustrate, akathisia may manifest in various ways and is not
necessarily easily recognisable as restlessness. The distress
associated with the unpleasant symptoms of akathisia may lead to
behavioural disturbance on the ward and to the use of neuroleptic
drugs, which will exacerbate the condition rather than ameliorate it.
Compliance with treatment may be affected, as in cases 1 and
2. Refusal of surgery after use of preoperative antiemetics has
been reported,6
and akathisia is thought to contribute appreciably to drug
non-compliance in psychiatric settings. Suicidal ideation or suicide
attempts have been reported with fluoxetine, droperidol, and
metoclopramide, 5
7
8
attributed to the distress and unpleasantness of severe akathisia.
Therefore, prompt diagnosis and management are crucial in minimising
patients' distress and disruption of medical or surgical
treatments. Patients often find it difficult to explain the inner restlessness or mental
unease, and the condition may easily be interpreted as acute anxiety
or depression. Therefore diagnosis relies on a high index of
suspicion on the part of the clinician. Thus when patients present
with acute symptoms of agitation and restlessness, their medication
should first be checked for a recent introduction or increase in the
dose of drugs associated with akathisia. There may be a history of
previous similar episodes, as in all our cases, which will help in
the diagnosis. Such individual susceptibility may indicate a genetic
predisposition.9
The diagnosis can be confirmed retrospectively when the symptoms
abate rapidly with the withdrawal of the offending drug.
On diagnosis, the offending or suspected drug should be withdrawn or the dose
reduced if possible. Where this is not possible, propranolol or other
lipophilic blockers are considered to be the most effective.
Benzodiazepines can be considered as additional treatment. Patients
should be made aware of the diagnosis so that they can report the
symptoms early if they experience similar problems in the
future.
Case reports
Top
Case reports
Discussion
References
A 54 year old female patient on a
surgical ward was referred as an urgent ward consultation for
depression and anxiety. For the preceding few days she had become
progressively agitated and weepy and had felt like smashing things on
the ward. She seemed angry and had shouted at staff on the ward.
(Credit: MARY EVANS PICTURE
LIBRARY) The Greeks had a word for that restless
feeling
A 62 year old woman was referred to the
psycho-oncology clinic from the radiotherapy department for anger and
distress. Depression was diagnosed, and she responded well to
antidepressants. She had had chemotherapy for breast cancer, which
she described as "an ordeal," and went on to have a further course.
After the first session, she became agitated, anxious, and unable to
sleep and had been pacing the house. Her next chemotherapy session
had to be cancelled owing to her distress and she was reviewed
by her oncologist, who diagnosed akathisia due to
metoclopramide. She reported similar reactions during the previous
course of chemotherapy, when she had metoclopramide intravenously and
orally. She settled after the antiemetic was changed to domperidone.
Further psychiatric review confirmed that this episode was not a
recurrence of her depressive illness. In view of the degree of
distress with previous chemotherapy, she was given a dose of
lorazepam for anticipatory anxiety before each chemotherapy session
and completed further treatment without problems.
A 62 year old man was referred urgently
to the psycho-oncology clinic by the community mental health
team after his general practitioner requested an urgent
assessment for suicidal ideation. He had received chemotherapy and
cranial irradiation for lung cancer and had been doing well except
for a general slowing of cognition. He was taking fluoxetine,
and the dose had been increased to 40 mg four weeks previously.
He reported increasing agitation, restlessness, and a sense of
dread triggered by minor events and had felt frightened of being
on his own because of suicidal urges. Nausea had caused him to
lose his appetite, and he had lost weight. He reported that the
symptoms were very similar to the time he had taken metoclopramide
(10 mg four times a day) during his chemotherapy. He had not
reported this to his oncologist at the time.
Discussion
Top
Case reports
Discussion
References
Non-neuroleptic drugs
reported to cause akathisia 3
4
10-12
Acknowledgments |
---|
Contributors: HA saw the patients, obtained clinical details, and reviewed the literature. HA and TMK discussed the cases and wrote the paper jointly. HA is guarantor.
Footnotes |
---|
Funding: None.
Competing interests: None declared.
References |
---|
Top Case reports Discussion References |
---|
1. | Weiden PJ, Mann JJ, Haas G, Mattson M, Frances A. Clinical nonrecognition of neuroleptic-induced movement disorders: a cautionary study. Am J Psychiatry 1987; 144: 1148-1153[Abstract]. |
2. | Fleishman SB, Lavin MR, Sattler M, Szarka H. Antiemetic-induced akathisia in cancer patients receiving chemotherapy. Am J Psychiatry 1994; 151: 763-765[Abstract]. |
3. | Eberstein S, Adler LA, Angrist B. Nefazodone and akathisia. Biol Psychiatry 1996; 40: 798-799[CrossRef][ISI][Medline]. |
4. | Jimenez-Jimenez FJ, Garcia-Ruiz PJ, Molina JA. Drug-induced movement disorders. Drug Safety 1997; 16: 180-204[ISI][Medline]. |
5. | Power AC, Cowen PJ. Fluoxetine and suicidal behaviour. Br J Psychiatry 1982; 161: 735-741[ISI][Medline]. |
6. | LaGorio J, Thompson VA, Sternberg D, Dorje P. Akathisia and anesthesia: refusal of surgery after the administration of metoclopramide. Aneth Analg 1998; 87: 224-227. |
7. | Chow LY, Cung D, Leung V, Leung TF, Leung CM. Suicide attempt due to metoclopramide-induced akathisia. Int J Clin Pract 1997; 51: 330-331[ISI][Medline]. |
8. | Hung YC, Ho YY, Shen CL. Delayed akathisia and suicidal attempts following epidural droperidol infusiona case report. Acta Anaesthesiol Sin 1999; 37: 151-154[Medline]. |
9. | Eichhammer P, Albus M, Borrmann-Hassenbach M, Schoeler A, Putzhammer A, Frick U, et al. Association of dopamine D3-receptor gene variants with neuroleptic induced akathisia in schizophrenic patients: a generalization of Steen's study on DRD3 and tardive dyskinesia. Am J Med Genet 2000; 96: 187-191[CrossRef][ISI][Medline]. |
10. | Sachev P, Loneragan C. The present status of akathisia. J Nerv Ment Dis 1991; 179: 381-391[ISI][Medline]. |
11. | Horikawa N, Yamazaki T, Sagawa M, Nagata T. A case of akathisia during interferon-alpha therapy for chronic hepatitis type C [letter]. Gen Hosp Psychiatry 1999; 21: 134-135[CrossRef][ISI][Medline]. |
12. | Lopez-Alemany M, Ferrer-Tuset C, Bernacer-Alpera B. Akathisia and acute dystonia induced by sumatriptan. J Neurol 1997; 244: 131-133[CrossRef][ISI][Medline]. |
Read all Rapid Responses
|
||||||||||
Collections under which this article
appears: Other Psychiatry Adverse drug reactions |
Home | Help | Search/Archive | Feedback | Table of Contents |