It had me by the hair and wouldn’t let go…. I was being led to my execution.

– Patient X, a successfully resuscitated teenager

Akathisia (from the Greek word káthisis, meaning “sitting”) is a dimensional disorder that also includes restless legs syndrome (RLS). It is a clinically important, mixed motor and emotional state that can be triggered by several groups of external physical (toxic, metabolic, infectious) or psychological (acute adjustment or stress disorder) factors.

Historically, the predominant mental manifestations of akathisia have caused confusion (Van Putten, 1975). Sir Thomas Willis first described the condition in 1672. It was further detailed by Karl Ekbom in 1945 (Teive & Barbosa, 2009). The syndrome is often referred to conjointly as Willis-Ekbom disease. Haskovic concluded that the disorder was of hysterical origin. Bing viewed akathisia as a “psychosis” characterized by a “morbid fear of sitting down,” but also explained it as a way of overcoming the muscular rigidity of Parkinson's disease. Oppenheim considered akathisia as a form of neurosis, “usually a form of phobia.”

In 1985, the author (Russell Copelan) coined a new descriptive investigative term: akathisia induced, autonomous suicidal disorder. The study cohorts included SSRI adverse effect, prescribed for a condition other than depression, and adjustment disorder without previous psychiatric substrate (Copelan, 2006). Hamilton and Opler subsequently influenced the diagnosis, describing it as: extrapyramidal induced dysphoric disorder. Hamilton and Opler further refined, as well as independently validated, the author’s description (1992).

Currently, drugs, including first- and second-generation antipsychotics, antiemetics, and antihistamines are implicated. Also, there is increasing data suggesting an association among SSRI administration, akathisia, and a distinct form of dysphoria with neurobiological underpinnings similar to disorders of the deep basal nuclei or ganglia.

Symptoms secondary to iron deficiency, streptococcal infection, Lyme disease, and mycoplasma infections have been reported. Other causes of akathisia include Parkinson’s disease, untreated schizophrenia, diabetes mellitus (Willis’ disease), rheumatoid arthritis, opioid withdrawal, and pregnancy. A significant proportion of persons with RLS have comorbid attention deficit hyperactivity disorder (ADHD).

The core of akathisia, which can be intense, is a combination of objective and subjective characteristics, including: motor agitation, inner restlessness, mental unease, and dysphoria. This blend of cognitive and motor features distinguishes it from a dyskinesia. Adverse drug-related movement disorders with associated psychological symptoms are most likely experienced soon after medications are started. However, akathisia may be further classified as continuous (as long as the offending drug is administered); chronic (after last dosage increment); tardive (and not related to drug or dose change); persistent (even after the causative agent has been discontinued); and withdrawal (or rebound, associated with medication switching).

In other words, the differential diagnosis is difficult. The mental manifestations of these extrapyramidal adverse effects are frequently misdiagnosed as psychiatric deteriorations, or mistreated by increased dosing of the offending drug.

There is a growing evidence to suggest that acute psychologically-induced akathisia without suicidal ideation is, tragically, an unrecognized consequence of interpersonal misfortune or insult, i.e., acute adjustment disorder (Copelan, 2006). This is characteristically unrecognized by evaluators. It may in part elucidate the distressing findings of the 2017 Director’s Report of the Council on Behavioral Health, and other investigators, that up to 50 percent of recent suicides occur within 30 days of last clinical contact wherein ideation is equivocal (i.e., denied), not elicited, or “cortically unreachable” (AFSP, 2016; Olfson et al., 2016). Recent analyses have revealed that those diagnosed with adjustment disorder had 12 times the rate of suicide compared to those without an adjustment disorder diagnosis after controlling for major depression and other matched factors (Gradus et al., 2010). 

Adjustment disorder is one of the few diagnostic entities in which external stress is linked to the abrupt onset of symptoms, the post-transcriptional changes of which persist for hours or days thus protracting the period of immediate vulnerability. Often, there is no previous psychiatric history. The condition cannot be diagnosed in the absence of a stressor, and stressors may be single or multiple. The severity of the stressor is not predictive. It must be external and in close proximity to the development of symptoms. The absence of clear symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders IV (or, ICD-10) means that greater weight must be attached to clinical observation and judgment. Importantly, it is not that the patient’s reaction is considered stronger than expected, but rather the personal salience of, or vulnerability to, the stressor.

Clinical features include memory or autobiographical deficits (i.e., “absent” or hijacked ideation, confusion, mutism or cognitive inflexibility, dysphoria, stereotypic motor movements, akathisia, intense inner distress, and rapid suicide transition without forethought (Copelan, 2006)). There is diurnal variation in that symptoms are often most intense at night, similar to RLS worsening in the evening.

Most adolescent suicide attempts are premeditated. However, evidence across studies and populations indicates that 20 percent to 30 percent of pediatric violent attempts have no apparent premeditation or ideation (Lewinsohn, 1994; Copelan, 2006). Investigations demonstrate that suicidal ideations vary widely by country, psychiatric disorder, cultural features, religious practices, sex, and childhood and family adversities. Some authors suggest that adolescent attempts without premeditation are committed impulsively. However, impulsive attempts are generally associated with lower lethality and lack of depression (Baca-Garcia, 2004).

Recent research indicates that suicidality may be a consequence of autonomous, irresistible, extrapyramidal motor behavior without forethought (Copelan, 2006). Therefore, merely obtaining a contract for safety from these patients and documenting that the patient denies suicidal ideation is not an adequate risk assessment (Simon, 2002).

These findings point out a current dilemma: the value of the independent finding of ideation is hard to determine. Thus, the absence of suicidal ideation, in combination with motor restlessness, may convey uniquely important information for assessing near-future violence and, therefore, should be carefully assessed as psychologically-induced akathisia in addition to other factors.

“It had me by the hair and wouldn’t let go.”

Although Patient X, like other successfully resuscitated individuals, was able to remember the moments just before the high risk/low rescue suicide attempt, the patient was not able to recall the actual moment of self-harm by horizontal hanging. Thus, it is time to seriously challenge the public’s belief, as well as the beliefs of evaluating professionals, that all suicide is a conscious and rational decision. Intriguingly, suicidal ideation, a cortical construct, often returns in these individuals once stabilized, signaling cortical-subcortical equilibrium, not unlike a post-coronary stent reperfusion arrhythmia encouraging myocardial recovery. 

Surely, some suicide cases define purposeful (actus reus) and appreciated (mens rea) components. However, if one assumes there is no rational thinking during the unconventional suicidal event, then it stands to reason that additional suicide training in, and screening for, unusual suicide phenotypes, with enhanced cooperation among institutions, should reasonably reduce the rate and awful burden of deadly akathisia-related youth suicides.

Russell Copelan, MD, is a retired emergency department psychiatrist. He graduated from Stanford University and UCLA Medical School. He completed residency and fellowship training at the University of California and University of Colorado.

References

American Foundation for Suicide Prevention (2016).

Copelan R., Messer M., Ashley D. Adolescent violence screening in the ED. Am. J. of Emergency Med. (2006). 24: 582–594.

Gradus JL, et al. The association between adjustment disorder diagnosed at psychiatric treatment facilities and completed suicide. Clin. Epidemiology (2010). Published online 2010 August 9.

Hamilton, MS, & Opler, LA. Akathisia, suicidality, and fluoxetine. J. Clin. Psychiatry (1992). 53(11): 401–406.

Lewinsohn PM, Rohde P, Seeley JR. Psychosocial risk factors for future adolescent suicide attempts. J. Consult Clin. Psychol. (1994). 62(2): 297–305.

National Council Medical Director Institute: National Council for Behavioral Health. The Psychiatric Shortage, Causes, and Solutions. March 28, 2017.

Olfson M, et al. Short term suicide risk after psychiatric hospital discharge. JAMA Psychiatry (2016).

Simon RI. Suicide risk assessment: what is the standard of care? J. Acad. Psychiatry Law (2002). 30(3): 340–4.

Teive, HAG., Barbosa ER: Professor Karl-Axel Ekbom and restless legs syndrome. Parkinsonism & Related Disorders (2009). 15(9): 254–257.

Van Putten T. The many faces of akathisia. Compr. Psychiatry (1975). Jan–Feb; 16(1): 43–7.

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