Unhappy feet: One woman’s severe akathisia
Continuous leg and arm movements have left Ms. K sleepless and suicidal. A medication change stills the involuntary motion but causes sudden weight gain. What would you try next?
Antipsychotics, antidepressants, and sympathomimetics all have been implicated in akathisia, but antipsychotics that are potent serotonin (5HT) receptor antagonists—such as olanzapine and clozapine—show a lower incidence compared with other psychotropic agents.3
Aripiprazole—a partial D2 and 5HT1A receptor agonist and 5HT2 receptor antagonist—could have caused Ms. K’s akathisia. In 1 study, 11% of patients receiving aripiprazole, 15 to 30 mg/d, for acute mania reported akathisia symptoms.15
Olanzapine cessation could have caused Ms. K’s akathisia, although no cases of akathisia secondary to olanzapine withdrawal have been reported. Alternatively, olanzapine could have interacted with lithium to block lithium’s ability to induce akathisia.
TREATMENT: Back to olanzapine
After we thoroughly discuss olanzapine’s risks and benefits with Ms. K, she consents to switch back to olanzapine, 10 mg/d. We also instruct her to exercise daily and strictly control her diet after discharge.
Ms. K’s akathisia improves dramatically within 1 to 2 days, and her psychosis and mania improve gradually. Her persistent delusions and hallucinations are less intense, although she is still concocting grandiose get-rich-quick schemes.
Ten days after this latest dosage change, we discharge Ms. K on olanzapine, 10 mg/d, and lithium, 300 mg bid. She has no akathisia symptoms, and we arrange placement in an adult home where a psychiatrist sees her regularly. Three years later, she has been lost to follow-up.
Related resource
- AkathisiaSupport.org. Online resource offers links to articles describing causes of and treatments for akathisia subtypes. www.akathisiasupport.org.
- Aripiprazole • Abilify
- Carbidopa/levodopa • Stalevo, Parcopa
- Clonazepam • Klonopin
- Clonidine • Catapres
- Cyproheptadine • Periactin
- Ethosuximide • Zarontin
- Lithium • Eskalith, others
- Lorazepam • Ativan
- Metoclopramide • Reglan
- Olanzapine • Zyprexa
- Quetiapine • Seroquel
- Reserpine • various
- Risperidone • Risperdal
- Trihexyphenidyl • Artane
- Valproic acid • Depakote
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
