Recognizing and Treating Medication-Induced Restless Legs and Akathisia

When you start a new medication-especially an antipsychotic-you expect relief from your symptoms, not new ones that feel worse. But for many, a strange, unbearable urge to move takes over. Legs twitch. Feet tap. You can’t sit still. Your doctor calls it anxiety. You’re told to take more pills. Instead of getting better, you feel like you’re losing control. This isn’t anxiety. It could be akathisia-a medication-induced movement disorder that’s often misdiagnosed and dangerously under-treated.

What Is Akathisia, and How Is It Different from Restless Legs?

Akathisia isn’t just fidgeting. It’s a deep, internal torment that makes you feel like you’re trapped in your own skin. You don’t just want to move-you have to move. It’s not about discomfort like a cramp. It’s a crushing, agitated restlessness that makes sitting impossible. You might pace back and forth, cross and uncross your legs repeatedly, shift your weight constantly, or rock in place. These movements aren’t voluntary. They’re desperate attempts to quiet an inner storm.

Restless Legs Syndrome (RLS) feels similar, but it’s different. RLS usually shows up at night or when you’re resting. It’s a crawling, tingling, or aching sensation in the legs that only eases when you move. Akathisia hits anytime, especially when seated, and affects your whole body-not just your legs. It’s not relieved by stretching or walking. It’s worsened by stillness.

The biggest clue? Timing. Akathisia shows up within days to weeks after starting or increasing a medication like haloperidol, risperidone, or even metoclopramide. RLS has no such link to drugs-it’s often genetic or tied to low iron. If your restlessness started after a new prescription, akathisia is far more likely.

Why Misdiagnosis Is Dangerous

Here’s the scary part: doctors miss akathisia more than half the time. A 2020 review in the Journal of Clinical Psychiatry found that up to 50% of cases are labeled as anxiety, agitation, or worsening psychosis. So what happens next? The patient gets a higher dose of the very drug causing the problem.

That’s like pouring gasoline on a fire.

A 2017 case study from the Royal Australian College of General Practitioners followed a patient on haloperidol who developed severe inner restlessness. His doctor thought it was anxiety and doubled his dose. Within days, he became suicidal. Only after stopping the medication-and adding clonazepam-did he return to normal. That’s not rare. In fact, the American Psychiatric Association warns that untreated akathisia is linked to aggression, violence, and suicide.

Patients describe it as worse than the psychosis they were being treated for. One Reddit user wrote: “My doctor kept saying it was anxiety and doubled my Seroquel dose. It made the leg bouncing and inner turmoil 10x worse.” Another told a support group: “I’d rather have the voices back than this feeling of being torn apart from the inside.”

Which Medications Cause Akathisia?

Not all drugs cause it-but some are far riskier.

First-generation antipsychotics like haloperidol and fluphenazine carry the highest risk because they strongly block dopamine receptors. Up to 40% of people on these meds develop akathisia.

Second-generation antipsychotics like risperidone, olanzapine, and quetiapine are better but still risky. About 5-15% of users experience it. Even metoclopramide (used for nausea and acid reflux) can trigger it, especially at high doses or with long-term use.

Newer drugs like lumateperone (Caplyta) have lower rates-just 3.6% in clinical trials-making them a better option for people with a history of movement side effects.

How Doctors Should Diagnose It

There’s no blood test. No scan. Diagnosis comes from asking the right questions and watching closely.

The Barnes Akathisia Rating Scale (BARS) is the gold standard. It takes five minutes. It rates two things:

• Subjective restlessness: “Do you feel an inner need to move? Does it feel like you can’t sit still, even if you want to?”
• Objective movement: “Do you shift your weight, cross and uncross your legs, or pace while sitting?”

Clinicians should also rule out other movement disorders:

• Parkinsonism: Slowed movement, stiff muscles, tremors
• Tardive dyskinesia: Involuntary lip-smacking, tongue protrusion, or chorea (jerky movements)

If a patient has new restlessness after starting a dopamine-blocking drug, akathisia is the leading suspect. If they say, “I feel like I’m going to jump out of my skin,” that’s textbook.

Treatment: Stop the Drug-or Add a Shield

The best fix? Stop the medication causing it. But that’s not always possible.

If someone needs the antipsychotic for severe psychosis, reducing the dose too fast can trigger relapse. So doctors often use add-on treatments:

• Propranolol (10-60 mg daily): A beta-blocker that calms the nervous system. Works for about 60% of patients.
• Clonazepam (0.5-2 mg nightly): A benzodiazepine that reduces inner tension. Fast-acting, but risk of dependence.
• Cyproheptadine (4 mg daily): An antihistamine with serotonin-blocking effects. Less common, but helpful in stubborn cases.

In the RACGP case, haloperidol was tapered over three days, and clonazepam was added. Within 72 hours, the patient said, “I’m back to myself.”

Never increase the antipsychotic dose to “treat” akathisia. That’s like treating a broken leg with a sledgehammer.

What Patients Should Do

If you’re on an antipsychotic and feel restless, don’t wait. Don’t assume it’s “just anxiety.”

• Write down when the symptoms started and what you were doing when they hit.
• Track whether movement helps-or makes it worse.
• Bring up akathisia by name. Say: “I think this might be akathisia. Can we check?”
• Ask if the Barnes Scale has been used.
• If your doctor dismisses you, ask for a referral to a movement disorder specialist or psychiatrist experienced in side effects.

The National Alliance on Mental Illness (NAMI) surveyed over 1,200 antipsychotic users in 2022. Of those with restlessness, 68% were misdiagnosed. Of those, 42% had their dose increased-and got worse. You’re not alone. But you have to speak up.

The Future: Better Tools, Fewer Mistakes

Progress is happening. In 2023, the International Parkinson and Movement Disorder Society launched an Akathisia Recognition and Management App that helps clinicians screen patients in real time.

Researchers are testing new treatments. A 2023 trial found pimavanserin (Nuplazid), a drug used for Parkinson’s hallucinations, reduced akathisia by 62%. Early studies at Harvard are exploring transcranial magnetic stimulation to calm overactive brain circuits.

Even AI is stepping in. Stanford’s 2024 pilot study used video analysis to detect akathisia movements during telehealth visits-with 89% accuracy. That could make diagnosis faster and more reliable.

But until these tools are everywhere, the most powerful tool remains awareness. If you’re a patient, know your symptoms. If you’re a provider, ask the right questions.

When to Seek Help Immediately

Akathisia isn’t just uncomfortable-it’s life-threatening. Go to the ER or call your doctor right away if you experience:

• Thoughts of self-harm or suicide
• Uncontrollable aggression or rage
• Overwhelming panic or feeling like you’re losing your mind

These aren’t signs of worsening mental illness. They’re signs of a treatable drug reaction.

Final Thoughts

Akathisia is not rare. It’s not imaginary. It’s not anxiety. It’s a real, measurable, and treatable side effect of common medications. Too many people suffer needlessly because no one recognizes it. But you can change that.

If you’re on an antipsychotic and feel like you can’t sit still-if you’ve been told it’s “just nerves”-ask for the Barnes Scale. Ask about alternatives. Ask for help.

Your restlessness isn’t weakness. It’s a signal. Listen to it.