Akathisia: “Ants in the Pants”



Akathisia remains an extreme reaction to drugs not always in the psychotropic class. The hospitalist will likely deal with the acute onset, a dramatic form, and a potentially poor outcome if untreated. The patient’s only true defense is the physician’s clinical acumen and their ability to recognize it.

Dr. Robert Killeen

Dr. Killeen is a physician in Tampa, Fla. He practices internal medicine, hematology, and oncology, and has worked in hospice and hospital medicine.

Recommended reading

Van Gool AR, Doorduijn JK, Sevnaeve C. Severe akathisia as a side effect of metoclopramide. Pharm World Sci. 2010; 32(6):704-706.

Loonen AJM, Stahl SM. The mechanism of drug-induced akathisia. CNS Spectr. 2010;15(11):491-494.

Forcen FE, Matsoukas K, Alici Y. Antipsychotic-induced akathisia in delirium: A systemic review. Palliat Support Care. 2016;14(1):77-84.

Sethuram K, Gedzior J. Akathisia: Case presentation and review of newer treatment agents. Psychiatric Annals. 2014;44(8):391-396.

Pringsheim T, et al. The assessment and treatment of antipsychotic-induced akathisia. Can J Psychiatry. 2018;63(11): 719-729.

Tachere RO, Mandana M. Beyond anxiety and agitation: A clinical approach to akathisia. Royal Australian Coll Gen Practitioners. 2017;46(5): 296-298.

Key points

  • Although associated more with psychiatric medications, akathisia can occur with non-psychotropics as well.
  • To recognize the illness, the clinician must notice the repetitive involuntary movements and pacing as well as the “ants in the pants” fidgeting involved.
  • Primary treatment consists of medication discontinuation with pharmaceutical intervention as a backup.
  • Recognition is the key to successful treatment.

Classic signs of akathisia

  • Fidgeting – “ants in the pants”
  • Swinging the legs while seated
  • Rocking from foot to foot
  • Walking while in a static position
  • Inability to sit or stand still – pacing
  • Onset appears with the initiation or dose adjustment of an offending drug


1. Which of the following findings occur in Akathisia?

A. Fidgeting

B. Pacing

C. Swinging the legs while seated

D. All the above

Answer: D

Akathisia is manifest as involuntary hyperactivity of the extremities, particularly the lower extremities. People feel the urge to move, to continue endlessly in motion, stopping only when fatigue sets in. The fidgeting has been described by patients as feeling like “ants in the pants.”

2. Which of the following interventions are used to treat akathisia?

A. Drug discontinuation

B. Propranolol

C. Mirtazapine

D. All the above

Answer: D

All the interventions mentioned are used to treat akathisia. The foremost is to stop the offending drug. Failing this, propranolol is the “gold standard” while 5HT2a antagonists, such as mirtazapine, are favored when beta-blockers either fail or are contraindicated.

3. The use of pyridoxine (Vitamin B6) in the treatment of akathisia is associated with what toxicities?

A. Headache

B. Nausea

C. Seizures

D. All the above

Answer: D

The use of Vitamin B6 in the treatment of akathisia has several drawbacks. Its administration is associated with headache and nausea, and high dose usage increases the risk of seizure.

4. If unresolved, akathisia can lead to which of the following?

A. Insomnia

B. Suicide

C. Physical exhaustion

D. All the above

Answer: D

Akathisia, left unrecognized and untreated, can eventually lead to physical exhaustion, and is compounded by difficulties in trying to rest, hence insomnia. The physical and mental torment of this malady can lead to suicide.


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