A rating scale for drug-induced akathisia.

T R Barnes
BJP 1989, 154:672-676.
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British Journal of Psychiatry (1989), 154, 672—676

A Rating Scale for Drug-Induced Akathisia

THOMAS R. E. BARNES

A ratingscalefordrug-inducedakathisia
has been derivedthatincorporates
diagnosticcriteria
for pseudoakathisia, and mild, moderate, and severe akathisia. It comprises items for rating
the observable, restless movements which characterise the condition, the subjective awareness
of restlessness, and any distress associated with the akathisia. In addition, there is an item
for rating global severity. A standard examination procedure is recommended. The inter-rater
reliabilityfor the scale items (Cohen's x) ranged from 0.738 to 0.955. Akathisia was found
in eight of 42 schizophrenic in-patients, and nine had pseudoakathisia, where the typical sense
of inner restlessness was not reported.

Akathisia is probably the commonest and one of the (Weiden et al, 1987). It may also contribute to the
more distressing of the movement disorders associated common misinterpretation of motor phenomena of
with antipsychotic drugs (Lancet, 1986;Barnes, 1987). akathisia as the signs and symptoms of psychiatric
Following the original descriptions of drug-induced illness (Van Putten, 1975; Braude et al, 1983). !f
akathisia (Sigwald et al, 1947; Steck, 1954), there akathisia is misdiagnosed as an exacerbation of
was little further work on the phenomenology of agitation or psychotic excitement, this error may
akathisia, and no consistent or clear operational prompt an increase in antipsychotic drug dose, which
definition emerged. The diagnosis of akathisia would almost certainly aggravate the problem.
tended to rest upon systematic questioning regarding
a patient's inner restlessness. However, reliance on
Validity of the scale
a patient's subjective report alone does not allow for
reliable diagnosis (Van Putten & Marder, 1986,1987). The validity of the rating scale (see Appendix) derives
The lack of delineation of the associated motor from its basis in signs and symptoms found to be
behaviour created difficulty in separating akathisia characteristic of the condition in our previous studies
from other movement disorders seen in drug-treated of both acute psychiatric admissions receiving anti
schizophrenic patients. These include Parkinsonian psychotic medication (Braude et al, 1983) and
tremor, dystonia, tardive dyskinesia, tics, stereo schizophrenic out-patients on maintenance medication
typies and mannerisms. The distinction between (Barnes & Braude, 1985).
tardive dyskinesia and akathisia is complicated by
the common coexistence of the two conditions
Subjective Item
(Barnes et al, 1983). Descriptions of tardive dyskinesia
have consistently mentioned motor restlessness, and These studies found that against the background of
subjective distress has been found to correate a relatively non-specific sense of inner restlessness
rather
better with trunk and limb movements than with or mental unease, sufferers were often particularly
orofacial movement (Rosen et al, 1982). aware of tension and discomfort in their limbs,
The lack of diagnostic criteria may partly account sometimes with paraesthesia and unpleasant pulling
for the wide range of prevalence figures reported in or drawing sensations in their legs. These complaints
the literature (Marsden et al, 1985): although a figure are akin to symptoms found in the ‘¿restless
legs', or
of around 20°lo is commonly accepted (Ayd, 1961; Ekbom's, syndrome (Blom & Ekbom, 1961; Lancet,
Braude et al, 1983), Freyhan (1958), for example, 1986).
found a prevalence of only 12.5%, while Van Putten In addition, the patients with akathisia would
(1975) recorded a figure of 45%. Furthermore, in typically experience a desire to move, an awareness
a sample of drug-free schizophrenic patients who that they were unable to keep their legs still, or a
received haloperidol (10 mg) at bedtime for seven compulsion to move which was often particularly
days, Van Putten et al (1984) found that 75°lo referable to the legs. Many patients complained that
experienced akathisia. the condition was least tolerable when they were
In addition, the absence of a precise clinical required to stand still, for example when queueing
definition might be partly responsible for the failure for meals or medication on the ward, waiting at the
of clinicians to recognise the condition consistently supermarket checkout, or standing in the kitchen

672
 RATING SCALE FOR DRUG.INDUCEDAKATHISIA 673

while cooking. These symptoms constitute the akathisia (Barnes & Braude, 1985). A common
subjective diagnostic criteria for akathisia included feature is rocking from foot to foot while standing.
in the item ‘¿awareness
of restlessness' of the scale. These movements seem to be of a volitional rather
The inner restlessness and emotional unease than choreic nature, and appear to represent motor
experienced by patients with akathisia is often restlessness. This syndrome has been called pseudo
distressing for patients, and may lead them to refuse akathisia (Munetz & Comes, 1982; Barnes & Braude,
further medication. The importance of akathisia as 1985), and its relationship with akathisia and tardive
a cause of poor compliance with antipyschotic drugs dyskinesia is a matter for speculation (Barnes &
has been emphasised by Van Putten (1974). The Braude, 1985; Stahl, 1985; Munetz, 1986).
overwhelming and intense nature of the subjective The signs of motor restlessness are not invariably
experience in severe cases is illustrated by reports present in mild cases of acute akathisia (Braude et
where akathisia has been thought to have contributed al, 1983). The typical subjective experience of
to violent, aggressive behaviour (Kekich, 1978; akathisia in the absence of restless movements has
Kumar, 1979; Schulte, 1985) or impulsive suicidal been referred to as ‘¿subjective
akathisia' (Van Putten
behaviour (Shear et al, 1983; Schulte, 1985; Drake & Marder, 1986). In practice, it may be difficult to
& Erlich, 1985;Shaw et al, 1986).An item for distress differentiate between this condition and subtle
related to restlessness was included in the scale. manifestations of anxiety or emotional distress
Any distress associated with akathisia can usually unrelated to akathisia. This difficulty is acknowledged
be elicited without difficulty, and is commonly by the ‘¿questionable'
rating in the global item of the
complained of spontaneously. scale, and the existence of subjective akathisia is
reflected in the ‘¿mild
akathisia' rating, as it does not
demand the presence of the characteristic restless
Objective criterion
phenomena.
The study by Braude et al (1983) and a similar The ratings for moderate, marked, and severe
investigation by Gibb & Lees (1986) also found that akathisia reflect increasing degrees of subjective
particular patterns of restless leg movements were distress and the desire or compulsion to move, an
observed in association with the subjective experience increasing inability to remain sitting comfortably,
of akathisia. The most characteristic signs that and an increasing amount of time spent exhibiting
emerged were rocking from foot to foot or walking restless movements, such as rocking from foot to
on the spot when standing. Van Putten & Marder foot when standing, and pacing up and down.
(1987) agree that these foot movements are easily
recognisable, and are present in all patients with Reliability
moderate or severe akathisia. Braude et al (1983)
observed other patterns of restless movement in Patients and method
seated patients, which accompanied the typical
subjective experience of akathisia. They described Forty-two chronic in-patients, all of whom fulfilled DSM-lll
these as shuffling or tramping of the legs. With severe criteria (American Psychiatric Association, 1980) for
schizophrenia, and were receiving antipsychotic medication,
akathisia, patients appeared to be unable to stand were each assessed by two raters during the same
without walking or pacing. Gibb & Lees (1986) examination period using the rating scale (Barnes &
generally confirmed these findings, and suggested Halstead, 1988).The age range of the sample was 32—65
further that fast walking and swinging of one leg (median 52) years, and 13 were women.
when sitting should also be considered as part of the
akathisia syndrome. Examination procedure
These motor phenomena were considered to be Each patient was observed seated for at least five minutes
observable diagnostic criteria for akathisia, and are whileconsent to take part in the study was obtained and
included in the ‘¿objective'
item of the rating scale. the patient completed a self-rating scale for anxiety,
modified from the Leeds Anxiety Scale (Snaith et al, 1976).
The patient wasthen askedto stand up, and wasexamined
Global Item for evidence of Parkinsonism using the Extrapyramidal
The rating of ‘¿absent'
refers to the failure of the rater Rating Scale (Simpson & Angus, 1970). Still standing,
patientswerethen engagedin conversationon neutraltopics
to elicit any subjective awareness or complaint of for severalminuteswhilebeingobserved,and finallywere
restlessness. However, in the absence of any report asked specific questions about inner restlessness, and
of a sense of inner restlessness or a compulsion to awareness of the features of akathisia. For example, inquiry
move, some patients may manifest obvious, complex, was made as to whetherthey experienceda senseof inner
repetitive movements resembling those seen in restlessness,and whether restless, fidgety feelingscould
674 BARNES

TABLE I where the characteristic movements of akathisia are

Inter-rater reliability observed in the absence of the subjective symptoms.
It is envisaged that the rating on the global item
RatingscaleitemLinearly weighted
alone should be sufficient for diagnostic purposes,
xObjective Cohen's
and for measuring change in the overall severity of
akathisia in response to treatment. Nevertheless, to
Subjective rate the global item accurately the elements of the
Awareness of restlessness 0.827 three other items need to be taken into account, and
Distress related to restlessness 0.901 these items should be completed first.
Global clinical assessment0.738 0.955 The individual ratings on the two subjective items,
‘¿awarenessof restlessness' and ‘¿distressrelated to
restlessness' , and the ‘¿objective'
item may be of value
be localisedto any part of theirbody.Further,theywere if an investigator wishes to detect whether the
asked if they had any awareness of difficulty sitting
objective and subjective components of akathisia are
comfortably for long periods, an increasing restlessness and
tension when required to stand still, or a compulsive desire differentially affected by particular drug treatments,
to move. or changeindependentlyover time. Also, when
If akathisia was present, additional information was assessing a patient with pseudoakathisia, either over
collected regarding any diurnal variation of symptoms, and time or in the context of a treatment trial, the main
whether the patient was aware of any particular situations measure of the condition is the rating on the
which seemed to provoke or exacerbate the restlessness and ‘¿objective'item. However, the emergence of a score
any associated distress. for the ‘¿awarenessof restlessness' item might warrant
a change in diagnosis to akathisia.
Inter-rater reliability It is recommended that the scale is completed after
observation of the patient in more than one setting.
The agreement between the two raters on the akathisia scale
was calculated. There was high inter-rater reliability on the Preferably, the patient should be unobtrusively
scores for the four items, expressed in terms of Cohen's watched in a natural setting, for example while
x (Table I). involved in activity on the ward, as well as during
There was completeagreementbetween thetwo raters a formal interview. Experience with the assessment
on the presence of akathisia, that is a rating of two or more of patients with akathisia suggests that the situation
on the global clinical assessment item. There was disagree in which the characteristic restless movements of
ment between the raters on the scores for the severity of rocking from foot to foot or treading on the spot
akathisia in only two patients. The scores differed by one
are most likely to be observed is when the patient
in both cases.
is standing with the rater, engaged in casual
According to the global rating, akathisia was found in
eight (19%) of 42 patients. The condition was rated as being conversation on some neutral topic.
of mild or moderate severity in six patients, and marked We are currently using this scale in a placebo
or severe in only two. Five (12%) of the 42 patients received controlled study of @3-adrenoceptor-blockingdrugs
a rating of ‘¿questionable'akathisia. They manifested non in akathisia, and in a prevalence study in a popula
specific restless movements and described a vague sense of tion of chronic schizophrenic in-patients. The scale
inner tension, but these features were unconvincing for a is also being employed in studies by other research
diagnosis of akathisia. groups in the UK and internationally. We plan to
Nine (21 °lo)patients were rated as having pseudo examine the reliability of the scale further in these
akathisia. These patients exhibited akathisic movements,
studies, and also hope to test the validity of the scale
that is, they scored one or more on the ‘¿objective'item,
but did not apparently experience any associated inner by using an electronic movement meter to quantify
restlessness or desire to move their legs, that is, they scored the restless activity of patients, to provide an
0 on the ‘¿subjective'item. objective measure of the condition.

Discussion Appendix: Rating scalefordrug-inducedakathisia

In this small reliability study, the rating scale was Patient name:
found to be viable and practical, and a high level Patient research no.:
of inter-rater reliability was achieved. The results Hospital no.:
confirm both the relatively high prevalence of Ward:
akathisia in chronic schizophrenic patients receiving Rater:
maintenance antipsychotic drugs, and the existence Patients should be observed while they are seated, and then
in a proportion of such patients of pseudoakathisia, standing while engaged in neutral conversation (for a
 RATING SCALE FOR DRUG-INDUCED AKATHISIA 675
minimum of two minutes in each position). Symptoms suchasrockingfromfootto footwhenstanding.
Patient
observed in other situations, for example, while engaged finds the condition distressing
in activity on the ward, may also be rated. Subsequently, 4 Marked akathisia
the subjective phenomena should be elicited by direct Subjective experience of restlessnessincludes a compul
questioning. sive desire to walk or pace. However, the patient is able
to remainseatedfor atleastfiveminutes.Thecondition
is obviously distressing
Objective
5 Severe akathisia
0 Normal, occasional fidgety movements of the limbs The patient reports a strong compulsion to pace up and
1 Presence of characteristic restless movements: shuffling down most of the time. Unable to sit or lie down for
or tramping movements of the legs/feet, or swinging of more than a few minutes. Constant restlessness which
one leg, whilesitting, and/or rocking from foot to foot is associated with intense distress and insomnia
or ‘¿walking
on the spot' whenstanding, but movements
present for less than half the time observed
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Thomas R. E. Barnes, Charing Cross and Westminster Medical School, Academic Unit, Horton Hospital,
Epsom, Surrey KTJ9 8PZ