When you start a new medication-especially an antipsychotic-you might notice something strange: an unbearable urge to move your legs. You can’t sit still. You pace. You cross and uncross your legs. You shift your weight constantly. Your doctor says it’s anxiety. So they increase your dose. And it gets worse.

This isn’t anxiety. It’s akathisia.

And if you’re feeling restless legs at night, you might think it’s restless legs syndrome (RLS). But the two aren’t the same. Mixing them up can lead to dangerous mistakes-like making your symptoms worse with more medication.

Here’s what you need to know: how to spot the difference, why it matters, and what actually works to fix it.

What Is Akathisia? It’s Not Just Being Nervous

Akathisia isn’t a mood. It’s a physical movement disorder caused by certain medications. It started showing up in medical records in the late 1950s, right after antipsychotics became common. Back then, doctors didn’t know what they were seeing. They called it ‘nervousness’ or ‘agitation.’

Today, we know better. Akathisia is a direct side effect of drugs that block dopamine in the brain-especially older antipsychotics like haloperidol, but also newer ones like risperidone and even some anti-nausea meds like metoclopramide.

The key signs? An intense, uncomfortable feeling inside your body-like your nerves are buzzing, your skin is crawling, or you’re about to jump out of your own skin. You don’t just feel restless. You need to move. Constantly. When you sit, you fidget. When you stand, you pace. You can’t relax. And the more medication you take, the worse it gets.

Here’s what patients describe:

• ‘I feel like I’m being eaten alive from the inside.’
• ‘I have to walk until my legs give out, then I collapse-but I still can’t sit still.’
• ‘It’s worse than the psychosis I was being treated for.’

And here’s the scary part: if your doctor mistakes akathisia for anxiety or agitation, they’ll often increase your antipsychotic dose. That makes the problem worse. Studies show this misdiagnosis leads to suicidal thoughts, aggression, and violent outbursts in up to 15% of cases.

Restless Legs Syndrome: The Nighttime Mimic

Now, let’s talk about restless legs syndrome. It’s different. RLS happens mostly at night or when you’re resting. You get a creepy-crawly, aching feeling in your legs. Moving helps-walking, stretching, shaking your legs. But the relief is temporary.

RLS isn’t caused by antipsychotics. It’s linked to low iron, genetics, or kidney disease. People with RLS often have family members with it too. And unlike akathisia, RLS responds to dopamine-boosting drugs like levodopa or ropinirole.

So here’s the big difference:

• Akathisia: Happens during the day, while sitting or standing. You feel an inner compulsion to move. It’s not about comfort-it’s about survival. Movement doesn’t bring relief; it just delays the agony.
• RLS: Happens at night or during inactivity. You feel a physical discomfort. Moving gives you relief. It’s not a compulsion-it’s a response to pain.

And here’s the trap: many patients with akathisia are told they have RLS. Why? Because both involve leg movement. But treating akathisia with RLS meds like gabapentin or iron supplements won’t help-and might make things worse.

How Doctors Miss It (And How You Can Help)

A 2022 survey by NAMI found that 68% of people on antipsychotics who had movement symptoms were misdiagnosed as having anxiety. Nearly half had their medication increased-making their akathisia 10 times worse.

Why does this keep happening?

• Doctors aren’t trained to look for it.
• Patients don’t know how to describe it.
• Electronic health records don’t have a checkbox for akathisia.

Here’s what you can do:

1. Track your symptoms. When did they start? Right after a new med? After a dose increase?
2. Describe the feeling. Don’t say ‘I’m anxious.’ Say: ‘I feel like I have to move or I’ll explode.’
3. Ask for the Barnes Scale. It’s a 10-minute test doctors can use to rate inner restlessness and visible movement. It’s simple, free, and reliable.

If your doctor says, ‘It’s just stress,’ ask: ‘Could this be akathisia? I read it’s common with antipsychotics.’

Many patients say the moment they named it-‘This is akathisia’-they finally got help.

What Actually Treats Akathisia?

The best treatment? Stop or reduce the drug causing it.

In the 2017 RACGP case study, a patient on haloperidol had severe akathisia. Her doctor doubled her dose. She became suicidal. Then, her psychiatrist stopped haloperidol and started clonazepam. Within three days, she was ‘back to herself.’

But sometimes you can’t just quit the antipsychotic. If you have severe psychosis, stopping could be dangerous. That’s where add-on treatments come in.

Here are the proven options:

• Propranolol (10-60 mg/day): A beta-blocker that calms the nervous system. Works for about 60% of patients.
• Clonazepam (0.5-2 mg/day): A benzodiazepine that reduces inner tension. Effective but can be sedating.
• Cyproheptadine (4-12 mg/day): An antihistamine that blocks serotonin. Less common but helpful in resistant cases.

Important: Avoid dopamine blockers like more antipsychotics. Don’t use RLS meds like ropinirole-they can make akathisia worse.

There’s new hope too. A 2023 trial showed pimavanserin (a drug used for Parkinson’s hallucinations) reduced akathisia by 62%. It’s not FDA-approved for this yet, but it’s being studied.

What to Do If You’re on Antipsychotics

If you’re taking any antipsychotic-whether it’s for schizophrenia, bipolar disorder, or even off-label for anxiety-do this now:

1. Check your meds. Haloperidol, risperidone, olanzapine, quetiapine, and metoclopramide are the biggest culprits.
2. Ask yourself: Do I feel an inner restlessness I can’t sit through? Do I move constantly even when I’m tired?
3. Write it down. Track when symptoms start, how bad they are, and what makes them better or worse.
4. Bring it to your doctor. Say: ‘I think I might have akathisia. Can we check?’
5. Don’t wait. The longer it goes untreated, the more likely it becomes chronic-and harder to fix.

Some newer antipsychotics have lower risk. Lumateperone (Caplyta) caused akathisia in only 3.6% of users in trials, compared to 14.3% with risperidone. If you’re on a high-risk drug and struggling, ask about switching.

Why This Matters More Than You Think

Akathisia isn’t just annoying. It’s life-threatening.

One patient told a psychiatrist: ‘I’d rather be psychotic than feel this.’

Another described it as ‘the most torturous experience of my life.’

And yet, only 37% of U.S. psychiatric clinics routinely screen for it.

This isn’t a rare glitch. Up to 40% of people on older antipsychotics get it. Even newer ones affect 5-15%. That’s tens of thousands of people every year, suffering silently because no one asked the right question.

Recognizing akathisia isn’t just about fixing a side effect. It’s about saving lives.

Because when you stop treating the symptom as ‘anxiety’ and start treating it as akathisia-you don’t just reduce movement. You restore dignity. You reduce suicide risk. You give people back their peace.

What’s Next? New Tools, New Hope

In 2023, the International Parkinson and Movement Disorder Society launched a free app to help doctors diagnose akathisia on the spot. It uses video analysis and symptom checklists.

Researchers are now using AI to detect subtle movements during telehealth visits. One Stanford study got 89% accuracy just from video footage.

And in 2024, a JAMA Neurology study found specific brainwave patterns that appear before akathisia starts. That could lead to early warnings-before the suffering begins.

But none of this matters if doctors don’t know to look.

Education is the real treatment.

If you’re on antipsychotics, know your risk. If you’re a caregiver, watch for movement. If you’re a clinician, screen every patient.

Because restlessness isn’t anxiety.

It’s a warning.