Restless Legs and Akathisia from Medications: How to Tell Them Apart and What to Do

It’s 2 a.m. You’re sitting on the couch, legs twitching, feet tapping, body buzzing like a live wire. You can’t sit still. You stand up, pace, sit down again-nothing helps. Your doctor says it’s anxiety. So they increase your antipsychotic dose. The restlessness gets worse. You feel like you’re losing your mind. But it’s not anxiety. It’s akathisia.

Thousands of people on antipsychotics, antidepressants, or even stomach meds like metoclopramide experience this. And most don’t know what it is. They’re told to tough it out, or worse, their meds are increased-making the problem ten times worse. This isn’t normal. This isn’t just being ‘nervous.’ This is a dangerous, underdiagnosed side effect that can lead to suicidal thoughts, violence, or complete treatment failure.

What Exactly Is Akathisia?

Akathisia isn’t just fidgeting. It’s an intense, unbearable inner restlessness that makes you feel like you have to move-even when you’re exhausted. The word comes from Greek: a- (not) + kathisis (to sit). You literally can’t sit still. It’s not voluntary. You don’t choose to do it. Your body is screaming to move.

It usually shows up within days to weeks after starting or increasing a medication like haloperidol, risperidone, or even metoclopramide. First-generation antipsychotics carry the highest risk-up to 40% of people on them develop it. Even second-generation drugs like Seroquel or Abilify can cause it, though less often.

The physical signs are clear: constant leg crossing and uncrossing, rocking back and forth, shifting weight from foot to foot, pacing in place, or rubbing your legs together. But the worst part isn’t what you see-it’s what you feel. Patients describe it as ‘aching restlessness,’ ‘feeling like you’re crawling out of your skin,’ or ‘your bones are buzzing.’ One man wrote: ‘I’d pace for hours, then sit down, then stand up again. There was no relief. Only torment.’

How Is It Different From Restless Legs Syndrome?

People mix up akathisia and restless legs syndrome (RLS) all the time. They both involve leg discomfort and movement. But they’re not the same.

RLS happens mostly at night or during quiet rest. It’s a crawling, tingling, or pulling feeling in the legs that gets better when you move. It often runs in families and can be linked to low iron. Treatment? Iron supplements or dopamine-boosting drugs like ropinirole.

Akathisia is different. It hits during the day, especially when sitting. The urge to move isn’t localized to the legs-it’s full-body. You feel it in your chest, your arms, your head. Movement doesn’t bring relief-it’s a desperate attempt to quiet the inner storm. And crucially, akathisia is directly tied to medication. Stop the drug? Symptoms often vanish in days.

Here’s the kicker: dopamine drugs that help RLS-like levodopa-can make akathisia worse. Beta-blockers like propranolol or benzodiazepines like clonazepam help akathisia but do nothing for RLS. If your ‘RLS’ got worse after starting an antipsychotic, it’s probably akathisia.

Why Misdiagnosis Is Deadly

Here’s the scary part: up to 50% of akathisia cases are misdiagnosed as anxiety, agitation, or worsening psychosis. And when doctors think it’s anxiety, they do the worst possible thing-they increase the antipsychotic.

That’s like pouring gasoline on a fire.

In a 2017 case published by the Royal Australian College of General Practitioners, a patient on haloperidol developed severe akathisia. His doctor thought it was ‘increasing psychosis’ and doubled his dose. Within days, he became suicidal. Only after stopping the drug and starting clonazepam did he improve-within 72 hours.

Studies show akathisia is linked to a 15-fold increase in suicidal ideation. People feel trapped in their own bodies. They can’t sleep. They can’t sit. They can’t think. Some describe it as worse than the psychosis they were being treated for. A 2022 survey by NAMI found 68% of people with medication-induced restlessness were wrongly told it was anxiety. 42% had their meds increased-making things worse.

It’s not just mental. Akathisia can trigger aggression, violence, and self-harm. The distress is real. And it’s treatable-if you catch it.

How Doctors Diagnose It

There’s no blood test. No scan. Diagnosis is clinical. That means a doctor has to ask the right questions and watch closely.

The gold standard is the Barnes Akathisia Rating Scale (BARS). It takes 5-10 minutes. Two parts: one for how the patient feels (inner restlessness), one for what the doctor sees (movements). Each is scored 0-3. A total score of 6 or higher means definite akathisia.

But most doctors don’t use it. They need to ask:

• ‘Do you feel an inner urge to move, even when you’re trying to sit still?’
• ‘Does this feeling get worse when you’re sitting or resting?’
• ‘Did this start after you began or changed a medication?’
• ‘Does moving help, or does it just make you feel more desperate?’

Watch for the telltale signs: foot tapping, leg crossing, rocking, shifting weight. If they can’t sit still for even a minute during your appointment, that’s a red flag.

How to Treat It

The first step? Stop or reduce the drug causing it-if you can.

For drugs like haloperidol, tapering over 3-7 days often leads to full recovery. Don’t stop cold turkey-work with your doctor. If the medication is essential (like for severe psychosis), you don’t have to quit. You can add a treatment to manage the side effect.

Here’s what works:

• Propranolol (a beta-blocker): Start at 10 mg twice daily. Works for about 60% of people. Safe, cheap, and non-addictive.
• Clonazepam (a benzodiazepine): 0.5 mg at night. Helps with both restlessness and sleep. Risk of dependence, so use short-term.
• Cyproheptadine: An antihistamine that blocks serotonin. 4 mg daily. Less common but effective in some cases.
• Vitamin B6: Some studies show 200-400 mg/day helps reduce symptoms, especially with antipsychotics.

Newer options are coming. Pimavanserin (Nuplazid), originally for Parkinson’s hallucinations, showed 62% reduction in akathisia in a 2023 trial. Transcranial magnetic stimulation (TMS) is being tested at Harvard. But right now, propranolol and clonazepam are your best bets.

And don’t forget: iron levels matter. Low iron can worsen both RLS and akathisia. Get a serum ferritin test. If it’s under 50 mcg/L, iron supplements may help.

What to Do If You Think You Have It

If you’re on an antipsychotic, metoclopramide, or similar drug and you feel this kind of restlessness:

1. Write down when it started and what meds you took around that time.
2. Track how bad it is: rate it 1-10 daily.
3. Take the Barnes Akathisia Rating Scale quiz online (search ‘BARS scale PDF’).
4. Bring your notes to your doctor. Say: ‘I think I have medication-induced akathisia. Can we rule it out?’
5. If they dismiss you, ask for a referral to a movement disorder specialist or psychiatrist experienced in side effects.

Don’t wait. Don’t assume it’s ‘just anxiety.’ This is a medical condition. And it’s treatable.

The Bigger Picture

Why is this still happening in 2025? Because training is lacking. Only 37% of U.S. psychiatric clinics routinely screen for akathisia. Most medical schools barely mention it. Pharmaceutical companies warn about it in tiny print on labels-but don’t train doctors.

But change is coming. The International Parkinson and Movement Disorder Society launched an Akathisia Recognition App in 2023. AI tools are being tested to detect movement patterns in video visits. New drugs like lumateperone have akathisia rates under 4%-compared to 14% for risperidone.

Still, without better education, this will keep happening. Patients will keep suffering. Doctors will keep increasing doses. Suicides will keep occurring.

You don’t have to be a statistic. Know the signs. Ask the questions. Demand a proper assessment. Your body is trying to tell you something. Listen.