Akathisia: The Restless Agony of Benzodiazepine Withdrawal

Key Takeaways

• Akathisia is a state of inner restlessness with a compelling urge to move, and tapering a benzodiazepine too quickly can bring it on.
• A useful clue that sets akathisia apart from anxiety is that moving tends to ease it, if only briefly, while keeping still makes it worse.
• The restlessness is often mistaken for an anxiety disorder, panic, or a drug problem, when in fact the person has physical dependence on a prescribed medication, not addiction.
• Restlessness that starts or sharpens after a dose reduction points to the pace of the taper, which is corrected with the prescribing physician and never by stopping suddenly.
• Adding another medication is usually not the answer, because some of the drugs given to quiet the restlessness can make it worse.
• Movement helps, and cutting back on caffeine is worth trying for a person whose restlessness climbs after coffee or an energy drink.
• Thoughts of suicide call for help right away, so call or text 988 at any hour, and call 911 for immediate danger, a seizure, or any other medical emergency.
• In most cases akathisia is not permanent, although for some people it lasts a long time, and when it will ease is hard to predict.

What is akathisia, and can benzodiazepine withdrawal cause it?

Akathisia is a state of inner restlessness with a compelling urge to move. The word comes from Greek and means, roughly, not being able to sit. A person with akathisia paces, rocks, and shifts from foot to foot, and many say they feel as if they are crawling out of their own skin.

Can tapering a benzodiazepine cause it? Yes. The Maudsley Deprescribing Guidelines, in their chapter on benzodiazepines and z-drugs, call akathisia one of the most distressing consequences of benzodiazepine withdrawal, a condition marked by “severe agitation, restlessness and a sense of terror.”

The older Ashton Manual, written by Professor C. Heather Ashton, does not use the word. Its table of withdrawal symptoms in Chapter III begins with excitability, described as jumpiness and restlessness. The name is newer than the suffering. So, what does it feel like, and how does a person tell it apart from the anxiety that withdrawal also brings?

What does akathisia feel like?

Patients often describe being unable to sit through a meal, a television show, or a car ride. Lying still in bed is worse, so the night is spent walking the hallway. Moving brings a little relief. Yet, the relief ends when the moving stops.

Sometimes the restlessness is easy to see: fidgeting, pacing, rocking, legs that cross and uncross. Sometimes nothing shows at all. The Maudsley Deprescribing Guidelines note that for some people it stays internal, felt as restlessness, irritability, and tension with no outward sign, which is sometimes called inner akathisia.

The fact is that akathisia is a torment that people who have not lived through it find hard to imagine. It is not ordinary nervousness, and it is not something a person can decide to stop.

How is akathisia different from anxiety?

Anxiety usually has a subject: worry or dread about something, even when the something is vague. Akathisia is a demand from the body. The person may not be worried about anything in particular, yet cannot stay still.

Two questions help sort it out. Does keeping still make it worse, while moving eases it, even briefly? And, did it begin, or sharpen, in the days after a dose reduction? Two yeses suggest akathisia. They are worth bringing to the prescribing physician, because they point at the pace of the taper.

Of course, the two can arrive together, because anxiety is a withdrawal symptom as well. Akathisia is also different from the restless legs that Chapter III of the Ashton Manual lists among the sleep disturbances of withdrawal. Restless legs usually stays in the legs and comes on at bedtime, while akathisia tends to take the whole body and does not wait for night.

Unfortunately, akathisia is often mistaken for something else.

The Maudsley Deprescribing Guidelines list what withdrawal akathisia gets called by clinicians who are unfamiliar with it: an anxiety disorder, a panic disorder, mania, psychosis, agitated depression, restless legs, even drug-seeking behavior. Each wrong name leads away from the taper and toward the wrong answer.

Patients misread it too. Many assume that the anxiety the medication was first prescribed for has come back stronger than ever. A doctor who says that the anxiety is back confirms the fear.

A person pacing an exam room and asking for relief can look, to a hurried eye, like a person with a drug problem. That reading is wrong.

Physical dependence on a medication taken as prescribed is a medical condition created by the prescription, and dependence is not addiction. In fact, a person in this state is not chasing a drug. The body is reacting to a reduction that came faster than the nervous system could follow.

Why does benzodiazepine withdrawal cause akathisia?

Benzodiazepines enhance gamma-aminobutyric acid (GABA), the brain’s main calming chemical, and z-drugs such as zolpidem (Ambien) act on the same receptors. Taken daily for months or years, the drug becomes part of how the nervous system slows itself down.

Chapter III of the Ashton Manual describes what happens when the drug leaves faster than that adaptation can reverse. Rapid removal “opens the floodgates,” and the systems the benzodiazepine had damped down rebound into overactivity. Nearly all of the excitatory mechanisms in the nervous system go into overdrive until it readjusts.

Yet, why that overactivity takes the form of akathisia in one person and not in another is poorly understood, and the Maudsley Deprescribing Guidelines say so. They do warn that tapering too quickly can bring on akathisia and suicidality.

Gradual tapering is thought to lower the risk, the Guidelines add, although no trials have looked at the question directly. They call the risk likely small, though unknown.

Why are more drugs usually not the answer?

The Maudsley Deprescribing Guidelines note that akathisia is most often recognized as a side effect of antipsychotic medications. So, when restlessness during a taper is mistaken for agitation or psychosis and an antipsychotic is prescribed to quiet it, the treatment can add to the very symptom it was meant to calm.

Professor Ashton made a related point in Chapter III. She warned that sedating drugs related to what she called the major tranquillisers, an older name for antipsychotics, can cause serious movement side effects and are not recommended as a substitute for a benzodiazepine.

The Guidelines are candid about how little is known. They write that even the medications usually suggested for akathisia have been linked to worsening in some patients, and that antipsychotics, antidepressants, and additional benzodiazepines are reported to make it worse at times.

This is not a blanket rule. The Guidelines accept that in the most severe cases, another medication may become unavoidable. That decision is individual. It belongs to the patient and a physician who understands benzodiazepine withdrawal, with the risks discussed first, and it comes after the taper itself has been corrected.

Fortunately, the first tool is the taper itself.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. In his practice, symptoms that spike after a reduction are treated as information. The nervous system is saying that the step was too large or came too soon, so the reductions stop and the dose is held. As a general rule, the schedule is adjusted before any added medication is considered.

When a single cut was plainly too big, holding may not be enough. Chapter II of the Ashton Manual prefers standing still for a few weeks to going back up. For withdrawal akathisia, though, the Maudsley Deprescribing Guidelines describe a cautious return to the original benzodiazepine, at the dose where the person was last stable, as the approach that most often succeeds in clinical practice.

Dr. Leeds regards a small updose after a cut that proved too large as legitimate. It is protection, not failure. It is also different from adding a new drug, because it corrects a step with the medication the nervous system already knows.

A separate article covers updosing and reinstatement. None of these changes should be made without the prescribing physician, and none of them means stopping abruptly.

After a short hold, the taper resumes with smaller steps, and how long the hold lasts differs from person to person. Reductions follow the hyperbolic pattern in the Maudsley Deprescribing Guidelines, which is why dose reductions get smaller as the dose gets lower. Where it helps, Dr. Leeds uses the crossover taper to diazepam (Valium) from the Ashton Manual, because a long-acting drug evens out the swings between doses. The pace belongs to the patient.

What helps while the nervous system settles?

Movement helps, and there is no reason to fight it. The Maudsley Deprescribing Guidelines note that patients widely find exercise helpful and that pacing somewhat lessens the sensations. Professor Ashton recommended regular moderate exercise during withdrawal in Chapter III, and another article asks whether exercise helps during a benzodiazepine taper.

Caffeine deserves an honest look. While Professor Ashton found tea or coffee in moderation compatible with withdrawal for most people, she made an exception in the same chapter for those who are very sensitive to caffeine or whose anxiety is very high. A person whose restlessness climbs after a cup of coffee or an energy drink has found one thing worth changing.

A regular sleep schedule, a cool and quiet bedroom, and a warm bath are comforts that some people find helpful. However, the evidence for any comfort measure in akathisia is limited, and responses vary from one person to the next. Supplements and over-the-counter remedies are a decision to make with a physician who understands the pharmacology, and none of them replaces a correction to the taper.

When is akathisia an emergency?

Unrelenting restlessness, with little sleep and no explanation, can wear a person down to thoughts of suicide. The Maudsley Deprescribing Guidelines connect withdrawal akathisia with suicidality because of the distress it causes. The United States Food and Drug Administration (FDA) listed suicidal thoughts among the more severe withdrawal reactions when it updated the benzodiazepine boxed warning in 2020.

These thoughts are a symptom, and they call for help right away. Anyone with thoughts of suicide can call or text 988, the Suicide and Crisis Lifeline, at any hour. Call 911 if a person has a plan or the means to end their life, is in immediate danger, has a seizure, or has any other medical emergency.

In an emergency room, it helps to say plainly that a benzodiazepine is being tapered, when the last reduction was made, and that the restlessness began afterward. Another article covers suicidal thoughts during benzodiazepine withdrawal.

Does akathisia go away?

In the middle of it, a person can be certain that the restlessness is permanent. It feels that way at three in the morning, on the hundredth lap of the living room.

In most cases, it is not permanent. The Maudsley Deprescribing Guidelines describe withdrawal as a syndrome that generally improves gradually, with symptoms that rise and fall in the pattern patients call windows and waves. Still, they also say that akathisia, once it has set in, is very difficult to treat and can be prolonged in some patients. Nobody can promise a date.

The nervous system is not broken. It is readjusting to the loss of a drug it was made to depend on, and it does that with time, a steady dose, and small steps. That is why the best taper is slow enough that the restlessness never takes hold.

The restlessness is a message about the pace.

Dr. Leeds’ practice has one primary service: medically supervised tapering of benzodiazepines and z-drugs for patients in Florida. It is a concierge practice with one physician, who works directly with every patient. The taper is gradual, patient directed, and adapted to the person, and it takes months, sometimes longer.

Akathisia after a dose reduction is not a new illness, and it is not a reason to stop abruptly. It is a sign that the plan needs to slow down. Dr. Leeds’ practice in Fort Lauderdale is a place to start. Contact the office to talk about a taper that moves at the pace the nervous system can follow.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.