A patient who cannot sit still two weeks into an antipsychotic is one of the more consequential forks in psychiatry, because the two readings lead in opposite directions. Called agitation, the dose goes up. Called akathisia, the dose comes down.
The distinction is mostly in the description, not the observation. Akathisia is felt in the legs and the trunk as an inner restlessness that movement relieves — patients rock, cross and uncross, march on the spot, and say they feel better while moving. It is largely free of ideation: there is no content, no target, no grievance. Agitation carries content. The patient is restless about something, and moving does not settle it. Ask directly: 'Where in your body do you feel it?' and 'Does walking about make it better or worse?' The answers separate the two more reliably than watching from the door.
Timing helps as well. Akathisia usually begins days to a couple of weeks after a start or a dose rise, and it is dose-related. The trap is the patient in whom both are present, which is common — and where raising the antipsychotic makes the akathisia worse and so makes the agitation look worse too, producing a spiral that reads as treatment resistance.
- Ask where the restlessness is felt and whether movement relieves it before changing any dose
- Check the timeline against the last dose change — akathisia is dose-related and usually recent
- Look for the motor signature: rocking, marching on the spot, inability to keep the legs still while seated
- Reduce the antipsychotic or add propranolol for akathisia rather than sedating through it
- Reassess after the akathisia settles before concluding the psychosis is resistant
Why it matters
Reading akathisia as agitation leads to raising the dose that caused it, and the resulting spiral is often recorded as treatment resistance.
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