INTRODUCTION
Akathisia is a common adverse effect of antipsychotics and, less commonly, antidepressants (Khawam et al., Reference Khawam, Laurencic and Malone2006). The clinical picture of akathisia involves complaints of restlessness accompanied by observable restless movements (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, or the inability to sit or stand still) developing within a few weeks of starting or raising the dose of antipsychotics and/or antidepressants (American Psychiatric Association, 2000). The reported prevalence of akathisia has varied between 20 and 75%. Its onset is within a few days of initiation of medication, but it can also occur later in the treatment course (Hsin-Tung & Simpton, Reference Hsin-Tung, Simpson, Sadock and Sadock2000).
Akathisia can cause great discomfort and even agitation and is often described by the patient as a most distressing sensation, and suicide is a reported complication (Shear et al., Reference Shear, Frances and Weiden1983; Cem et al., 2001). Therefore, early detection and treatment are necessary.
The diagnostic criteria of akathisia in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV) are as follows: (A) The development of subjective complaints of restlessness after exposure to a neuroleptic medication (B) when at least one of the following is observed: (1) fidgety movements or swinging of the legs, (2) rocking from foot to foot while standing, (3) pacing to relieve restlessness, and (4) inability to sit or stand still for at least several minutes (American Psychiatric Association, 2000).
However, the condition is often underdiagnosed or misdiagnosed as anxiety, agitation, and violent behavior (Hirose, Reference Hirose2003; Rodgers, Reference Rodgers1992; Siris, Reference Siris1985). The reasons for underdiagnosis are considered to be related to both the patient's symptoms and the clinician's attitude toward akathisia. Patient-related factors include a mild degree of akathisia, lack of apparent motor restlessness, lack of clear communication about subjective sensations of restlessness, restlessness in body areas other than the legs, and other clinical signs. Clinician-related factors include overemphasis of objective restlessness, failure to consider akathisia during antipsychotic therapy, and failure to fully implement antiakathisia treatments in ambiguous cases (Hirose, Reference Hirose2003).
In oncological settings, neuroleptics and antidepressants that induce akathisia are also administered. Antipsychotics are frequently used for the prevention of morphine-induced nausea (Mannix, Reference Mannix, Doyle, Hanks and MacDonald1999) and for the treatment of delirium (Meagher, Reference Meagher2001). Tricyclic antidepressants are used in the management of neuropathic pain (Botney & Fields, Reference Botney and Fields1983; Hamon et al., Reference Hamon, Gozlan and Bourgoin1987; Magni et al., Reference Magni, Conlon and Arsie1987). In a previous article, we reported that akathisia is the fourth most common psychiatric referral in a cancer center hospital (Kawanishi et al., Reference Kawanishi, Onishi and Kato2007). However, reports of akathisia in oncology settings are few (Fleishman et al., Reference Fleishman, Lavin and Sattler1994; Onishi et al., Reference Onishi, Yamamoto and Wada2007; Sunakawa et al., Reference Sunakawa, Wada and Nishida2008). Considering these findings, patients who develop akathisia during cancer treatment may not be rare in clinical settings.
The performance status (Oken et al., Reference Oken, Creech and Tormey1982) of cancer patients may deteriorate because of disease progression. Some of these patients become bedridden and cannot walk around, stand up, or sit down. However, no case of akathisia in a bedridden patient has been reported as far as we know. Akathisia causes great discomfort for patients and patients with akathisia walk around or swing their legs to relieve restlessness. However, the distress of akathisia might not be relieved if patients cannot walk around, stand up, or sit down.
In this article, we report on a cancer patient who was bedridden and could not walk around, stand up, or sit down and who developed akathisia. We also discuss factors that make the diagnosis of akathisia difficult, and provide clues to its correct diagnosis.
To determine the etiology of delirium, Francis' criteria (Francis et al., Reference Francis, Martin and Kapoor1990) were used to standardize judgments. On the basis of clinical assessment and medical chart review, a potential cause was categorized as (1) definite, if it was temporally related, there was laboratory confirmation, the patient improved with treatment or cessation of administration of the offending agent, and there was no other cause present; and (2) probable, if all the previous criteria were met but another main cause was present or laboratory confirmation was not obtained.
CASE REPORT
A 72-year-old man was referred by his surgeon for psychiatric consultation because of a depressed mood. He could not sit down or stand up because of complications after an operation for esophageal cancer. Psychiatric examination revealed a depressed mood, loss of interest, insomnia, agitation, difficulty in concentrating, and generalized fatigue. In particular, agitation was noted. His psychiatric features fulfilled the DSM-IV criteria for major depressive disorder. To relieve psychomotor agitation, 5 mg/day intravenous haloperidol was administered. Three days after initiation of the administration of 5 mg/day haloperidol, the agitation seemed to have become worse than that before the administration of haloperidol. Careful observation revealed that the patient sometimes showed slight rubbing movement of lower extremities and slight twisting movements of the body, which had not been observed before the administration of haloperidol. The patient moved his body and lower extremities to relieve restlessness, which developed after the administration of haloperidol. From these findings, akathisia was suspected and haloperidol treatment was discontinued. The symptoms of akathisia then disappeared within a few days.
MEDICAL HISTORY
The patient had no medical history of psychiatric illness or of alcohol or drug abuse. He normally had a cooperative character and was kind to others.
DISCUSSION
We witnessed akathisia in a cancer patient who could not stand up or sit down because of poor performance status. This is the first report of akathisia in a cancer patient who cannot sit down because of poor performance status.
The symptoms of akathisia developed after the administration of haloperidol and disappeared after cessation of the administration of haloperidol. The clinical findings and effective alleviation of symptoms after the discontinuation of the medication fulfilled Francis' criteria for drug-induced akathisia.
This case suggests several factors that make the diagnosis of akathisia difficult. First, it is known that the symptoms of akathisia have many variations, which might sometimes lead to misdiagnosis and underdiagnosis of akathisia (Hirose, Reference Hirose2003). However, the various symptoms of akathisia that have been described are those of patients who can stand up and walk around. The symptoms of akathisia in bedridden patients have not been described. This patient was unable to stand up or sit down. In this situation, many of the clues for a correct diagnosis are absent, but would be present if the patient were able to walk, stand up, or sit down. In this case, the clues to the correct diagnosis were slight rubbing movements of the lower extremities and slight twisting movements of the body, which might be overlooked because these movements were not always exhibited.
Second, the diagnostic criteria for akathisia might not fully cover situations in which the patient cannot stand up or sit down.
Considering the diagnostic criteria B, which refer to the objective findings of akathisia, criteria B(2), B(3), and B(4) concern actions in the sitting and standing positions, but do not apply to patients who cannot stand up or sit down. For a bedridden patient, criterion B(1) is the only key to the diagnosis of akathisia, although this criterion defines the general symptoms of akathisia and does not specifically mention patients who cannot stand up or sit down. It might be an improvement to add a description of symptoms of akathisia for bedridden patients.
Third, the naming of the disease in Japanese might be a cause of the misdiagnosis of akathisia.
In Japanese, the term for akathisia, seizafunoushou, literally translates as “inability to sit still syndrome.” This terminology does not include patients who are bedridden all day and who cannot stand up or sit down. In Japan, the Japanese translation of the name of the disease itself might be a cause of the underdiagnosis of akathisia.
Akathisia causes great discomfort for patients. In the clinical setting of cancer treatment, there are many patients who are administered drugs that can induce akathisia. Some patients who take these drugs and cannot stand up or sit down may develop akathisia. The failure to diagnose akathisia in these patients causes great discomfort for them because they cannot stand up or sit down to relieve their restlessness. A correct diagnosis and treatment of akathisia in these bedridden patients will greatly improve their quality of life.
