Key Takeaways
- Restless legs syndrome lives in the legs, gets worse in the evening and at rest, and eases while you move.
- Akathisia is a whole-body restlessness with a sense of dread that runs through the day, and moving helps only for a moment.
- Akathisia nearly always traces back to a medication: most often a new or raised dose, or a taper that is moving too fast.
- Five questions sort them out: when it happens, where you feel it, what changed in your medicines, what movement does, and how long it has been going on.
- Restless legs syndrome has its own evaluation and management, while akathisia is treated by finding the cause and slowing or reversing the medication change under supervision.
- Never stop a benzodiazepine, an antidepressant or an antipsychotic abruptly to escape either one, and tell your prescriber what you feel and when it started.
Restless legs syndrome is an urge to move the legs, worse at night and at rest, and moving relieves it. Akathisia is an inner restlessness of the whole body, with dread, present all day, that follows a medication change, and movement relieves it only for a moment. The timing, the location and the medication history tell them apart.
What restless legs syndrome is
Restless legs syndrome is an urge to move the legs that comes on in the evening or at night and when you are sitting or lying still. People describe it as an uncomfortable feeling deep in the legs that is hard to put into words, and the urge builds until they move.
Moving works. The relief lasts as long as the legs are in motion, and the sensation returns when they stop. It is usually a long-standing condition, quiet in the morning, worse as the day winds down, and worst in bed.
In some people it is linked to low iron or to pregnancy, and some antihistamines and some antidepressants can make it worse. While it can wreck sleep, restless legs syndrome does not usually bring fear with it. That is the first clue.
What akathisia is
Akathisia is a different animal. It is a movement disorder that is experienced as a feeling of inner restlessness, an inability to sit still that comes from the inside rather than from the legs. The person may pace, rock, or cross and uncross their legs. While the legs do the visible work, the engine is in the nervous system.
Then there is the dread. People with akathisia describe a sense of terror that is nearly impossible to explain to someone who has not felt it. And, it keeps no schedule. It is there in the morning, through the afternoon and into the night, and lying down changes nothing.
Unfortunately, movement does not fix it. Getting up and walking buys a moment of relief, and the restlessness is back before the end of the hallway. Yet, the pacing continues, because standing still feels worse.
In most cases, akathisia follows a change in medication. A drug that blocks dopamine, such as an antipsychotic, can bring it on when it is started or raised, and so can a new or increased antidepressant. A taper that is moving too fast off a benzodiazepine, an antidepressant or an antipsychotic can bring it on as a withdrawal symptom.
The causes of akathisia deserve a closer look, because the cause is the treatment. So, the question is not whether your legs are restless. The question is what set it off.
Five questions that tell them apart
An analogy may help, even though it is not a perfect one. Restless legs syndrome is like an itch between the shoulder blades. It is maddening, it lives in one place, and a good scratch, or in this case a good walk, settles it for a while. Akathisia is more like a smoke alarm with a dying battery, chirping in every room of the house at once. You can walk from the kitchen to the bedroom, but the chirp follows you, because the problem was never the room.
First, when does it happen? Restless legs syndrome keeps to a schedule, worst in the evening, at night, and at rest, and mostly quiet in the morning. Akathisia is present when you wake and still present at dinner.
Second, where do you feel it? Restless legs syndrome is in the legs, as the name says. Akathisia is a whole-body agitation that the legs happen to express, because the legs are what you move.
Third, what changed in your medicines? This is the most useful question of the five. If a medication was started, raised, lowered or stopped in the weeks before the restlessness began, akathisia moves to the top of the list. While an antihistamine or an antidepressant can make an old case of restless legs worse, restless legs syndrome usually has no such trigger.
Fourth, what does movement do? For restless legs, movement works, and it keeps working while you move. For akathisia, movement helps only briefly, and then the restlessness returns, so the person paces and gets nowhere.
Fifth, how long has this been going on? Restless legs syndrome is often an old companion, present on and off for years. Akathisia is usually new, and it usually arrived with the medication change. When the answers line up on one side, the diagnosis is rarely in doubt. When they split, your doctor needs to hear all five.
Can a medication cause both?
Yes, and this is where much of the confusion comes from. Some antidepressants can worsen restless legs syndrome in a person who already has it, and the same medications can bring on akathisia when they are started, raised or tapered too quickly. Of course, a person can have both at once.
Benzodiazepines complicate the picture further. Benzodiazepine-induced neurological dysfunction, or BIND, is the collection of nervous-system symptoms that can appear during and after a benzodiazepine taper. Sometimes it appears while the dose is still steady. Akathisia is one of its recognized symptoms. In fact, BIND can mimic a variety of neurological conditions without the person actually having them. So, what looks like restless legs during a taper may be a withdrawal symptom.
While the overlap is real, the five questions still sort most cases. The timing and the medication history carry the most weight. A new, round-the-clock, whole-body restlessness that began after a dose change deserves to be treated as akathisia until a physician has ruled it out.
Why the distinction changes what a physician does
Restless legs syndrome has its own evaluation and management. A physician takes a history, may look for a cause such as low iron, and reviews the medications known to make it worse. It is a condition to be managed, usually over the long run.
Akathisia is treated by finding the cause and adjusting it. If a medication was just started or raised, the prescriber looks hard at that medication. If a taper is under way, the taper is very likely moving too fast for that person, and the answer is to slow it, hold the dose, or step back to the last dose that was comfortable. The Maudsley Deprescribing Guidelines put it plainly for benzodiazepines: if symptoms are severe, the “dose should be increased to the last dose at which the patient was stable, wait for stabilisation and then make reductions at half the rate, or less” (chapter 3, p. 353).
Mistaking one for the other leads to the wrong treatment. Treating akathisia as restless legs misses the cause, and the cause keeps working. Treating it as anxiety can be worse, because the usual response to anxiety is more medication.
If a doctor’s prescription started this, it is fair to be wary of a doctor’s next suggestion. Yet, the way out of akathisia runs through a prescriber, because the fix is a medication change done carefully. Never stop a benzodiazepine, an antidepressant or an antipsychotic abruptly to escape it. Stopping suddenly can make the restlessness far worse, and with benzodiazepines it can cause seizures. If the restlessness ever comes with thoughts of ending your life, call or text 988, the Suicide and Crisis Lifeline, and call 911 for any medical emergency.
A person who develops akathisia in the middle of a prescribed benzodiazepine taper is not addicted. They are physically dependent, and physical dependence is not addiction. It is a medical condition caused by the medication, and the right response is a slower, patient-directed taper rather than an addiction program. Dr. Leeds, an osteopathic physician in Fort Lauderdale whose practice is built on supervised tapering, treats a symptom like this as information about the pace of the taper. Comfort measures, such as progressive muscle relaxation during a benzodiazepine taper, have a place, but they do not fix a taper that is moving too fast.
Akathisia from a medication change usually eases once the change is undone or slowed, although the Maudsley Deprescribing Guidelines note that it can be prolonged in some people. The pace varies from person to person, and in benzodiazepine withdrawal it can come and go in waves before it settles. The restlessness is a message. It is the nervous system saying that something moved too fast, and the job is to listen to it.
Frequently asked questions
Is akathisia a form of restless legs syndrome?
No. They are separate conditions that share one feature, the urge to move. Restless legs syndrome is in the legs, at night, and relieved by moving. Akathisia is whole-body, all day, driven by a medication change, and movement helps only briefly. A person can have both, which is why the history matters more than the label.
Can benzodiazepine withdrawal cause restless legs?
Benzodiazepine withdrawal can bring either one. The Ashton Manual lists restless legs syndrome among the sleep disturbances of withdrawal. The Maudsley Deprescribing Guidelines describe akathisia set off by benzodiazepine withdrawal, and they note that it is sometimes misdiagnosed as restless legs. Because BIND can mimic other neurological conditions, a new restless-legs picture during a taper should be weighed against the pace of the taper first. Your doctor can sort out which it is.
Does akathisia happen only in the legs?
No. The legs do most of the visible moving, because pacing and shifting are how a body answers a need to move, but the restlessness itself is felt through the whole body and as dread in the mind. If the feeling stays in the legs and is quiet by day, it is probably not akathisia.
Can antidepressants cause either one?
They can be involved in both. Some antidepressants can worsen restless legs syndrome in a person who already has it, and starting, raising or tapering an antidepressant too quickly can bring on akathisia. For antidepressant withdrawal that becomes intolerable, the Maudsley Deprescribing Guidelines advise the prescriber to “either hold the current dose for longer to allow them to resolve, or to increase the dose to the last dose at which the symptoms were tolerable” (chapter 2, p. 153). Never change a dose on your own to test the theory.
What should you tell your doctor?
Tell your doctor when it happens, where you feel it, what movement does, how long it has been going on, and every medication change in the past few months, including doses that went up, doses that came down, anything stopped, and any over-the-counter antihistamine or sleep aid. A clear timeline does more for the diagnosis than any single symptom.
In Dr. Leeds’ practice, patients taper under medical supervision with weekly visits, often up to an hour, and 24/7 text access for urgent questions, so a new symptom such as akathisia can be reported the day it appears. The pace is set with the patient, and when a taper gets hard the first moves are a hold, a slower rate, or a small physician-guided updose, not a second medication with its own dependence. Contact the office today to ask about a consultation.
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.
