Key Takeaways
- How long akathisia lasts depends on what caused it, not on how severe it feels.
- Akathisia after a new or increased medication often eases within days to a few weeks once the dose is lowered or the drug stopped under supervision.
- Akathisia from stopping a medication too quickly can last weeks to months, and in protracted benzodiazepine withdrawal it can come and go in waves.
- Unlike anxiety, akathisia is a physical restlessness with a compulsion to move, and it is not in your head.
- Never stop a medication suddenly to escape it, because the pace of a taper is the main lever.
- Restlessness that comes with thoughts of harming yourself is an emergency, so call 988 for a mental health crisis or 911 for a medical emergency.
It depends on what caused it. Akathisia after a new or increased medication often eases within days to a few weeks once the dose is lowered or the drug is stopped under a doctor’s care. Akathisia from stopping a medication too fast can last weeks to months, and in protracted benzodiazepine withdrawal it can come and go for longer.
What is akathisia, and why does the cause decide how long it lasts?
Akathisia is an inner restlessness with a compulsion to move. Sitting still is harder than it sounds. It is worse than moving, so you move. Patients often describe pacing the hallway at three in the morning, not because they want to walk, but because every chair has become unbearable.
It is not anxiety, and it is not in your head. Unfortunately, some people with akathisia are told exactly that, which is why this site carries a separate article on medication-induced akathisia and why it must never be dismissed.
In fact, some people with akathisia can tell you the week it began. The causes of akathisia usually come down to a medication change: starting or raising a medication that blocks dopamine, such as an antipsychotic or some anti-nausea medicines, starting some antidepressants, or stopping a benzodiazepine, an antidepressant, or an antipsychotic too quickly.
So, why does the cause decide the timeline? Because the restlessness is a nervous system reacting to a change, and it settles on the schedule of that change. A nervous system that spent years adapting to a drug has to readapt without it, and that takes longer. Which kind do you have?
How long does akathisia last when it comes from starting or raising a medication?
This is the more fortunate kind, if there is such a thing. When a dopamine-blocking medication is started or raised and restlessness follows within days, the medication is the likely cause. Lowering the dose or stopping the drug under a doctor’s supervision typically lets the restlessness fade over days to a few weeks.
Yet, “typically” covers a wide range. Some people settle within days of a dose change, and others are not comfortable until weeks after the drug has cleared.
Unfortunately, a common first response is to read the restlessness as agitation from the condition being treated and raise the dose. That is the wrong direction. If restlessness began shortly after a medication was started or increased, give your prescriber the dates. Timing is the clue.
While a physician may consider a medication aimed at the restlessness itself in some of these cases, the main treatment is removing the cause, gradually and with your doctor’s help. Still, do not stop the drug on your own. An abrupt stop can bring withdrawal of its own, and the restlessness can get worse before it gets better.
How long does akathisia last after stopping a medication too fast?
Longer. This is withdrawal akathisia, and it is the kind that brings people to Dr. Leeds’ practice. It can follow a rapid taper of a benzodiazepine, an antidepressant, or an antipsychotic, and with benzodiazepines it can also appear at a steady dose, as tolerance develops.
Imagine a garden hose that someone has stood on for years. Pressure built up behind the foot, and the hose adapted. Lift the foot all at once and the hose whips around the yard. Lift it a little at a time and you get a steady stream.
While no analogy is perfect, this one gets the main point right. The whipping is not a broken hose. It is pressure finding its way out too fast, and the fix is to lift the foot slowly.
In benzodiazepine withdrawal, akathisia is one symptom of BIND, short for benzodiazepine-induced neurological dysfunction. BIND covers the nervous system symptoms that can occur during and after a taper. The 2020 Food and Drug Administration (FDA) label update recognizes these withdrawal reactions, protracted ones included. In that setting, akathisia can last weeks to months, and in protracted withdrawal it can come and go for longer still.
A person who took a benzodiazepine as prescribed and now cannot stop without symptoms is physically dependent. That is not addiction. It is a medical condition caused by the medication, and the treatment that matches it is a gradual, supervised taper, not an addiction program.
Unfortunately, some people with withdrawal akathisia got it from a program that promised to get them off in a week or a month. The thirty-day program that caused it is rarely around to see how long it lasts.
When does akathisia become long-lasting?
Three situations make it stay. The first is a sudden stop. The Maudsley Deprescribing Guidelines, in chapter 3, note that abrupt cessation probably carries the greatest risk of protracted withdrawal symptoms, and restlessness is one of them.
Repetition is the second. Each failed rapid taper or cold turkey attempt can make the next withdrawal worse, a pattern known as kindling. So, a third attempt to come off a benzodiazepine quickly may bring restlessness that lasts far longer than the first.
Long use of a dopamine-blocking medication is the third. Akathisia that develops after years on an antipsychotic, sometimes called tardive akathisia, can persist even after the medication is reduced. Of course, that is a reason to taper gradually and under supervision, not a reason to stop in a day.
Is any of this permanent? In most cases, it is not, but after months of restlessness coming and going, it can feel as if it is. BIND reflects a nervous system reacting to the loss of a drug it had adapted to, not structural damage, and that system can settle again with time, safety, and proper medical supervision.
What shortens akathisia, and what makes it worse?
Fortunately, the pace of the taper is something you and your doctor control. If restlessness spikes after a reduction, the spike is telling you something. The cut was too large or too soon.
When symptoms are severe, the Maudsley Deprescribing Guidelines, in chapter 3, describe going back to the last dose at which the patient was stable, waiting for things to settle, and then reducing at half the rate or less. The 2020 FDA label says much the same: pause, or return to the previous dose, then go more slowly.
Holding is not going backward. Professor C. Heather Ashton wrote in the Ashton Manual, chapter II, that “You can stand still at a certain stage in your schedule and have a vacation from further withdrawal for a few weeks,” for instance during a family crisis. She preferred holding to raising the dose again, while the Maudsley guidelines and the FDA label allow a return to the previous dose when symptoms are severe. A hold is treatment.
Fear makes it worse. It keeps the stress system switched on and amplifies every physical sensation, which is why understanding what is happening is itself part of the treatment.
Stimulants can make it worse too. Caffeine and sugar can increase anxiety and magnify withdrawal symptoms. And, alcohol, which acts on the same receptors as a benzodiazepine, can destabilize a taper and raise the risk of a seizure.
What about medication for the restlessness itself? For some causes of akathisia, a physician may consider one. That is a decision for the physician who knows your history, and it is never a substitute for fixing the pace.
Dr. Leeds’ practice is built around that lever. Patients taper with weekly visits, often up to an hour, and 24/7 text access for urgent questions, so a reduction that brings on restlessness can be held or slowed that week, not at a visit three months away. A benzodiazepine taper there typically takes a year to 18 months or longer, as long as the nervous system needs. The practice is concierge rather than insurance-based, prescribes in Florida only, and sees patients by telemedicine throughout Florida and in the office in Fort Lauderdale.
Frequently asked questions
Can akathisia go away on its own?
Sometimes. When the cause is a new or increased medication, the restlessness usually needs the dose lowered or the drug stopped, under supervision, before it fades. Withdrawal akathisia eases with time as the nervous system readapts, and a sensible taper pace is what helps it along.
Is akathisia permanent?
In most cases, it is not. While akathisia after long use of a dopamine-blocking medication can persist, that is one reason those medications are tapered slowly rather than stopped. Withdrawal akathisia tends to settle as the rest of withdrawal settles.
Does akathisia come in waves?
In withdrawal, it often does. Benzodiazepine withdrawal tends to run in windows and waves. A window is a period when you feel much better, and a wave is a period when symptoms return. Over time the windows usually grow longer and the waves shorter and milder, and a wave is not a sign that something new has gone wrong.
Can lowering a dose too fast cause akathisia?
Yes. A reduction that is too large for where you are in the taper can bring on restlessness within days. The Maudsley Deprescribing Guidelines, in chapter 3, describe a hyperbolic pattern, in which each cut becomes smaller as the total dose comes down. If a cut brings on restlessness, tell your prescriber.
When should you call a doctor about restlessness?
Call when restlessness begins within days of a medication change, keeps you from sitting or sleeping, or is getting worse rather than better. The Maudsley Deprescribing Guidelines, in chapter 3, list suicidal thinking as a recognized withdrawal effect, even in people who never had it before. If restlessness comes with thoughts of harming yourself, call 988, the Suicide and Crisis Lifeline, and call 911 for a medical emergency such as a seizure.
If your restlessness began after a medication change, or after a taper that moved too fast, both the cause and the pace deserve a look. 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.
