Akatiziya — constant internal motivation to the movement, pathological restlessness. A subjective component of a phenomenon — burdensome desire to move, discomfortable feelings, feeling of the increasing alarm in the absence of movements. The objective symptomatology is expressed in fussiness, restlessness, marking time, aimless movement. Diagnostics is performed clinically, tool researches are applied to an exception of organic damage of a brain. Treatment depends on a state etiology, use of magnesium, holinolitik, adrenoblokator, blockers of 5-HT2-retseptorov, GAMK of exponential and adrenoblokiruyushchy medicines is possible.
The term "akatiziya" is entered in 1901 by the Czech psychiatrist L. Gaskovts for designation of the constant need for the movement arising at a number of patients with mental disorders. In 1923 the French psychiatrists described an akatiziya at patients with the secondary parkinsonism which developed after the postponed encephalitis. Soon there were descriptions of pathological restlessness at Parkinson's disease, drug addiction, alcoholism, postnarcotic awakening. After introduction to medical practice of typical anti-psychotics (in the middle of the 20th century) it turned out that they along with other side extrapyramidal effects rather often cause an akatizivny syndrome. According to modern data, the akatiziya at treatment by typical anti-psychotics meets in 8-75% of cases. The considerable dispersion of this indicator is caused by variability of the applied therapeutic techniques (a dosage, the treatment duration, the used medicines) and diagnostic approaches to establishment of an akatiziya.
In modern neurology and psychiatry the syndrome of pathological restlessness became practically a synonym of side effect of a number of psychotropic pharmaceuticals. However other reasons of this phenomenon in some cases meet. The main etiofaktor under the influence of which there is an akatiziya can be divided into the following groups:
- Psychotropic drugs. Most often pathology is side effect of application of typical neuroleptics (a haloperidol, a pimozid, a droperidol), is more rare — atypical anti-psychotics (an aripiprazol, an olanzapin), antidepressants (mirtazapin), sedative pharmaceuticals (hlorpromazin). In literature there are instructions on emergence of this syndrome at abstinency against the background of abuse of separate groups of sleeping medicines (for example, barbiturates).
- Drug taking. Akatiziya is observed against the background of cocaine intoxication, opium drug addiction, abuse of other psychostimulators (amphetamines, methylphenidate). Development of an akatizivny syndrome is caused by impact of the specified chemicals on the main neuromediator systems of a brain.
- Chronic alcoholism. Toxic effect of alcohol on brain neurons leads to degenerate changes subcrustal over time. The last are directly involved in synthesis of neurotransmitters, their metabolism and interaction with the corresponding receptors. Violation of the specified transmitterny systems provokes an akatiziya.
- Parkinsonism. Violation meets in some cases primary and secondary parkinsonism. Authentically it is not established whether it is a consequence of a disease or arises as result of application of dofaminomimetik – medicines of a levodopa, D2 agonists.
Allocate the contributing factors increasing probability of emergence of pathological restlessness. So, patients with disturbing frustration and affective states are more subject to emergence of extrapyramidal frustration, than patients with schizophrenia. The risk of a disease is increased at patients with organic defeat of TsNS, ChMT in the anamnesis, dementia. A number of researches showed existence of genetically determined predisposition connected with a gene of DRD2 of the 1st chromosome.
The last researches demonstrate that the akatiziya has more difficult mechanism of development, than the isolated dofaminergichesky dysfunction. A part is played by frustration noradrenergichesky, serotoninovy, GAMK-oposredovannoy, holinergichesky systems. In 2011 the theory according to which reduction of dofaminergichesky activity at parkinsonism or treatment by anti-psychotics sometimes involves compensatory mechanisms was put forward. Activation of the noradrenergichesky axons of a bluish kernel stimulating an adjacent kernel that causes emergence of motive concern, disturbing feelings concerns to the last.
In parallel under the influence of noradrenergichesky incentives the adrenaline secretion by adrenal glands supporting feeling of alarm and excitement amplifies. Also mediated increase in concentration in TsNS of the glutamate accelerating signaling in various neyrotransmitterny systems is supposed and at excessive accumulation leading to an overstrain of neurons. Surplus of a glutamate is followed by decrease in the concentration synthesized from the GAMK glutamic acid — the brake mediator providing a quiet state, concentration, steadiness.
There are several clinically significant classifications of an akatizivny syndrome. By the etiologichesky principle pathology is subdivided on yatrogenny, parkinsonichesky, arisen owing to the use of psychoactive agents, abstinent, spontaneous (caused by mental violations), postinsultny. On the prevailing clinical manifestations allocate three forms:
- Motor — is characterized by mainly motive manifestations. Tendency to the constant movement prevails: to walking, marking time. Patients do not feel essential psychological discomfort, alarm.
- Touch and mental (subjective) — differs in existence of subjective complaints in the absence of an objective motive component. Patients are subject to constant discomfort, feeling of alarm, various unpleasant feelings in legs. The visible giperkineziya is absent.
- Classical — represents a combination of subjective feelings and an objective motive hyperactivity. Patients complain of the internal discomfort forcing them to move constantly. Pathological restlessness is confirmed at observation of the patient.
In case of a yatrogenny etiology an important point in the choice of medical tactics is definition of time of emergence of a syndrome in relation to the beginning of the therapy which provoked its development. According to a temporary factor allocate four types of an akatiziya:
- Sharp. Develops in the first days or weeks of therapy by anti-psychotics, is more rare — during the first hours. It can be provoked by increase in a dosage. Regresses after medicine replacement. Against the background of the continuing reception without increase in a dose the symptomatology can decrease, sometimes — to persistirovat.
- Chronic. Symptoms appear with treatment duration for a month and more. It is noted in 25-30% of cases of therapy by neuroleptics. Cancellation of provocative pharmaceutical leads to gradual regress of manifestations.
- Late. Comes to light many months (several years) of treatment later. Cancellation of therapy is followed by increase of manifestations, increase in dosages can cause temporary improvement of a state with the subsequent strengthening of symptoms. After medicine provoker cancellation the symptomatology slowly decreases, sometimes remaining until the end of life.
- Akatiziya of cancellation. Arises in the first two weeks after the termination of reception of a medicine, 1-1,5 months remain. Longer current demonstrates probable existence of a late form.
The classical akatizivny syndrome includes subjective and objective (motor) components. In the beginning motor manifestations are localized mainly in the lower extremities. The patient cannot quietly lie, sit or stand. He constantly goes, is often aimless on one trajectory, is not necessary, and marks time. Lying in a bed, the patient often changes a pose, turns over, constantly moves legs, sitting on a chair — fidgets, turns, shakes legs. In process of progressing of pathology of the movement gain more stereotypic character, the akatiziya extends from below up, covers a trunk, the top extremities, the head. At the expressed extent of violations of the patient turns, shaken, coils all over, can move jumps, grimaces, run, his eyes constantly move, the look moves.
The subjective component of a syndrome is heavily transferred by patients, the felt feelings difficult give in to the description and the formulation. The touch akatiziya includes various extremely discomfortable feelings (burning, prickings, twisting, an itch) which are localized in the depth of muscles and joints. The mental component is expressed in not clear requirement of the movement, strong concern, constant tension, impossibility to relax, to a dysphoria. Patients specify that the movement gives them some relief, at stay in rest the internal alarm, tension quickly increase.
In most cases pathology provokes sleep disorders, difficulties of falling asleep are caused by torsion in a bed, night awakenings are connected with the insuperable need to go. It is long the proceeding akatiziya is followed by gradual formation of pathological changes of character. Patients become importunate, hypochondriac, disturbing, with captation - sugary, irritable. Nelechenny frustration aggravates the course of a basic mental disease, leads to development of complications.
Akatiziya can become a reason for negative attitude of the patient to the carried-out therapy up to full refusal of it. Pathological restlessness complicates full participation of the patient in psychotherapeutic and social and rehabilitation occupations. The intolerable dysphoria is complicated by a depression, emergence of suicide thoughts, attempts of a suicide. The expressed akatiziya can provoke impulsive actions, aggressive behavior of the patient with an autoaggression, danger to people around. In the absence of adequate treatment of an akatizivny syndrome development of full intolerance of psychopharmacological means is possible. Attempts of patients to facilitate symptomatology smoking, alcohol intake, various psychoactive agents become the reason of development of dependences.
It is extremely difficult to suspect existence of an akatizivny syndrome at an early stage. Patients can constrain will power motor manifestations, are inclined to hide subjective feelings, are incapable to put them into words, sometimes do not understand happening to them owing to features of the main mental disease, dementia. In certain cases sudden negative attitude of the patient to treatment acts as the only clinical symptom. Modern neurophysiological (EEG, REG) and neurovisualization (brain MPT, KT, MCKT) researches are informative only in respect of a difdiagnostika.
Diagnostic search is carried out by the psychiatrist within the poll and clinical observation. Considering that the patient is capable to constrain physical activity effort of will, poll of relatives, observation of behavior of the patient without his permission practices. Identification of an akatizivny syndrome, definition of its expressiveness are promoted by use of the scale of Burns including:
- Objective assessment of motive concern. 0 — the motive sphere without features. 1 — the motive concern is noted less than a half of time of observation. 2 — manifestations of motor restlessness cover more than a half of time of inspection. 3 — the motor akatiziya is so expressed that the patient is incapable to remain on the place during survey.
- Definition of expressiveness of subjective feelings. 0 — the concern is absent. 1 — uncertain discomfortable feelings. 2 — impossibility to keep the lower extremities without the movement, increase in uneasiness at rest. 3 — strong desire to move, feeling of forcedness of physical activity. Extent of experience of restlessness is separately estimated: zero, weak, average, expressed.
- The general conclusion about akatiziya degree. If there is only a subjective component, frustration is considered doubtful (psevdoakatiziya). Existence of nonspecific complaints and the objective increased fussiness testifies to an ill-defined syndrome. To average weight there corresponds the combination of nonspecific subjective feelings to an obvious motor component. The distinct akatiziya is diagnosed in the presence of internal concern and a motor component, expressed — at their combination to sleeplessness.
Pathology demands differential diagnostics from disturbing states, psychomotor excitement, Turett's syndrome, giperkinez. Disturbing states differ in the smaller need to move, in presence of vegetative symptomatology, prevalence of excess movements at the top extremities (torsion of buttons, shuffle of beads). Psychomotor excitement is characterized by diffusion increase in motility, has no specific subjective coloring, the movements do not give mental relief. Turett's syndrome is followed by vocal, facial tics, patients note the "itching" desire to make a certain movement only in attempt to constrain a tic. Giperkineza have a typical motive pattern, can be only partially constrained.
Treatment of an akatiziya
Exact establishment of an etiology of an akatizivny syndrome is the cornerstone of adequate therapy. As the vast majority of cases has the yatrogenny nature, revision of the existing scheme of treatment regarding availability of pharmaceuticals – the potential reason of the arisen phenomenon is made. Decrease in doses or replacement of the specified medicines by means with a smaller extrapyramidal potential is carried out. Practically magnesium administration of drugs is recommended to all patients, at the expressed symptoms — its parenteral introduction. Further treatment is carried out with the combined use of the following main groups of pharmaceuticals:
- Central holinolitik. Are appointed if the akatiziya is combined with extrapyramidal symptomatology (a tremor, medicinal parkinsonism). The combination with medicines of other groups as holinolitik are insufficiently effective concerning the expressed akatizivny manifestations is recommended.
- Beta . The lipophilic means capable to get through a hematoencephalic barrier are used. Are medicines of the first line in therapy of patients without extrapyramidal frustration.
- Gamkergichesky means. Exponentiating GAMK, reduce uneasiness, excitement, improve a dream. Poorly affect a motor component therefore are appointed in combination with medicines of the previous two groups.
- 5-HT2-blokatorov. Observation that the akatiziya arises at purpose of anti-psychotics with 5-HT2-blokiruyushchim effect less often became theoretical base of application of medicines of this group. The subsequent clinical tests proved their therapeutic efficiency.
- Antiadrenergetikov. The positive effect of these pharmaceuticals confirms a pathogenetic role of noradrenergichesky system. Along with antiakatizichesky action they reduce expressiveness of nightmares.
- Dofaminergichesky means. Are used at persistent character of symptomatology. In addition korrigirut depressive, disforichesky violations.
Forecast and prevention
Success of therapy depends on timeliness of its beginning, an etiology, a form and expressiveness of an akatizivny syndrome. Adequate therapy allows to achieve improvement of a state from most of patients, to avoid complications. As the akatiziya is mainly a complication of medicinal therapy, as measures of its prevention serve rational use of antipsychotic pharmaceuticals and antidepressants, careful selection of a dose, drawing up the combined schemes of treatment taking into account intermedicinal interaction. Use of atypical anti-psychotics with the smallest potential of emergence of extrapyramidal symptomatology is recommended. In need of use of medicines with high risk of an akatiziya it is necessary to appoint preventively holinolitik, beta-blockers or GAMK-ergichesky means.