Severe withdrawal akathisia following neuroleptic discontinuation successfully controlled by clozapine

Akathisia is one of the most distressing side effects of neuroleptic treatment. It is usually managed by manipulating the neuroleptic dose and administering anti-akathisic compounds (beta-blockers, anticholinergics, serotonin antagonists). However, the pathophysiological background of withdrawal akathisia which follows the discontinuation of neuroleptic treatment remains unclear, and there is as yet no adequate treatment. We report a case of severe withdrawal akathisia associated with suicidal and autoaggressive behaviour during a gradual transition from perphenazine/trihexyphenidyl to clozapine. The akathisia was effectively managed by titration of clozapine (maximum dose 200 mg/day) Thereafter, reduction of the clozapine dose resulted in a recurrence of the akathisia, and the resumption of clozapine dose was accompanied by full amelioration of symptoms. We suggest that the antiserotonergic properties of clozapine were responsible for its anti-akathisic effect. Differences in the treatment of acute and withdrawal types of akathisia are emphasized.