Q: Can Lithium cause Akathisia and Muscle Twitching?
Thanks for all the information you have on the net. It's a great help.
I was diagnosed bipolar 2 in 1994 in college after being wired beyond belief on
antidepressants. I took lithium from 1994- 001 at 1500 mg. I did very well
with it as monotherapy and lived a great, healthy life with almost no side
Then, in 2001, I got silent thyroiditis and have never returned to stability -
particularly with anxiety which seems to frequently drive my being depressed.
In summer of 2002, I tried Wellbutrin. It made the horrible insomnia that I was
having worse and I started to have these muscle twitches all over my body. At
one point, my wife counted the rate of my twitches at over 60 per minute. I
quickly got off Wellbutrin - those symptoms have improved, but the insomnia and
twitching to a lesser degree (but still regular) have continued since. I then
took Depakote (I decreased the Lithium from 1500 to 1200 and am still on that
amount) for 2 years. I could sleep (only b/c of Depakote's effects) but still
had mind- umbing, constant agitation even with all those drugs in me to knock it
down. Unlike earlier in my healthier days, I NEVER got tired during the day -
at all. I felt like my RPM was always revved up too high.
I tried Lamictal with the Lithium this winter. It made me even more agitated
and unstable. Then, in the periods lately while only on 1200 mg Lithium, I had
some more stable weeks but could not sleep at all without Klonopin and was still
wired (although less than with other drugs added). If I took the amount of
Klonopin I needed to stifle the anxiety, I'd get depressed at low doses (.75
mg). I felt like couldn't find a balance and that the anxiety was not
sustainable. So, we've tried Abilify and Seroquel in the last month.
IMMEDIATELY with both (even Seroquel), the agitation, motor running, wired in
the brain feeling has gotten much worse, not better. And, the twitching/muscle
jerks, which have continued to some degree for 3 years, have gotten much worse.
When still on only 25 mg. Seroquel, I called the Dr. yesterday and she
prescribed 1 mg. of Cogentin b/c she says I have akisthesia. I haven't felt
much of a difference yet. My head is exploding - I'm thinking I'm going to
have to stop the Seroquel after just 10 days unless there's sudden improvement.
I'm wondering if Lithium could have been causing akisthesia the whole time and
that might have been the culprit here since all the drugs just seem to make the
anxiety/agitation/wired feeling worse. Have you ever seen that? In 2002, my Li
levels were 1.2/1.3 when the twitching/anxiety got really bad and they're in the
.8 range on the 1200 mg. now.
Thanks for your help,
Dear H' --
Hmm, very tricky. As you have already analyzed, there seem to be many factors
which can affect this muscle thing. Reasonable question you're asking. There is
at least one case report of lithium-associated akathisia, along with some other
weird muscle reaction stuff. I haven't dug it up (it's a letter, not online) to
see if there were many other potential factors involved in that case, which
you'd want to know (Muthane).
As a friend says, medications are guilty until proven
innocent, so in theory you do indeed have to question lithium as the basis of
this and consider a very careful tapering off, substituting alternatives if
necessary as you go down, to see what happens in a no-lithium environment. Of
course you'd do this only in discussion with your doctor and with her full
approval and guidance. Of course. Remember that lowering lithium appears to be
a potentially destabilizing event if done too quickly. No one knows what "too
quickly" is so we compensate by going very slowly when possible, e.g. something
like 150 mg steps down every two weeks or slower is my usual approach.
As you've probably learned, movement problems induced
by medications include akathisia, and also tardive dyskinesia. Though related
they are separate animals. There is also a "tardive akathisia" (e.g. see a
neurologist's review ). So we could wonder whether some agent in the past
might be the culprit, having triggered some sensitivity that now can be
exacerbated by all sorts of things, including even Seroquel (I have had one
patient who got some sort of akathisia-like response to Seroquel and had to
stop; don't stop without talking with your doc', though...). This would include
antidepressants (here's an article on
antidepressant induced movement problems, including not just akathisia but
also more lasting "tardive"-type syndromes) as well as the more common
movement-problem-inducers such as antipsychotics.
But as for lithium, which is the focus of your
question, I've definitely seen twitching kinds of reactions to too high a blood
level. I think most clinicians would regard this as part of the beginning of a
complex of symptoms we generally refer to as "lithium toxicity". I've seen this
as low as 1.0, though only once; and several times at 1.2-1.3. But I mention
this because it is also generally thought that once a person has had lithium
toxicity (e.g. a blood level of 2.0 or higher, really clear toxicity) that they
may be more susceptible to lithium-induced problems. I've even heard the
recommendation that people move on to some other mood stabilizer after they've
had an episode of lithium toxicity, the implication being that any
lithium around might not be a good idea after such an event. To my knowledge
this is not a standard recommendation, however. But, if there was some wisdom
in it, we might postulate that getting to 1.2 or 1.3 is perhaps a bit too high
for you, gets you too close to more severe problems, and that having been there
for a while you're now susceptible in a similar way at lower blood levels. All
that is speculation, and none of it intended to imply that there was any mistake
made in getting you to or keeping you at 1.2-1.3 in the past. That is a standard
procedure, especially in Europe. It does provide an additional rationale,
beyond "guilty until proven innocent", for trying a very cautious taper of
I'd guess that the reason you haven't tried that before
is out of concern for return of severe symptoms which the lithium might to some
degree be controlling. That's the obvious risk in this strategy all right, and
merits considerable discussion with your doc' (e.g. what are you going to use to
address symptoms which might emerge during this taper) before proceeding. Good
luck with all this.
Published October, 2005