This is NOT a study. There is a lot of information that reads like this or very similar.

Infrequently, agitation and violence have been reported to be associated with antipsychotic treatment and
could be related to akathisia.2,3 Differentiating between akathi-
sia that manifests itself as violence and generalized psychotic
agitation is clinically important in order to avoid a vicious
circle of violence in patients who are being treated with anti-
psychotics. We report a case of persistent agitation and vio-
lence in a patient with bipolar mood disorder that was probably
a manifestation of akathisia.

(JOUNAL OF CLINICAL PSYCHIATRY 1997)

link: (PDF) Akathisia as Violence

CASE REPORT
Case Report. Mr. A, a 47-year-old white man with a diag-
nosis of bipolar mood disorder, was brought to the emergency
room because he was screaming in the streets. Mr. A had over
30 past psychiatric admissions associated with agitation and
violence and was often discharged against medical advice. He
was nearly always noncompliant with his antipsychotic medi-
cations, claiming that they made him “jump and lose my tem-
per.” Prior to the present admission, Mr. A’s daily medications
included haloperidol 20 mg, lithium carbonate 1500 mg, dival-
proex sodium 500 mg, and benztropine 1 mg. At admission, the
patient was grandiose, had loud and pressured speech, and ad-
mitted he was not taking haloperidol. He was given haloperidol
15 mg q.h.s. and benztropine 1 mg q.a.m. Within 24 hours he
started pacing; became restless, agitated, and violent; com-
plained of feeling “jumpy”; and attacked a staff member. On
Day 5 of his hospitalization, haloperidol and benztropine were
discontinued; chlorpromazine was started, and the dose was in-
creased to 950 mg/day. Mr. A, although sedated, remained
threatening and violent. On Day 13, chlorpromazine was dis-
continued, and haloperidol was restarted at a higher dose of 15
mg p.o. b.i.d. Mr. A again complained of “jumpiness” and
punched a television cabinet, causing a self-inflicted fracture.
On hospital Day 17, owing to an error, haloperidol was discon-
tinued. The patient became calmer, less irritable, displayed no
angry outbursts, and required no further room restrictions.
After 5 days, when the error was discovered, haloperidol was
restarted at a lower daily dose of 10 mg. Within 3 days, the pa-
tient became violent and required room restriction. Haloperi-
dol was then discontinued, the patient’s agitation and violence
resolved, and a week later he was discharged. His daily medi-
cations were lithium carbonate 1500 mg (serum level = 0.9
mEq/L; this dose had not been changed during his hospitaliza-
tion), lorazepam 1 mg, and divalproex sodium 500 mg. On
these medications, he remained well 6 months postdischarge,
his longest period as an outpatient.
The association between antipsychotic administration, aka-
thisia, and violence in psychiatric patients has been noted in
two reports.2,3 Herrera et al.2 showed a trend for more violent
episodes to occur with haloperidol than with placebo or low-
potency neuroleptics. Crowner et al.3 found that for violent
psychiatric patients taking antipsychotics, half of the assailants
had akathisia before the assaults, while only 20% of nonviolent
patients had akathisia. However, to support a causal relation-
ship between antipsychotic administration, akathisia, and vio-
lence, it is necessary to document a clear onset of akathisia and
violent behavior upon initiation of antipsychotic treatment and
resolution of both with antipsychotic discontinuation. Al-
though agitation and violence result from a severe manic epi-
sode, Mr. A’s case documents such an association: on two occa-
sions, the onset and the resolution of both his “jumpiness” and
his violent behavior coincided with the beginning and the end-
ing of antipsychotic medication treatment. The fact that the
jumpiness occurred with haloperidol and not with chlorproma-
zine is another factor indicative that Mr. A has exhibited aka-
thisia rather than nonspecific activation of mania; this is be-
cause akathisia is more common with higher potency as
compared with low-potency neuroleptics. One can also specu-
late that Mr. A’s rocky clinical history was related to aggressive
behavior perpetuated by antipsychotic administration. The pos-
sibility that aggressive and violent behavior unresponsive to
antipsychotic treatment could be a variant of akathisia should
be included in the differential diagnosis of acute psychosis and
in alternative treatment strategies for bipolar mood disorder.
Benzodiazepines in combination with lower neuroleptic doses,
lithium, or valproate should be considered.
REFERENCES
1. Braude WM, Barnes TRE, Gore SM. Clinical characteristics of aka-
thisia: a systematic investigation of acute psychiatric inpatient admis-
sions. Br J Psychiatry 1983;143:139–150
2. Herrera JN, Srameck JJ, Roy S, et al. High potency neuroleptics and
violence in schizophrenics. J Nerv Ment Dis 1988;176:558–561
3. Crowner ML, Douyon R, Convit A, et al. Akathisia and violence [let-
ter]. Psychopharmacol Bull 1990;26(1):115
Igor I. Galynker, M.D., Ph.D.
Deborah Nazarian, M.D.
New York, New York
Cessation of Self-Mutilation in a Patient