A Rating Scale for Acute Drug-Induced Akathisia:

Development, Reliability, and Validity

Perminder Sachdev
ii

This paper describes the process of developing a new rating scalefor acute neuroleptic-induced
akathisia. Previously reported clinical characteristics of akathisia were used to construct the
initial version of the scale. This was administered to 100 consecutively admitted psychiatric
patients treated with neuroleptic medication. The scale was then subjected to a reliability
analysis, and the number .of items reduced. A factor analysis of the ratings supported the
decision to rate subjective and objective items separately. The new version of the scale (The
Prince Henry Hospital Akathisia Rating Scale) wasfurther standardized in its administration. A
preliminary examination of its construct validity was performed by calculating the correlations
with the ratings on the analogue and global scales, as well as those of depression, anxiety, and
hyperactivity. The new scale was administered to $0 new subjects to examine its interrater
reliability and concurrent validity with respect to the Barnes Akathisia Rating Scale.

Key Words: Akathisia, neuroleptic drugs, schizophrenia, scale, reliability, validity

Introduction tion of akathisia, with no examination of the relative merits

Akathisia is a side effect of neuroleptic medication that is
characterized by a subjective component of restlessness and
distress, particularly referable to the legs, and an objective
component of restless movements in the form of an inability
to sit or stand for prolonged periods, leg and arm move-
ments, shifting weight from foot to foot while standing, and
so on (Brands et al 1983). It is not only common but, being
extremely distressing, significantly impacts the clinical
management of psychiatric disorders (Barnes and Braude
1985; Sachdev and Loneragan 1991). A number of studies
investigating the treatment of neuroleptic-induced akathisia
(NIA) have been published (see reviews by Adler et al 1989;
Fleischhacker et al 1990). A close examination of these
publications reveals two major deficiencies: (a) A large
number of rating scales have been used for the quantifica-
From the Neuropsychiatric Institute, The Prince Henry Hospital. Sydney, Australia.
Address reprint requests to Dr. Perminder Sachdev, P.O. Box 233, Matraville NSW
2036. Australia.
Received October 29,1992; revised September 20,1993.
O 1994 Society of Biological Psychiatry
of the scales. Unlike tardive dyskinesia (TD), for which the
Abnormal Involuntary Movements Scale (AIMS) (National
Institute of Mental Health 1976) became widely accepted,
no single NIA scale has come to the fore. (b) Research
diagnostic criteria for NIA have not been published with the
exception of the Burke et al (1989) criteria for chronic NIA.
These deficiencies make it difficult to compare studies on
NIA, especially when it is recognized that the diagnosis of
NIA is difficult and different subsyndromes may exist
(Sachdev and Loneragan 1991).
In this paper we report the development of a rating scale
for acute NIA, using as the starting point published work on
the clinical characteristics of NIA. In the second part of the
paper the reliability and validity of this scale are reported.
Published Rating Scales for NIA
A number of rating scales for NIA have been used by inves-
tigators in the past. The Extrapyramidal Rating Scale of
Chouinard et al (1980) rates akathisia on a 0 to 6 scale (0 =
absent, 6 = constant movement). It also rates the patient's
0006-3223/94/$07.00
264 BIOLPSYCHIATRY
1994;35:263-271
complaints of being "restless, nervous, unable to sit still"
from 0 (none) to 3 (unable to sit down). Some investigators
have used the sum of the objective and subjective items of
the above scale to obtain an overall akathisia rating on a 0 to
9 scale (Lipinski et al 1984). Barrels et al (1981, 1987) used
a 3-point scale for akathisia based on subjective and objec-
tive symptoms. Kabes et al (1982) used a global 0 (none) to
3 (unable to sit down) objective rating of akathisia for a
pharmacological study. Friis et al (1983) described a 4-point
rating scale for both subjective and objective items, along
with definitions of each rating. Van Putten et ai (1984) used
a 7-point rating of akathisia, based on subjective report and
observed movements, as part of the Involuntary Movement
and Extrapyramidai Scale (May PRA and Van Putten T,
unpublished). Adler et al (1985, 1986) used the Hillside-LIJ
modification of the Extrapyramidal Symptoms Scale of
Simpson and Angus (1970), which rates the movement (ob-
jective) component of akathisia on a 0 to 4 scale (0 ---
absent, 4 --- extreme, heightened activity). Fleischhacker et
al (1989) subsequently published the Hillside Akathisia
Rating Scale, which comprises two subjective and three
objective items, with anchor points provided for the ratings.
A German version of this scale has also been published
(Fleischhacker et al 1991). Adler et al (1985) also used a
100-mm anchored line to assess subjective akathisia. We
have used a visual analogue scale for the global assessment
of akathisia (Sachdev and Chee 1990; Sachdev and Lonera-
gan 1993).
Most of the above scales have some common characteris-
tics: the ratings are global, using either objective alone or
both subjective and objective features; the scales were de-
veloped by groups for their own particular investigations;
the akathisia ratings often form a part of larger scales for
rating extrapyramidal symptoms; and, the psychometric
properties of the scales have not generally been published.
Only two scales (Barnes 1989; Fleischhacker et al 1989)
have been presented as rating scales specifically for akathi-
sia with reliability data having been published.
Braude et al (1983), in their investigation of the clinical
characteristics of NIA, used a 4-point scale to rate four
subjective (questionnaire) and 14 objective (examination)
items of NIA. Severity was judged by the proportion of
observation time that a particular movement was present. A
global rating into absent, mild, moderate, and severe was
also made. Although the authors described the procedure of
assessment in detail, it was never developed into the form of
a rating scale. Nevertheless, it was adapted to serve that
function by Brown et al (1987) in a subsequent investiga-
tion, without any published data on its reliability. The clini-
cal characteristics of NIA reported by Braude et al (1983),
and subsequently by Barnes and Braude (1985), were the
basis for the rating scale derived by Barnes (1989). This
scale rates the objectively observable movements and the
P. Sachdev
subjectively experienced restlessness on a 0 to 3 scale, and
also separately rates the subjective distress. It is thus unique
in separating the experience of restlessness from the distress
because of this experience. This was based on the observa-
tion (Barnes and Braude 1985) that in some cases, espe-
cially in chronic NIA, restlessness may be present without
any subjective distress. In addition, the scale rates NIA
globally on a 0 to 5 scale (absent, nil, mild, moderate,
marked, severe). The ratings take into consideration obser-
vations in the ward outside the time of the formal rating
procedure. A high interrater reliability was demonstrated by
the author for all items of the scale.
The Hillside Akathisia Scale (Heischhacker et al 1989)
rates subjective and objective features separately, charac-
terizing the frequency and magnitude of the phenomena
rather than their exact nature. The objective items relate to
the body regions involved (head and trunk; hands and arms;
feet and legs). Because this scale was primarily designed to
measure severity of akathisia in psychopharmacological
research, it incorporates a global measure of improvement
on a 0-7 scale. The reliability of this scale has been reported
to be satisfactory (Fleischhacker et al 1989, 199 I).
The summary characteristics of the above scales are
presented in Table 1.
Part h Development of a New Rating Scale
The varied clinical features of NIA were best captured by
the questionnaire used by Braude et al (1983) which, as we
argue in this paper, is a suitable starting point for the devel-
opment of a valid and reliable scale. The Barnes scale,
which manifestly evolved from the same questionnaire, re-
stricted itself to global judgments, disregarding the richness
of the clinical features of NIA, It is quite likely that the
different signs and symptoms of NIA find variable expres-
sion in different patients, and therefore deserve to be rated
separately to represent the uniqueness of the individual
patient, as has been recognized in the Hillside Scale. Fur-
ther, global ratings, often required to consider multiple fea-
tures simultaneously, may suffer from poor'interrater reli-
ability and reproducibility,
We investigated a series of patients recently started on
neuroleptic medication with the questionnaire items modi-
fied (see below) from Braude et al (1983) in order to derive
and standardize a rating scale for acute NIA. The criteria for
inclusion into the study allowed only acute NIA patients to
be included, although excluding subjects with tardive
akathisia. We now describe the process of development of
the scale, and provide data on its reliability and validity.
Patients and Method
Consecutive patients (n = 100) admitted to the psychiatric
units of two University of New South Wales teaching hospi-
Rating Scale for Drug-Induced Almthisia BIOLPSYCHIATRY 265
1994;35:263--271

Table 1. Synopsis of Akathisia Rating Scales

Subjective/
Specific Global Subjective objective Reliability
for ratings features ratings data
Au~o~ Scale akathisia? range considered separately published
Chouinard et al Chouinard Extrapyramidal No 0-9 Yes Yes Yes
(1980) Rating Scale ( 0 6 and 0 3 )
Barrels et al AkathisiaRating Scale Yes 0--3 Yes No No
(1981)
Friiset al Akathisia Rating Scale Yes 0-3 Yes No No
(1983)
Van Puuen, May InvoluntaryMovement and No 0-6 Yes No No
andM~ler ExtrapyramidalScale
(unpublished)
Brande et al AkathisiaQuestionnaire Yes 0--3 Yes Yes No
(1983) and Examination
Kabeset ai ExtrapyramidalSide- No 0-3 No No No
(1982) Effects Rating Scale
Adleretal Hilside-LU modification Yes 0-4 No No No
(1985,1986) of Simpson & Angus Scale
Adleret al Analogue Scale for Yes 100-mmline No No No
(1985) Akathlsia
Barnes(1989) Rating Scale for Drag- Yes 0-5 Yes Yes Yes
Induced Akathisia
Fleischhacker The Hillside Akathisia Yes 0-.8 Yes Yes Yes
et al (1989) Scale
Sachdevand Chee Visual Analogue Scale Yes 100-mm line Yes No No
(1990)

tals who fulfilled the following criteria were included:
(1) clinically eligible for initiation on neuroleptic medica-
tion for the treatment of psychosis; (2) free of antipsychotic
medication for at least 2 weeks (6 weeks in case of a depot
preparation) at the time of admission; (3) free of anticholin-
ergic or antiadrenergic medication for least 2 weeks; (4)
absence of akathisia at the time of initial assessment; (5) not
currently on drugs other than neuroleptics known to cause
agathisia; (6) no history of restless legs syndrome, Parkin-
son's disease, peripheral neuropathy, diabetes meilitus, or
peripheral vascular disease.
The subjects, 45 men, 55 women, had a mean age of 34.4
(SD 10.8) years. Their psychiatric diagnoses, using DSM-
III-R criteria (American Psychiatric Association 1987),
were Schizophrenic Disorder 75, Bipolar Disorder manic 4,
Delusional Disorder 8, Brief Reactive Psychosis 4, and
Psychotic Disorder other 9. They received a mean (SD)
dose of 413 (233) mg chlorpromazine equivalents (CPZE)
on the day of initiation of neuroleptics, and a maximum dose
of 595 (672) in the first 2 weeks, using the neuroleptic
equivalence data of Davis (1976).
Subjects were assessed at baseline within 48 hr of admis-
sion, prior to the initiation of antipsychodc drugs, and the
inclusion criteria satisfied. A few subjects had received an
"emergency" dose of a neuroleptic prior to the initial as-
sessment, but as they fulfilled all other criteria, were in-
cluded in the study. After a full psychiatric and physical
assessment, they were started on an antipsychodc drug,
most commonly haloperidol, chlorpromazine, trifluopera-
zine or thioridazine by the treating psychiatrist. Nocturnal
sedation was permitted but anticholinergic and antiadrener-
gic drugs were not administered until after full assessment
and a decision about continuing inclusion by the research
team. The subjects were reviewed daily in the morning with
a short questionnaire to pick up any early manifestations of
NIA. A full assessment was performed on day 7, or earlier if
a subject developed NIA severe enough to need some inter-
vention (Postdrug assessment PDI). Those subjects who
did not need the introduction of any antiakathisia medica-
tion up to day 7 were followed up until day 14, when another
full assessment was performed (Postdmg assessment PD2).
The baseline PDI and PD2 assessments comprised the fol-
lowing: Long Akathisia Rating Scale (Long) (see below),
Analogue Akathisia Rating Scale (see below), Global Rat-
ing Scale for Akathisia (see below), Scale for Extrapyrami-
dal Side Effects (Simpson and Angus 1970), the Abnormal
Involuntary Movements Scale (National Institute of Mental
Health 1976), Zung's Depression Scale (Zung 1965) and
Spielberger's State Anxiety Inventory (Spielberger et al
1967). The PDI and PD2 akathisia assessments were video-
taped for most subjects for later independent review.
One hundred subjects were assessed on PDI and 8S on
PD2. Data were analyzed using the SPSS-PC+ package
(SPSS Inc 1988).
266 BIOLPSYCHIATRY P. Sachdev
1994;35:263-271

Table 2. ItemsIncluded in the Long Scale full body visible to the examiner, with arms and legs par-
Subjective items tially unclothed. They were engaged in neutral conversation
"Sub I Distressing sensations in the limbs for the first 5 rain, without the movements being rated in this
Sub 2 Feeling of inner restlessness period. The objective ratings were performed in the next
Sub 3 Inability to remain still, standing/sitting 8 min, 4 min in the sitting, and two each in the standing and
Sub 4 Inabifity to keep legs still
lying positions. A mental task, counting from 30 backwards,
Objectiveitems and a motor task, tapping the fingers of both hands for 15 sec
Sitting
Sit 1 Inability to remain seated each, were performed in each position. The subjects also
Sit2 Semipurposeful/purposeless normal leg/feet movements listened to an audiotape recording of a passage for 2 min
"Sit 3 Inability to keep toes still while sitting. They were then rated on their subjective re-
Sit4 Shifting body position in chair port. Observations outside the period of the rating were not
Sits Semipuq~seful hand/arm movements
used for the ratings, although these were noted separately.
Standing The Analogue Scale was a 100-mm anchored line repre-
Stand I Shifting weight from foot to foot &/or walking on the spot
Other purposeless (normal) foot movements
senting a global judgment formed after completion of the
Stand 2
Stand 3 Inability to remain standing on one spot (walked or paced) examination, based on report of distress and observations of
Lying movements: 0 = none; 25 = sometimes and mild; 50 =
"Lie 1 Come tremorof legs/feet sometimes and severe, or most of the time and mild; 75 =
"Lie 2 Myoelonicjerksof the feet most of the time and severe; 100 = as severe as is possible
"Lie 3 Semipurposefulor purposelessleg/feetmovements and continuous.
"Lie4 Inabilityto remainlyingdown
The Global Ratings were overall ratings on a 0 to 3
A~p|ed from0mude et a11983. (absent, mild, moderate, severe) scale for akathisia based on
' Itemsthat weresubsequentlydropped, the clinical judgment of the investigators.

Akathisia Scales Results

The Long Scale comprised 16 items drawn from the Braude
et al (1983) questionnaire, which are listed in Table 2, Each
item was rated on a 0 to 3 scale, which, however, was
different from the one used by Braude et al. The subjective
items were rated as absent, mild, moderate, and severe on
the basis of the patient's response to specific questions. The
objective items were rated on the basis of both intensity and
duration, unlike Braude et al who rated these solely on the
basis of the proportion of observation time for which these
were present. We found the Braude et al ratings of "present
for less than half the observation time" and "more than half
the time" difficult to apply in practice. Movements that
were otherwise judged to be severe in intensity often oc-
curred intermittently for a few seconds at a time, thus mak-
ing their total duration of occurrence for only a small pro-
portion of the actual period of observation. Furthermore,
precise timing of the movements proved to be difficult when
multiple movements were being observed simultaneously,
and could only be done if the videotapes of the ratings were
rated on multiple occasions. Our decision to use both inten-
sity and duration in the ratings is in agreement with the
practice adopted in the Hillside Scale.
Our ratings were conservative, and when there was doubt
about the presence of a particular item, it was rated as "0."
There was, therefore, a categorical shift from "0" to "1"
denoting absence or presence, and the rating of 1,2, or 3 was
then a decision regarding severity.
A standardized procedure was followed for the examina-
tions. Subjects were seated in a comfortable chair with the
The Long Scale ratings on PD I and PD2 assessments were
analyzed for internal consistency of the scale using the
Reliability Analysis subcommand of the SPSS-PC+ pack-
age. It became clear from the examination of the mean
scores for the items that the lying items were scoring very
low (range of means for lying items, day 7 = 0.05 to 0.24,
day 14 = 0.03 to 0.16). We examined the cases with a rating
of 2 or more on any of the lying items. There were 5 such
cases on PDI and 3 on PD2. All these subjects had been
simultaneously rated 2 or more on at least two other objec-
tive items (sitting or standing), thereby suggesting that the
lying items were not providing further information. Dele-
tion of the lying items did not considerably alter the Cron-
bach'salpha(day7 = 0.9008,day 14 = 0.9053),andforthe
item "coarse tremor of legsReet," deletion actually in-
creased the alpha. We concluded from these results that the
lying items could be omitted without affecting the ability of
the scale to accurately assess the presence of akathisia or
rate its severity. The omission, however, would result in a
considerable saving in assessment time.
Two other items were noted to have low mean values and a
negative impact on Cronbach's alpha: Sub 1 "distressing
sensations in the legs" and sit 3 "inability to keep toes still."
These symptoms were not considered critical to the diagnosis
of akathisia, and the items were, therefore, deleted. Three
more items rated low: sit 1 "inability to remain seated," sit 5
"semipurposeful hand/arm movements," and stand 3 "in-
ability to remain standing on one spot." Because these fea-
tures were considered to be fairly characteristic of moderate
Rating Scale for Drug-Induced Akathisia alOL PSYCmATRY 267
1994;35:263-27 i

T a b l e 3. S p e a r m a n ' s C o r r e l a t i o n C o e f f i c i e n t s B e t w e e n S c o r e s o n D i f f e r e n t A k a t h i s i a S c a l e I t e m s o n D a y 7 (n = 100)

Items Sub 2 Sub 3 Sub 4 Sit I Sit 2 Sit 4 Sit 5 Stand I Stand 2 Stand 3 Sum sub Sum obj Sum

Sub 2 1.00
Sub 3 0.51 c 1.00
Sub4 0.39 c 0.53 ~ 1.00
Sit I 0.42 ¢ 0.40 ~ 0.40 ~ 1.00
Sit 2 0.44 ¢ 0.43 c 0.32 b 0.54 ¢ 1.00
Sit4 0.33 ~ 0.31 b 0.31 b 0.51 ¢ 0.46 ¢ 1.00
Sit5 0.21 ° 0.18 ° 0.22 ° 0.30 b 0.36 ¢ 0.57 ¢ 1.00
Stand ! 0.37 ~ 0.37 ~ 0.43 ~ 0.55 ~ 0.58 ~ 0.66~ 0.54~ !.0o
Stand 2 0.30 b 0.25 b 0.33 ~ 0.52 ~ 0.46 ~ 0.66 ~ 0.54 ~ 0.72 ~ 1.00
Stand 3 0.30 b 0.30 b 0.36 ~ 0.53 ~ 0.41 ~ 0.41 ¢ 0.51" 0.46 ~ 0.5Oc !.00
Sum sub 0.85 ~ 0.78 ~ 0.68 ~ 0.48 ~ 0.48 ~ 0.41 ~ 0.27 b 0.44 c 0.35c 0.38¢ 1.00
Sumobj 0.46 ~ 0.4Y 0.37 ~ 0.59 ~ 0.77 ~ 0.76 ~ 0.58 ~ 0.78 ~ 0.75¢ 0.54~ 0.54 ~ i .00
Sum 0.70 ~ 0.65 ~ 0.$7 ~ 0.57 ~ 0.69 ~ 0.68~ 0.52~ 0.72~ 0.67~ 0.52¢ 0.83 ¢ 0.88 c 1.00

Two.tailed,'p < 0.05, bp < 0.01,' p < 0.001.

Sum sub and Sum obj are Sums of Three Subjective and Seven Objective Items, respectively, and Sum is total of all items.

to severe akathisia, and exclusion of these items lowered the tions produced similar factor solutions, with the correlations
alpha, these were retained for the final version of the scale. between the factors being 0.45 for both PDI and PD2 data.
The new version of the scale had three subjective and The results of this analysis were interpreted as supporting
seven objective items, and needed an examination of the the decision to separately rate the subjective and objective
subject in sitting and standing positions only. The ratings on features of akathisia.
this 10-item scale (New Scale) were then subjected to a The sums of the subjective and objective items were
Reliability Analysis using the same date set as above with considered to represent the total subjective (Sum sub) and
the following results: PDI assessment: item mean 0.33 objective (Sum obj) scores, respectively. The sum of all the
(variance 0.02); interitem correlation mean 0.49 (range items gave an overall "Sum" score, which represented a
0.17--0.79, variance 0.02); Cronbach's alpha 0.9001; Stan- global rating for the severity of akathisia.
dardized item alpha 0.9053. PD2 assessment: item mean
0.32 (variance 0.03); interitem correlation mean 0.41 (range Validity
0.13--0.66; variance 0.01); Cronbach's alpha 0.8674; Stan- Because the items were drawn from those recognized to be
dardized item alpha = 0.8739. Split-half statistics were characteristic of acute drug-induced akathisia, the scale has
computed for the 10-item scale with the following results: face validity. Construct validation was examined by calcu-
PDI: alpha for part 1 = 0.87, part 2 = 0.89; correlation lating the Spearman correlation coefficients of the Sum sub,
between forms - 0.62; equal-length Spearman-Brown co- Sum obj, and Stun scores of PDI and PD2 with the Global
efficient = 0.77. PD2: alpha for part 1 = 0.77, part 2 = and Analogue Scores. The correlations with the Global
0.81; correlation between forms = 0.70; equal length Scores were highly significant (range 0.45 to 0.81, p <
Spearman-Brown coefficient = 0.82. 0.001 for all). The relatively low correlations may reflect the
The Spearman's rank order correlation coefficients be- fact that many subjects with a "0" Global rating did score at
tween the subjective and objective items, and their sums least on some items of the 10-item scale.
(Sum sub and Sum obj, respectively) are presented in Table The factorial separation of subjective and objective fea-
3. Most correlations were significant, suggesting an internal tures has been alluded to. We were interested in examining
consistency ~n the scale. The Sum sub and Sum obj scores whether the subjective items were rating something differ-
had a modest but significant correlation (day 7, p = 0.54, ent from anxiety as rated on the Spielberger scale and the
p < 0.001). Brief Psychiatric Rating Scale (BPRS), and depression as
rated on Zung's scale. Similarly, we wanted to know how
FACTOR ANALYSIS. The 10-item scale ratings for the objective ratings correlated with the ratings of hyperac-
PDI and PD2 were subjected to a factor analysis, the results tivity on the BPRS. The Spearman' s correlation coefficients
of which are presented ia Table 4. As is apparent, the sub- are presented in Table 5. Of note is the fact that Sum sub had
jective items loaded highly on factor 2, on which only one a low correlation with the anxiety and depression scores,
objective item had a high loading. A varimax rotation of the suggesting that it was measuring a different construct. The
matrix suggested the first factor as the "Objective" factor objective akathisia ratings correlated poorly with the BPRS
and the second as the "Subjective" factor. Oblique rota- ratings of motor activity. This further supported the conten-
268 BIOLPSYCHIATRY P. Sachdev
1994;35:263-271

Table 4. Factor Analysis of the 10-Item New Scale on Day 7 and Day 14
Day 7 Day 14
(n = !00) (n = 88)
Item Mean Mean
score Unrotated factors Rotated factors score Unrotated factors Rotated factors
(SD) 1 2 1 2 (SD) 1 2 I 2
Sub 2 0.59 (0.8) 0.62 0.54 0.14 0.8 ! 0.71 (0.8) 0.64 0.47 0.20 0.77
Sub 3 0.41 (0.7) 0.59 0.64 0.06 0.86 0.33 (0.5) 0.60 0.54 0.13 0.80
Sub 4 0.26 (0.5) 0.68 0.37 0.30 0.7 I 0.30 (0.5) 0.62 0.36 0.26 0.67
Sit ! 0.19 (0.5) 0.75 0.21 0.45 0,63 0.10 (0.3) 0.61 -0,11 0.55 0,50
Sit 2 0.43 (0,73) 0.82 0.10 0,57 0,59 0.56 (0.7) 0.82 -0.01 0.65 0.50
Sit 4 0.33 (0,68) 0.79 -0,24 0.76 0,31 0.37 (0.6) 0.73 -0.05 0,61 0.37
Sit 5 0.19 (0,5) 0.61 -0.50 0.85 0.05 0.19 (0.4) 0.75 -0.05 0.61 0.43
Stand ! 0.39 (0.7) 0,89 -0,13 0.78 0,46 0.28 (0.6) 0.80 -0. ! 3 030 0,40
Stand 2 0,34 (0.6) 0.79 -0.38 0,85 0,20 0,27 (0.3) 0,65 -0.32 0.70 0.16
Stand 3 O.16 (0.4) 0,73 -0,33 0,77 0,20 O. 14 (0.4) 0.62 -0,57 0.84 -0.05
ThefactorIoadingson the unrotatedandvarimaxrotatedfactormatrices,

tion that akathisia, as a syndrome, was distinguishable from
anxiety, depression, and agitation.
Comment
We have described the process of development of a scale
(Prince Henry Hospital Rating Scale for Akathisia, or the
PHH Scale), which rates the characteristic features of
akathisia, yet is not too elaborate and is simple to adminis-
ter. Its internal consistency is evidenced by the high Crow
bach's alpha and split.half reliability. A preliminary dem-
onstration of its construct validity is satisfactory, as
evidenced by the highly significant correlations with the
global and analogue ratings, and the low correlations of the
subjective and objective scores with measures of anxiety,
depression, and agitation. However, the potential risk of
method artifact in the validity study cannot be ruled out.
Ideally, the PHH Scale and the global ratings should be
performed by independent raters for the validity analysis to
be adequate. This condition was not met in our study, thus
making further investigations necessary to fully establish
the construct validity of the scale. In the subsequent section,
its interrater reliability and concurrent validity with the
Barnes Scale will be reported. In our experience, the PHH
Scale can be easily taught to a clinician or researcher. We
have attempted to define each item as explicitly as is clini-
cally possible in order to increase the reliability of the
scores. The ratings proposed are such that a categorical shift
occurs from "0" to "1." This feature is different from the
AIMS ratings of tardive dyskinesia in which a "fence"
rating of "minimal" is permissible. In our experience, a
similar scale for akathisia results in many items being rated
"minimal," often reflecting anxiety or agitation, with a
consequent reduction in the validity of the ratings. Our
proposal is conservative, but we feel that the gain in specifi-
city more than compensates for any loss of sensitivity.
Our scale has been developed for acute NIA. Its suitabil-

Table 5. Spearman's CorrelationCoefficients between Akathisia Scores and Other Ratings

Anxiety rating Depression Motor
rating hyperactivity
Spielberger BPRS (Zung) (BPRS)
Day7
FomlGroup(n = 100)
Sum sub 0, ! 7 0,05 0,20" -0.02
Sum obj 0,01 0,09 0,09 0.26b
Akathisia Group (n = 23)
Sum sub 0.10 0,12 0.40 0.22
Sum obj --0.10 0,12 0.05 0.27
Day 14 (n - 88)
Sum sub O,I 1 -0.03 0.04 0.06
Sum obj -0.04 0.02 -0.02 0.18
Two-tailed,'p< 0.05;~ < 0.01.
Rating Scale for Drug-lnduced Akathisia tool. PS~'CmATRY 269
1994;35:263--271

ity for tardive akathisia is not known, and warrants empiri- Table 6. Interrater Reliability of the New Akathisia Scale
cal investigation. There is some suggestion that the move- Rating Mean (SD)
ments observed in chronic akathisia may be qualitatively
Scale item Rater ! Rater 2 Kappa t score
different, and the overlap with TD quite common (Sachdev
and Loneragan 1991), factors that have to be considered in Sub I 0.40 0.48 0.65 6.75
(0.73) (0.81)
determining an appropriate scale for tardive akathisia.
Sub 2 0.38 0.32 0.80 7.54
Our scale is clearly not a diagnostic instrument, and (0.40) (0.68)
should not be used solely for this purpose. For research Sub 3 0.20 0.26 0.63 5.28
purposes, however, if it is indeed used to establish the inclu- (0.45) (0.56)
sion criteria of akathisia, we propose that a rating of at least Sit I 0.44 0.36 0.81 8.18
(0.76) (0.75)
"2" on both the Sum sub and Sum obj scores should be
Sit 2 0.14 0.18 0.48 4.08
considered necessary. This strict criterion recognizes the (0.76) (0.75)
fact that even though the scale makes a categorical distinc- Sit 3 0.06 0,18 0,42 4,67
tion between " 0 " and "1" ratings, a clinical distinction (0,31) (0,48)
between the phenomena of akathisia and anxiety and psy- Sit4 0,02 0,04 0,66 4,95
(0,14) (0,20)
chomotor agitation is extremely difficult and prone to error. Stand I 0,15 0.17 0,55 5,12
A sum score of " 2 " offers some protection against some (0.57) (0,59)
error at the risk of reduced sensitivity. It is, at present, not Stand 2 0,15 0,22 0.53 4,37
clear whether a diagnosis of akathisia should be made if (0.53) (0.49)
either the subjective or the objective features only are Stand 3 0,00 0,05 -- --
(0,00) (0,22)
present. Clinical data do suggest that in mild cases, no Gbl 0.36 0,36 0.70 6,75
objective features may be apparent, especially at the time of (0.72) (0,75)
formal rating. The diagnosis should then be based on obser-
The mean (SD) ratings by two investigators,and the kappa coefficients,on 50
vations over a longer period of time, including nurses' ob- subjectspresented.Allcorrelationswerehighlysignificant(p < 0.0l).
servation on the ward. It also remains to be established
whether a diagnosis of acute akathisia can be made in the
absence of subjective symptoms. It is, of course, not un- The subjects were rated on the PHH Scale by two investi-
common to see patients in the clinic who demonstrate gators (PS and CL) experienced in diagnosing and rating
movements fairly characteristic of akathisia but do not re- akathisia, with one of us interviewing the patient while the
port distress. This may be caused by the fact they are preoc- other observed. No consultation took place at the time of the
cupied with psychotic phenomena, or are uncommunica- ratings, and the guidelines for the administration were
tive, withdrawn, or unable to dissociate the akathisic strictly adhered to. Forty-three of the 50 were also simulta-
distress from the agitation they were already experiencing neous rated on the Barnes (1989) scale. The interrater reli-
because of their psychosis. Such patients need to be fol. ability for the PHH Scale was determined by calculating the
lowed up, as the diagnosis of akathisia usually becomes kappa coefficient for each item and for the global ratings by
clearer once the psychosis and the agitation improve. the two raters. The sum sub, sum obj and global ratings by
each rater were correlated with the subjective, objective,
Part lh Reliability and Concurrent Validity and global scores respectively on the Barnes Scale to exam-
ine the concurrent validity.
The reliability of the PHH Scale was examined by adminis-
tering it to a new group of 50 patients treated with neurolep-
tic drugs. Its concurrent validity was examined in relation to Results
the Barnes (1989) Rating Scale for Akathisia (Barnes Table 6 gives the kappa coefficients for each item and the
Scale). global akathisia ratings. All correlations were highly signif-
icant (p < 0.01), with kappa ranging from 0.42 to 0.81.
Method The Pearson' s correlations with the ratings on the Barnes
Fifty subjects, 22 men and 28 women, admitted to the psy- scale were high: (1) the sum of subjective items of the PHH
chiatric units of the two hospitals and then treated with Scale, when correlated with the subjective (awareness) and
neuroleptic medication were recruited for this part of the subjective (distress) scores of the Barnes scale had r - 0.84,
study. All were diagnosed to suffer from a DSM-III-R diag- 0.86 (rater 1) and 0.75, 0.82 (rater 2); (2) the sum of the
nosis of Schizophrenia or Schizophreniform Disorder. objective items correlated with the objective rating on the
Thirteen (26%) were judged to be clinically suffering from Barnes scale as r - 0.91 (rater 1) and 0.94 (rater 2). The
acute NIA. global akathisia ratings on the two scales had correlations of
270 BiOL PSYCHIATRY P. Sachdev
1994:35:263--271

0.84 (rater 1) and 0.86 (rater 2). All correlations were signif-
icant (t-test, two tailedp < 0.01).
Comment
We have demonstrated a high interrater reliability for all
items of the PHI1 Scale and for the global ratings. The
ratings on this scale correlate significantly with the subjec-
tive, objective, and global measures of the Barnes Scale,
thus providing preliminary evidence for its concurrent va-
lidity. The next step in the investigations would be the
administration of the scale by independent raters, a step
necessary to establish its validity and determine its ease of
administration. The suitability of the scale for the assess-
ment of tardive akathisia, and its sensitivity to change in
symptomatology in the course of treatment need to be as-
sessed.
Celia Loneragan assisted with data collection and the reliability studies,
This study was supported by the National Health & Medical Research
Council of Australia, and in part by the Rebecca Cooper Foundation and the
Rama¢iotti Foundations. ! am grateful to Prof. Gordon Parker for support.
Steven Caroming, Kearin Anstey, Anthony Kuk, and Jane Kruk assisted
with statistical analysis and Doreen Hanlon with manuscript preparation,
Appendix: Prince Henry Hospital Akathisia
Rating Scale
Instructions
Perform objective before subjective ratings
OBJ~CTiVE RATINGS, (ratings by observer)
Patient should be seated in a comfortable chair with full
body visible to examiner, preferably with arms and legs
unclothed. Engage in neutral conversation for the first 5
min, observing the patient' s movements. Perform two"dis-
tracting" procedures (counting from 30 backwards, and
tapping fingers of right and left hand for 15 sec each) to see
effect on movements. Play a recording of a passage for 2
min on which patient has to concentrate (optional: Observe
patient while he/she is watching a 2-min video cartoon clip).
Make the patient stand in one spot and engage in neutral
conversation for 2 min, with the examiner standing as well.
Repeat distracting procedures while standing. Encircle the
rating that applies to each item. Rate sitting and standing
separately. If in doubt, rate conservatively.
SUBJECTIVE RATINGS. Elicit from patient by direct
questioning the best responses to the items listed below.
Offer choices in case of indecision. Rate patient's experi-
ence currently (for the duration of this assessment only).
Key: 0-3: absent, mild, moderate, severe
0---~bsent
1--mild and present some of the time
2--mild and present most of the time or severe and
present some of the time
3--severe and present all the time
Note: There is a categorical shift between " 0 " and "1,"
with "1" representing a definite presence of the
feature.
GLOBAL RATINGS. Take overall observations and re-
port into consideration to make a global judgment on the
movements and the subjective symptoms.

ID No _ _ . _ . . Date of a s s e s s m e n t _ _ / / Rater ID
Project: Time begin: end: Initials

OBJECTIVE RA TINGS
I. Sitting
1. Semipurposeful/purposeless leg/feet movement 0 1 2 3
2. Semipurposeful hand/arm movements 0 I 2 3
3. Shifting body position in chair 0 ! 2 3
4. Inability to remain seated 0 I 2 3

II. Standing
1. Purposeless/semipurposeless leg/feet movements 0 1 2 3
2. Shifting weight from foot-to-foot and/or walking on spot. 0 1 2 3
3. Inabiility to remain standing on one spot (walking or pacing) 0 1 2 3

Sum Score
Rating Scale for Dmg-lnduced Akathisia
SUBJECTIVE RA TINGS
1. Feelings of restlessness, especially in the legs
2. Inability to keep legs still
3. Inability to remain still, standing or sitting
Global rating (by rater)
Absent Mild Moderate
0 1
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