Information For First Responders

Are you a frontline worker, community health advocate or member of an outreach programme that encounters individuals in acute crisis? This page is for you. Its purpose is to bridge the gap between standard behavioral addiction and mental health models and the complex, underlying neurochemical realities of central nervous system injury, helping responders best diagnose and treat individuals in crisis. 

1. Education in Akathisia: Free Clinician & Responder Training

When a patient stops, starts or changes dose of a medication, they are at risk of developing akathisia. Akathisia may also occur as a result of encephalitis and traumatic brain injury. Akathisia is a severe, often misdiagnosed medication-induced neurological condition characterised by profound inner restlessness, physical agitation, and a high risk of self-harm or suicide.¹  In some individuals, akathisia is also associated with increased homicide risk.² It is routinely mistaken for a worsening psychiatric illness, leading to the dangerous error of increasing and adding medication.³ Akathisia is NOT simple anxiety. It is an iatrogenic disorder⁴  Throwing medication and sedatives at a person with akathisia in an attempt to 'calm them down' risks causing further damage to neurological functioning.²

1. We invite readers to familiarise themselves with the Akathisia section of this site and what medications are contraindicated.  

2. We also invite medical professionals, clinicians and crisis workers to complete the free, accredited training modules accessible through MISSD (The Medication-Induced Suicide Prevention and Education Foundation in Memory of Stewart Dolin). These courses provide critical instruction on recognising, diagnosing, and safely responding to akathisia. These can be accessed directly through the MISSD Free Akathisia Training Catalog.

3. See also Akathisia for Clinicians.

Remember:

• If it's med-induced (iatrogenic), look at the drugs (has the patient started a new medication? has the patient reduced or increased medication? has the patient recently cold turkeyed a medication?)

• If it's organic (TBI), protect the brain (avoid chemical sedation⁵ ⁶ , prioritize environment) 

How Responders Can Help

For someone experiencing akathisia or severe medication-induced agitation, the priority should be to keep them safe while allowing them to move. In an emergency where there is an immediate risk of serious harm, trained professionals may need to use restrictive measures as a last resort, but this should be accompanied by appropriate medical assessment and monitoring.¹  

Akathisia can involve an extremely distressing internal feeling of restlessness and an overwhelming need to move. Trying to stop the person's movements without first understanding what is causing the agitation may increase their distress rather than calm it. Clinical guidance for severe agitation recommends starting with the least restrictive approach possible, including environmental changes and verbal de-escalation, with physical restraint reserved for situations where it is genuinely necessary for safety.¹ 

• Give them a safe space to move. Clear away objects that could cause injury and, where possible, give the person enough room to pace, rock, shift position or move their legs safely. Movement may be an important part of how they cope with the overwhelming internal restlessness of akathisia.³ 

• Reduce sensory stimulation. Dim harsh lighting where possible, reduce unnecessary noise and avoid crowding the person. Environmental interventions that reduce light, noise and other stimulation are recommended as part of managing severe agitation.¹ ²

• Keep communication calm and simple. Use a slow, steady and reassuring voice. Avoid bombarding the person with questions, demanding eye contact or repeatedly telling them to “calm down” or “just sit still.” Acknowledge that you understand how distressed they are feeling, and give them space to move while maintaining a safe environment.¹ ²

• Don't automatically assume the agitation is psychiatric. If severe restlessness appears after starting, stopping or changing a medication, akathisia should be considered as a possible cause. Misidentifying akathisia as ordinary psychiatric agitation can lead to inappropriate treatment and, in some circumstances, increasing the medication that caused the akathisia can make the problem worse.²

• Be cautious about medication choices: If akathisia is suspected, the treating clinician should consider whether the medication itself is contributing to the problem (through an adverse effect or withdrawal). Evidence-based management of medication-induced akathisia generally begins with reviewing the offending medication, rather than immediately adding another medication.³  Find out more about the potential dangers of polydrugging here.

See courses and visit the Akathisia Alliance for more information. 

2. Safe Tapering Psychotropic Medications 

When a patient wants to come off a medication, you may be familiar with instructions to reduce psychiatric medications by large cuts, or to take them “every other day.” This is sometimes referred to as a linear or rapid reduction taper.⁷ 

Why this method of tapering can be problematic 

Alternating doses or making large, sweeping cuts assumes that drug clearance and receptor binding operate in a straight, linear fashion. This approach ignores how psychotropic drugs bind to brain receptors on a hyperbolic curve. 8 Dropping doses in large chunks or skipping days causes massive, abrupt drops in receptor occupancy, increasing risk of withdrawal and destabilisation.⁸

The Maudsley Standard (Hyperbolic Tapering)

Endorsed internationally, the Maudsley Deprescribing Guidelines offers the new gold standard framework. The guidelines describe a hyperbolic approach to tapering certain psychiatric medications, operating on the basic idea that reductions may need to become progressively smaller as the dose gets lower, because the relationship between dose and receptor effects is not necessarily linear.⁹ This ensures proportional, gradual reductions that match the brain's natural receptor curve, protecting the central nervous system from more severe withdrawal. The Maudsley approach does not mean that everyone should follow exactly the same tapering schedule. The appropriate pace depends on the medication, the person's circumstances and how they respond to each reduction. NICE specifically states that the rate of safe withdrawal varies between people and can vary over time for the same person, and recommends that reductions can be made smaller or delayed when withdrawal symptoms become intolerable.⁷ 

We invite readers to familiarise themselves the withdrawal section of this website and comprehensive tapering guides  for further clinical breakdowns. 

For patients that have recently cold turkeyed off medication, please see our page on Reinstatement To Reduce Withdrawal.

3. First Responders & Task Forces: Understanding Benzodiazepine Addiction

For frontline workers, drugs and alcohol task forces and emergency responders, understanding the physiological reality of benzodiazepines is vital.

Benzodiazepine dependence involves significant adaptations in the GABA-ergic nervous system.¹⁰ Physical dependence can develop after relatively short periods of regular use (days to weeks), even when benzodiazepines are taken as prescribed.¹¹ Those who use benzodiazepines regularly can develop tolerance and may experience interdose withdrawal, particularly with shorter-acting benzodiazepines.¹² 

The Dangers of Mismanaged Cessation

Abrupt cessation or rapid reduction of benzodiazepines can trigger significant withdrawal symptoms and, in some cases, life-threatening seizures.¹³ Withdrawal can also involve severe psychological and physical symptoms, and some people experience symptoms that persist for a prolonged period after stopping.¹⁴ 

This is why someone who is physically dependent on a benzodiazepine should not simply be told to stop taking it or be put through a rapid detox without careful consideration of their individual circumstances. Current clinical guidance recommends a gradual, individually tailored taper, with the pace adjusted according to how the person responds.¹⁵

First responders equipped with this insight can better navigate crisis calls involving polypharmacy, withdrawal mimics and complex substance-benzo overlaps. 

We recommend familiarising yourself with the withdrawal section of our website, the Ashton Manual (pdf) and visiting the Benzodiazepine Information Coalition for more information.

References:

1.Garriga, M., Pacchiarotti, I., Kasper, S., et al. (2016). Assessment and management of agitation in psychiatry: Expert consensus. World Journal of Biological Psychiatry, 17(7), 1–40. https://doi.org/10.1080/15622975.2016.1167072

2. Salem, H., Nagpal, C., Pigott, T., & Teixeira, A. L. (2017). Revisiting antipsychotic-induced akathisia: Current issues and prospective challenges. Current Neuropharmacology, 15(5), 789–798. https://doi.org/10.2174/1570159X15666170118110138

3. Pringsheim, T., Gardner, D., Addington, D., Martino, D., Morgante, F., Ricciardi, L., Poortvliet, P., & others. (2018). The assessment and treatment of antipsychotic-induced akathisia. Canadian Journal of Psychiatry, 63(11), 719–729. https://doi.org/10.1177/0706743718796715

4. Brown, P. (1988). Review: Drug induced akathisia in medical and surgical patients. International Journal of Psychiatry in Medicine, 18(1), 1–15. https://doi.org/10.2190/N4V0-RTY4-V8FX-PWTX

5. Ponsford, J., Bayley, M., Wiseman-Hakes, C., Togher, L., Velikonja, D., McIntyre, A., Janzen, S., & INCOG Expert Panel. (2014). INCOG recommendations for management of cognition following traumatic brain injury, part I: Posttraumatic amnesia/delirium. Journal of Head Trauma Rehabilitation, 29(4), 307–320. https://doi.org/10.1097/HTR.0000000000000077

6. Clinical practice guidelines on post-traumatic cognitive impairment: Assessment and remedial measures. (2025). [Journal details as published in PMC]. https://pmc.ncbi.nlm.nih.gov/articles/PMC11878456/

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 7. National Institute for Health and Care Excellence. (2022). Medicines associated with dependence or withdrawal symptoms: Safe prescribing and withdrawal management for adults (NG215). NICE guideline NG215

8. Horowitz, M., & Taylor, D. (2024). The Maudsley deprescribing guidelines: Antidepressants, benzodiazepines, gabapentinoids and Z-drugs. Wiley-Blackwell.

9. Horowitz, M. A., & Taylor, D. (2019). Tapering of SSRI treatment to mitigate withdrawal symptoms. The Lancet Psychiatry, 6(6), 538–546. https://doi.org/10.1016/S2215-0366(19)30032-X

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10. American Society of Addiction Medicine. (2025). The joint clinical practice guideline on benzodiazepine tapering: Considerations when benzodiazepine risks outweigh benefits. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-025-09348-4

11. U.S. Food and Drug Administration. (2020, September 23). FDA requiring boxed warning updated to improve safe use of benzodiazepine drug class. https://www.fda.gov/drugs/fda-drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

12. Benzodiazepine Information Coalition. (n.d.). Interdose withdrawal. Benzodiazepine Information Coalition https://www.benzoinfo.com/

13. Hu, X. (2011). Benzodiazepine withdrawal seizures and management. Journal of Clinical Neuroscience, 18(4), 465–469. https://doi.org/10.1016/j.jocn.2010.09.020

14. Lader, M. (2015). Benzodiazepine harm: How can it be avoided? Journal of Clinical Psychiatry, 76(11), e1472–e1473. https://doi.org/10.4088/JCP.15ac10197

15. American Society of Addiction Medicine. (2025). The joint clinical practice guideline on benzodiazepine tapering: Considerations when benzodiazepine risks outweigh benefits. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-025-09348-4