Physical restlessness: when the body cannot settle

What it can look like

While waiting, somebody repeatedly stands up, moves one foot and checks their telephone. At bedtime, they notice tense shoulders and a need to change position. Another person walks around the house while thinking about a problem. They may describe energy, nerves, agitation or an inability to ‘switch off’ the body.

These behaviours are not always visible. Somebody may remain seated while clenching the jaw, curling the toes or holding the abdomen rigid. Internal experience and outward appearance do not necessarily match.

Activation and movement

When threat is expected, the body prepares for action. Heart rate, breathing and muscle tone change. If there is no specific action to perform, that preparation may be noticed as restlessness.

Movement is not necessarily harmful. Walking briefly or changing position may meet an ordinary physical need. Difficulty arises when movement is hard to control, prevents rest or becomes a constant test of whether anxiety has fallen.

Not all restlessness is anxiety

Akathisia is severe inner restlessness accompanied by a need to move and difficulty sitting or standing still. It can occur as an adverse effect of some medicines and requires assessment. It should not simply be interpreted as greater nervousness.

Assessment may also consider timing, sleep, caffeine and other substances, pain, iron, thyroid function and specific leg sensations. Medicine should not be stopped or altered without medical advice.

Questions that clarify the pattern

• Does restlessness occur with a specific worry, or remain when the subject changes?
• Did it begin after starting, stopping or changing a medicine?
• Is it mainly in the legs, with temporary improvement during movement?
• Does it prevent sleep, eating, study, driving or remaining in an appointment?
• Does it occur with palpitations, weight loss, fever, pain, confusion or substance use?

When it forms part of anxiety

Assessment identifies worries, avoided situations and behaviours used to check or reduce activation. Cognitive behavioural therapy may change interpretations of sensations, reduce avoidance and restore activities. Relaxation techniques may be useful, but should not become a test repeated until perfect calm is achieved.

Advice is warranted when restlessness lasts for weeks, worsens, restricts life or occurs with other physical symptoms. Marked onset after a medicine change should be reported promptly to the prescriber. Severe agitation with confusion, danger or an inability to remain safe requires urgent help.