Restlessness and Agitation: Causes and What Helps

What restlessness feels like

Restlessness has two parts that often occur together:

• Inner restlessness: feeling keyed up, on edge, unable to relax or switch off, with racing thoughts.
• Physical restlessness: fidgeting, tapping, pacing, shifting position, wringing hands, getting up repeatedly.

When it is severe, with tension, irritability and purposeless movement, it is called psychomotor agitation. Some people describe it as "feeling like I want to crawl out of my skin".

Restlessness that is only in the legs, worse in the evening and relieved by moving, is a different problem: see restless legs.

Common causes of restlessness

Anxiety and stress

Anxiety is the most common cause. Stress hormones such as adrenaline prepare the body to act, which causes restlessness, muscle tension, a fast heartbeat and poor sleep. Feeling restless or on edge is one of the core symptoms of generalized anxiety disorder. Panic attacks, PTSD and obsessive-compulsive disorder can cause it too.

Caffeine, nicotine and stimulants

Coffee, energy drinks, pre-workout supplements, decongestants such as pseudoephedrine, and stimulant medicines can cause jitteriness, restlessness and trouble sleeping. Sensitivity varies. Effects of caffeine can last 5 to 6 hours or longer.

Sleep loss

Short or broken sleep increases irritability and makes it harder to sit still and concentrate, especially in children, who often become overactive rather than sleepy.

ADHD

Attention deficit hyperactivity disorder causes lifelong restlessness, fidgeting, difficulty waiting, and trouble focusing. In adults, hyperactivity often shows as inner restlessness rather than running around.

Depression and bipolar disorder

Depression is often thought of as slowing down, but agitated depression causes pacing, hand-wringing and irritability. In bipolar disorder, a manic or hypomanic phase causes restlessness with little need for sleep, racing thoughts and impulsive behavior.

Hormonal changes

Premenstrual syndrome, perimenopause and pregnancy can bring restlessness, irritability and poor sleep.

Medical causes of restlessness

• Overactive thyroid: hyperthyroidism speeds up the body, causing restlessness, tremor, sweating, weight loss, heat intolerance and palpitations.
• Low blood sugar: shakiness, sweating, hunger and restlessness, especially in people taking insulin or sulfonylureas.
• Pain, a full bladder or constipation: common hidden causes in people who cannot explain discomfort, such as young children and people with dementia.
• Delirium: a sudden change in attention and awareness caused by infection, dehydration, medicines, surgery or low oxygen. It is common in older adults. See delirium.
• Dementia: restlessness and pacing, often worse in late afternoon and evening ("sundowning").
• Withdrawal: from alcohol, benzodiazepines, opioids or nicotine. Alcohol withdrawal can become dangerous. See drug withdrawal.
• Breathing problems: low oxygen from asthma, pneumonia or heart failure can make people restless before other signs are obvious.

Akathisia: restlessness from medicines

Akathisia is an intense inner urge to move with inability to stay still, caused by medicines that block dopamine. It typically starts days to weeks after starting or increasing:

• antipsychotics (such as haloperidol, aripiprazole, risperidone)
• anti-nausea drugs (metoclopramide, prochlorperazine)
• some antidepressants, especially SSRIs

People rock, cross and uncross their legs, or march on the spot. It is distressing and can raise the risk of suicidal thoughts, so tell your prescriber promptly. Do not stop the medicine suddenly without advice.

How doctors find the cause

A doctor will ask when the restlessness started, whether it is constant or comes in episodes, about caffeine, alcohol and drug use, new medicines, sleep, mood, worries and weight changes. In older adults they will check for confusion and look for infection, pain and constipation.

Useful tests can include thyroid function, blood sugar, a complete blood count, electrolytes and kidney function, a urine test for infection, and screening questionnaires for anxiety, depression or ADHD.

Treatment and what helps

Treatment depends on the cause:

• Anxiety: cognitive behavioral therapy (CBT) is first-line. SSRIs or SNRIs help many people.
• ADHD: behavioral strategies, coaching and medicines.
• Overactive thyroid: beta-blockers ease symptoms quickly while the thyroid is treated.
• Akathisia: lowering or changing the causative medicine. Some people are prescribed propranolol.
• Delirium: finding and treating the underlying cause, with calm, familiar surroundings.

Things you can do yourself

• Cut down caffeine gradually, and avoid it after midday.
• Get 20 to 30 minutes of physical activity most days. Exercise burns off stress hormones.
• Try slow breathing: breathe in for 4 seconds, out for 6 seconds, for 5 minutes.
• Keep a regular sleep schedule and limit screens before bed.
• Limit alcohol, which worsens anxiety and sleep the next day.
• Break tasks into short blocks with movement breaks if you find it hard to sit still.

Frequently asked questions

What causes restlessness and agitation?

The most common causes are anxiety, stress, caffeine, poor sleep and ADHD. Medical causes include an overactive thyroid, low blood sugar, pain, infection, delirium, dementia, withdrawal from alcohol or drugs, and side effects of antipsychotics, antidepressants and anti-nausea medicines.

What is the difference between restlessness and agitation?

Restlessness is an inability to relax or keep still. Agitation is a more intense state with irritability, tension and purposeless movement such as pacing or hand-wringing. Agitation is more likely to have a medical or psychiatric cause that needs assessment.

Can restlessness be a sign of a heart problem?

Restlessness itself is rarely a heart problem, but a racing or irregular heart, low oxygen or heart failure can make you feel restless and anxious. Restlessness with chest pain, breathlessness or fainting needs emergency care.

Why do I feel restless at night?

Night-time restlessness is often due to anxiety, caffeine late in the day, screen use, irregular sleep times or alcohol. An urge to move the legs that eases with movement suggests restless legs syndrome. Night-time restlessness and confusion in older adults can be sundowning or delirium.

Can medicines cause restlessness?

Yes. Stimulants, decongestants, steroids, thyroid hormone in excess, some asthma inhalers, and especially antipsychotics, anti-nausea medicines and SSRIs (through akathisia) can cause it. Talk to your prescriber rather than stopping a medicine on your own.