Akathisia is one of the most distressing side effects of neuroleptic treatment. It is usually managed by manipulating the neuroleptic dose and administering anti-akathisic compounds (beta-blockers, anticholinergics, serotonin antagonists). However, the pathophysiological background of withdrawal akathisia which follows the discontinuation of neuroleptic treatment remains unclear, and there is as yet no adequate treatment. We report a case of severe withdrawal akathisia associated with suicidal and autoaggressive behaviour during a gradual transition from perphenazine/trihexyphenidyl to clozapine. The akathisia was effectively managed by titration of clozapine (maximum dose 200 mg/day) Thereafter, reduction of the clozapine dose resulted in a recurrence of the akathisia, and the resumption of clozapine dose was accompanied by full amelioration of symptoms. We suggest that the antiserotonergic properties of clozapine were responsible for its anti-akathisic effect. Differences in the treatment of acute and withdrawal types of akathisia are emphasized.