Akathisia is considered an extrapyramidal symptom (EPS) that is characterized by an objective inability to sit or stand still and by a subjective feeling of inner restlessness. The prevalence of acute akathisia ranges from 8% to 76%, while that of chronic or tardive akathisia varies from 0.1% to 41%during treatment with typical antipsychotics. We present a patient who developed severe acute akathisia after paliperidone administration for treatment of major depressive disorder. A 35-year-old man, Mr. S., was admitted our hospital in February 2014. Mr. S. had been treated for major depressive disorder for almost 8 months. Multiple antidepressant treatments, most recently 40 mg/day paroxetine had failed to achieve an adequate response. One day before admission to our hospital, 3 mg/day paliperidone had been added to his treatment. On admission to our hospital, Mr. S. manifested a number of symptoms such as unable to sit and stand still, excessive anxiety, depressive mood, anhedonia, fatigue, psychomotor agitation, decreased appetite, and severe insomnia. He was diagnosed as drug induced movement disorder (akathisia) and major depressive disorder according to DSM-IV-TR. We stopped paliperidone treatment and started 3mg/day clonazepam and 60 mg/d propranolol treatment. Three days after beginning the clonazepam and propranolol, the patient’s akathisia symptoms were remitted. A large part of patients with major depressive disorder fail to achieve remission, evidence indicates that augmentation of atypical antipsychotics can play an important role in the treatment-resistant depression. Akathisia is frequently associated with the use of typical antipsychotic drugs. Akathisia develops after starting antipsychotic medication or can be seen following dose increase. Incidence of typical antipsychotic induced acute akathisia that is developed in first 2 weeks is reported to be occurred approximately 31%. Although akathisia can be seen during treatment with paliperidone, there are restricted numbers of reports in which akathisia had occurred after a single dose. We suggest that patients should be informed about akathisia and clinicians should keep akathisia in their mind as potential and severe side effect while patients were started on treatment of paliperidone.