AGITATION

BY MEAZA SEMA(PSY R1)

MODERATOR DR ELIAS
TESFAYE(MD,ASS’T PRO.OF PSYCHIATRY)
 OUTLINE
• OVER VIEWON PSYCHIATRIC EMERGENCY
• DEFINE TERMS
• PATHOPHYSIOLOGY OF AGITATION
• CAUSE OF AGITATION
• APPROCH TO AGITATED PATIENT
• MANAGMEN OF AGITATION
 PSYCHIATRIC EMERGENCY

• Is any disturbance in thoughts, feelings, or

actions for which immediate therapeutic
intervention is necessary.
• Emergency psychiatry originated in the Russo-Japanese War
(1904–1905).

• Psychiatrists in the Imperial Russian Army championed

treating psychiatric emergencies at the front lines.

• Healthy components of personality were strengthened, and

soldiers returned to action as soon as they were stabilized and
reconstituted.
• Rapid intervention strategies were termed crisis intervention
and referred to a variety of psychotherapeutic techniques for
treating patients who are confronted with stressful or
overwhelming psychological events.

• PES evaluated and treated patients suffering from acute

psychopathology with the goal of providing treatment at the
least restrictive level of care.
• A psychiatrist working in a PES must have an in-depth
knowledge of
 psychiatry,
 substance-related illnesses,
 medicine,
 neurology,
 and the available community resources.

• Many clinicians consider emergency psychiatry a

subspecialty of psychiatry.
• The priorities and goals of an emergency psychiatric
assessment are as follows:
o To control aggressive behavior in order to protect other
patients, the PES staff, and the patient from him- or herself.

o To rule out any etiology for a patient’s behavior that might

be life threatening or may increase medical morbidity.

o To facilitate a thorough clinical evaluation and an

appropriate longitudinal plan.
 TERMS
• Aggression: intention to harm another individual who does not wish to be
harmed.
o Physical or non physical
o Reactive or proactive

• Violence: is aggression that has extreme physical harm, such as injury or

death, as its goal.

• Assault: a threat or attempt offensive physical contact or bodily harm on a

person. ( verbal, sexual, physical)

• Agitation: is an unpleasant state of extreme arousal.

• Anger: an emotion characterized by tension and hostility

 Agitation
• Agitation is a nonspecific
symptom that occurs
across all medical and
psychiatric diagnoses

• Excessive motor or
verbal activity or

• Severe anxiety
associated with motor
restlessness.
 AGITATION CON’T

• psychomotor agitation

 Physical and mental over

activity that is usually
nonproductive and is
associated with a feeling
of inner turmoil, as seen in
agitated depression

• Untreated agitation can

escalate to violence
 Behaviors of Agitation
• Non-aggressive behaviors
o Restlessness (akathisia, fidgeting)
o Loud, excited speech
o Pacing or frequently changing body positions
o Inappropriate behavior (disrobing, intrusive, repetitive
questioning)
 BEHAVIORS CON’T
• Aggressive behaviors
 Physical
• Combativeness, punching
walls
• Throwing or grabbing
objects, destroying items
• Clenching hands into fists,
posturing
• Self-injury (repeatedly
banging one’s head)
 Verbal ( cursing,
screaming)
 Pathophysiology of aggression
• The pathogenesis is not well understood

• A wide range of factors may play a role, including

the
 Environment &interpersonal relations
 a patient's social and medical history
 Genetics
 neurochemistry and endocrine function,
 substance abuse.
 Neuroanatomy and aggression

• Cortical(VMPFC/DLPFC)
VMPFC reactive/impulsive
aggression.
DLPFC intentional
aggression
• Amygdala( central role)
assessor of the need for
possible aggressive responses
• Sub cortical( basal ganglia,
thalamus, midbrain,
hypothalamus
 Neurochemistry
• Hormones

 Testosterone
 Cortisol
 Peptide hormones

• metabolism
 High VLDL increase risk of aggression, especially in male.
 Neurotransmitter

• Serotonin(5-HT): - low serotonin are more common

in impulsive aggression

• Norepinephrine/ epinephrine: - “get ready for

vigorous behavior” switch. E.g. propranolol

• GABA: ( BZD decrease aggression)

 Underlying cause
• Mnemonics “ FIND ME”
F functional / psychiatric
I infectious
N neurologic
D drug
M metabolic
E endocrine
 Approach to patient
• Patients should be evaluated and treated in
areas that have
 adequate space, appropriate lighting and alarm
systems,
 and the ready availability of security officers.
• Interviewing rooms should have
 multiple exits and
 a minimum of materials and furniture that could be
used as weapons.
 APPROACH CON’T
• As a clinician, it is important to understand your physical and
psychological limitations in dealing with the unpredictability
of a psychiatric emergency setting.

• Ensuring safety of patient and staff is the first priority and will
mitigate the risk of a potential secondary emergency.

• Be aware of your surroundings, communicate effectively, and

utilize resources available on site.
 CON’T
• Establishing emotional contact with the patient to help
identify the patient’s feelings will help build the treatment
alliance.

• Even a psychotic patient’s feelings are not unique, and the

interviewer should be capable of identifying and empathizing
with them
 CON’T
• The clinician should avoid the temptation to use logic
to convince the patient that he or she is wrong.

• Such an approach makes the patient more defensive

and can lead to escalation with potential for
dangerousness
 APP.CON’T
• When patients have disordered perceptions, it is important
not to attempt to correct the misperceptions but to clarify
how the patient experiences them..

• The interview should be geared toward fact gathering and

establishing a baseline understanding of psychopathologic-
related impairments.
 CON’T
• Severe agitation may make it impossible to obtain an initial
medical history, complete a medical examination, or collect
screening laboratory studies.

• Once agitation subsides and the patient is more cooperative, a

medical history and evaluation should be considered as
medical illness can precipitate violent and aggressive behavior
 IN SUMMARY
 address whether the problem is medical, psychiatric, or
both.

 make an initial diagnosis

 identify the precipitating factors and immediate needs

 begin treatment or refer the patient to the most

appropriate treatment setting.
 Features that indicate Medical Cause

 Acute onset (within hours or minutes)

 First episode Older age
 Current medical illness or injury
 Significant substance abuse
 Non auditory disturbances of perception
 Neurologic symptoms—loss of consciousness,
seizures, head injury, change in headache pattern,
change in vision
 MEDICAL CON’T
• Classic mental status signs—diminished alertness,
disorientation, memory impairment.

• Other mental status signs—speech, movement, or gait

disorders

• Constructional apraxia—difficulties in drawing clock, cube,

intersecting pentagons, Bender–Gestalt test
 Assess the risk of violence

past history: violence,

violent ideation, wish, demographics—sex nonviolent antisocial
intention, plan, (male), age (15–24), acts, impulse
overt stressors (e.g.,
availability of means, socioeconomic status dyscontrol (e.g.,
marital conflict, loss).
implementation of (low), social supports gambling, substance
plan, wish for help. (few). abuse, self-injury,
psychosis).
 Signs predicting assault

 Threats  Hands clenched or gripping

 Anger  Pacing about in the room
 Demanding immediate  Possessing weapons
attention  Pushing furniture
 Loud voice  Uncooperativeness and
 Excitement suspiciousness
 Staring eyes Signs  Slamming objects
predicting assault  Sudden movements
 Flared nostrils
 Factors contributing to violence

• Intrinsic factor such as

 Personality type
 Intense mental distress
• Extrinsic factors
 Attitude and behavior of surrounding people including
staff.
 Restrictions
 Schizophrenia and violence

• A meta-analysis of 20 studies compared risks of violence in

18,423 patients diagnosed with schizophrenia and other psychoses with
general population.

• increase of risk of violence in schizophrenia with

o an odds ratio (OR) of 2.1 without comorbidity
o an OR of 8.9 with comorbid substance abuse.
o substance abuse ( no psychosis) showed an OR of 7.4.
• Agitation and violence increase in pts with
schizophrenia
o Male pts.
o Pts with substantial cognitive impairment
o comorbidity like substance abuse
o Extrapyramidal side effect like TD
o Previous history of conduct d/o & poor impulse
control
o Paranoid delusions +/- commanding hallucinations.
 Bipolar d/o and violence
• The risk of violence is greater in bipolar disorder
than in schizophrenia.
• Violence is 3x more in bipolar compared to general
population
• Most of the violence in bipolar disorder occurs
during the manic phase. Especially
o comorbid Substance abuse
o with psychotic symptoms
o dysphoric mania and
o comorbid personality disorder
 MANAGEMENT OF AGITATION
• GENERAL PRINCIPLE
• COMPONENT OF MANAGMENT
1. INVOLVING CLIENTS IN DECISION-MAKING
2. ATTITUDINAL MANAGEMENT
3. DE-ESCALATING TECHNIQUE
4. USING PRN MEDICATION
5. RESTRICTIVE INTERVANTION
6. RAPID TRANQULAZATION
General principleManagement of agitation

• Interventions for agitation should be conceptualized

as hierarchal, beginning with the least restrictive and
least intrusive interventions

• The core clinical strategy for managing agitation is

the use of interpersonal strategies that emphasize
verbal de-escalation
 CON’T
• A patient who is treated with honesty, dignity, and
respect is likely to respond with reciprocity if there is
retained reality testing.

• Affect management is central to any effective

aggression management technique
RASS
 RASS CON’T
• Reassess the patient every 30 minutes and quantify
the degree of tranquilization/ agitation in terms of
the scores of RASS; evaluate vital signs

• RASS score of -2 to 0 should be obtained on all

agitated or violent patients

• In case additional medication is required, repeat the

drug (or drug combination) used previously, in the
same doses
 1. INVOLVING CLIENTS IN DECISION-
MAKING

 Involve clients in all decisions about their care and

treatment.

 If a client is unable or unwilling to participate,

involve their career

 Ensure that client understand the main side-effect

profiles of the medications recommended for rapid
tranquillization.
 CON’T
• Ensure that clients understand that during any
restrictive intervention their human rights will be
respected
• and the least restrictive intervention will be used to
enable them to exercise their rights
e.g. their right to follow religious or cultural
practices during restrictive interventions as much as
possible.
 CON’T
• Identify and reduce any barriers to a client exercising
the rights and, if this is not possible, record the
reasons in their notes.
 2.Attitudinal management of agitated

1.Avoid abrupt movements

2. Look directly at the patient during the
interview
3. Remain at a certain distance
4. Avoid taking notes
5. Introduce oneself and other staff members
6. Speak slowly, but firmly
7. Ask clear and direct questions
 3.De-escalation techniques
• Verbal de-escalation
techniques require time and
are often sufficient to
reduce agitation and
eliminate the risk of
violence.

• Offering food or drink may

also help facilitate a
therapeutic alliance and
reduce a patient’s agitation
 Descalation CON’T
• Respect personal space • Listen closely to what the
patients is saying
• Do not be provocative
• Agree or agree to disagree

• Establish verbal contact

• Lay down the law and set
clear limits
• Be concise
• Offer choices and optimism
• Identify wants and
feelings • Debrief the patient and staff
 4. USING P.R.N MEDICATION
 Do not prescribe p.r.n. medication routinely or automatically

 Tailor p.r.n. medication to individual need and include

discussion with the client if possible

 Ensure there is clarity about the rationale and circumstances

in which p.r .n. medication may be used and that these are
included in the care plan
 P.R.N CON’T
• Ensure that the interval between p.r.n. doses is
specified.
• Whenever a p.r.n. medication is administered the
 time it is administered,
 dose and type of medication used
 and who administered it must be recorded on the
client’s chart.
 P.R.N. CON’T
• Ensure that the maximum daily dose is specified and does not
inadvertently exceed the maximum daily dose.
• If p.r.n. medication is to be continued, the rationale for its
continuation should be included in the review.
• If p.r.n. medication has not been used since the last review,
consider stopping it.
• As much as possible Include PRN medication into a standing
dose, whenever PRN is needed too often or for longer period
of time
 5.USING RESTRICTIVE INTERVENTIONS
 USE A RESTRICTIVE INTERVENTION ONLY IF:

1. De-escalation and other preventive strategies, including p.r .n.

medication, have failed

2. There is potential for harm to the client or other people if no action is

taken

 Do not use restrictive interventions to punish, inflict pain, suffering or

humiliation, or establish dominance.

 Be aware that without consciously realizing it, restrictive interventions

could be used in response to a negative counter-transference feeling.
 A.OBSERVATION
• Staff should be aware of the location of all clients for
whom they are responsible, but not all clients need to
be kept within sight.

• At least once during each shift a nurse should set

aside dedicated time to assess the mental state of,
and engage positively with, the client
• Levels of observation

1.Low-level intermittent observation the baseline level of

observation in a specified psychiatric setting (30-
60minutes)

2.High-level intermittent observation usually used if a

client is at risk of becoming violent or aggressive but does
not represent an immediate risk (15-30minutes)
3.Continuous observation: usually used when a client
presents an immediate threat and needs to be kept within
eyesight or at arm’s length of a designated one-to-one nurse,

4.Multi-professional continuous observation: usually used

when a client is at the highest risk of harming themselves or
others and needs to be kept within eyesight of 2 or 3 staff
members and at arm’s length of at least 1 staff member
 B. Restrains
INDICATION:
o Imminent harm to others
o Imminent harm to the patient.
o Significant disruption of important treatment or
damage
o Continuation of an effective, ongoing behavior
treatment program.
 MANUAL RESTRAINS
• Do not use manual restraint in
 a way that interferes with the client’s airway,
breathing or circulation,
or client’s ability to communicate
 applying pressure to the rib cage, neck or
abdomen,
obstructing the mouth or nose, eyes, ears or
mouth
 Manual con’t
 avoid taking client to the floor , unless this becomes
necessary:
 Use the supine (face up) position if possible
 Ensure that the level of force applied during manual
restraint is justifable
 Do not routinely use manual restraint for more than 10
minutes.
 •Consider rapid tranquillization or seclusion as alternatives
to prolonged manual restraint (longer than 10 minutes).
 MECHANICAL RESTRAINT
• Managing extreme violence directed
at other people

• Record the reason for mechanical

restraints

• Record for how long you intend to

use mechanical restraints and clear
instruction of monitoring.

• The order must be signed by a

physician
.
• The re- evaluation of client should
be 2-4hrs
 Post restraint evaluation

 Check V/S , PSO2, RBS.

 Secure IV line or start treatment

 investigate the cause of agitation and determine

whether it is medical or psychiatric .
 MEDICATION USED
• Benzodiazepines
• First-generation (typical) antipsychotics
• Second-generation (atypical) antipsychotics
• Combinations
• Ketamine
• Dexmedetomidine sublingual
 BENZODIAZEPINE
• Lorazepam and midazolam are used most often.
• Preferred for sedating the patient with agitation from an
unknown cause.
• especially useful in patients who are agitated from drug
intoxication or withdrawal( including alcohol), but retain
efficacy in acute psychosis.
• May cause
o respiratory depression
o excessive somnolence and
o less commonly, paradoxical disinhibition.

• In agitated but cooperative patients use po medi cation

 First-generation (typical) antipsychotics
• Haloperidol and droperidol are used.

• Dose 2.5 – 10 mg PO OR IM and give half dose in elderly

• All FGAs possess quinidine-like cardiac effects resulting in QT prolongation, causing

dysrhythmias, particularly ‘torsades de pointes’.

• preferred with severe agitation secondary to alcohol intoxication.

• should be avoided in cases of

o withdrawal syndromes (alcohol, benzodiazepine & others)

o patients with seizures.
o If possible, should be avoided in pregnant and lactating females and
phencyclidine (PCP) overdose.
 Atypical anti psychotics
• cause fewer extrapyramidal side effects and less sedation
than FGAs.
• Mostly used - olanzapine, risperidone, and ziprasidone.
• Olanzapine : 5- 10mg IM used.
• Risperidone: 2mg po and preferred in psychosis pts.
• Many psychiatric emergency services in the United States
use a 20 mg IM dose of ziprasidone as first line treatment
for severe agitation.
• risk of respiratory depression.
• cause some degree of QT prolongation, likely
with ziprasidone.
 COMBINATION
• BZDs and FGAs

• Midazolam(5 mg IV or IM) and droperidol(5 mg IM)

• Lorazepam (2 mg IV or IM) and haloperidol (5 mg

IM)

• these combinations achieve more rapid sedation

than either drug alone and may reduce side effects.
 Dexmedetomidine sublingual
• an alpha-2 adrenergic receptor agonist,
• is a commonly used IV sedative in mechanically ventilated
patients.
• The sublingual formulation received approval in April 2022 in
the United States for the acute treatment of agitation
associated with schizophrenia and bipolar disorder in adults.
• For agitated but cooperative patient.
 6.RAPID TRANQUILLIZATION(RT)

• Refers to the use of medication by the parenteral

route (usually intramuscular or, exceptionally,
intravenous)

• if oral medication is not possible or appropriate and

urgent sedation with medication is needed.
 Rapid tranquilization CON’T
• When deciding which medication to use, take
into account:
 Pre-existing physical health problems or pregnancy
 Children, adolescents and elderly
 Possible intoxication
 Previous response to these medications, including adverse
effects
 Potential for interactions with other medications
 The total daily dose of medications prescribed and
administered.
CON’T
CON’T
 AFTER RAPID TRANQUILLIZATION

• Monitor side effects Monitor pulse, blood pressure,

respiratory rate, temperature, level of hydration,

• and level of consciousness at least every hour until

there are no further concerns about their physical
health status
 MONITOR CON’T
• Monitor every 15 minutes if the maximum dose has
been exceeded
• OR the client o appears to be asleep or sedated
• has taken illicit drugs or alcohol
• has a pre-existing physical health problem
• has experienced any complication as a result of any
restrictive intervention.
 Special population
• Children and adolescents

– Be aware of or suspect abuse as a contributory factor.

– Use calming techniques and distraction.

– Offer the child the opportunity to move away from the situation in
which the violence is occurring, for example to a quiet area.

– Do not use punishments.

– Do not use mechanical restraint in children rather manual restraint.

Use intramuscular lorazepam or PO diazepam for rapid
tranquillization
 2.Pregnancy and maternity
• if rapid tranquillization required use the same
protocol as above

• Restraint procedures should be adapted to avoid

possible harm to the fetus.

• She should not be secluded after rapid

tranquillization.
3.Alcohol intoxication
 Drug intoxication
• Agitation
• Perplexed
• Slurred speech
• Smell on shirt or breath
• Pupil size( dilated or
constricted)
• Injected eye
• Incoordination &
abnormal Gait
• Nystagmus
 4.ELDERLY
• Are prone to side effects
• Use low dose of high potent typical antipsychotics
• Avoid long acting Benzodiazepines ----risk of Delirium
• Consider organic cause in an elderly patient with a
sudden onset of disturbed behavior
• BIPOLAR PATIENTS:
Patients with Bipolar disorder are sensitive to the Extra Pyramidal Side effect of
antipsychotics, caution should be taken.
• ORGANIC BRAIN SYNDROME :Consider the diagnosis
Altered level of consciousness
Visual, tactile or olfactory hallucinations
Prescribe haloperidol with caution
Use the lowest effect dosage
Diagnose and treat the underlying cause
 LEGAL CONSIDERATION
• Work with coworker.
• documentation
• Ask permission of caretaker in decision making.
• Physical restraint should be removed as soon as
possible.
• U have duty to warn others ( coworkers, attendants).
 Take home massage
• Don’t be a “HERO”
• Thrust your “gut feeling”.
• don’t use dominance as technique to calm pts
• Don’t predict potential for violence based on pts
physique.
• Always try escaping plan first
• If u can’ t avoid confrontation use self defense
technique
 REFFERENCE
1.PAUL’S HOSPITAL MILLENNIUM MEDICAL COLLEGE
PSYCHIATRIC TREATMENT GUIDELINE
2. KAPLAN & SADOCK’S COMPREHENSIVE TEXTBOOK
OF PSYCHIATRY (TWELIVETH E D I T I O N)
3. UPTODATE 2023
THANK YOU