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ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY
Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health The Medical Management of Acute Agitation APM Resident Education Curriculum Revised 2019: Ariadna Forray, MD, Naomi Schmelzer, MD Original version: R. Scott Babe, M.D ., Clinical Assistant Professor of Psychiatry, Western University of Health Sciences, Samaritan Mental Health, Corvallis, Oregon Thomas W. Heinrich, MD , Associate Professor of Psychiatry & Family Medicine, Chief, Psychiatric Consult Service at Froedtert Hospital, Department of Psychiatry & Behavioral Medicine, Medical College of Wisconsin Version of March 15, 2019
Objectives
Identify the behavioral spectrum of agitation
Describe the broad differential diagnosis behind the symptoms of agitation and
aggression.
Apply non-pharmacologic and pharmacologic approaches to management of the
agitated patient in the general medical setting.
Definitions
Agitation
- (^) Excessive motor or verbal activity
- (^) “an emergent situation that is temporary, breaks the therapeutic alliance, and is in need of a prompt and immediate intervention” (Garriga et al. 2016)
Aggression
- (^) Hostile, injurious, or destructive behavior. Can be verbal or physical.
Violence
- (^) Denotes physical aggression by people against other people
- (^) 2 general types: (^) Impulsive/reactive (^) Instrumental/premeditated –goal-oriented violence (Siever L. (2008) Neurobiology of aggression and violence. Am J Psychiatry 165: 429-42. Garriga M., Pacchiarotti, I., Kasper, S. et al. (2016) Assessment and Management of Agitation in Psychiatry: Expert consensus. World J Biol Psychiatry. 17, 170-185.)
Component Behaviors of Agitation
Nonaggressive behaviors
- (^) Restlessness (akathisia, fidgeting)
- (^) Wandering
- (^) Loud, excited speech
- (^) Pacing or frequently changing body positions
- (^) Inappropriate behavior (disrobing, intrusive, repetitive questioning)
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
Epidemiology
Studies for health care workers
- (^) California: (^) 465 assaults per 100,000 hospital workers vs. 82.5 assaults per 100,000 for all workers (Peek-Asa et al 1997)
- (^) Minnesota Nurses Study (Gerberich et al 2004) : (^) 13.2 per 100 persons per year for physical assaults (^) 38.8 per 100 persons per year for non-physical assaults (^) Greatest risk for persons working in/with: (^) Long term care facility (^) Intensive care (^) Psychiatric unit (^) Emergency department (^) Geriatric patients Peek-Asa, C., Howard, J., Vargas, L., & Kraus, J. F. (1997). Incidence of non-fatal workplace assault injuries determined from employer's reports in California. Journal of Occupational and Environmental Medicine , 39 (1), 44-50. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H. E., Nachreiner, N. M., Geisser, M. S., ... & Watt, G. D. (2004). An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occupational and environmental medicine , 61 (6), 495-503.
Etiology of Agitation
A. Disease-related: three major categories
- (^) Psychiatric manifestations of general medical conditions
- (^) Substance intoxication/withdrawal
- (^) Primary psychiatric illness
B. Instrumental: unlikely to benefit from medical intervention (e.g., criminal
behavior)
- (^) Consider short trial of verbal de-escalation
- (^) Depending on severity, consider involving security or law enforcement
These are not mutually exclusive
Etiology of Agitation: Medical Causes
Head trauma
Encephalitis, meningitis, other
infection
Encephalopathy (e.g., liver or renal
failure)
Environmental toxins
Metabolic abnormalities (sodium,
calcium, glucose)
10
Hypoxia
Thyroid disease
Seizure (including post-ictal state)
Toxic levels of medications
Nordstrom, K., Zun, L. S., Wilson, M. P., Stiebel, V., Ng, A. T., Bregman, B., & Anderson, E. L. (2012). Medical evaluation and triage of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup. Western Journal of Emergency Medicine , 13 (1), 3.
Etiology of Agitation: Delirium
Diagnostic Features
Disturbance of consciousness
A change in cognition or development of perceptual disturbance
Not accounted for by a dementia
Disturbance develops over a short period of time and tends to fluctuate
(“waxing and waning”)
Caused by a general medical condition
Etiology of Agitation: Primary Psychiatric disorders
Schizophrenia
Bipolar Disorder
Neurocognitive Disorder (Dementia)
Personality Disorders
Agitated depression
Anxiety disorder
Autism spectrum disorder
Etiology of Agitation: Common Triggers
Akathisia from antipsychotic or antidepressant use
Comorbid substance use or intoxication
Poor impulse control or other comorbid cognitive deficits
Chaotic or disruptive environment
Medical illness
Exacerbation of symptoms of primary illness
Psychosocial trigger
Garriga, M., Pacchiarotti, I., Bernardo, M., & Vieta, E. (2017). Psychiatric Causes of Agitation: Exacerbation of Mood and Psychotic Disorders. The Diagnosis and Management of Agitation , 126..
Etiology of Agitation: Schizophrenia
– Patients at highest risk for violence
(^) More suspicious and hostile (^) More severe hallucinations (^) Less insight into delusions (^) Greater thought disorder (^) Poor impulse control
– Risk factors for being targeted for violence by person with schizophrenia
(^) Parent or immediate family member (^) Cohabitation (^) Patient financially dependent on you Sachs, G. S. (2006). A review of agitation in mental illness: burden of illness and underlying pathology. The Journal of clinical psychiatry , 67 , 5-12.
Etiology of Agitation: Personality Disorders
Some personality disorders are more prone to agitation
Decreased stress tolerance
Poor impulse control
E.g., Borderline personality disorder, Antisocial personality disorder
Etiology of Agitation: Dementia
– Agitation may be a final common pathway for the expression of…
Depression
Anxiety
Psychosis
Pain
Delirium
– While agitation may be of multifactorial etiology in patients with dementia, it is
also true that many patients have only agitation as a target symptom for
treatment (Madhusoodanan, 2001)
Madhusoodanan, S. (2001). Introduction: antipsychotic treatment of behavioral and psychological symptoms of dementia in geropsychiatric patients. The American Journal of Geriatric Psychiatry , 9 (3), 283-288.
Etiology of Agitation: Psychodynamic Perspectives
A Psychodynamic framework can be used to complement treatment strategies
- Helps temper counter-transference
Psychodynamic perspectives of agitation and violence
- (^) In contemporary psychoanalytic thought, “the capacity for aggression is innate and universal, aggressive behavior occurs in response to threats that the self perceives in relation to internal and external objects.”
- (^) Crisis can be defined as an assault on the person’s sense of self (Bernstein 2007) Yakeley, J. (2018). Psychodynamic approaches to violence. BJPsych Advances , 24 (2), 83-92.
