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![Signs and symptoms of psychomotor agitation [2]](publication/319625186/figure/tbl1/AS:631640715972669@1527606290812/Signs-and-symptoms-of-psychomotor-agitation-2.png)
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![Table 1 Signs and symptoms of psychomotor agitation [2]](publication/319625186/figure/tbl1/AS:631640715972669@1527606290812/Signs-and-symptoms-of-psychomotor-agitation-2_Q320.jpg)
Background
Psychomotor agitation (PMA) is a state of motor restlessness and mental tension that requires prompt recognition, appropriate assessment and management to minimize anxiety for the patient and reduce the risk for escalation to aggression and violence. Standardized and applicable protocols and algorithms can assist healthcare providers to...
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Citations
... Due to the heterogeneity of underlying causes of PMA, several clinical scenarios with a specific treatment based on underlying etiology may be present. Four major categories are described in the available algorithms/protocols and guidelines: PMA due to psychiatric disorder without intoxication, PMA due to Central Nervous System (CNS) depressants, PMA due to CNS stimulants, PMA due to Delirium [4][5][6][7][8]. Non-coercive, non-pharmacological interventions should be preferred in agitation treatment. ...
... To our knowledge, prescription patterns among Italian psychiatrists haven't been studied before, remaining currently still unknown. The present study was conducted to determine current practices and to describe the prescribing preferences of psychiatrists in Italy in the management of PMA of uncooperative patients and empirically study their grade of adherence to conventional guidelines [6][7][8]13,20]. This may help to identify which areas may benefit from professional development training programs. ...
... Lorazepam is the most used benzodiazepine followed by delorazepam, diazepam and midazolam Overall, delorazepam, promazine, clothiapine and tiapride are frequently used although not recommended or not even mentioned in international guidelines and available algorithms/protocols for the management of psychomotor agitation [4,[6][7][8]11,14,15,21]. ...
... Although restrictive practices should be considered the last option, only to be resorted to when other procedures have failed and individuals are a danger to themselves or others (Krieger et al., 2018), they are frequently applied to inpatients in response to management difficulties, conflict or aggression (Fletcher et al., 2017). It is possible that lower rates of conflict and coercion can be achieved through collaborative working between professionals and mental health service users (Tingleff et al., 2017;Vieta et al., 2017;WHO, 2019). However, not only inpatients experience coercion; the transference of many mental healthcare interventions to outpatient settings has led to the application of coercive measures in the community, such as Community Treatment Orders (CTOs) (Nakhost et al., 2018). ...
Coercion in mental healthcare is ubiquitous and affects the physical health, recovery and psychological and emotional well-being of those who experience it. Numerous studies have explored different issues related to coercion, and the present umbrella review aims to gather, evaluate and synthesise the evidence found across systematic reviews. The protocol, registered in the International Prospective Register of Systematic Reviews (PROSPERO registration number: CRD42020196713), included 46 systematic reviews and meta-analyses of primary studies whose main theme was coercion and which were obtained from databases (Medline/PubMed, PsycINFO, EMBASE and CINAHL) and repositories of systematic reviews following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. All the reviews were subjected to independent assessment of quality and risk of bias and were grouped in two categories: (1) evidence on specific coercive measures (including Community Treatment Orders, forced treatment, involuntary admissions, seclusion and restriction and informal coercion), taking into account their prevalence, related factors, effectiveness, harmful effects and alternatives to reduce their use; and (2) experiences, perceptions and attitudes concerning coercion of professionals, mental health service users and their caregivers or relatives. This umbrella review can be useful to professionals and users in addressing the wide variety of aspects encompassed by coercion and the implications for professionals' daily clinical practice in mental health units. This research received funding from two competitive calls.
... Aggressive behaviour is a complex behavioural syndrome characterized by excessive motor activity (e.g., pacing, restlessness), verbal (e.g., yelling, shouting), and/or physical aggression (e.g., self-injury, grabbing, hitting others, destroying property) [1,2]. These behaviours are commonly observed in children with neurodevelopmental disorders [3,4], patients with neurodegenerative diseases of ageing [5,6] and those with psychiatric disorders [7,8]. In addition to suffering, these symptoms comprise a leading cause of institutionalization, reducing the quality of life of patients and caregivers [8,9]. ...
Background: Aggressive behaviour (AB) may occur in patients with different neuropsychiatric disorders. Although most patients respond to conventional treatments, a small percentage continue to experience AB despite optimized pharmacological management and are considered to be treatment-refractory. For these patients, hypothalamic deep brain stimulation (pHyp-DBS) has been investigated. The hypothalamus is a key structure in the neurocircuitry of AB. An imbalance between serotonin (5-HT) and steroid hormones seems to exacerbate AB.
Objectives: To test whether pHyp-DBS reduces aggressive behavior in mice through mechanisms involving testosterone and 5-HT.
Methods: Male mice were housed with females for two weeks. These resident animals tend to become territorial and aggressive towards intruder mice placed in their cages. Residents had electrodes implanted in the pHyp. DBS was administered for 5h/day for 8 consecutive days prior to daily encounters with the intruder. After testing, blood and brain were recovered for measuring testosterone and 5-HT receptor density, respectively. In a second experiment, residents received WAY-100635 (5-HT1A antagonist) or saline injections prior to pHyp-DBS. After the first 4 encounters, the injection allocation was crossed, and animals received the alternative treatment during the next 4 days.
Results: DBS-treated mice showed reduced AB that was correlated with testosterone levels and an increase in 5-HT1A receptor density in the orbitofrontal cortex and amygdala. Pre-treatment with WAY-100635 blocked the anti-aggressive effect of pHyp-DBS.
Conclusions: This study shows that pHyp-DBS reduces AB in mice via changes in testosterone and 5-HT1A mechanisms.
... Molecular imaging posits that neurotransmitter mechanisms underlying sleep-wake regulation are involved in anxiety (63). In addition, psychomotor agitation is a potentially violent syndrome characterized by uncontrollable motor increases and psychological and emotional activities (64,65); as a marker of depression severity, psychomotor retardation is characterized by persistent slowness of cognitive and motor processing in speech, thinking and movements (66,67). In fact, psychomotor retardation may be more common in functionally impaired elderly individuals, and the inhibition and poverty of thoughts caused by psychomotor retardation may relieve the nervousness of functionally impaired elderly individuals. ...
Background
Evidence from previous studies has confirmed that functionally impaired elderly individuals are susceptible to comorbid anxiety and depression. Network theory holds that the comorbidity emerges from interactions between anxiety and depression symptoms. This study aimed to investigate the fine-grained relationships among anxiety and depression symptoms in the functionally impaired elderly and identify central and bridge symptoms to provide potential targets for intervention of these two comorbid disorders.
Methods
A total of 325 functionally impaired elderly individuals from five communities in Xi'an, China, were recruited for our investigation. The GAD-7 and PHQ-9 were used to measure anxiety and depression, respectively. SPSS 22.0 software was used for descriptive statistics, and R 4.1.1 software was used for network model construction, expected influence (EI) evaluation and bridge expected influence (BEI) evaluation.
Results
In the network, there were 35 edges (indicating partial correlations between symptoms) across the communities of anxiety and depression, among which the strongest edge was A1 “Nervousness or anxiety”-D2 “Depressed or sad mood.” A2 “Uncontrollable worry” and D2 “Depressed or sad mood” had the highest EI values in the network, while A6 “Irritable” and D7 “Concentration difficulties” had the highest BEI values of their respective community. In the flow network, the strongest direct edge of D9 “Thoughts of death” was with D6 “Feeling of worthlessness.”
Conclusion
Complex fine-grained relationships exist between anxiety and depression in functionally impaired elderly individuals. “Uncontrollable worry,” “depressed or sad mood,” “irritable” and “concentration difficulties” are identified as the potential targets for intervention of anxiety and depression. Our study emphasizes the necessity of suicide prevention for functionally impaired elderly individuals, and the symptom “feeling of worthlessness” can be used as an effective target.
... People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. Among the possible forms of presentation of psychomotor agitation are mental illness, disease of the central nervous system, associated organic pathology and/or substance abuse, among other aetiologies [1,2]. Psychomotor agitation is a behavioural category of motor hyperactivity that leads those affected from it to engage in unproductive, incomplete and repetitive conduct; it does not constitute a specific condition but rather a syndrome that can be present in various pathologies [3,4]. ...
... Psychomotor agitation is associated with certain risk factors [1]. Demographic factors include being male, being aged younger than 40 years, being single, having a family history of alcoholism or aggressive behaviour, having a low level of education and being of a low socioeconomic level; psychological factors include having a history of conflict with healthcare personnel or other patients, recent stressful life events or involuntary or prolonged admission to hospital; and clinical factors include having a family history of previous episodes of agitation, anxiety, fear, substance abuse, low cooperation in treatment, low-level awareness of illness, cognitive and behavioural disorganisation and positive symptoms, mental retardation, dementia, epilepsy, schizophrenia and comorbidity with personality disorders [8]. ...
Psychomotor agitation is characterised by an increase in psychomotor activity, restlessness and irritability. People with psychomotor agitation respond by over-reacting to both intrinsic and extrinsic stimuli, experiencing stress and/or altered cognition. The objective of this study is to assess the clinical and sociodemographic profile of psychomotor agitation in patients with severe mental disorders. The study was carried out in Spain by means of multicentre cross-sectional convenience sampling involving 140 patients who had been admitted to psychiatric hospital units and had experienced an episode of psychomotor agitation between 2018 and 2021.Corrigan’s Agitated Behaviour Scale was used to assess psychomotor agitation. The results show that the predominant characteristic in psychomotor agitation is aggressiveness, which is also the most reported factor in patients with severe mental disorder. Patients who also have anxiety develop psychomotor agitation symptoms of moderate/severe intensity. The clinical and sociodemographic profile found in our study is consistent with other studies on the prevalence of psychomotor agitation.
... Aj keď existujú isté odporúčania, je zrejmé, že takto vyostrené prípady nemajú jednoznačne predpísaný scenár postupov. 8 Tu je pritom vždy nevyhnutné racionálne vyhodnotiť riziká potencionálnych zákrokov a až následne na základe konkrétnej situácie a prípadných výpovedí svedkov dôsledne zvážiť alternatívy plánovaných postupov, včítane možnosti privolania iných odborníkov. Celý zákrok by mal byť koordinovaný s dôrazom na ochranu života/zdravia zasahujúcich osôb, na ochranu života/zdravia klientov a nakoniec na ochranu súkromného, alebo verejného majetku. ...
Súhrn Makovický P, Matlach r, Makovický P. Letálne sa končiaci prípad zásahu proti osobe so schizofréniou Tu referujeme letálne sa končiaci bezpeč-nostný zásah proti 26-ročnému mužovi s paranoidnou schizofréniou, ktorý igno-roval ambulantným psychiatrom nariade-nú terapiu. V priebehu 14-dní dochádza k nápadnému stupňovaniu nepokoja, opakovaným verbálnym útokom, vyhrá-žaniu a agresívnemu správaniu. Privolaný lekár nedokázal nadviazať kontakt s mu-žom, a tak si zavolal na pomoc policajnú hliadku, ktorá muža spacifikovala. Lekár pritom injekčnou formou aplikoval mužovi do svalu Haloperidol, ktorý však nezabral, a tak v krátkom časovom intervale aplikoval ďalšiu dávku Haloperidolu. Po prvotnom utlmení dochádza k náhlej zástave dýcha-nia, pričom muž je opakovane resuscito-vaný a transportovaný do nemocnice, kde na šiesty deň umiera. Nariadenou súdnou pitvou bolo zistené, že príčinou smrti muža bol malígny edém mozgu. Práca na pod-klade prípadu z praxe upozorňuje lekárov prvého kontaktu, lekárov pracujúcich v te-réne, zdravotné sestry, iných pomocných zdravotníkov, sociálnych pracovníkov, ale aj príslušníkov bezpečnostných síl na mož-né nebezpečenstvá pri komunikácii a práci s klientmi, ktorí sa verbálne vyhrážajú, ale-bo aj správajú agresívne. Tu odporúčame racionálne vyhodnotiť riziká potencionál-nych zákrokov a až následne na základe konkrétnej situácie a výpovedí svedkov zvážiť alternatívy postupov, včítane mož-nosti privolania iných odborníkov. Zákroky by mali prebehnúť koordinovane s priorit-ným akcentom na ochranu vlastných živo-tov, životov klientov, na ochranu vlastného
... Multiple guidelines have been written to direct the assessment and treatment of agitation in patients with acute psychiatric disorders [1,4,13,17,18]. These guidelines generally recommend that the physician evaluate the patient and attempt to determine the etiology of agitation, that symptoms be assessed with the use of a standardized rating scale, and that treatment for agitation be specific to the underlying cause [13,19,20]. ...
Agitation is a common and potentially dangerous condition requiring rapid recognition and treatment in acute psychiatric units. Prompt intervention can prevent a patient with agitation from harming themselves, harming others, or needing restraints or seclusion. After the review of numerous guidelines, the Modified Agitation Severity Scale (MASS) agitation treatment protocol was developed to identify and manage agitation in an inpatient adult psychiatric setting. This protocol involved modifying an existing agitation scale and pairing scores with a treatment algorithm to indicate which behavioral and medication interventions would be most appropriate. All scoring and interventions were recorded in the electronic medical record (EMR). Three months of data were collected before and after the protocol was implemented. The new, modified scale had high reliability and correlated well with another validated agitation scale. Perceived patient safety was high during both study phases. Nurses’ perceptions of safety trended upward after the protocol was implemented, though these differences were not significant, likely due to insufficient power. Although there was no decrease in seclusion events after implementation of the treatment protocol, there was a 44% decrease in restraint events and average restraint minutes per incident. Despite a potential increase in workload for nursing staff, implementation of the protocol did not increase burnout scores. Physicians continued to order the protocol for 55% of patients after the study period ended. These findings suggest that including a rapid agitation assessment and protocol within the EMR potentially improves nurses’ perceptions of unit safety, helps assess treatment response, reduces time patients spend restrained, and supports decision making for nurses.
... Psychomotor agitation may be evidenced by increased motor activity (e.g., excessive gesturing) and emotional activation but may also be accompanied by emotional lability and a decreased level of attention and alterations in cognitive function [9,15,16], all of which were observed in our patient, as evidenced in the case presentation. Psychomotor agitation is particularly prevalent among the schizophrenia and bipolar disorder population [15]. ...
... Psychomotor agitation may be evidenced by increased motor activity (e.g., excessive gesturing) and emotional activation but may also be accompanied by emotional lability and a decreased level of attention and alterations in cognitive function [9,15,16], all of which were observed in our patient, as evidenced in the case presentation. Psychomotor agitation is particularly prevalent among the schizophrenia and bipolar disorder population [15]. To address psychomotor agitation, we decided to discontinue buspirone, a drug commonly used to treat anxiety disorders, and ordered lorazepam 1 mg twice and temazepam 15 mg at bedtime. ...
... To address psychomotor agitation, we decided to discontinue buspirone, a drug commonly used to treat anxiety disorders, and ordered lorazepam 1 mg twice and temazepam 15 mg at bedtime. In the case of psychiatric agitation, the preferred pharmacological treatment option, if agitation is due to psychotic symptoms, is antipsychotic agents, although benzodiazepines may also be considered when agitation is due to a non-psychotic agitation [15,16]. Because we had already increased the dose of ziprasidone (antipsychotic) and discontinued quetiapine (antipsychotic), the addition of benzodiazepines was warranted to help stabilize the patient's acute condition. ...
Psychosis is a mental disorder in which an individual exhibits a loss of contact with reality; this definition, however, often fails to convey the broadness and complexity behind the diagnosis. While studies agree that it is best practice to address psychosis by treating its underlying cause, manifestations of psychosis do vary widely and may be challenging to identify in some clinical scenarios, such as the one presented here. Binge eating in the setting of psychosis has been observed in instances where alterations of the gut microbiota in response to an eating disorder trigger psychotic episodes. However, instances in which the manifestation of psychosis itself is the catalytic factor for the presentation of a binge-eating event with aggression and delusions are seldom observed in the current medical literature. Of note, many of the drugs used to treat mental illness have been associated with regulating food intake. We aim to further expand on the association between psychosis, eating disorders, and management thereof in the setting of polypharmacy and undesired side effects. Here, we present the case and management of a 71-year-old male Hispanic patient with a significant history of mental illness who was admitted to the hospital due to acute gastroenteritis precipitated by binge eating during a psychotic episode.
... A large portion of older people who are diagnosed with dementia experience one or more BPSD symptoms during their illness [1]. A recent systematic review stated that more than 80% of BPSD episodes manifest as agitation [2]. ...
... A recent systematic review stated that more than 80% of BPSD episodes manifest as agitation [2]. Psychomotor agitation and motor restlessness, characterized by inappropriate behavior [3], be it by verbal or vocal expression or physical activity that can be repetitive, aggressive, and often contradictory to social standards, are all symptoms of mood disorders [1,4]. Recent clinical guidelines recommended non-pharmacological interventions as the first attempt to manage agitation. ...
... Recent clinical guidelines recommended non-pharmacological interventions as the first attempt to manage agitation. However, if agitation causes distress and potentiates the risk of harm to others, then pharmacological approaches may be considered for alleviating agitation [1]. RCTs have evaluated different psychotropic interventions, such as antidepressants, antipsychotics, cholinesterase inhibitors, benzodiazepines, and anticonvulsants [5,6]. ...
Background:
Psychomotor agitation as part of the behavioral and psychological symptoms of dementia (BPSD) is one of the common issues found in aged care facilities. The current inadequate management strategies lead to poor functional and medical outcomes. Psychotropic interventions are the current preferred treatment method, but should these medications be the prescribers' first preference? This review aims to compare pharmacological interventions for psychomotor agitation, judging them according to their effectuality and justifiability profiles. This is to be achieved by retrieving information from Randomized Control Trials (RCTs) and systematic reviews.
Objectives:
This review evaluates evidence from RCTs, systematic reviews, and meta-analyses of BPSD patients who have taken agitation treatments. Assessing the efficacy of citalopram, other selective serotonin reuptake inhibitors (SSRIs) and antipsychotic treatments were compared to each other for the purpose of improving agitation outcomes and lowering patient side effects.
Methods:
This review includes RCT that compared citalopram with one or more atypical antipsychotics or with a placebo, along with systematic reviews comparing citalopram (SSRI) with antipsychotics such as quetiapine, olanzapine, and risperidone. Studies were extracted by searching and accessing databases, such as PubMed, OVID, and Cochrane with restrictions of date from 2000 to 2021 and published in the English language.
Conclusion:
There are still a limited number of studies including SSRIs for the treatment of agitation in BPSD. SSRIs such as citalopram were associated with a reduction in the symptoms of agitation, and lower risk of adverse effects when compared to antipsychotics. Future studies are required to assess the long-term safety and efficacy of SSRI treatments for agitation in BPSD.
... Professionals intervene to prevent or minimize risks, using a variety of methods to ensure safety for users and staff . Th ese methods include drugs, close observation (Pettit et al., 2017), and/or de-escalation (Vieta et al., 2017;WHO, 2019). To achieve a safe working environment with lower rates of confl ict and coercion, there is a need to encourage collaborative working between professionals and clients in the units (Tingleff et al., 2017;Vieta et al., 2017;WHO, 2019). ...
... Th ese methods include drugs, close observation (Pettit et al., 2017), and/or de-escalation (Vieta et al., 2017;WHO, 2019). To achieve a safe working environment with lower rates of confl ict and coercion, there is a need to encourage collaborative working between professionals and clients in the units (Tingleff et al., 2017;Vieta et al., 2017;WHO, 2019). ...
... A variety of studies have covered various topics related to coercion, such as diff erent types of coercion (Berge et al., 2018;Krieger et al., 2018;Staniszewska et al., 2019;Tingleff et al., 2017), and specifi c interventions to reduce restrictive practices (Bowers et al., 2014;Bowers et al., 2015;Fletcher et al., 2017;Gaynes et al., 2017;Gooding et al., 2018;McSherry, 2017;National Association of State Mental Health Program Directors, 2008;Stensgaard et al., 2018;Stirling et al., 2017;Vieta et al., 2017;Wilson et al., 2018;WHO, 2019), among others. Th erefore, the aim of the current study is to gather, evaluate, synthesize, and improve the accessibility of existing evidence on mental health coercion through an umbrella review. ...
In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].
