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Agitation and aggression are nonspecific symptoms that do not necessarily imply a specific etiology.


  • Causal or contributing factors

    • ✓ Alcohol and substance intoxication or withdrawal

    • ✓ Infection

    • ✓ Immune-mediated conditions

    • ✓ Primary psychiatric disorders

    • ✓ Psychosis

    • ✓ Severe conduct disorder

    • ✓ Autism spectrum disorders

    • ✓ Intellectual and developmental disabilities

    • ✓ Anxiety

    • ✓ Delirium

    • ✓ Temporal lobe seizures

    • ✓ Other causes (e.g., medication related adverse effects, encephalopathy, cerebritis)

  • Risk factors and exacerbating factors

    • ✓ History of prior aggression

    • ✓ History of exposure to aggression/violence

    • ✓ Male gender

    • ✓ Substance abuse/intoxication

    • ✓ Psychiatric disorders or conditions that affect judgement and impulsivity

    • ✓ Pain

    • ✓ Inability to understand treatment plan and/or their environment (as can be seen in young children, individuals with delirium, autism, or intellectual disability)

Clinical Manifestations

  • Present along a spectrum with verbal and/or physical manifestations. Recognition of early warning signs of agitation or potential for aggression provides opportunity for intervention and prevention of escalation, and to preemptively call for additional help and resources.

  • Warning signs and behaviors

    • ✓ Verbal

      • Increased volume of voice, yelling, shouting

      • Use of expletives

      • Threatening statements to harm self or others

      • Verbal refusal to cooperate

    • ✓ Physical

      • Pacing, physical restlessness

      • Violation of typical personal space boundaries

      • Throwing or destroying objects

      • Attempts to harm self

      • Body contact with other (pushing, hitting, punching, kicking)

  • Other clinical manifestations will depend on the underlying cause:

    • ✓ Delirium

      • Altered level of alertness and concentration

      • Disorientation

      • Hallucinations or delusions

    • ✓ Primary psychiatric disorder

      • Mood/affect lability can be seen in mood disorders, alcohol and drug intoxication or withdrawal

      • Irritability can be seen with mood and anxiety disorders, autism spectrum disorders, disruptive behavior disorders, alcohol and drug intoxication or withdrawal

      • Anxiety can be seen with mood and anxiety disorders, autism spectrum disorders, alcohol and drug intoxication or withdrawal

      • Impulsivity can be seen with attention-deficit/hyperactivity disorder (ADHD), disruptive behavior disorders, as well as other psychiatric, neurologic, medical and developmental conditions

      • Psychotic symptoms can be seen with schizophrenia, mood disorders, delirium, and other neurologic and medical conditions.

      • Suicidal or homicidal ideation may be associated with mood and behavioral disorder, and may contribute to agitation and agression in the inpatient medical setting.

      • Poor insight and impaired judgment are typically present when a patient is agitated or acting in an aggressive manner and can be due to numerous psychiatric, neurologic, medical, and developmental factors.

  • Signs of intoxication:

    • ✓ Alcohol: Smell of alcohol on breath, dysarthria, incoordination, ataxia

    • ✓ Amphetamines: Dilated pupils, altered pulse or blood pressure

    • ✓ Marijuana: Tachycardia, dry mouth, conjunctival injection

    • ✓ Cocaine: Dilated pupils, hypertension, tachycardia, paranoia

    • ✓ Hallucinogens: Dilated pupils, tachycardia, sweating, palpitations, tremors, incoordination

    • ✓ Phencyclidine (PCP): Nystagmus, hypertension, tachycardia, ataxia, dysarthria, muscle rigidity, seizures

  • Signs of withdrawal:

    • ✓ Alcohol: Tremulousness, hypertension, fever, sweating, disorientation, seizures

    • ✓ Opiates: Dilated pupils, tachycardia, hypertension, fever, sweating, rhinorrhea,

    • ✓ Marijuana: Vomiting, abdominal pain, sweating, fever, chills, headache, restlessness, tremulousness


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