Chapter 27: Psychiatry

ACUTE AGITATION/AGGRESSION

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

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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