Management of psychomotor agitation
The onset of psychomotor agitation in a patient is always an urgent situation. As a general rule, such patients require immediate hospitalization in a psychiatric inpatient facility.
Exceptions to this rule are conditions not accompanied by actions dangerous to others or the patient themselves. These include:
- Hebefrenic agitation.
- Amential agitation. It develops against the background of severe somatic diseases, so such patients are treated in regular somatic departments. Agitation in amentia poses no threat and is limited to the hospital bed.
In modern medicine, cessation of agitation relies exclusively on psychopharmacotherapy (antipsychotics and benzodiazepine tranquilizers). Historical restraint methods, such as straitjackets, straps, and seclusion rooms, have become almost entirely a thing of the past.
Features of hysterical agitation
This type of agitation is always secondary to a psychotraumatic situation. The clinical picture is characterized by extreme demonstrativeness and theatricality. Patients may roll on the floor, wring their hands, tear their clothes, sob loudly, or beat their fists.
A particular hazard is demonstrative suicide. Patients prepare for suicide exclusively in front of an audience (stepping onto the edge of a windowsill, tying a noose). Although they have no genuine intention to end their life, the physician must remain vigilant: the risk of accidental falling or unintentional strangulation is extremely high.
The reaction to external stimuli in hysteria is paradoxical. The more actively those around try to calm the patient, the stronger the agitation becomes. Conversely, unexpected triggers (a clap, a sharp call, splashes of cold water) can instantly distract the patient and interrupt the episode. Complete resolution of the condition occurs after the psychotraumatic situation itself is resolved.
Types and differential diagnosis of stupor
Stuporous states are less common than agitation and belong to negative disorders. They may accompany catatonic, depressive, and apathy-abulic syndromes, as well as occur in brain frontal lobe damage or in response to acute stress.
Depressive stupor is closely associated with pronounced affective melancholy. Patients assume a sorrowful yet comfortable posture (e.g., lying with extended arms and open eyes). Speech is preserved, complete mutism does not occur, but answers to questions are monosyllabic and given with a long delay. Due to hypochondriacal ideas and lack of appetite, patients refuse food, yet they can be persuaded to eat. It is important to remember that torpor temporarily hinders them from committing suicide, but they require strict supervision due to the risk of sudden execution of the intent.
Apathetic stupor most frequently forms as an outcome of schizophrenia. It is characterized by profound indifference and amimia. Unlike catatonic stupor, there is no suppression of drives: patients do not refuse food, gain weight due to hypodynamics, and express verbal discontent when their comfort is disturbed (asked to get up or wash).
Hysterical stupor develops immediately after psychological trauma. It is characterized by mutism without phenomena of negativism. The patient wants to communicate: opens the mouth without producing a sound ("fish" sign), readily answers with gestures or in writing. The condition is always demonstrative in nature and does not occur without witnesses.
State of perplexity
Perplexity is a manifestation of acute sensuous delusion syndrome. Although it more frequently proceeds with agitation, sometimes patients freeze in complete incomprehension of what is happening. They are silent, look around, and closely observe others.
The face reflects a specific affect of bewilderment — a frozen expression of extreme surprise, dismay, or concentration. Against the background of such torpor, dangerous impulsive actions are possible, and further development of the pathology often leads to the formation of oneiroid clouding of consciousness.
Treatment and drug disinhibition procedure
Stupor rarely leads to socially dangerous actions, so special activating drugs are not used in routine practice. The main principle is treatment of the underlying disease (antipsychotics in catatonia, antidepressants in depression). It is strictly forbidden to prescribe disinhibiting agents in depressive stupor, as relieving motor torpor may provoke immediate suicide.
The drug disinhibition procedure is used infrequently, mainly in catatonic and hysterical stupor.
- Drugs: Benzodiazepine solutions (diazepam, lorazepam). Historically, an amobarbital-caffeine mixture was used, but sodium amobarbital is now excluded from the pharmacopoeia.
- Methodology: The drug is administered intravenously very slowly. At this time, the physician continuously attempts to establish verbal contact with the patient.
- Result: Administration is stopped as soon as the patient begins to respond. The procedure allows for gathering important anamnesis, and patients with catatonia against the background of disinhibition may begin to eat independently.
Briefly: answers to topical questions
Which motor disorders are included in the classic structure of extrapyramidal syndrome?
- Drug-induced parkinsonism (parkinsonismus) — tremor, general muscle hypertonus, amimia, shuffling gait.
- Acute dystonia (dystonia acuta) — painful spasms of the face, neck, tongue, eyes, pharynx, larynx.
- Akathisia and tasikinesia (akathisia et tasikinesia) — restlessness, urge to move, agitation.
- Tardive dyskinesia (dyskinesia tarda) — facial hyperkinesias, choreiform and athetoid movements in the limbs.
The classical structure of extrapyramidal neurological disorders when using antipsychotics includes acute dystonia, parkinsonism, akathisia, tasikinesia, and tardive dyskinesia. These disorders are associated with the blockade of dopamine $D_2$ receptors in the neostriatum of the nigrostriatal system.
Which anticholinergic drugs are used as correctors of extrapyramidal syndrome?
- Trihexyphenidyl (trihexyphenidylum) — cyclodol.
- Biperiden (biperidenum) — akineton.
- Diphenhydramine (diphenhydraminum) — diphenhydramine.
As correctors of extrapyramidal disorders and drug-induced parkinsonism, anticholinergics are used: trihexyphenidyl (cyclodol), biperiden (akineton), and diphenhydramine (dimedrol). These drugs are used to eliminate neurological side effects of antipsychotics, although their prescription during pregnancy is undesirable.
Class and exam questions
Why are disinhibiting drugs contraindicated in depressive stupor?
Relieving motor inhibition against the background of preserved melancholic affect allows the patient to immediately carry out suicidal intentions.
How to distinguish apathetic stupor from catatonic?
In apathetic stupor (apathy-abulic syndrome), there is no suppression of drives and no negativism. Patients eat, gain weight due to hypodynamics, and express discontent if forced to move.
In which department are patients with amential agitation treated?
In a somatic inpatient unit. The cause of amentia is severe somatic diseases, while the agitation itself is confined to the bed and poses no danger.
What else to study on this topic
- Catatonic syndrome: clinical picture and course variants
- Acute sensuous delusion syndrome
- Oneiroid clouding of consciousness
- Affective-shock reactions in psychiatry
- Apathy-abulic syndrome in schizophrenia
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Other topics in section "Chapter 13. Motor Sphere Disorders"
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