Psychomotor agitation

Clinical presentation and behavioral risks

Motor agitation is typical for acute psychoses (including schizophrenia exacerbations and agitated depression), as well as conditions with altered consciousness, such as delirium, oneirophrenia, and twilight states. Patients may experience confusion, anxiety, and be under the influence of acute sensory delusions or hallucinations.

The patient's behavior becomes disorganized and chaotic. In attempts to escape from imaginary pursuers, a person may run out into traffic, jump out of a window, or attack random passersby.

Special forms of aggression:

• Hidden threat: an outwardly motionless patient who is inaccessible to contact may be in a state of catatonia with immense internal tension, indicated only by a wary gaze. Such patients are prone to sudden, impulsive, and senseless actions.
• Exacerbation of chronic psychosis: aggression is provoked by command hallucinations, delusions of jealousy, or persecutory delusions.
• «Pursued pursuer» syndrome: an extremely dangerous condition in which the patient accuses a specific person of imaginary harm and meticulously plans physical retaliation against them.

Medical tactics and communication rules

The primary task of the specialist is to stop acute manifestations as quickly as possible and arrange for hospitalization. Involving law enforcement officers is justified only in extreme cases when there is a direct threat to life.

Often, it is possible to obtain the patient's consent to take medication without using force. To achieve this, the physician must establish effective communication:

1. Demonstrate complete self-control, empathy, and a sincere desire to help.
2. Conduct a persistent yet calm conversation, acting as an ally.
3. Strictly avoid objections and attempts to logically persuade the patient, as this repeatedly increases their tension.

Pharmacological management of agitation

The drugs of choice are antipsychotics. Caution: blood pressure must be measured before administering them due to the high risk of severe hypotension.

Oral therapy: Shows high efficacy, especially when using orally disintegrating forms. Clozapine, olanzapine, or levomepromazine are used.

Parenteral administration: Used when the patient refuses to take tablets or in emergency circumstances. Chlorpromazine, haloperidol, droperidol, or zuclopenthixol injections are prescribed.

• Dosages for patients who have not previously taken antipsychotics (neuroleptic-naive): chlorpromazine 50–75 mg, haloperidol 10 mg, droperidol 5 mg, clozapine 50 mg.
• Standard therapeutic doses: chlorpromazine 100–200 mg, zuclopenthixol 100 mg, droperidol up to 10 mg.

Concomitant pharmacotherapy: To prevent circulatory collapse, nikethamide (2 mL) is administered subcutaneously simultaneously with the antipsychotic. To enhance the sedative effect and reduce the risk of neurological complications, diphenhydramine (10–20 mg) is administered intramuscularly.

Alternative benzodiazepine therapy: Indicated when antipsychotics are contraindicated (heart failure, severe liver pathology, pronounced hypotension). Diazepam (up to 20 mg), lorazepam (up to 4 mg), phenazepam (up to 3 mg), as well as flunitrazepam or midazolam (parenterally and per os) are used. Elderly patients are prescribed minimal doses, while patients with alcoholism receive maximum doses. The main complication of intravenous benzodiazepine administration is respiratory depression.

Rules for physical restraint

Immobilization is an exceptional and strictly short-term measure applied only until the sedative medications take effect. Restraint does not guarantee absolute safety, as the patient may break free.

Key requirements:

• Use exclusively soft materials (sheets, special fabric straps).
• Secure the shoulder girdle and each limb separately and as securely as possible.
• Carefully ensure that nerve trunks and blood vessels are not compressed.
• It is strictly forbidden to leave a restrained patient alone. An observer must be continuously present, whose duties include monitoring the condition, warming, feeding, and assisting with elimination.

Suicidal behavior and emergency hospitalization

Self-directed aggression is most often the result of severe depressive episodes. A history of past suicide attempts is a predictor of a high risk of recurrence. The peak of despair and, accordingly, the maximum danger of suicide occur in the morning hours.

Patients rarely conceal such thoughts from a physician. Any mention of suicide (even if made jokingly) should be perceived as a subconscious cry for help to a professional. In such a situation, it is necessary to immediately insist on placement in a hospital, where round-the-clock monitoring will be organized. Leaving the patient at home is unacceptable: relatives lack proper training and often underestimate the level of threat. If the patient refuses, Russian law allows for involuntary hospitalization.

Intensive care units in psychiatry

To ensure safe treatment and reduce mortality (from suicide, overdoses, and pharmacotherapy complications), intensive care units (ICUs) are being integrated into the structure of psychiatric hospitals. They implement strict monitoring of water-electrolyte balance and the coagulation system, and provide mechanical ventilation and parenteral nutrition. The ICU base allows for the use of active methods such as electroconvulsive therapy (ECT), plasmapheresis, hemosorption, hyperbaric oxygen therapy (HBOT), and cranial hypothermia.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Acute organic brain lesions (encephalopathies) in psychiatry
• Principles of electroconvulsive therapy (ECT) in the ICU
• Febrile catatonia and status epilepticus
• Differential diagnosis of altered states of consciousness (delirium, oneirophrenia)

Other topics in the section "Chapter 28. Psychiatric Emergencies"

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