This article was published on April 6, 2022. It was last updated/ edited on April 26, 2022.
Agitation/ aggressiveness is a common issue that mental health clinicians have to deal with, most commonly in acute care situations (emergency room, inpatient psychiatric unit). Unfortunately, many or most of us have been in situations in which we were subjected to verbal aggression, threats, and, not rarely, even physical aggression. So, strategies for managing agitation and aggressiveness are extremely important for us to continue to master.
Unfortunately, research evidence on what works to prevent or de-escalate aggressive behavior among psychiatric patients is very limited (Gaynes et al., 2017). The clinical tips about the evaluation and management of agitation, aggressiveness, and violence in mental health settings that we provide in different articles on this website are based mainly on clinical experience and expert opinion.
Treat the cause AND manage the agitation/ aggressiveness
Agitation/ aggressive behavior can occur due to a known underlying etiology(for example, schizophrenia, mania, delirium, substance intoxication, substance withdrawal, and so on) that can potentially be treated acutely or even reversed. In such cases, the management of agitation/ aggressiveness will depend in large part on the underlying cause(s).
On the other hand, for anger, agitation, and aggressiveness due to emotional issues, interpersonal conflict, personality disorders, etc, non-pharmacological interventions and non-specific pharmacological treatments are typically needed.
But, despite this important distinction, many of the general strategies to ensure safety and manage agitation/ aggressiveness are applicable to a wide variety of clinical situations.
Actions speak louder than words
Tip: Looking at motor activity helps predict impending aggressive behavior.
It would be helpful if we could recognize earlier on that a patient is becoming agitated and may be at risk of becoming verbally or even physically aggressive. While agitation is not necessarily related to aggressive behavior, it is an important predictor.
Psychomotor agitation was defined in the DSM-5 glossary as “excessive motor activity associated with a feeling of inner tension” (American Psychiatric Association, 2013). This excessive motor activity is usually nonproductive and repetitious (American Psychiatric Association, 2013).
Here’s a useful clinical tip: LOOKING at the patient’s motor activity can often be as helpful (or even more helpful) in assessing the risk of aggressive behavior as the content of what the patient is saying.
Examples of warning signs in patients’ psychomotor activity may include (American Psychiatric Association, 2013)
– Loud and rapid speech
– Speaking through clenched teeth
– Pacing back and forth
– Clenched fists
– Wringing of the hands
– Banging the table
– Fiddling with or pulling at one’s clothes
– Inability to sit still
– Repetitive foot tapping (Richmond et al., 2012)
Overview of strategies for evaluation and management
While we aim to use the least restrictive interventions possible, we should note that:
– Safety of the patient, other patients, and staff members sometimes requires directly going to more restrictive strategies (for example, physical restraints) without trying less restrictive strategies first.
– It is sometimes unclear which strategy is the less restrictive one.
Strategies for the management of acute agitation/ aggressive behavior can include one or more of those listed below.
– Ensuring the safety of the patient and others
– Risk evaluation
– Identification and management of the underlying condition, for example, psychosis, substance withdrawal, delirium, and so on.
– Verbal de-escalation
– Oral medications—Oral medications are deliberately listed here ahead of other interventions because they may prevent further escalation and the need for more restrictive interventions.
– Open seclusion/ Quiet room—Directing the patient to voluntarily go into a quiet room in which there is minimal stimulation and which is designed to not have objects that agitated patients could use to harm themselves or others.
Note: Irrespective of where a patient is placed, if they are prevented from leaving that space (whether or not the door is locked), this is considered to be “seclusion” and the regulations related to seclusion apply.
– Locked seclusion—Same as above but the door is locked so that the patient cannot come out of the room unless a staff member lets them out.
– Injected medications
– Physical restraints
“Chemical restraints”: What’s in a name?
The term “chemical restraints” has traditionally been used to describe the use of oral or injected medications to calm an agitated/ aggressive patient down. This has the effect of “chemically” rather than physically “restraining” the patient.
But, the term chemical restraints has acquired negative connotations. Also, it is not clear if the term “chemical restraint” applies only to using medications to largely immobilize (“restrain”) the patient or also to their use for inducing calm wakefulness or light sedation. For these reasons, many leading experts strongly recommend that we NOT use the term “chemical restraints”.
When medications can be safely used as an alternative to physical restraints, we would, obviously, favor this. In other articles on this website, we will discuss in detail the use of oral and injected medications to treat agitated/ aggressive behavior.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines restraint as any chemical or physical method of restricting a patient’s freedom of movement, physical activity, or normal access to his or her body—a method that is NOT a usual and customary part of a medical diagnostic or treatment procedure performed with the patient’s consent.
So, when applicable, a distinction needs to be made between medications that are being used to treat the underlying illness (for example, a standing dose of an antipsychotic medication to treat schizophrenia or of a mood stabilizer to treat a manic episode of bipolar disorder) and medications that are being used to treat the acute agitation/ aggressiveness (for example, a benzodiazepine given to an agitated patient with schizophrenia). The term “chemical restraint”, if it is used at all, should only be used if medications are being used with the specific purpose of reducing acute agitation instead of for the treatment of the underlying illness.
Ahmad Shobassy, MD, adds that medications for agitation may be considered restrictive only when these medications are given against the patient’s will. Some patients recognize that they are getting agitated and they may ask to be given medications to calm down. Those medications should not be considered a restrictive intervention since the patient’s consent is implied in their request for the medications.
Next, please see the following articles on this website:
Simple and Practical Medical Education thanks Kenneth Certa, MD, and Ahmad Shobassy, MD, for their valuable comments and suggested edits for this article.
Dr. Certa is an Associate Professor of Psychiatry and Human Behavior and Director of Acute Psychiatric Services at Thomas Jefferson University in Philadelphia, Pennsylvania, USA. Dr. Certa is a senior psychiatrist with very extensive experience and expertise in emergency and acute care psychiatry.
Dr. Shobassy is a Clinical Assistant Professor of Psychiatry at the University of Michigan School of Medicine in Ann Arbor, Michigan, USA.
When calm needs to be injected: Intramuscular and intravenous injections for agitation or aggressiveness
Key Points from the APA Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
Coburn VA, Mycyk MB. Physical and chemical restraints. Emerg Med Clin North Am. 2009 Nov;27(4):655-67, ix. doi: 10.1016/j.emc.2009.07.003. PMID: 19932399.
Gaynes BN, Brown CL, Lux LJ, Brownley KA, Van Dorn RA, Edlund MJ, Coker-Schwimmer E, Weber RP, Sheitman B, Zarzar T, Viswanathan M, Lohr KN. Preventing and De-escalating Aggressive Behavior Among Adult Psychiatric Patients: A Systematic Review of the Evidence. Psychiatr Serv. 2017 Aug 1;68(8):819-831. doi: 10.1176/appi.ps.201600314. Epub 2017 Apr 17. PMID: 28412887.
Guerrero P, Mycyk MB. Physical and Chemical Restraints (an Update). Emerg Med Clin North Am. 2020 May;38(2):437-451. doi: 10.1016/j.emc.2020.02.002. PMID: 32336335.
Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses. Cochrane Database Syst Rev. 2000;2000(2):CD001163. doi: 10.1002/14651858.CD001163. PMID: 10796606; PMCID: PMC6669266.
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