Agitation. As a mental health professional, you know it when you see it. While technically, it is the behavior that precedes aggression and violence, every clinical setting has its own flavor, from the voluntary psychiatric unit where I see my most acutely ill patients to the state hospital where I witnessed the type of violence that sent another patient to the emergency department.
Over the past 2 years of residency, I have developed a personal scale for measuring and responding to patient agitation. Through experiences that have provided the lower, upper (and even more upper) bounds to this scale, I have evolved from a nervous first-year intern to become a resident conscious of the need for a cool demeanor and continued engagement with the patient with escalating agitation.
Dr. Jacqueline Posada
The 2003 Treatment of Behavioral Emergencies: A Summary of the Expert Consensus Guidelines1 provides an excellent visual scale to measure agitation. It begins with a patient’s refusal to cooperate and ascends stepwise toward motor restlessness, lability and loud speech, intimidation, aggression against property, and hostile verbal behavior, and it ends with directly threatening or assaultive behavior.2 Only when I witnessed signs of clinically significant agitation, hostile countenance, unpredictable anger, pacing, clenched fists, yelling, and threats, did I develop a personal understanding and approach for measuring agitation on the inpatient unit.
The upper bound for my scale initially was defined by my first incident of severe agitation and aggression while on call. I no longer remember if the patient was agitated and psychotic or just angry and agitated. Though schizophrenia and bipolar disorder often are the underlying causes of agitation, personality disorders and substance use complicate or contribute to agitation.3 The nurse called me, saying: “Can you come to the unit right now? Mr. X is agitated and has ripped the soap dispenser off the wall in his bathroom.” It was just after midnight, and already several nursing calls into this situation. Verbal de-escalation had failed with Mr. X, who moved from agitation to aggressive behavior. He already had received two doses of haloperidol and lorazepam since my evening shift began. I looked into his bedroom and saw him wrestling with the sink, which did not come off the wall as easily as the soap dispenser. The thought process of an inexperienced intern went like this: “How much haloperidol is too much haloperidol? Will this night never end?” I called my attending for help, and there was desperation in my voice as I explained: “The medications aren’t working.
These situations usually result in good clinical lessons: Medications take time to work, and in some individuals, the “standard cocktail” might not be the best option. Nonetheless, the lag time can be excruciating. As a more experienced resident, I now consider how certain medications may fail an individual, and there might be a better alternative to haloperidol and lorazepam. I’ve expanded my repertoire of pharmacological methods and opt often for second-generation antipsychotics, such as olanzapine or risperidone, without or without a benzodiazepine, when possible.2
Of course, not all agitation becomes a behavioral health emergency, and an integral part of my training as a resident has been watching an attending run an intervention smoothly. It requires coordination and experience, skills that I’m gaining. In these cases, the agitation is addressed before it escalates, nursing staff and the physicians collaborate to deliver treatment, and the patient responds to verbal redirection and, if offered, accepts oral medications. These types of patients help cement the lower bound for my agitation scale.
Nonetheless, the patients who challenge the positive archetype are the ones who cement lessons for physicians. I remember a man who with his history of serious mental illness had adverse reactions to haloperidol, aripiprazole, olanzapine, and fluphenazine. To address his agitation, the nurses prepared 2 mg of lorazepam and 50 mg of diphenhydramine. As the patient ramped up, I heard a nurse sigh, “Why can’t we add IM thorazine?” I commiserated with the nurse; the psychiatric unit is a dangerous place to work. Psychiatry and emergency department nurses, compared with their counterparts in other units, are the most likely to be assaulted at work.4,5 It is personal for me as well. Studies suggest that 30%-40% of psychiatric residents will be attacked during their 4-year training, and I am in that 70%-90% of residents who has been verbally threatened more than once.6
With time and training, my verbal de-escalation techniques have improved, as I’ve learned to avoid threatening and judgmental body language, avoiding a natural tendency to stand with my arms crossed over my chest or hands on my hips. I now more accurately and incisively inquire about a patient’s mental state. How can I address their frustration? In a nonaccusatory way, I let the patients know that they are behaving in a way that is frightening and that continued behavior may have consequences. Even when faced by the heat of agitation, I try to value the patients’ choice: This event will affect our therapeutic relationship in the longer term.
Whenever possible, I want the patients to choose their medication formulation or at least be able to ask them, “Would you be willing to take … ?” With time, I am earning that cool demeanor psychiatrists are known for. I can model calm behavior and effectively use my knowledge about mentalization to try to de-escalate the situation.
My scale of measuring of agitation and violence had its upper level increased significantly from just a soap dispenser being ripped off the wall. One patient really upped the ante by swiping a public telephone off the wall and then went tearing down the hallway to pull the fire extinguisher out of its supposed “safe” case and hurl it. So on a recent night shift, when I heard yelling through the door of the call room, it was with a sense of understanding rather than trepidation that my co-resident and I approached the patient, already being corralled to his room by nursing staff. He was an enormous man, angry, paranoid, pacing, and shouting about how the other patients wanted to attack him. Despite his size, his menacing posture, and that somewhere in his agitation he had ripped off his scrub shirt, I couldn’t help but think, “Well at least the phone and the fire extinguisher are still attached to the wall.”
References
1 J Psychiatr Pract. 2003 Jan;9(1):16-38. Treatment of behavioral emergencies: A summary of the expert consensus guidelines.
2 J Psychiatr Pract. 2005 Nov;11 Suppl 1:5-108; quiz 110-2. The expert consensus guideline series. Treatment of behavioral emergencies 2005.
3 Clin Pract Epidemiol Ment Health. 2016 Oct 27;12:75-86. State of acute agitation at psychiatric emergencies in Europe: The STAGE study.
4 J Emerg Nurs. 2014 May;40(3):218-28; quiz 295. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors.
5 Work. 2010;35(2):191-200. Physical assault among nursing staff employed in acute care.
6 Psychiatr Serv. 1999 Mar;50(3):381-3. Assaults by patients on psychiatric residents: a survey and training recommendations.
Dr. Posada is a second-year resident in the psychiatry & behavioral sciences department at George Washington University, Washington. She completed a bachelor’s degree at the George Washington University. For 2 years after her undergraduate education, she worked at the National Institutes of Allergy and Infectious Diseases studying HIV pathogenesis. Dr. Posada completed her medical degree at the University of Texas Medical Branch in Galveston. Her interests include public psychiatry, health care policy, health disparities, and psychosomatic medicine.