Psychomotor agitation

Psychomotor agitation
Other namesPacing
SpecialtyPsychiatry, emergency medicine

Psychomotor agitation is a symptom in various disorders and health conditions. It is characterized by unintentional and purposeless motions and restlessness, often but not always accompanied by emotional distress.[1] Typical manifestations include pacing around, wringing of the hands, uncontrolled tongue movement, pulling off clothing and putting it back on, and other similar actions.[2] In more severe cases, the motions may become harmful to the individual, and may involve things such as ripping, tearing, or chewing at the skin around one's fingernails, lips, or other body parts to the point of bleeding. Psychomotor agitation is typically found in major depressive disorder or obsessive-compulsive disorder, and sometimes the manic phase in bipolar disorder, though it can also be a result of an excess intake of stimulants. It can also be caused by severe hyponatremia. The middle-aged and the elderly are more at risk to express it.

Psychomotor agitation overlaps with agitation generally, such as agitation in predementia and dementia; see Agitation (dementia) for details.

Signs and symptoms

People experiencing psychomotor agitation may feel the following emotions or do the following actions. Some of these actions are not inherently bad or maladaptive, but they can have maladaptively excessive versions. For example, self-hugging can be therapeutically advisable, but self-hugging as a component of a set of motor agitation movements is a sign of psychomotor agitation.

  • unable to sit still
  • fidgeting
  • as if their body is stiff
  • unable to relieve tension
  • desperate to find a comfortable position
  • increasingly anxious
  • exasperated
  • tearful
  • extreme irritability, like snapping at friends and family, or being annoyed at small things
  • anger
  • agitation
  • racing thoughts and incessant talking
  • restlessness
  • pacing
  • hand-wringing
  • self-hugging
  • nail-biting
  • outbursts of complaining or shouting
  • pulling at clothes or hair
  • picking at skin, as either a sign of PMA or even progressing to a disorder (excoriation disorder)
  • tapping fingers
  • tapping feet
  • starting and stopping tasks abruptly
  • talking very quickly
  • moving objects around for no reason
  • taking off clothes then putting them back on

Causes

Causes include:[3]

As explained in a 2008 study, in people with mood disorders there is a dynamic link between their mood and the way they move.[7]

People showing signs of psychomotor agitation may be experiencing mental tension and anxiety, which comes out physically as:

  • fast or repetitive movements
  • movements that have no purpose
  • movements that are not intentional

These activities are the subconscious mind's way of trying to relieve tension. Often people experiencing psychomotor agitation feel as if their movements are not deliberate.

Sometimes, however, psychomotor agitation does not relate to mental tension and anxiety.

Recent studies found that nicotine withdrawal induces psychomotor agitation (motor deficit).[8][9][10][11]

In other cases, psychomotor agitation can be caused by antipsychotic medications. For instance, akathisia, a movement disorder sometimes induced by antipsychotics and other psychotropics, is estimated to affect 15-35% of patients with schizophrenia.[12][13]

Treatment

A form of self-treatment arises in that many patients develop stimming in a natural, unplanned, and largely nonconscious way, simply because they coincidentally discover behavior that brings some relief to their psychomotor agitation, and develop habits around it. Stimming has many forms, some quite adaptive and others maladaptive (for example, excessive hand-wringing can injure joints, and excessive rubbing or scratching of skin can injure it). Another form of self-treatment that arises not uncommonly is self-medication, which unfortunately can lead to substance use disorders such as alcohol use disorder.

Whereas stimming is a nonpharmacologic but undirected and sometimes harmful amelioration, directed therapy tries to introduce another and generally better nonpharmacologic help in the form of the following lifestyle changes, to help a person to reduce their anxiety levels:[7]

Because nonpharmacologic treatment by itself is often not enough, medications are also often used. Intramuscular midazolam, lorazepam, or another benzodiazepine can be used both to sedate agitated patients and to control semi-involuntary muscle movements in cases of suspected akathisia.

Droperidol, haloperidol, or other typical antipsychotics can decrease the duration of agitation caused by acute psychosis, but should be avoided if the agitation is suspected to be akathisia, which can be potentially worsened.[14] Also using promethazine may be useful.[15] Recently, three atypical antipsychotics, olanzapine, aripiprazole and ziprasidone, have become available and FDA approved as an instant release intramuscular injection formulations to control acute agitation. The IM formulations of these three atypical antipsychotics are considered to be at least as effective or even more effective than the IM administration of haloperidol alone or haloperidol with lorazepam[16][17][18] (which is the standard treatment of agitation in most hospitals) and the atypicals have a dramatically improved tolerability due to a milder side-effect profile.

In those with psychosis causing agitation, there is a lack of support for the use of benzodiazepines alone, however they are commonly used in combination with antipsychotics since they can prevent side effects associated with dopamine antagonists.[19]

See also

References

  1. ↑ Scaccia, Annamarya (25 April 2017). "Everything You Should Know About Psychomotor Agitation". Healthline. Retrieved 13 June 2021.{{cite web}}: CS1 maint: url-status (link)
  2. ↑ Burgess, Lana (16 October 2017). "What is psychomotor agitation?". Medical News Today. Retrieved 13 June 2021.{{cite web}}: CS1 maint: url-status (link)
  3. ↑ Causes of Psychomotor agitation Archived 2016-03-11 at the Wayback Machine, Retrieved 11 March 2016.
  4. ↑ Koenig AM, Arnold SE, Streim JE (January 2016). "Agitation and Irritability in Alzheimer's Disease: Evidenced-Based Treatments and the Black-Box Warning". Current Psychiatry Reports. 18 (1): 3. doi:10.1007/s11920-015-0640-7. PMC 6483820. PMID 26695173.
  5. ↑ "Acute Intermittent Porphyria (AIP)". American Porphyria Foundation. 18 February 2009. Archived from the original on 2 October 2015. Retrieved 8 December 2017.
  6. 1 2 "Agitated Depression: Symptoms, Treatment, and Outlook". Healthline. Retrieved 31 July 2018.
  7. 1 2 "What is psychomotor agitation?". Medical News Today. 16 October 2017.
  8. ↑ Hughes JR (2007). "Effects of abstinence from tobacco: valid symptoms and time course". Nicotine Tob Res. 9 (3): 315–327. doi:10.1080/14622200701188919. PMID 17365764.
  9. ↑ Grundey J, et al. (2017). "Diverging effects of nicotine on motor learning performance: Improvement in deprived smokers and attenuation in non-smokers". Addict. Behav. 74: 90–97. doi:10.1016/j.addbeh.2017.05.017. PMID 28600927.
  10. ↑ Becker JA, Kieffer BL, Le Merrer J (2017). "Differential behavioral and molecular alterations upon protracted abstinence from cocaine versus morphine, nicotine, THC and alcohol". Addiction Biology. 22 (5): 1205–1217. doi:10.1111/adb.12405. PMC 5085894. PMID 27126842.
  11. ↑ Kim B, Im HI (2020). "Chronic nicotine impairs sparse motor learning via striatal fast‐spiking parvalbumin interneurons". Addiction Biology. Early View (3): e12956. doi:10.1111/adb.12956. PMC 8243919. PMID 32767546.
  12. ↑ Berna F, Misdrahi D, Boyer L, Aouizerate B, Brunel L, Capdevielle D, et al. (December 2015). "Akathisia: prevalence and risk factors in a community-dwelling sample of patients with schizophrenia. Results from the FACE-SZ dataset". Schizophrenia Research. 169 (1–3): 255–261. doi:10.1016/j.schres.2015.10.040. PMID 26589388. S2CID 26752064.
  13. ↑ Salem H, Nagpal C, Pigott T, Teixeira AL (15 June 2017). "Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges". Current Neuropharmacology. 15 (5): 789–798. doi:10.2174/1570159X14666161208153644. PMC 5771055. PMID 27928948.
  14. ↑ Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA (October 2010). "Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study". Annals of Emergency Medicine. 56 (4): 392–401.e1. doi:10.1016/j.annemergmed.2010.05.037. PMID 20868907.
  15. ↑ Ostinelli EG, Brooke-Powney MJ, Li X, Adams CE (July 2017). "Haloperidol for psychosis-induced aggression or agitation (rapid tranquillisation)". The Cochrane Database of Systematic Reviews. 2017 (7): CD009377. doi:10.1002/14651858.CD009377.pub3. PMC 6483410. PMID 28758203.
  16. ↑ Huang CL, Hwang TJ, Chen YH, Huang GH, Hsieh MH, Chen HH, Hwu HG (May 2015). "Intramuscular olanzapine versus intramuscular haloperidol plus lorazepam for the treatment of acute schizophrenia with agitation: An open-label, randomized controlled trial". Journal of the Formosan Medical Association = Taiwan Yi Zhi. 114 (5): 438–45. doi:10.1016/j.jfma.2015.01.018. PMID 25791540.
  17. ↑ Citrome L, Brook S, Warrington L, Loebel A, Mandel FS (October 2004). "Ziprasidone versus haloperidol for the treatment of agitation". Annals of Emergency Medicine. 44 (4): S22. doi:10.1016/j.annemergmed.2004.07.073.
  18. ↑ Cañas F (March 2007). "Management of agitation in the acute psychotic patient--efficacy without excessive sedation". European Neuropsychopharmacology. 17 Suppl 2: S108-14. doi:10.1016/j.euroneuro.2007.02.004. PMID 17336765. S2CID 14534413.
  19. ↑ Gillies D, Sampson S, Beck A, Rathbone J (April 2013). "Benzodiazepines for psychosis-induced aggression or agitation". The Cochrane Database of Systematic Reviews. 4 (4): CD003079. doi:10.1002/14651858.CD003079.pub3. hdl:10454/16512. PMID 23633309.
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