The Anxious Patient 141

Table 6–1. Disorders associated with anxiety

syndromes
Psychiatric Neurological
Cognitive disorders Cerebral syphilis
Depressive episodes with anxiety Cerebrovascular insufficiency
Generalized anxiety disorder Encephalopathies (infectious,
Obsessive-compulsive disorder metabolic, and toxic)
Panic disorder Essential tremor
Personality disorders Huntington’s chorea
(especially Clusters B and C) Intracranial mass lesions
Posttraumatic stress disorder Migraine headaches
Psychotic disorders Multiple sclerosis
Social anxiety disorder Postconcussive syndrome
Specific phobia Posterolateral sclerosis
Cardiovascular Polyneuritis
Angina pectoris Seizure disorders (especially temporal
Arrhythmias lobe seizures)
Congestive heart failure Vasculitis
Hypertension Vertigo
Hyperventilation Wilson’s disease
Hypovolemia Respiratory
Myocardial infarction Asthma
Shock Chronic obstructive pulmonary disease
Syncope Pneumonia
Valvular disease Pneumothorax
Endocrine Pulmonary edema
Cushing’s syndrome Pulmonary embolus
Hyperkalemia Drug related
Hyperthermia Stimulant, marijuana, or hallucinogen
Hyperthyroidism abuse
Hypocalcemia Alcohol or sedative-hypnotic
Hypoglycemia withdrawal
Hyponatremia Akathisia (secondary to antipsychotic
medications or SSRIs)
Hypoparathyroidism
Anticholinergic, digitalis, or
Hypothyroidism
theophylline toxicity
Menopause
Abuse of over-the-counter diet pills
142 Clinical Manual of Emergency Psychiatry

Table 6–1. Disorders associated with anxiety

syndromes (continued)
Dietary Neoplastic
Caffeinism Carcinoid tumor
Monosodium glutamate Insulinoma
Tyramine-containing foods in those Pheochromocytoma
taking MAOIs Infectious/inflammatory
Vitamin deficiency Acute or chronic infection
Hematological Anaphylaxis
Acute intermittent porphyria Systemic lupus erythematosus
Anemias
Note. MAOIs=monoamine oxidase inhibitors; SSRIs=selective serotonin reuptake inhibitors.
Source. Milner et al. 1999.

and increases the chances that the patient presents to the emergency depart-
ment with “physical” complaints. The next section focuses on panic disorder.

Panic Disorder
Why Focus on Panic Disorder?
Panic disorder is a particularly important anxiety disorder for emergency de-
partment personnel to understand. The patient’s heightened sensitivity to
bodily sensations and catastrophic misinterpretation of them as serious med-
ical threats that is typical of panic lead to frequent emergency room visits and
hospital admissions to rule out myocardial infarctions, manage dyspnea, and
evaluate presyncope. Repeated emergency department visits from patients
with panic disorder cost the medical system a substantial amount of money;
these costs could be significantly reduced with early recognition and effective
management of the panic disorder (Coley et al. 2009).
One characteristic of panic disorder that can help differentiate it from
other types of anxiety problems is an extreme sensitivity to bodily sensations.
Patients with panic disorder pay considerable attention to the normal “sounds
of the bodily machinery” and are quite frightened by them, whereas most
people have habituated and learned to screen out these “sounds” unless some-
thing clearly changes or goes awry. Panic attacks are often triggered in patients
 The Anxious Patient 143

with panic disorder when what should be a “silent” event is attended to and
interpreted as a danger signal (Austin and Richards 2001). Instead of thinking
about a perceived palpitation as a normal sensation, a patient with panic dis-
order is prone to catastrophic interpretation (i.e., jumping to the conclusion
that a heart attack might be imminent). This reactivity to bodily sensations
has been labeled anxiety sensitivity. It can be measured using the Anxiety Sen-
sitivity Index (Reiss et al. 1986) and can be helpful in predicting the appear-
ance of spontaneous panic attacks as are seen in panic disorder (Schmidt et al.
2006). This trait also contributes to the frequent appearance of panic disorder
patients in emergency departments.
Numerous studies have examined presentation of patients with panic dis-
order to the medical emergency room, and multiple factors that make symp-
toms such as chest pain more likely to be due to panic disorder have been
distilled. If a patient is younger, female, without known coronary artery dis-
ease, presenting with atypical chest pain, and reporting high levels of anxiety,
the probability of panic disorder is higher than in the absence of these factors
(Huffman and Pollack 2003). All of these factors should be readily identified
in the initial evaluation of the chest pain complaint. In patients with low risk
of cardiac-related chest pain, a simple set of screening questions can provide
data that correlates well with gold-standard techniques for diagnosing panic
disorder. Wulsin et al. (2002) have shown that emergency department physi-
cians with no additional training in psychiatric assessment can diagnose panic
disorder in patients with low to moderate risk of acute coronary syndrome,
with fairly good agreement with psychiatric experts (=0.53; 95% confi-
dence interval, 0.26–0.80), by asking 1) whether a sudden attack of fear or
anxiety has occurred in the 4 weeks prior to the emergency department pre-
sentation; 2) whether similar attacks have occurred previously; and 3)
whether these attacks come out of the blue, cause worry about having another
attack, and feature any cardinal symptoms of panic attacks (shortness of
breath, chest pain, heart racing or pounding, sweating, chills or flushing, diz-
ziness, nausea, choking sensation, or tingling or numbness). In this study,
diagnosis and initiation of selective serotonin reuptake inhibitor (SSRI) treat-
ment in the emergency department correlated with a significant enhancement
of continued treatment at 1-month and 3-month follow-ups.
It can be critically important to screen for and make the diagnosis of panic
disorder in the emergency department. Patients come to the emergency room
144 Clinical Manual of Emergency Psychiatry

disturbed or distressed by their symptoms and wanting to know what is

wrong with them. Simple reassurance that nothing serious can be identified
and that tests have “ruled out” the heart attack or other “catastrophic” diag-
nosis that patients feared often falls on unhearing ears. The fear associated
with a panic attack amplifies the personal importance of the symptoms being
experienced, so a provider’s assertion that “nothing is wrong” does not match
the patient’s experience.
Receiving a clear diagnosis of a fairly easily treatable brain-based pathology,
based on a carefully done screening approach with proven efficacy, may be far
more satisfying to the patient. This diagnosis, however, must be delivered with
an appropriate amount of compassion and recognition of the potential need to
reduce the stigma attached to psychiatric disorders. It may also help to assure
the patient that he or she is not being told that the symptoms are “all in the
head,” even if those symptoms are generated by misfiring neurons in the brain.
Simply ruling out a heart attack, for example, leaves open the possibility of in-
numerable other interpretations of the symptoms. A panic-prone patient may
well go home, do some online research, and become convinced the problem was
an arrhythmia or something wrong with the lungs. The patient will return to
the emergency room for further rule-outs each time symptoms recur, inconve-
niencing the patient and increasing medical costs. When a careful diagnosis of
panic disorder is made during an emergency department visit, it usually proves
to be stable 2 years later; in contrast, patients with panic disorder who do not
receive a panic diagnosis and appropriate panic treatment do worse over that
2-year period, both psychiatrically and medically (Fleet et al. 2003).

Initial Treatment of Panic Disorder

If panic is accurately diagnosed, appropriate treatment can be initiated in the
emergency department, using both medications and nonpharmacological
treatments. SSRI antidepressants are the drugs of choice; they can reduce
both the frequency and intensity of panic attacks, and can be initiated in the
emergency department (Wulsin et al. 2002). SSRIs have the advantage of also
being useful for treating many of the comorbidities that are common in pa-
tients with panic disorder, including social anxiety, generalized anxiety disor-
der, PTSD, and depression.
When prescribing SSRIs, the clinician should keep in mind that these pa-
tients have a heightened propensity for catastrophic thinking around bodily
 The Anxious Patient 145

sensations. Because SSRIs can cause bodily sensations in the first days to
weeks of treatment, the risk of having a panic attack and abruptly discontin-
uing the medication in the titration phase is high. If started at too high a dose
or without adequate preparation, this early activation effect can lead some pa-
tients with panic disorder to refuse all future efforts to prescribe an SSRI for
them. This early risk should be managed with clear instructions to the patient
about what to anticipate and very gradual titration of the medication from
the lowest initiation dose. Sertraline or citalopram are good first-choice drugs
for patients with panic disorder. Sertraline has a very broad dosing range, so
it can be started at very low levels (25 mg/day) and titrated slowly to a target
dosage of 100 mg/day. Citalopram is a good alternative, because it tends to
be minimally activating, with fewer bodily sensations for the patient to mis-
interpret during titration. It can be started at 5 mg/day and titrated to a target
dosage of 20 mg/day. With either drug, the titration pace can be adjusted to
individual sensitivities and should be done under supervision, so close follow-
up is important. Long-acting benzodiazepines, such as clonazepam, can be
prescribed in a scheduled fashion to reduce the patient’s sensitivity to side ef-
fects during the titration of an SSRI antidepressant, although this approach
must be taken judiciously and is not appropriate for all patients. Rapid fol-
low-up and active management of the medication titration is key to successful
treatment.
Cognitive management of panic attacks is a cornerstone of treatment for
panic disorder. Although the emergency room will not likely lend itself to per-
forming intensive CBT, the emergency physician should at least inform the pa-
tient that a nonpharmacological treatment for panic disorder exists. Knowing
that treatment other than medication is available can help alleviate some of the
patient’s anxiety about treatment side effects and may make him or her more
willing to pursue outpatient follow-up. Relaxation techniques—slow breathing
and progressive muscle relaxation—were discussed earlier in the chapter (see
“Management of a Panic Attack”) as useful approaches to managing acute anx-
iety within the emergency room. Evidence is mixed as to whether these tech-
niques add meaningfully to the standard CBT package used to treat panic, but
they definitely will have some value to some patients during initial efforts to
manage overwhelming anxiety and initiate a fuller treatment.
As discussed in the earlier section on managing panic attacks, full treatment
of anxiety disorders often includes an exposure-based component in the CBT
146 Clinical Manual of Emergency Psychiatry

package. However, the patient in an acute crisis may be too unstable to begin
this form of treatment, and the emergency room is not the place to initiate it.
Instead. rapid follow-up should be arranged with a skilled clinician experienced
with these techniques to produce the greatest impact and enhance outcomes.

Somatic Symptom and Related Disorders

in the Medical Setting
DSM-5 includes a new category of psychiatric diagnoses known as the so-
matic symptom and related disorders, which includes the diagnoses of so-
matic symptom disorder, illness anxiety disorder, and conversion disorder
(functional neurological symptom disorder), along with others. These diag-
noses represent a reorganization of related DSM-IV-TR diagnoses, such as so-
matoform disorder and hypochondriasis, and now emphasize the presence of
distress associated with perceived somatic symptoms rather that the absence
of a medical explanation for these symptoms. Although somatic symptom
and related disorders are not classified as anxiety disorders, they all share a
common feature: pronounced somatic symptoms associated with significant
distress and impairment, which will cause highly anxious patients to seek
medical care. These somatizing patients have disproportionately high rates of
medical care utilization. Barsky et al. (2005) found that compared with non-
somatizing patients, the somatizing patients had approximately twice the
number of outpatient, inpatient, and emergency department visits over a
12-month period. In fact, due to the nature of their condition, patients with
somatic symptom and related disorders are much more likely to present to the
emergency department or other medical setting than they are to seek help
from a mental health professional.
A diagnosis of somatic symptom disorder may be appropriate for an indi-
vidual who has one or more somatic symptoms that are distressing or causing
a significant disruption in daily life. Although the prevalence of somatic
symptom disorder is not known, the disorder is thought to occur in 5%–7%
of the adult population, likely more commonly in females (American Psychi-
atric Association 2013). An individual diagnosed with this disorder may de-
vote a disproportionate amount of time to thinking about the perceived
seriousness of his or her symptoms; may demonstrate high levels of anxiety
associated with the symptoms; and may expend a great deal of time, energy,
 The Anxious Patient 147

and resources on these health concerns. In severe cases, health concerns may
become central in patients’ lives, overtaking their identity and straining their
interpersonal relationships, as well as their relationship with their likely mul-
tiple medical providers. The symptoms may range from pain to fatigue to
normal body perceptions, but the individual’s suffering is genuine.
In contrast to patients with somatic symptom disorder, individuals with
illness anxiety disorder are less concerned about somatic symptoms in and of
themselves, but they may be convinced that they have acquired a serious and
undiagnosed medical illness. In illness anxiety disorder, somatic symptoms
typically either are not present or are mild in intensity. Thorough evaluations
do little to quell the individual’s concern, and the patient may, for example,
continue to interpret a tension headache as evidence of a brain tumor or tran-
sient tinnitus as a clear sign of an impending stroke. These patients may en-
gage in excessive and maladaptive behaviors such as repeatedly checking their
body for signs of illness, extensively researching their suspected disease, seek-
ing constant reassurance from others, and avoiding situations that they fear
might jeopardize their health. If a diagnosable medical condition is in fact
present, the patient’s anxiety is often significantly out of proportion to the se-
verity of the condition. Attempts by medical providers to provide reassurance
or palliate symptoms do little to alleviate the patient’s concerns and may even
heighten them.
A patient with conversion disorder (functional neurological symptom dis-
order) may present to the emergency department with one or more symptoms
of altered motor function (e.g., left-sided weakness) or sensory function (e.g.,
blindness). To support a diagnosis of conversion disorder, clinical findings
must provide evidence of incompatibility between the symptom and estab-
lished neurological or medical conditions (e.g., Hoover’s sign, tunnel vision).
The onset of symptoms in conversion disorder may be associated with acute
stress or trauma, although this is not always the case. Conversion disorder is
thought to be relatively common; however, the precise prevalence is unknown
because symptoms are often transient.
A diagnosis of somatic symptom disorder, illness anxiety disorder, or con-
version disorder does not preclude an individual from also having a separate
medical (or psychiatric) condition, so the first step in evaluation, as with
panic attack, is to rule out serious medical threats. This rule-out may include
a focused physical examination while avoiding more invasive laboratory or
148 Clinical Manual of Emergency Psychiatry

diagnostic procedures, although clinical judgment should always dictate the

extent of the workup.
The role of the emergency physician in managing somatic symptom and re-
lated disorders is to first assure the patient that there is no life-threatening pa-
thology at play while also validating the patient’s experience and maintaining a
balanced emotional response (i.e., not blaming the patient for his or her somatic
experience). Because patients who fall under this diagnostic category are likely
to have been told by previous providers that their symptoms are imaginary, they
are prone to feeling dismissed. The emergency room physician should empha-
size that the patient’s symptoms are real, that the condition is common and
treatable, and that the brain has powerful influences over the body, especially
during times of stress (Stephenson and Price 2006). This approach is some-
times termed the “good news” approach, which may improve a patient’s will-
ingness to engage in mental health evaluation and treatment (Thompson et al.
2013). Additionally, making the patient feel invalidated risks his or her aban-
donment of use of the emergency department, leaving the patient without a
safety net should he or she experience a true medical emergency.
The most important therapeutic intervention the emergency physician
can undertake is to arrange for outpatient follow-up with the patient’s pri-
mary care provider. The primary care provider may then consider referral to
a psychiatrist or to a subspecialty clinic that matches the patient’s particular
somatic complaints. In some tertiary centers, subspecialty clinics are develop-
ing integrated behavioral health programs for patients with functional bowel
disorders, nonepileptic spells, and so forth. Somatic symptom and related dis-
orders are best treated within one health care system so as to prevent unnec-
essary workup. Ideally, the patient will eventually be willing to follow up with
a mental health professional, because individual and group psychotherapy has
been shown to reduce these patients’ health care costs by 50% (Sadock and
Sadock 2003).

Other Anxiety Disorders and Related Conditions

Although panic and somatization have particular salience in the emergency de-
partment context, other types of anxiety-related conditions impact the likeli-
hood and nature of patient presentations to the emergency room. All of the
anxiety and anxiety-related disorders can contribute to heightened fear or
 The Anxious Patient 149

worry in the face of physical symptoms and can increase the odds that a patient
will appear for emergent care instead of pursuing help through less urgent
avenues. Patients with obsessive-compulsive disorder may demonstrate a near-
delusional level of concern about germs or infection. Patients with a blood-
injection-injury phobia may faint when in the emergency department for an-
other reason. Trauma is the triggering event for many psychiatric disorders, in-
cluding PTSD, and trauma patients often first present for medical care in the
emergency department. A full discussion of these conditions is beyond the
scope of this chapter given that neither clinical experience nor research studies
would support a particular approach for diagnostic or therapeutic interven-
tions specific to an emergency department setting.

Key Clinical Points

• Anxiety is a common complaint in the emergency department,

and anxiety disorders pose a significant burden to the medical
system if they are not adequately recognized and treated.
• Panic attacks can be managed without medications, using cog-
nitive and behavioral techniques.
• SSRIs provide relief from most anxiety disorders, although a
slow titration to the target dose may be needed, given the pro-
pensity of SSRIs to cause anxiety-provoking physical symptoms
during the medication-initiation phase.
• Somatic symptom and related disorders are characterized by
pronounced somatic symptoms associated with significant dis-
tress and impairment that can prompt highly anxious patients
to seek emergency care.
• The presence of severe anxiety does not reduce the likelihood
of major medical problems requiring urgent attention and
should not divert attention from necessary medical evaluation.
High risk may remain even if life-threatening medical illness is
ruled out, because anxiety may reflect an underlying psychiatric
disturbance that carries a serious risk of self-harm or harm to
others.
150 Clinical Manual of Emergency Psychiatry

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor-
ders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Associ-
ation, 2000
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disor-
ders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013
Austin DW, Richards JC: The catastrophic misinterpretation model of panic disorder.
Behav Res Ther 39(11):1277–1291, 2001 11686264
Barsky AJ, Orav EJ, Bates DW: Somatization increases medical utilization and costs
independent of psychiatric and medical comorbidity. Arch Gen Psychiatry
62(8):903–910, 2005 16061768
Coley KC, Saul MI, Seybert AL: Economic burden of not recognizing panic disorder
in the emergency department. J Emerg Med 36(1):3–7, 2009 17933481
Deacon B, Lickel J, Abramowitz JS: Medical utilization across the anxiety disorders.
J Anxiety Disord 22(2):344–350, 2008 17420113
Fleet RP, Lavoie KL, Martel JP, et al: Two-year follow-up status of emergency depart-
ment patients with chest pain: Was it panic disorder? CJEM 5(4):247–254, 2003
17472767
Huffman JC, Pollack MH: Predicting panic disorder among patients with chest pain:
an analysis of the literature. Psychosomatics 44(3):222–236, 2003 12724504
Milner KK, Florence T, Glick RL: Mood and anxiety syndromes in emergency psy-
chiatry. Psychiatr Clin North Am 22(4):755–777, 1999 10623969
Reiss S, Peterson RA, Gursky DM, et al: Anxiety sensitivity, anxiety frequency and the
prediction of fearfulness. Behav Res Ther 24(1):1–8, 1986 3947307
Sadock BJ, Sadock VA: Synopsis of Psychiatry, 9th Edition. Philadelphia, PA, Lippin-
cott Williams & Wilkins, 2003, pp 591–642
Schmidt NB, Zvolensky MJ, Maner JK: Anxiety sensitivity: prospective prediction of
panic attacks and Axis I pathology. J Psychiatr Res 40(8):691–699, 2006
16956622
Stephenson DT, Price JR: Medically unexplained physical symptoms in emergency
medicine. Emerg Med J 23(8):595–600, 2006 16858088
Thompson N, Connelly L, Peltzer J, et al: Psychogenic nonepileptic seizures: a pilot
study of a brief educational intervention. Perspect Psychiatr Care 49(2):78–83,
2013 23557450
Wulsin L, Liu T, Storrow A, et al: A randomized, controlled trial of panic disorder
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 The Anxious Patient 151

Suggested Readings
Craske MG, Barlow DH: Master of Your Anxiety and Panic: Therapists Guide, 4th
Edition. New York, Oxford University Press, 2006
Stein MB, Goin MK, Pollack MH, et al: Practice Guideline for the Treatment of Patients
With Panic Disorder, 2nd Edition. January 2009. Available at: http://www.
psychiatryonline.com. Accessed December 23, 2014.
Wells A: Cognitive Therapy of Anxiety Disorders. Chichester, UK, Wiley, 1997
 7
The Agitated Patient
Gerald Scott Winder, M.D.
Rachel L. Glick, M.D.

Case Example
Mr. H is a 43-year-old single white man with a past psychiatric history of
schizophrenia, cannabis use disorder, alcohol use disorder, and stimulant in-
toxication, as well as a past medical history significant for obesity, hyperlip-
idemia, hypertension, and prediabetes. He was brought to the emergency
department by police after patrons in a local supermarket reported that he
was exhibiting bizarre behavior on the premises. He quickly became belliger-
ent and combative when approached by police and paramedics. He was seen
in the emergency department under similar circumstances a year earlier and
was admitted to inpatient psychiatry at an outside facility. No more recent
documentation is available. Lab work is significant for positive urine toxicol-
ogy for cannabis, a negative blood alcohol level, and a mild transaminitis. His
current medications are unknown, and a previous note prominently states
that he is generally noncompliant with psychiatric medications and that he
does not follow up regularly with his primary care physician. The paramedics
administered intravenous midazolam 2 mg en route to the hospital in re-

153
154 Clinical Manual of Emergency Psychiatry

sponse to Mr. H’s persistent agitation while restrained on the gurney. His last
set of vital signs is notable for a blood pressure of 182/98 mmHg and tachy-
cardia into the 120s but is otherwise unremarkable. From the gurney, the pa-
tient continues to speak loudly to staff about his desire to leave. He mumbles
under his breath even when not spoken to, and audible content of his speech
includes ideas about “government nanotechnology.” He is malodorous and
disheveled, has poor dentition, and is wearing clothes inappropriate for the
cold weather. (At the conclusion of this chapter, we present an approach to
the assessment, diagnosis, and treatment of this patient.)

Agitation is a common symptom evaluated by emergency providers. Be-

havioral emergencies of various etiologies make up 6% of emergency depart-
ment visits in the United States (Lukens et al. 2006). Agitation threatens the
provider-patient relationship, a complete and accurate history, and patient
and staff safety. The ability of emergency clinicians to intervene early and ef-
fectively is of immense importance.
A composite of fluctuating behaviors, agitation includes motor restless-
ness, stimulus sensitivity, irritability, and inappropriate verbal or motor activ-
ity (Lindenmayer 2000). It is classified into aggressive and nonaggressive
forms of both physical and verbal phenomena (Cohen-Mansfield and Billig
1986). Its onset can lead to aggression and a behavioral emergency. Under
certain conditions, agitation confers survival benefits (Buss and Shackelford
1997), but it becomes a clinical concern when it threatens the safety of the
patient or staff, interferes with diagnosis and treatment, or leads to property
damage. Personnel in the emergency setting are particularly vulnerable to in-
jury from agitated patients (Gates et al. 2006).
Agitation arises from the complex interaction of biology and behavior.
The neurophysiology is not well understood, in large part because of how
poorly agitation lends itself to study (de Almeida et al. 2005). The existing
literature indicates that aggressive behavior likely involves various genes, neu-
rocircuitry, and neurotransmitters (de Almeida et al. 2005; Lindenmayer
2000). Compounding complexity, agitation also subsumes arrays of environ-
mental factors and psychological constructs, which can lead to a varied pre-
sentation across patients. All of these factors combine to make agitation a
challenging symptom to understand, diagnose, and treat.
A unique aspect of agitation is the strong emotion elicited from the treat-
ing clinician (Balducci 2013). Clinicians have differing levels of comfort with
 The Agitated Patient 155

Table 7–1. Early signs of agitation

Speech Loud speech volume
Use of profanity
Interpersonal Argumentativeness
Uncooperativeness
Excitability
Expressed distrust of staff
Threats (to self or others)
Phobic reactions including poor eye contact
Negativism
Psychomotor Pacing
Sleep disturbance
Muscle tension
Hyperkinetic movement (e.g., bouncing leg, changing positions)
Tearing paper or clothing
Wandering
Repetitious mannerisms (e.g., asking questions, trying the doors)
Source. Lindenmayer 2000; Richmond et al. 2012.

behavioral symptoms, and their comfort levels directly affect assessment and
treatment. Clinical skill sets should include prevention strategies, a thought-
ful diagnostic approach, and evidence-based treatment.

Prevention and Early Intervention

General Strategies
Personnel should be properly instructed in detection of agitation and early in-
tervention techniques. Table 7–1 lists clinical signs that should alert staff to
act. At the first sign of patient agitation, a staff member should connect em-
pathically using open-ended questions to query for immediate needs and then
follow up at appropriate intervals.
Agitated individuals display anxiety and inner turmoil in various ways,
and proficient assessment using a reliable clinical scale (e.g., Behavioural Ac-
tivity Rating Scale [Swift et al. 2002]) optimizes communication and docu-
156 Clinical Manual of Emergency Psychiatry

mentation. Integrating courtesy, respect, and reliable detection strategies into

the culture of an emergency department can decrease the incidence and sever-
ity of behavioral emergencies over time.

The Patient
Beginning with triage, the patient adjusts to new surroundings and processes.
Emergency department staff can easily forget patients’ nonmedical needs.
Boredom, acclimation to the facility’s temperature, and nutrition status are
easily overlooked. Blankets, food, television, or reading materials increase
comfort and convey attentiveness and concern. Introductions to staff mem-
bers, an orientation to facility procedures, and a review of patient rights may
ease tension arising from uncertainty and fear. In all interactions, staff should
remain flexible, maintain a professional demeanor, and communicate with
empathic dialogue.
As the clinical encounter progresses, several strategies reduce the likeli-
hood of agitation. Clear instructions with careful attention to personal space
are essential. The interview should take place in a quiet space, which is dis-
tinctly important for intoxicated patients. The room should allow maximal
privacy and should be set up so both patient and provider have easy, unob-
structed access to the room’s exit. There should not be anything in the room
that could be used as a weapon.
The provider should avoid prolonged eye contact with, touching of, or
standing over the patient, to decrease perceived provocation. By positioning
oneself at an angle alongside the patient (instead of standing directly in front
of him or her), the provider shows alliance. Another staff member in the room
can be a comfort to both patient and provider, while supporting the guideline
of ready access to adequate trained staff at all times (four to six persons are
recommended for a show of force). The provider’s speech should be clear,
gentle, and sincere. These measures may be insufficient, however, and the pa-
tient’s behavior may remain a concern. There is always a low threshold to end
the interview, involve security, and reconsider the course of the evaluation.

Family and Friends

Family and friends accompanying the patient can themselves escalate behav-
iorally given the time spent waiting. Emergencies rarely allow preparation for
 The Agitated Patient 157

the hours spent in the hospital. Many individuals will neglect basic needs or
arrive without supplies (food, cell phone, device for Internet connection, toi-
letries, medication) and will appreciate any accommodation. Providing inter-
val updates to the family, while maintaining confidentiality, may alleviate
their frustration stemming from the evaluation process.

Differential Diagnosis
Gathering Information
The cause of agitation will not often emerge from a single laboratory or radio-
graphic finding. Instead, accurate assessment of the symptom and appropriate
treatment depend primarily on how the provider accesses and assembles infor-
mation. Collateral information is invaluable in formulating an accurate clini-
cal assessment and plan. With severely affected patients, early pharmacological
treatment may be needed to facilitate obtaining a history. Family members
should be asked to provide details about the patient’s recent behavior, any psy-
chiatric and medical history, recent sleep patterns, and any known substance
use. Emergency medical services and nursing home personnel are reliable
sources in building a narrative and differential diagnosis.
The evaluating clinician needs to elicit and consider several aspects of the
agitated patient’s history. One important question is how the current constel-
lation of symptoms compares with past behaviors. Abrupt differences may sug-
gest an underlying medical cause. Regardless of setting, clinicians must always
consider reversible causes underlying agitation. The onset of many psychiatric
conditions usually occurs earlier in life, so new symptoms after age 45 should
pique suspicion for a nonpsychiatric etiology. Medical causes of agitation are
numerous and should be individually considered during acute evaluation. Ta-
ble 7–2 lists several findings that if present at any point in the evaluation
should prompt medical workup.

Medical Causes
There are several general categories of medical causes of agitation. Infectious
processes, especially when present in the elderly, can disseminate as sepsis and/
or directly involve the central nervous system (CNS), resulting in agitated de-
lirium. These are accompanied by fluctuations in awareness, vital sign abnor-
158 Clinical Manual of Emergency Psychiatry

Table 7–2. When agitation requires a medical evaluation

General Abnormal vital signs (pulse, blood pressure, body temperature)
Difficulty rousing the patient (i.e., score of 1 on BARS) with poor
attention
Obvious bodily trauma and injury
Slurred speech
Suspicion of acute intoxication or toxin exposure
Cardiovascular Chest pain
Persistent tachycardia or palpitations
Metabolic Unintentional weight loss
Temperature intolerance
High fever
Musculoskeletal Extreme muscle stiffness or weakness
Neurological Discordant pupil size
Hemiparesis, hemiplegia
Seizures
Incoordination
Severe headache
Psychiatric New-onset psychosis
Significant cognitive deficits (i.e., orientation, language, memory,
executive function)
Respiratory Difficulty breathing
Note. BARS= Behavioural Activity Rating Scale (Swift et al. 2002).
Source. Adapted from Nordstrom K, Zun LS, Wilson MP, et al.: “Medical Evaluation and
Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency
Psychiatry Project BETA Medical Evaluation Workgroup.” Western Journal of Emergency Medi-
cine 13(1):3–10, 2012.

malities (e.g., hypotension, fever), and perceptual disturbances, including

visual hallucinations. The co-occurrence of altered mental status, nuchal rigid-
ity, and temperature change (hypothermia or fever greater than 38°C) are of
immediate concern and may indicate a primary infection in the CNS. Agitated
patients may exhibit seizures or focal neurological deficits when there is direct
CNS involvement. For example, head trauma often presents with symptoms
of amnesia, speech irregularities, discordant pupil size, headache, or decreased
consciousness. If the patient has recently had a seizure, the postictal period is
 The Agitated Patient 159

characterized by confusion and agitation. Primary degenerative neurological

processes (i.e., neurocognitive disorders) often involve agitation as a primary
symptom. Electrolyte disturbances (e.g., hyponatremia), abnormal glucose
levels, hypoxia, hepatic encephalopathy, and thyroid axis irregularities may
masquerade as behavioral symptoms. Each of these processes may alter the pa-
tient’s sensorium and awareness sufficiently to cause agitation.

Medications
Routine doses of medications can account for agitation. Steroids for an in-
flammatory process (CNS or elsewhere) are associated with behavioral dis-
turbances. Any use of anticholinergic agents, opioid painkillers, sedatives,
psychiatric medications, or antiepileptics should be elicited in the history.
Verification of drug adherence and serum drug levels are useful. Paradoxically,
antipsychotic medications can worsen symptoms of agitation in some pa-
tients. Akathisia, an idiopathic inner sensation of restlessness, muscular dis-
comfort, and the need to move, can be confused for persistent or worsening
agitation. If not detected, a positive feedback loop of worsening symptoms
and repeat antipsychotic dosing develops. Polypharmacy itself can lead to
altered mental status, and medication interactions at the hepatic and renal
levels should always be considered.

Substance Abuse
Agitated patients are frequently evaluated in the context of recreational drug
use. Reliable history is often difficult to obtain from patients who have re-
cently used substances. Attention to vital signs, physical presentation (sites of
intravenous drug use, scars), treatment history, and belongings (for parapher-
nalia, odor) becomes important. The intoxication or withdrawal phase of
multiple drugs can account for severe behavioral symptoms.
Psychostimulants (e.g., cocaine, amphetamine, synthetic cathinones), via
their sympathomimetic effects on monoamine neurotransmitters, are well
known for causing agitation. Hallucinogens, many with serotonergic action,
may lead to aggression when patients misinterpret their surroundings, hallu-
cinate, or harbor delusional beliefs. Phencyclidine (PCP), an N-methyl-D-
aspartate receptor antagonist, is notorious for its association with violent be-
havior. When sedatives such as benzodiazepines or alcohol are involved, there
160 Clinical Manual of Emergency Psychiatry

should be a low threshold for medical stabilization because risks from an abrupt
withdrawal include seizures and death. Altered mental status (disorientation,
impaired memory), unstable vital signs, diaphoresis, neurological symptoms
(tremor, seizures), and perceptual disturbances (hallucinations) are frequently
observed in patients withdrawing from alcohol and benzodiazepines.

Psychiatric Illness
Many major psychiatric illnesses, including bipolar disorder (particularly the
manic and mixed phases), major depressive disorder, and schizophrenia, are
associated with acute agitation. Aggression is often related to disease course,
nonadherence with prescribed treatment, or changes in a patient’s personal
life. Patients with personality disorders or developmental delays also experi-
ence agitation. Frequently, however, agitation and aggression exist indepen-
dently of mental illness. (Chapter 3, “Violence Risk Assessment,” provides
helpful information.)

Evaluation and Workup

Transported Patients
Agitated patients often arrive via ambulance from residences, nursing homes,
or other hospitals. To optimize care, paramedics and/or the facility of origin
should provide descriptions of the patient’s behavior along with other key his-
tory. This information is useful to ensure safety and a thorough evaluation in
the event that an involuntary hold or hospitalization is indicated. Receiving
clinicians should quickly ensure that they have a working understanding of the
patient’s medical and psychiatric history, current symptoms, and any treat-
ments administered en route (including any medications administered or re-
straints applied), all of which are important for any quick treatment decisions
that need to be made. If the patient arrives in restraints, prompt vital-sign as-
sessment and laboratory assessment are essential (Chapter 11, “Seclusion and
Restraint in Emergency Settings,” includes additional relevant information).

Collaboration With General and Emergency Medicine

Care for the agitated patient frequently requires collaboration between med-
ical and mental health professionals. The various factors contributing to or
 The Agitated Patient 161

causing patient agitation span multiple disciplines and are approached differ-
ently across the divisions of medicine and psychiatry. These differences have
monetary and clinical effects. For example, psychiatrists and emergency phy-
sicians may differ in the type and frequency of lab tests they order in cases of
agitation. Whereas emergency department physicians may not consider urine
toxicology to be immediately useful, psychiatrists may later use the results
diagnostically (independent of its pertinence in the acute setting). In the
emergency department, tests such as thyroid-stimulating hormone blood test
or urinalysis may be done in anticipation of what an admitting psychiatric
unit will want to see, not because the physician suspects abnormal results
(Zun et al. 2004). Even if psychiatric admission requires medical clearance—
a term with an unreliable and vague definition (Korn et al. 2000)—the pro-
cess should avoid rote procedure and remain patient centered, utilizing a dif-
ferential diagnosis. Detailed clinician-to-clinician handoffs optimize the
patient’s transition between caregivers of different disciplines.

Mental Status Examination

Physical examination of an agitated patient can be limited by the psychiatric
symptoms, but mental status examination can begin in spite of them at the
first moment of patient contact. Inviting a colleague into the room with an
agitated patient can be a safety measure, an opportunity for collaboration,
and a logistical strategy when multiple clinicians evaluate patients. Psycho-
motor activity is a key aspect of the patient’s presentation to be examined early
in the encounter. Questions or observations about any increased psychomo-
tor activity may be an appropriate starting point for the patient interview
(thus allowing the clinician to promptly discuss medications if needed). In-
formation about cognitive function, including orientation, becomes directly
and indirectly available as the interview progresses with questions about the
history. Using a flexible approach to interview structure, the examiner can si-
multaneously allow the agitated patient to recount the events while gathering
data about the patient’s affect, insight, judgment, and executive functioning.
Thought content, if not volunteered by the patient spontaneously, should be
carefully examined for suicidal or homicidal ideation as part of fundamental
risk assessment. Paranoia, hallucinations, and delusional systems are impor-
tant to detect and understand early because they may impact how staff should
interact with the patient. Combining multiple steps in this way ensures a
162 Clinical Manual of Emergency Psychiatry

timely, efficient interaction and can contribute to a reduction in the level of

patient frustration that often accompanies a prolonged interview.

Intoxicated Patients
For patients intoxicated with alcohol, there is not a standard blood alcohol
level below which a psychiatric interview can be conducted. The practice of
routinely postponing examination of agitated and intoxicated patients until
their blood alcohol level drops below a certain threshold is not literature
based. Cognitive testing and the application of principles of capacity and in-
formed consent to each case will ensure that the patient can meaningfully par-
ticipate in the examination and that the results are reliable. Consent cannot
be ethically obtained from a clinically intoxicated patient.

Physical Examination
Physical examination is essential regardless of the setting—medical or psy-
chiatric. When performed, maneuvers used during the examination should
answer clinical questions motivated by the history. It is important to include
adequate examination of key organ systems—cardiovascular, respiratory, neu-
rological, gastrointestinal, and skin—with additional evaluation depending
on the history obtained. This is essential not only for the refining of the dif-
ferential diagnosis but also for adequate documentation if the patient requires
psychiatric admission.

Imaging and Laboratory Tests

If certain at-risk groups of agitated patients display abnormal vital signs or
physical examination findings, the clinician’s level of concern should rise ac-
cordingly. These groups include elderly patients, substance-abusing patients,
individuals with no prior psychiatric history, and those of lower socioeco-
nomic status (Lukens et al. 2006). The clinician may consider serum labora-
tory testing (urinalysis, toxicology, electrolytes, complete blood count, glu-
cose, urea nitrogen, serum B12 levels), lumbar puncture, electrocardiogram,
electroencephalogram, chest X ray, or computed tomography of the head, as
appropriate.
The literature, however, is mixed on how this should be done if a patient
in one of these groups requires further workup. Some authors argue for exten-
 The Agitated Patient 163

sive testing, citing statistics that many patients have treatable medical reasons
causing the agitation. Others caution against high costs and elevated rates of
false positives. They assert that few lab findings are not predicted by the his-
tory and physical examination findings and believe that widespread labs and
imaging are an expensive redundancy. The American College of Emergency
Physicians recommends that the workup of behavioral symptoms, including
laboratory assay and imaging, should be directed by history and physical ex-
amination and contends that routine lab testing is of low yield (Lukens et al.
2006).

Do No Harm
Treatment of behavioral emergencies is impacted simultaneously by what the
clinician does and does not do. Whether the provider empirically treats or
cautiously waits, the ethical principle of doing no harm is invoked. Both in-
action and hasty intervention can adversely affect the outcome.
Current or historical agitation may make verbal de-escalation impossible
and instead necessitate the use of medications. Forestalling medication may
risk injury or property damage. Proper evaluation of the patient, including in-
terview, laboratory testing, and physical examination, may not be feasible un-
til medication has taken effect. However, routine and automatic medication
use (especially involuntary, intramuscular injections) risks direct physiologi-
cal and psychological side effects. Restraint and involuntary medication are
frequently detrimental to the provider-patient alliance. Patients with a history
of trauma are at particularly high risk of psychological side effects due to the
arousal of past memories and behaviors.

Verbal De-Escalation
Although medications such as antipsychotics and benzodiazepines have tradi-
tionally been first-line treatments for agitation, recommendations now focus
more on verbal de-escalation strategies with the goal of avoiding medication
altogether. This approach improves the assessment and treatment of the agi-
tated patient. There are several reasons why a noncoercive approach is in the
interest of both providers and patients: 1) physical intervention may intro-
duce or reinforce the idea that use of force solves problems, 2) restraining a
164 Clinical Manual of Emergency Psychiatry

patient increases the chances of a hospital admission and a prolonged length

of stay, 3) the Joint Commission and the Centers for Medicaid and Medicare
Services deem low rates of physical restraint to be a key indicator of quality
care, and 4) the likelihood of staff and patient injury is reduced when physical
management is avoided (Richmond et al. 2012).
The American Association for Emergency Psychiatry Project BETA (Best
practices in Evaluation and Treatment of Agitation) De-Escalation Work-
group has put forth a practical, noncoercive, three-part overarching philoso-
phy (Richmond et al. 2012) for patient de-escalation. It includes verbal
engagement of the patient, establishment of a collaborative relationship with
the team, and the actual verbal de-escalation out of the agitated state. Table
7–3 summarizes the group’s domains of verbal de-escalation.
It is important that during the de-escalation process only one person at a
time should verbally engage the patient. More than one communicator risks
discontinuity, confusion, frustration, and potentially further escalation. Of-
ten, however, having several staff members present in a simultaneous display
of concern for the patient in a show of force facilitates the de-escalation efforts
of the leading clinician.

Medication Considerations
Inevitably, verbal de-escalation will be ineffective for a segment of agitated pa-
tients (e.g., patients who are too psychotic or cognitively impaired to be able
to communicate effectively), and medications then become an important part
of treatment. When medications are being considered, allergies should be re-
viewed in the chart and verified with the patient. With the first signs of agi-
tation, offering the patient an oral formulation is ideal (oral agents should
precede parenteral formulations). Simultaneously, the clinician should dis-
cuss why the recommendation is being made. Allowing the patient to partic-
ipate in the selection of the drug maintains the clinical alliance and informed
consent (Allen et al. 2005). Medications can be approached in an open-
ended, nonthreatening way by asking about past medications that have
helped.
Selecting the right agent with an appropriate onset of action and duration
involves a series of psychiatric and medical considerations. This task under-
 The Agitated Patient 165

Table 7–3. American Association for Emergency Psychiatry

Project BETA De-Escalation Workgroup’s 10 Domains
of De-Escalation
Respect Maintain two arms’ lengths of distance (more if needed); heed and respond
personal to any patient threats; be aware of patient vulnerabilities (past trauma,
space sexual abuse, homelessness) to avoid exacerbating symptoms
Do not be Use body language to convey empathy and safety; keep hands visible and
provocative unclenched; stand at an angle to avoid confrontation; maintain calm
facial expression and demeanor; avoid challenging patient
Establish verbal Have only one person interacting with patient at a time; introduce self;
contact provide orientation for what to expect; ask how patient would like to
be addressed and then use patient’s preferred name
Be concise Use short sentences and simple vocabulary; allow patient time to process
and respond; repeat message until it is heard
Identify wants Allow patient to share expectations and immediate needs; synthesize free
and feelings information (trivial dialogue, body language, past encounters) to
identify wants; frequently express desire to help
Listen closely Use active listening (verbal acknowledgment, body language,
to the patient conversation); use clarifying statements; assume that what patient says
is true
Agree or agree Agree with truths (“needlesticks are uncomfortable”), principles
to disagree (“everyone wants to be respected”), and odds (“many people would
also find that frustrating”) while maintaining neutrality; be willing to
agree to disagree
Set clear limits Inform patient of acceptable behaviors; mention consequences as a
matter of fact (not as a threat); acknowledge when patient causes fear
and discomfort; limit violation results in reasonable consequence; use
gentle confrontation
Offer choices Offer things that can be perceived as kindness (blankets, magazines,
and optimism phone, food); avoid deception; offer medications and allow patient to
participate; do not rush to medicate but do not delay either; reaffirm
belief that things will improve
Debrief patient Restore therapeutic alliance after involuntary action; explain why action was
and staff necessary; explore alternatives; teach proper expression of anger; touch base
with family who may have witnessed the encounter; allow staff to express
feelings and point out areas for improvement
Note. BETA= Best practices in Evaluation and Treatment of Agitation.
Source. Adapted from Richmond JS, Berlin JS, Fishkind AB, et al.: “Verbal De-Escalation of the Agi-
tated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project
BETA De-Escalation Workgroup.” Western Journal of Emergency Medicine 13(1):17–25, 2012.
166 Clinical Manual of Emergency Psychiatry

scores the importance of gathering an accurate history and maintaining a

wide differential diagnosis. The clinician should establish a provisional etiol-
ogy for the agitation and target it with appropriate pharmacotherapy. Table
7–4 features several major classes of drugs that are used in treating agitation
along with common agents that are used. For patients in whom medications
may become a stable part of their ongoing treatment, establishing tolerability
early is essential. Inducing severe side effects, such as a dystonic reaction with
an antipsychotic, will decrease the likelihood of future treatment compliance
from a pharmacotherapy perspective (if the patient fears taking medication
again) and may damage the therapeutic relationship (Yildiz et al. 2003).

Approach to Involuntary Medication

If a patient is unable to participate in the selection and use of medication and
the need for pharmacotherapy persists, then involuntary medication should
be considered. Usage of involuntary medication does not preclude providing
the patient with relevant information, however. Every effort should still be
made to explain the rationale for proceeding in this way and to clearly de-
scribe how the treatment will be carried out. If the patient requires seclusion
or restraint, medications should invariably accompany this intervention in an
effort to facilitate rapid removal. It is important to note that medications
should not be used as restraints themselves or to induce sleep. Oversedation
increases the risk of falls, respiratory insufficiency, and aspiration, and thereby
increases the burden on nursing due to the need for frequent monitoring and
generally interferes with the clinical evaluation.

Substance Use Disorders

Agitation may originate from recreational drug use. The clinician should use
the history (subjective and collateral), medical record (internal and external),
and any available toxicology assay to discern which agents may be involved.
Agitation resulting from the majority of recreational substances, especially
stimulants, generally responds to benzodiazepines. When psychosis compli-
cates the behavioral emergency, as frequently occurs in chronic amphetamine
users, an antipsychotic is first-line treatment (it may be given along with a
sedative as appropriate).
If the agitated patient is intoxicated with alcohol, minimal medication, if
any, should be used due to the risk of respiratory depression with any increas-
Table 7–4. Useful medications in agitation
Drug class Psychiatric FDA Recommended acute Metabolism/ Notable adverse effects Absorption,
and name indications dosing in adults half-life in acute setting Formulation(s) Tmax
Second-generation antipsychotics
Risperidonei Bipolar I disorder, PO: CYP2D6 EPS, akathisia, NMS, PO (tablet, PO: 1 hour
schizophrenia initial dose of 1–2 mg; 3–20 hours cerebrovascular events disintegratin
MAX: 4 mg/day (mean in elderly patients, g tablet)
half-life of orthostatic
risperidone hypotension
and active
metabolites is
20 hours)
Olanzapineii Bipolar I disorder PO: CYP1A2, Orthostatic hypotension, PO (tablet, PO: 6 hours
(acute mixed or initial dose of 5–10 mg; CYP2D6 sedation, EPS, disintegratin IM: 15–45 min
manic, maintenance, MAX: 20 mg/day (minor) akathisia, constipation, g tablet), IM (peak
depression [with IM: 21–54 hours dizziness, concentration
fluoxetine]), 10 mg (5 mg or 7.5 mg cerebrovascular events five times
treatment-resistant when clinically in elderly patients, higher than
depression, agitation warranted); NMS PO)
(related to MAX: 20 mg/day
schizophrenia or
bipolar I disorder)
The Agitated Patient
167
Table 7–4. Useful medications in agitation (continued)
Drug class Psychiatric FDA Recommended acute Metabolism/ Notable adverse effects Absorption,
and name indications dosing in adults half-life in acute setting Formulation(s) Tmax
Second-generation antipsychotics (continued)
Ziprasidoneiii Bipolar I disorder PO: CYP3A4, QT prolongation, EPS, PO, IM PO: 6–8 hours
(acute mixed or initial dose of CYP1A2 akathisia, NMS, (increased
manic) monotherapy 10–20 mg at (minor) cerebrovascular events twofold in the
or adjunct, 4-hour intervals; 7 hours in elderly patients, presence of
schizophrenia MAX: 80 mg/day sedation food)
IM: IM: 1 hour
initial dose of
10–20 mg; can be given
at 4-hour intervals;
MAX: 40 mg/day
Asenapineiv Bipolar I disorder SL: UGT1A4, Somnolence, dizziness, SL (avoid eating SL: 1 hour
(acute mixed, manic) initial dose of 5 mg; CYP1A2 EPS, akathisia, NMS and drinking
168 Clinical Manual of Emergency Psychiatry

monotherapy or MAX: 10 mg/day 24 hours for 10 min after

adjunct administration)