Exploring Diagnostic and Treatment Options for Agitation

This book looks at psychiatric causes of agitation in mood, personality, and psychotic disorders.

Agitation is a condition afflicting many patients who seek treatment. But as the new book The Diagnosis and Management of Agitation, (Cambridge University Press, Cambridge, United Kingdom) edited by Scott L. Zeller, MD, Kimberly D. Nordstrom, MD, JD, and Michael P. Wilson, MD, PhD states, there is an international crisis with regard to the diagnosis, treatment, and coordinated care in a growing number of patients who demonstrate various forms of behavioral emergencies with agitation.

One of the book’s central conceits is the demystification of agitated individuals as “the enemy.” “What we all need to understand is that our patients, in an episode of agitation, are not bad people even though they might be using profanity, making threatening statements, posturing, or even becoming physical.”

In keeping with this concept, the book surveys such topics as substance use and withdrawal, elder care, mood, personality, and psychotic disorders. For example, a clinician can learn about the pitfalls in evaluating agitation in the elderly, which include neglecting to perform a thorough history and physical examination, failure to diagnose the underlying cause of delirium, and assuming that a patient’s agitation is a symptom of substance abuse or a psychiatric disorder. The book outlines an alternative model for personality disorders from Section III of the DSM-5, in which assessment relies on logical and distinct steps.

And in dealing with agitation due to substance abuse, the process should mimic that used to treat other mental disorders, according to contributors Alexander Schorb and Heinz Grunze. Nonpharmacologic means of behavioral control should precede pharmacologic intervention, and, if needed, medication administration should be easy and non-traumatic.

In addition, Joachim Scharfetter outlines the tenets of the psychiatric evaluation of agitation. “A clinician should never hesitate to ask questions related to suicidality. Such questions do not increase the suicide risk or introduce ideas in the patient just by asking, as is sometimes assumed and feared by inexperienced interviewers,” he says. He also emphasizes de-escalation techniques, which can help reduce a patient’s level of agitation while also giving the patient the ability to make choices and concentrate on questions, both of which can allow a patient to begin to regain self-control.

Agitation also acknowledges several obstacles complicating the assessment of patients with agitation, including general uncooperativeness and the inability to get a complete history because the patient’s state only allows them to provide limited information. In addition, the mere administration of interviews and self-reports can escalate agitated behaviors.

When it comes to emerging standards of care, Jon S. Berlin opines that the onus of de-escalation should be on the best-trained physicians; having experts intervene early in patients with agitation can produce better outcomes. Berlin also mentions the growing inclusion of psychiatry emergency services in practice; the need for physicians who are more experienced than psychiatric residents and trainees to make decisions that respond to a combination of the biological, physical, and humanitarian aspects of psychiatry; and the importance of patient follow-up.

Accessible, straight-forward, well-researched and well-organized, The Diagnosis and Management of Agitation is an essential primer on how psychiatrists can address patients who demonstrate agitation. With this book as a guide, we can hope to see many improved outcomes in the future.

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