Depression Symptoms Treatment

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Agitation and aggression are common symptoms in inpatient psychiatric settings, geriatric medicine and emergency room care. For example, some 10% of patients admitted to psychiatric services with chronic psychiatric disorders exhibited violence toward others prior to admission. About half of patients with Alzheimer’s disease have agitation or violent behavior and 24% have verbal outbursts. Between 10% and 30% of patients hospitalized on inpatient medical units commonly develop agitation as a complication of delirium. An expansive discussion on the management of delirium in the medically ill is beyond the scope of this paper and readers are referred to the American Psychiatric Association Practice Guidelines for the Treatment of Patients with Delirium. The purpose of this article is to provide a framework for pharmacists to describe and quantify agitation and aggression as they present in their patients, outline a logical basis for treatment selection and justification, and review follow-up strategies to minimize future problems.

Impact of Agitation and Aggression

The impact of agitation and aggression in mental illness is profound. The fear of violence from people with psychiatric conditions is one of the predominant stigmatizing factors in the public perception of the mentally ill. In fact, people with mental illness do not commit the majority of violent crimes in this country and are often themselves victims. The impact of agitation and aggression on staff caring for these patients and their families is significant. Staff caring for an aggressive patient may develop negative feelings and unknowingly escalate future episodes. They may also become fearful and unwilling to engage therapeutically with that patient. Aggression is also often the reason for nursing home or residential care placement of a loved one.

Describing the Problem

There is no widely accepted definition for agitation and aggression. Some clinicians use these terms interchangeably, while others see them as a spectrum ranging from simple anxiety (e.g., fidgeting), to agitation (e.g., pacing), to the most extreme, physical aggression against self or others. The Glossary of Technical Terms in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR), describes agitation as excessive nonproductive and repetitious motor activity (pacing, fidgeting, inability to sit still) secondary to feelings of inner tension. Aggression and violence are not defined by the DSM-IV-TR. Due to the lack of consistency in definitions, it is better to describe the specific behaviors a patient exhibits rather than use a single label or term to represent what is occurring.

An effective way to describe behaviors associated with agitation and aggression are with rating scales designed to systematically evaluate the symptoms. Two widely recognized scales are the Overt Aggression Scale (OAS) and the Overt Agitation Severity Scale (OASS).The OAS classifies aggression as verbal, physical against self, physical against objects, or physical against other people. Levels of severity exist within each of these four domains. For example, physical aggression against other people ranges in severity from a patient making threatening gestures and swinging at people to causing them severe physical injury. A helpful monitoring component of the OAS allows the staff to describe the intervention. The OAS not only provides an objective framework to describe an aggressive incident, but is also a way to track change in the type and frequency of behaviors and interventions needed to address the behavior.

The OASS has three domains of behavior including vocalizations and oral/facial movements (grunting, moaning, crying, head banging, screaming, cursing), upper extremity movements (finger tapping, opening and closing of drawers, rocking, hitting at objects rocking), and lower extremity movements (toe tapping, pacing, shaking legs or kicking at others). Again, the behaviors exist on a spectrum of severity under each major category. There is some degree of crossover in behavior across these two scales and the OAS is the more widely used tool in patient care and research. Recently, clinical trials evaluating treatment of agitation and aggression have used the “excited” component of the Positive and Negative Syndrome Scale (PANSS-EC) as a way of determining response. These scales help clinicians define agitation and aggression more specifically, and they provide a systematic method to track behavioral changes and treatment intervention.

Like agitation, aggression is also described as acute or chronic. There is no clearly accepted boundary between acute and chronic aggression, but a one-month timeframe is often used as the breakpoint. The distinction becomes important because chronic aggression requires treatment approaches such as behavioral modification and pharmacologic treatment, which may include propranolol, valproic acid, and antipsychotic agents. When determining the transition from a problem acute to chronic in nature, one must consider the frequency and severity of the outburst along with the type of intervention needed to resolve the situation. In addition, the words used to document the patient’s condition should be descriptive. This is especially critical for repeated aggression. For example, it would not be accurate to describe a patient as “agitated” if he or she is pacing the floor three hours a day and responds to verbal redirection. But “agitation” would be more accurately used if the patient threw chairs and yelled threats when approached. This person may have a resolving acute problem and is not experiencing “chronic aggression” that would necessitate the addition of more medication. Discussion of chronic aggression is outside the scope of this article and readers are referred elsewhere.