Psychomotor Agitation

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 and is always an indicative for admission. Typical manifestations include pacing around, wringing of the hands, uncontrolled tongue movement, pulling off clothing and putting it back on, and other similar actions.[1] 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 various mental disorders, especially in psychotic and mood disorders. It can be a result of drug intoxication or withdrawal. It can also be caused by severe hyponatremia. People with existing psychiatric disorders and men under the age of 40 are at a higher risk of developing psychomotor agitation.[2]

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 harmful, but may be evaluated as psychomotor agitation as these symptoms may escalate and become dangerous.[2]

unable to sit still

fidgeting

body stiffness

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 by 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]

Schizophrenia

Bipolar disorder

Post-traumatic stress disorder (PTSD)

Panic attacks

Anxiety disorder

Obsessive-compulsive disorder (OCD)

Nicotine withdrawal

Alcohol withdrawal

Opioid withdrawal

Autism

Asperger syndrome

Claustrophobia

Intellectual disability

Attention deficit hyperactivity disorder

Dementia

Parkinson's disease

Traumatic brain injury

Alzheimer's disease[4]

Acute intermittent porphyria[5][verification needed]

Hereditary coproporphyria

Variegate porphyria

Side effects of stimulants such as cocaine or methylphenidate

Side effects of antipsychotics like haloperidol

SSRI or SNRI medications

As explained in a 2008 study, in people with mood disorders there is a dynamic link between their mood and the way they move.[6]

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[citation needed]. 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).[7][8][9][10]

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.[11][12]

Diagnosis

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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.[citation needed]

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:[6]

regular exercise

yoga and meditation

deep breathing exercises

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.[13] Also using promethazine may be useful.[14] 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[15][16][17] (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.[18]