When ‘agitation’ spells a medical problem
A side from posing a psychiatric emergency, agitation can also signal a potentially serious medical problem (Box). After the patient’s behavior is stabilized, a medical evaluation may be necessary. The letters that spell “agitation” remind us to watch for these problems:
Alcohol dependence, intoxication, or withdrawal can lead to agitation even when obvious signs or symptoms of alcohol use are not present.1 Watch for nausea, vomiting, tremors, sweating, auditory or visual hallucinations, headaches, and abnormal vital signs. Also watch for confusion, which may precede delirium.
Genetics. Agitation is a presenting symptom in several congenital diseases, such as Huntington’s disease.2 Look for Huntington’s chorea, psychotic symptoms, and family history of a congenital disease associated with agitation.
Infections. Agitation in patients with systemic, local, or CNS infections may be seen as psychogenic, thereby delaying medical evaluation.3 Watch for abnormal vital signs, especially fever or sweating. General achiness could signal meningitis, a viral infection prodrome, or tetanus infection.
Tumors. Patients with primary cancer with CNS metastasis or primary CNS tumors may present with agitation but no other symptoms or signs of cancer.4 Find out if the patient has a personal or family history of cancer. Watch for unexplained pain that cannot be adequately controlled.
Akathisia. Inner psychological restlessness and observable movements associated with akathisia can manifest as agitation.5 Ask whether the patient is using illicit drugs or medications (eg, some antipsychotics) that may cause akathisia.
Trauma. Agitated patients with brain injuries caused by surgery, burns, or heatstroke usually present with obvious clinical signs. However, persons with asymptomatic, undiagnosed bone and skull fractures may also become agitated.6 Elderly and frail persons and patients with a past head injury also are at risk for trauma-related agitation.
Potential sources of agitation
- Alcohol dependence/intoxication/withdrawal
- Genetic diseases
- Illicit drug use
- Other predisposing medical factors
- Neuropsychiatric conditions
Illicit drugs. Agitation may point to drug intoxication, addiction, or withdrawal. Do a urine and blood screen to check for use of stimulants, anabolic steroids, ketamine, phencyclidine (PCP), or “club drugs” such as methylenedioxymethamphetamine (MDMA, or Ecstasy) and gamma hydroxybutyrate (GHB).7
Other predisposing medical factors for agitation include chronic pain, respiratory distress, and endocrine and metabolic abnormalities.1,2,7,8 Refer the patient for a medical workup, including laboratory and diagnostic tests based on lab results.
Neuropsychiatric conditions. Agitation may be the main presenting symptom of seizures, as well as:
- degenerative CNS diseases such as Parkinson’s disease, multiple sclerosis, and dementias, especially the Alzheimer’s type
- Tourette syndrome
- a pervasive developmental disorder
- inherited movement disorders, such as Wilson’s disease or Hallervorden-Spatz syndrome.2,8-10
Get a detailed patient and family history, then refer the patient for comprehensive physical and neurologic examinations.
The authors thank Leonard D. Williams, PA, and Drs. Nestor Manzano, Craig Campbell, Scott Ahles, Robert Hierholzer, and Avak Howsepian for their help.
1. Lindenmayer JP. The pathophysiology of agitation. J Clin Psychiatry 2000;61(suppl 14):5-10.
2. Paulsen JS, Ready RE, Hamilton JM, et al. Neuropsychiatric aspects of Huntington’s disease. J Neurol Neurosurg Psychiatry 2001;71:310-4.
3. Basler T, Meier-Hellman A, Bredle D, Reinhart K. Amino acid imbalance early in septic encephalopathy. Intensive Care Med 2002;28:293-8.
4. Nowels DE, Bublitz C, Kassner CT, Kutner JS. Estimation of confusion prevalence in hospice patients. J Palliat Med 2002;5:687-95.
5. DeQuardo JR. Worsened agitation with aripiprazole: adverse effect of dopamine partial agonism? J Clin Psychiatry 2004;65:132-3.
6. Lemke DM. Riding the storm: sympathetic storming after traumatic brain injury. J Neurosci Nurs 2004;36:4-9.
7. Teter CJ, Guthrie SK. A comprehensive review of MDMA and GHB: two common club drugs. Pharmacotherapy 2001;21:1486-513.
8. Khouzam HR. Chronic pain and its management in primary care. South Med J 2000;93:946-52.
9. Kompoliti K, Goetz CG. Hyperkinetic movement disorders misdiagnosed as tics in Gilles de la Tourette syndrome. Mov Disord 1998;13:477-80.
10. Sharma N, Standaert DG. Inherited movement disorders. Neurol Clin 2002;20:759-78.
Dr. Khouzam is medical director, chemical dependency treatment program, Veterans Affairs Central California Health Care System (VACCHCS), Fresno, and associate clinical professor of psychiatry, University of California, San Francisco (UCSF)-Fresno medical education program.
Dr. Gill is chief of inpatient psychiatry, VACCHCS, and assistant clinical professor of psychiatry, UCSF-Fresno medical education program.
Dr. Tan is staff psychiatrist, inpatient psychiatry, VACCHCS.