1. Introduction

Psychomotor agitation (PMA) is characterized by increased psychomotor activity, motor restlessness, and irritability. Individuals with PMA exhibit heightened responsiveness to internal and external stimuli and experience mental tension or altered cognitive function. PMA can occur as a manifestation of a psychiatric disorder (e.g., schizophrenia and bipolar disorder (BD)), central nervous system disease (e.g., Parkinson’s disease, Alzheimer’s disease or dementia), or substance abuse ^[1][2]. In the context of BD or schizophrenia, patients experiencing an episode of PMA report feeling uneasy, restless, or nervous and have little success controlling or coping with their agitation ^[3]. PMA symptom progression usually follows a fluctuating course and can include aggression; however, in all cases, escalation can result in unpredictable, dangerous, and violent behavior that requires a rapid response on healthcare workers and clinicians ^[4]. Accordingly, prompt recognition and immediate management of PMA symptoms are imperative for decreasing the risk of harm to the patient, healthcare staff, and other individuals in the patient’s proximity ^[5]. 

2. Epidemiology

Data regarding the epidemiology of PMA are poorly generalizable and mainly derive from studies conducted in specific care settings or patient populations. The reported prevalence of agitation in psychiatric emergency services is between 4–10% ^[5][6][7]. Moreover, up to 50% of psychiatric emergency service visits involve patients affected by schizophrenia, BD, or dementia, who are patients in which PMA is considered a common symptom in emergency contexts ^[8][9]. A study in Spain suggested that about 25% of patients with schizophrenia and 15% of those with BD. Experience at least 1 episode of PMA per year, with a median of 2 episodes per year ^[10].

3. Causes

PMA frequently emerges in psychiatric patients who engage in recreational substance abuse or develop comorbid substance abuse disorder; this phenomenon is especially well-documented in schizophrenia and BD. An estimated 50% of patients with schizophrenia have a comorbid substance abuse disorder ^[11][12]. Alcohol abuse is another frequent cause of PMA, especially in idiosyncratic reactions, acute intoxication, or withdrawal. Subjects who exhibit PMA associated with alcohol abuse are frequently dependent on the substance and have heavily used alcohol in the long term. PMA can also manifest as the result of mixing alcohol with other substances, resulting in a loss of impulse control and aggressive behaviors.

4. PMA Recognition and Assessment

PMA is an evolving phenomenon for which rapid intervention is essential to avoid escalation to violent behavior. Tools for its evaluation must facilitate quick and easy assessment based only on clinical observation without interviewing the patient. These tools should provide scores and cut-offs to assess PMA severity and inform therapeutic decision-making. The early signs of PMA include changes in different domains ^[13]. In the presence of one or more of these signs, immediate identification of PMA severity and intervention is necessary to avoid escalation to higher levels:

5. Management Strategies

The management of PMA in emergency care settings largely depends on the severity of patient symptoms and the care context’s nature. In general, non-pharmacological management should progress from less invasive or coercive measures to more invasive or coercive measures ^[14]. In many circumstances, behavioral control methods and de-escalation strategies such as verbal intervention, offering food or beverages, and letting patients smoke or offering nicotine replacement are helpful to manage agitation and prevent its escalation into aggression or violence ^[15]. Therefore, the approach to an agitated patient should start with environmental modification and verbal de-escalation in a manner that provides physical comfort and minimizes external stimuli. Effective management is significantly influenced by the coordination of this response among healthcare professionals and the ability to enact environmental modification in a timely fashion ^[16]. To this end, another critical goal during initial de-escalation is to ensure the safety of the patient and those around them (e.g., remove or secure all objects that can be potentially harmful) while respecting the patient’s dignity and ensuring that the patient does not feel threatened.

6. Pharmacological Management

Pharmacological strategies for PMA in emergency care settings should control agitation or violent behavior without producing excessive sedation and should preferably avoid invasive administration routes ^[17]. The pharmacological management of agitation has traditionally employed three classes of medications: first-generation antipsychotics (FGAs), benzodiazepines (BZDs), and second-generation antipsychotics (SGAs) ^[15]. Available pharmacological tools and emerging treatment options for PMA are outlined below and summarized in Table 2.

Table 2. Parenteral and inhaled pharmacological treatments for psychomotor agitation.