Trouble in Mind

An unorthodox view of psychiatry.

Agitation Situation

All riled up and no foe to fight? You're agitated!

Agitated people tend to be described in cataclysmic ways: She exploded, he had a meltdown, she blew her top, he burned with rage. What fuels these cataclysms of arousal?

Perhaps a better question is: What keeps them from happening all the time? In the past few posts I have talked about how the brain translates states of bodily need into the impetus for action. Whether the impetus is too much or too little depends on the circumstances. When you're safe and your needs and desires are all satisfied, any sense of arousal might seem strange or even uncomfortable. When you're in dire need or threatened with violence, you seek resources and fight enemies--the greater the need or threat, the stronger the impetus, and more stridently you seek, fight, or flee. 

Agitation refers to an abnormal mental state, often dangerous, in which the brain is highly aroused for action, but does not know why--something has prevented the brain from linking its arousal to a meaningful goal. An agitated person is restless physically and mentally, and is emotionally volatile. It is an uncomfortable state: Arousal without purpose. Restlessness induces behavior such as pacing, a form of movement without purpose. A caged and angry animal, or prisoner, highly aroused, impotent to find a salient course of action or object on which to act, can do naught but pace and growl at passers-by.

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This disconnection between arousal and goal can occur for a number of reasons. If the general (tonic) arousal system that governs wakefulness is overactive, as in some states of delirium or intoxication, the resulting energy surge affects behavior globally. In such a person, there may seem to be no meaning to the stimuli that trigger an eruption of violence. In the more common and familiar states of high arousal triggered by some identifiable trigger, any remaining sense of arousal that still exists after one has acted can be attributed to some other as yet unmet or unacknowledged state of urgent need.

The dangerously explosive thing about agitation is that the unrestrained actions of an agitated person yield no ready relief from the urgency of the drive that spawned them. Thus the agitated person may seek out increasingly aggressive and reckless means to find some satisfying activity to quell the urge to act. This may be seen in severely psychiatrically ill patients whose agitation is fueled by delusional ideas or emotional perturbations. In such people, action doesn't relieve the urge because the urge comes from some abnormal internal process, not an environmental threat or normal drive. The resulting pattern is one of escalation. As a hospitalized patient grows more agitated, a mildly perturbed response to being asked to get dressed for breakfast in the morning may grow to the hostile refusal of a therapy group by lunchtime, a loud argument with another patient by mid-afternoon, and placement in locked-door seclusion by dinner, after the patient has punched a fist through a wall and threatened a nurse.

Almost anyone can experience similar, if less drastic, kinds of agitation when in the grip of strong emotions, and in some cases it might be adaptive to remain on high alert, ready to spring into action when the opportunity arises. The generalized form of delirious agitation mentioned above, where there is a total disconnect between arousal and actual threat or need, is the more dangerous form.

One reason for the enhanced danger is the unpredictability of violence--if as an outside observer you have no idea what's riling an agitated person, because in a sense everything is riling the person, it's hard to take effective precautions.

The other reason states of delirious agitation tend to be dangerous is that they most often occur as a result of gross brain malfunction, which doctors call by many names including delta MS (change in mental status), toxic encephalopathy, and, as I call it, delirium. The severity of the medical problems that produce this kind of brain dysfunction, and the medical frailty of people who tend to be vulnerable to it, mean the delirious person is in a very serious, possibly life threatening situation. Indeed, the mortality rate among delirious patients in a hospital setting is sky high.

Of course, if you've ever been really stoned or had a few too many cocktails, you know delirium first-hand, because alcohol and many drugs tend to affect the brain, transiently, in the same way severe medical illness affects the brain. Intoxication is indeed a form of delirium.

Here's the take-home message: If your elderly parent or grandparent or friend or spouse, who has never suffered a mental illness up to his or her advanced age, suddenly starts talking nonsense and exploding in anger over nothing, chances are this person does not have late onset schizophrenia or bipolar disorder or some other condition that affects otherwise healthy people. You and the doctor should be thinking delirium first and foremost, so that the likely underlying medical problem can be addressed urgently.

Dean F. MacKinnon, M.D. studies and treats affective disorders and teaches medical students at the Johns Hopkins University School of Medicine.

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