Managing Acute Agitation and Psychotic Symptoms in the Emergency Department

Author(s): Nidal Moukaddam*, Raymond Choi, Veronica Tucci

Journal Name: Adolescent Psychiatry

Volume 9 , Issue 2 , 2019

Become EABM
Become Reviewer
Call for Editor


Background and Aims: It is fairly common for adolescents with a presenting problem of acute agitation to present to the Emergency Department. These patients present challenges with respect to both differential diagnosis and management. Furthermore, with many adolescents having extended stays in emergency departments, it is important for ED physicians to have a basic familiarity with diagnosis and treatment.

Methods: In this paper, we present a primer on the conditions underlying acute agitation and review approaches to management in the emergency department.

Results and Discussion: Psychotic disorders, such as schizophrenia, are distinct from other conditions presenting with psychotic symptoms, which can range from depression to substance use to non-psychiatric medical conditions. Agitation, a state of excessive verbal and physical activity, can accompany any of these conditions. Unlike the case for adults, practice guidelines do not exist, and there is no fully agreed upon expert consensus yet. Emergency physicians should have a working knowledge of antipsychotic medications and need to consider pharmacological as well as non-pharmacological treatments for optimal management.

Keywords: Adolescents, agitation, antipsychotic drugs, emergency department, psychosis, psychotic symptoms.

Allen, M.H. (2000). Managing the agitated psychotic patient: a reappraisal of the evidence. J. Clin. Psychiatry, 61 (Suppl. 14), 11-20.
Allen, M. H., Currier, G. W., Carpenter, D., Ross, R. W., Docherty, J. P. & Expert Consensus Panel for Behavioral Emergencies. (2005). The expert consensus guideline series. Treatment of behavioral emergencies 2005. J. Psychiatr. Pract., 11 (Suppl. 1), 5-108. quiz 110-102
Allison, D.B., Mentore, J.L., Heo, M., Chandler, L.P., Cappelleri, J.C., Infante, M.C., Weiden, P.J. (1999). Antipsychotic-induced weight gain: a comprehensive research synthesis. American Journal of Psychiatry, 156(11), 1686-1696.
American Academy of, C., & Adolescent, P. (2001). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. American Academy of Child and Adolescent Psychiatry. J. Am. Acad. Child Adolesc. Psychiatry, 40(7) (Suppl.), 4S-23S.
Baandrup, L., Cerqueira, C., Haller, L., Korshoj, L., Voldsgaard, I., Nordentoft, M. (2016). The Danish Schizophrenia Registry. Clin. Epidemiol., 8, 691-695.
Bartels-Velthuis, A.A., Jenner, J.A., van de Willige, G., van Os, J., Wiersma, D. (2010). Prevalence and correlates of auditory vocal hallucinations in middle childhood. Br. J. Psychiatry, 196(1), 41-46.
Barzman, D.H., DelBello, M.P., Forrester, J.J., Keck, P.E., Jr, Strakowski, S.M. (2007). A retrospective chart review of intramuscular ziprasidone for agitation in children and adolescents on psychiatric units: Prospective studies are needed. J. Child Adolesc. Psychopharmacol., 17(4), 503-509.
Bitter, I., Dossenbach, M.R., Brook, S., Feldman, P.D., Metcalfe, S., Gagiano, C.A. . . . Olanzapine HGCK Study Group. (2004). Olanzapine versus clozapine in treatment-resistant or treatment-intolerant schizophrenia. Progress in Neuropsychopharmacology and Biological Psychiatry, 28(1), 173-180.
Camm, A.J., Karayal, O.N., Meltzer, H., Kolluri, S., O’Gorman, C., Miceli, J. . . . Kane, J. M. (2012). Ziprasidone and the corrected QT interval: a comprehensive summary of clinical data. CNS Drugs, 26(4), 351-365.
Castaneto, M.S., Gorelick, D.A., Desrosiers, N.A., Hartman, R.L., Pirard, S., Huestis, M.A. (2014). Synthetic cannabinoids: epidemiology, pharmacodynamics, and clinical implications. Drug Alcohol Depend., 144, 12-41.
Close, C., Kouvonen, A., Bosqui, T., Patel, K., O’Reilly, D., Donnelly, M. (2016). The mental health and wellbeing of first generation migrants: a systematic-narrative review of reviews. Global. Health, 12(1), 47.
Cole, J.B., Moore, J.C., Nystrom, P.C., Orozco, B.S., Stellpflug, S.J., Kornas, R.L. . . . Ho, J. D. (2016). A prospective study of ketamine versus haloperidol for severe prehospital agitation. Clin. Toxicol. (Phila.), 54(7), 556-562.
Correll, C.U. (2008). Assessing and maximizing the safety and tolerability of antipsychotics used in the treatment of children and adolescents. J. Clin. Psychiatry, 69 (Suppl. 4), 26-36.
Correll, C.U., Kane, J.M. (2007). One-year incidence rates of tardive dyskinesia in children and adolescents treated with second-generation antipsychotics: A systematic review. J. Child Adolesc. Psychopharmacol., 17(5), 647-656.
Correll, C.U., Lops, J.D., Figen, V., Malhotra, A.K., Kane, J.M., Manu, P. (2011). QT interval duration and dispersion in children and adolescents treated with ziprasidone. J. Clin. Psychiatry, 72(6), 854-860.
Curran, C., Byrappa, N., McBride, A. (2004). Stimulant psychosis: systematic review. British Journal of Psychiatry, 185, 196-204.
De Hert, M., Dobbelaere, M., Sheridan, E.M., Cohen, D., Correll, C.U. (2011). Metabolic and endocrine adverse effects of second-generation antipsychotics in children and adolescents: A systematic review of randomized, placebo controlled trials and guidelines for clinical practice. Eur. Psychiatry, 26(3), 144-158.
Deal, N., Hong, M., Matorin, A., Shah, A.A. (2015). Stabilization and management of the acutely agitated or psychotic patient. Emergency Medicine Clinics of North America, 33(4), 739-752.
DelBello, M.P., Lopez-Larson, M.P., Soutullo, C.A., Strakowski, S.M. (2001). Effects of race on psychiatric diagnosis of hospitalized adolescents: a retrospective chart review. J. Child Adolesc. Psychopharmacol., 11(1), 95-103.
Ferguson, P. (2003). A historical note. Fla. Nurse, 51(2), 15.
Findling, R.L., Robb, A., Nyilas, M., Forbes, R.A., Jin, N., Ivanova, S. . . . Carson, W. H. (2008). A multiple-center, randomized, double-blind, placebo-controlled study of oral aripiprazole for treatment of adolescents with schizophrenia. Am. J. Psychiatry, 165(11), 1432-1441.
Freudenreich, O. (2007). Psychotic disorders: A practical guide.. Philadelphia: Wolters Kluwer Health.
Golick, J. (2016). Shifting the Paradigm: Adolescent cannabis abuse and the need for early intervention. J. Psychoactive Drugs, 48(1), 24-27.
Haas, M., Eerdekens, M., Kushner, S., Singer, J., Augustyns, I., Quiroz, J. . . . Kusumakar, V. (2009). Efficacy, safety and tolerability of two dosing regimens in adolescent schizophrenia: double-blind study. Br. J. Psychiatry, 194(2), 158-164.
Haas, M., Unis, A.S., Armenteros, J., Copenhaver, M.D., Quiroz, J.A., Kushner, S.F. (2009). A 6-week, randomized, double-blind, placebo-controlled study of the efficacy and safety of risperidone in adolescents with schizophrenia. J. Child Adolesc. Psychopharmacol., 19(6), 611-621.
Hazaray, E., Ehret, J., Posey, D.J., Petti, T.A., McDougle, C.J. (2004). Intramuscular ziprasidone for acute agitation in adolescents. J. Child Adolesc. Psychopharmacol., 14(3), 464-470.
Holloman, G.H., Jr, Zeller, S.L. (2012). Overview of Project BETA: Best practices in evaluation and treatment of agitation. West Journal of Emergency Medicine, 13(1), 1-2.
Horwood, J., Salvi, G., Thomas, K., Duffy, L., Gunnell, D., Hollis, C. . . . Harrison, G. (2008). IQ and non-clinical psychotic symptoms in 12-year-olds: results from the ALSPAC birth cohort. Br. J. Psychiatry, 193(3), 185-191.
Isbister, G. K., Calver, L. A., Downes, M. A., Page, C. B. (2016). Ketamine as rescue treatment for difficult-tosedate severe acute behavioral disturbance in the emergency department. Annals of Emergency Medicine, 67(5), 581-587 e581.
Jangro, W.C., Preval, H., Southard, R., Klotz, S.G., Francis, A. (2009). Conventional intramuscular sedatives versus ziprasidone for severe agitation in adolescents: case-control study. Child Adolesc. Psychiatry Ment. Health, 3(1), 9.
Jansen, K.L. (2000). A review of the nonmedical use of ketamine: use, users and consequences. J. Psychoactive Drugs, 32(4), 419-433.
Kaufman, J., Birmaher, B., Clayton, S., Retano, A., Wongchaowart, B. (1997). Case study: trauma-related hallucinations. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1602-1605.
Kaufman, K.R., Zuber, N., Rueda-Lara, M.A., Tobia, A. (2010). MELAS with recurrent complex partial seizures, nonconvulsive status epilepticus, psychosis, and behavioral disturbances: case analysis with literature review. Epilepsy Behav., 18(4), 494-497.
Keshavan, M.S., Kaneko, Y. (2013). Secondary psychoses: an update. World Psychiatry, 12(1), 4-15.
Khan, S.S., Mican, L.M. (2006). A naturalistic evaluation of intramuscular ziprasidone versus intramuscular olanzapine for the management of acute agitation and aggression in children and adolescents. J. Child Adolesc. Psychopharmacol., 16(6), 671-677.
Kryzhanovskaya, L., Schulz, S.C., McDougle, C., Frazier, J., Dittmann, R., Robertson-Plouch, C. . . . Tohen, M. (2009). Olanzapine versus placebo in adolescents with schizophrenia: a 6-week, randomized, double-blind, placebo-controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 48(1), 60-70.
Leucht, S., Corves, C., Arbter, D., Engel, R.R., Li, C., Davis, J.M. (2009). Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet, 373(9657), 31-41.
McClellan, J., Stock, S. American Academy of, C., & Adolescent Psychiatry Committee on Quality, I. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976-990.
McDonell, M.M.J. (2007). Early-onset schizophrenia. (4th ed.). New York, NY: Guilford Press.
Melis, M., Frau, R., Kalivas, P.W., Spencer, S., Chioma, V., Zamberletti, E. . . . Parolaro, D. (2017). New vistas on cannabis use disorder. Neuropharmacology.
Nasrallah, H.A., Keshavan, M.S., Benes, F.M., Braff, D.L., Green, A.I., Gur, R.E. . . . Correll, C. U. (2009). Proceedings and data from The Schizophrenia Summit: a critical appraisal to improve the management of Schizophrenia. J. Clin. Psychiatry, 70 (Suppl. 1), 4-46.
Neuhut, R., Lindenmayer, J.P., Silva, R. (2009). Neuroleptic malignant syndrome in children and adolescents on atypical antipsychotic medication: a review. J. Child Adolesc. Psychopharmacol., 19(4), 415-422.
Nordstrom, K., Allen, M.H. (2007). Managing the acutely agitated and psychotic patient. CNS Spectr., 12(10) (Suppl. 17), 5-11.
Pavuluri, M.N., Herbener, E.S., Sweeney, J.A. (2004). Psychotic symptoms in pediatric bipolar disorder. J. Affect. Disord., 80(1), 19-28.
Ruhrmann, S., Schultze-Lutter, F., Klosterkotter, J. (2003). Early detection and intervention in the initial prodromal phase of schizophrenia. Pharmacopsychiatry, 36 (Suppl. 3), S162-S167.
Schaeffer, J.L., Ross, R.G. (2002). Childhood-onset schizophrenia: premorbid and prodromal diagnostic and treatment histories. Journal of the American Academy of Child and Adolescent Psychiatry, 41(5), 538-545.
Shaw, P., Sporn, A., Gogtay, N., Overman, G.P., Greenstein, D., Gochman, P. . . . Rapoport, J. L. (2006). Childhood-onset schizophrenia: A double-blind, randomized clozapine-olanzapine comparison. Arch. Gen. Psychiatry, 63(7), 721-730.
Sikich, L., Frazier, J.A., McClellan, J., Findling, R.L., Vitiello, B., Ritz, L. . . . Lieberman, J. A. (2008). Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the treatment of early-onset schizophrenia spectrum disorders (TEOSS) study. Am. J. Psychiatry, 165(11), 1420-1431.
Singh, J., Robb, A., Vijapurkar, U., Nuamah, I., Hough, D. (2011). A randomized, double-blind study of paliperidone extended-release in treatment of acute schizophrenia in adolescents. Biol. Psychiatry, 70(12), 1179-1187.
Sonnier, L., Barzman, D. (2011). Pharmacologic management of acutely agitated pediatric patients. Paediatr. Drugs, 13(1), 1-10.
Staller, J.A. (2004). Intramuscular ziprasidone in youth: a retrospective chart review. J. Child Adolesc. Psychopharmacol., 14(4), 590-592.
Stevens, J.R., Prince, J.B., Prager, L.M., Stern, T.A. (2014). Psychotic disorders in children and adolescents: a primer on contemporary evaluation and management. Prim. Care Companion CNS Disord., 16(2)
Strawn, J.R., Keck, P.E., Jr, Caroff, S.N. (2007). Neuroleptic malignant syndrome. Am. J. Psychiatry, 164(6), 870-876.
Tandon, R., Keshavan, M.S., Nasrallah, H.A. (2008). Schizophrenia, “Just the Facts”: what we know in 2008 part 1: overview. Schizophr. Res., 100(1-3), 4-19.
Thirthalli, J., Benegal, V. (2006). Psychosis among substance users. Curr. Opin. Psychiatry, 19(3), 239-245.
Tollefson, G.D., Birkett, M.A., Kiesler, G.M., Wood, A.J. & Lilly Resistant Schizophrenia Study Group. (2001). Double-blind comparison of olanzapine versus clozapine in schizophrenic patients clinically eligible for treatment with clozapine. Biol. Psychiatry, 49(1), 52-63.
Trollor, J.N., Chen, X., Chitty, K., Sachdev, P.S. (2012). Comparison of neuroleptic malignant syndrome induced by first- and second-generation antipsychotics. Br. J. Psychiatry, 201(1), 52-56.
Vilke, G.M., Payne-James, J., Karch, S.B. (2012). Excited delirium syndrome (ExDS): Redefining an old diagnosis. J. Forensic Leg. Med., 19(1), 7-11.
Volavka, J., Czobor, P., Sheitman, B., Lindenmayer, J.P., Citrome, L., McEvoy, J.P. . . . Lieberman, J. A. (2002). Clozapine, olanzapine, risperidone, and haloperidol in the treatment of patients with chronic schizophrenia and schizoaffective disorder. Am. J. Psychiatry, 159(2), 255-262.

Rights & PermissionsPrintExport Cite as

Article Details

Year: 2019
Page: [118 - 128]
Pages: 11
DOI: 10.2174/2210676609666191015123943
Price: $65

Article Metrics

PDF: 26
PRC: 1