I've got to get out of here.” 3 Irritability and heightened responsiveness to stimuli may be present, 4 but the association of agitation and aggression has not been clearly established. Repetitive thoughts are exhibited by vocalizations such as, “I've got to get out of here. Associated motor activity is usually repetitive and non–goal directed and may include such behaviors as foot tapping, hand wringing, hair pulling, and fiddling with clothes or other objects. However, using medication too quickly may seem dismissive, rejecting, or humiliating to the patient 2 and can lead to more agitation and violence.Īgitation is a behavioral syndrome that may be connected to different underlying emotions. A clinician who has many patients to see and too little time may prematurely use medication to avoid verbal engagement. For example, in an emergency department, both the clinician and patient can slip into irrational thinking or expediency at the price of engaging each other. These objectives may be challenging to pursue in some situations and settings. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area (2) help the patient manage his emotions and distress and maintain or regain control of his behavior (3) avoid the use of restraint when at all possible and (4) avoid coercive interventions that escalate agitation. The act of verbally de-escalating a patient is therefore a form of treatment in which the patient is enabled to rapidly develop his own internal locus of control. The traditional goal of “calming the patient” often has a dominant-submissive connotation, while the contemporary goal of “helping the patient calm himself” is more collaborative. In some ways, this is a return to Lazare's methods published in an article written more than 35 years ago. First, the patient is verbally engaged then a collaborative relationship is established and, finally, the patient is verbally de-escalated out of the agitated state.
In the new paradigm, a 3-step approach is used. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the “10 domains of de-escalation.” Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. Agitation is an acute behavioral emergency requiring immediate intervention.
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