Aggressive disruptive behaviour

Aggressive disruptive behaviour refers to a state of acute agitation, aggression, or severe behavioural disturbance that poses a risk to the patient, healthcare workers, caregivers, or the surrounding environment.

Such presentations may occur in patients with psychiatric illness, substance intoxication or withdrawal, neurological disease, or acute medical conditions. Agitation should therefore always be considered a medical emergency until proven otherwise.

Early recognition, safe containment, and identification of the underlying cause are essential to prevent injury, medical deterioration, or death.

Risk Factors

Psychiatric Conditions

• Schizophrenia

• Bipolar disorder (mania)

• Acute psychosis

• Personality disorders

• Severe anxiety or panic states

Medical Causes

• Delirium

• Hypoglycaemia

• Head injury

• Central nervous system infection

• Hypoxia

• Metabolic disturbances

Substance-Related Causes

• Alcohol intoxication or withdrawal

• Stimulant intoxication (e.g., cocaine, amphetamines)

• Drug withdrawal states

• Polysubstance abuse

Environmental and Social Factors

• Overcrowding

• Sleep deprivation

• Pain or discomfort

• Fear or perceived threat

• Poor communication

Signs and Symptoms

Behavioural Features

• Agitation

• Verbal aggression

• Physical aggression

• Threatening behaviour

• Destructive actions

• Non-cooperation

Psychological Features

• Irritability

• Paranoia

• Severe anxiety

• Emotional lability

• Impulsivity

Physical Indicators of Escalation

• Pacing

• Clenched fists

• Loud speech or shouting

• Increased motor activity

• Poor impulse control

Diagnostic Criteria

Clinical diagnosis based on:

• Agitation

• Aggressive or violent behaviour

• Risk of harm to self or others

• Acute disturbance requiring urgent intervention

Always assess for delirium or medical illness before diagnosing primary psychiatric agitation.

Differential Diagnosis

• Delirium

• Acute psychosis

• Mania

• Substance intoxication

• Alcohol withdrawal

• Hypoglycaemia

• Traumatic brain injury

• Dementia-related agitation

Investigations

Investigations depend on clinical suspicion.

Immediate Assessment

• Vital signs monitoring

• Blood glucose measurement

• Oxygen saturation

• Mental status examination

Laboratory Tests

• Full blood count

• Electrolytes

• Renal and liver function tests

• Toxicology screening

• Blood alcohol level

Additional Investigations

• ECG (before antipsychotics)

• Neuroimaging if head injury suspected

Management

Treatment Priorities

1. Ensure safety

2. De-escalate behaviour

3. Identify underlying cause

4. Use medication only when necessary

5. Continuous monitoring

Non-Pharmacological Management

Safety Measures

• Ensure safety of patient and staff

• Remove potentially harmful objects

• Maintain adequate staff presence

• Use calm communication

Elderly and frail patients require special caution due to increased fall and sedation risks.

De-escalation Techniques (First-Line)

Must always be attempted before medication:

• Speak calmly and respectfully

• Reduce environmental stimulation

• Provide reassurance

• Maintain safe personal distance

• Offer choices where possible

• Manage patient in a safe environment

Physical Restraint

Used only when absolutely necessary:

• To prevent immediate harm

• For shortest duration possible

• Continuous monitoring required

• Regular reassessment mandatory

Pharmacological Management

Medication indicated when:

• De-escalation fails

• Immediate danger exists

• Severe agitation prevents care

Cooperative patients

• Promethazine – 25–50 mg – PO – stat.

OR

• Diazepam – 10 mg – PO – stat.

OR

• Lorazepam – 4 mg – PO – stat.

Uncooperative and severely agitated patients

If oral treatment fails after 30–60 minutes, or if there is a significant risk to the patient or others, administer parenteral treatment.

• Haloperidol – 2.5–5 mg – IM – stat; repeat after 30–60 minutes if required (maximum dose: 20 mg within 24 hours).

AND

• Diazepam – 10 mg – IV/IM – stat; repeat after 30–60 minutes if needed (maximum dose: 60 mg within 24 hours).

OR

• Promethazine – 25–50 mg – deep IM – stat; repeat after 30–60 minutes if needed.

OR

• Lorazepam – 1–4 mg – IM – stat; repeat after 30–60 minutes if needed (maximum dose: 12 mg within 24 hours).

OR

• Midazolam – 2–10 mg – IV/IM – stat.

If haloperidol is unavailable

• Chlorpromazine – 25–50 mg – deep IM – may be repeated as necessary up to 4 times within 24 hours (maximum dose: 2,000 mg within 24 hours).

Patients with known schizophrenia who are not neuroleptic-naïve

• Zuclopenthixol acetate – 50–150 mg – IM – single dose; repeat after 2–3 days if necessary. Administer a maximum of 3 repeat injections and do not continue treatment for longer than 2 weeks. The total cumulative dose should not exceed 400 mg.

Management of acute dystonia

If acute dystonia develops following antipsychotic administration:

• Promethazine – 25–50 mg – deep IM – stat.

For elderly patients:

• Promethazine – 25 mg – deep IM – stat.

OR

• Atropine – 0.5–2 mg – IM – when required.

Serious Complication: Neuroleptic Malignant Syndrome (NMS)

Repeated high-dose antipsychotics may cause:

• Hyperthermia

• Muscle rigidity

• Autonomic instability

• Altered consciousness

• Markedly elevated serum CK

Management

• Immediately stop antipsychotic

• Supportive intensive care

• Hydration and cooling measures

Monitoring During Sedation

Continuous monitoring required:

• Airway and breathing

• Pulse and blood pressure

• Oxygen saturation

• Level of consciousness

• Temperature

• Risk of respiratory depression

Sedated patients must never be left unattended.

Complications

• Injury to patient or staff

• Respiratory depression

• Falls

• Aspiration

• Cardiac arrhythmias

• Neuroleptic malignant syndrome

Prevention

• Early identification of agitation triggers

• Adequate psychiatric follow-up

• Medication adherence

• Substance abuse treatment

• Staff training in de-escalation

• Safe ward environments

Prognosis

Outcome depends on:

• Speed of intervention

• Identification of underlying cause

• Appropriate sedation and monitoring

• Long-term psychiatric management

Early structured intervention significantly reduces morbidity and recurrence.

Patient and Caregiver Education

• Agitation often has treatable causes

• Medication adherence prevents relapse

• Substance avoidance reduces recurrence

• Early help-seeking prevents escalation

• Follow-up mental health care is essential