What is the best treatment for anger and agitation?

Treatment of Anger and Agitation

The best treatment for anger and agitation begins with verbal de-escalation techniques, followed by pharmacological intervention with either a benzodiazepine (lorazepam 2-4mg) or antipsychotic (haloperidol 5mg, olanzapine 10mg IM, or ziprasidone IM) if non-pharmacological methods fail, with physical restraints reserved only as a last resort when safety cannot be maintained by other means. 1, 2, 3

Immediate Safety and Assessment

Rule out life-threatening medical causes first - this is non-negotiable as missing reversible medical conditions can be fatal 1:

• Check point-of-care glucose immediately 4
• Obtain vital signs to identify medical illness requiring urgent attention 1
• Perform comprehensive metabolic panel including electrolytes 1
• Order urinalysis to exclude urinary tract infection 1
• Consider toxicology screen if substance use suspected 1
• Assess for undiagnosed pain, which disproportionately contributes to agitation, especially in patients with communication difficulties 1
• Review medications for anticholinergic agents, sympathomimetics, or drug interactions 1

Treatment Algorithm

Step 1: Non-Pharmacological De-escalation (First-Line)

Attempt verbal de-escalation before any medication or restraint 1, 3, 4:

• Use the "10 domains of de-escalation" approach: respect personal space, avoid provocative behavior, establish verbal contact, be concise, identify wants and feelings, listen closely, agree or agree to disagree, set clear limits, offer choices and optimism, and debrief the patient and staff 3
• Modify the environment: decrease sensory stimulation, remove potential weapons, eliminate triggers (argumentative visitors, long wait times) 5
• Consider involving a child life specialist for pediatric patients 5
• Staff should remove neckties, stethoscopes, and secure long hair to minimize risk 5

Step 2: Pharmacological Intervention (When De-escalation Fails)

For undifferentiated violent agitation, choose one of the following first-line options 2:

Option A: Benzodiazepine Monotherapy

• Lorazepam 2-4mg IM/IV - preferred due to fast onset, rapid complete absorption, no active metabolites 5, 2
• Midazolam 5mg IM - more rapid onset but shorter duration of action 5, 2
• Avoid diazepam IM due to erratic absorption 5

Option B: Antipsychotic Monotherapy

• Haloperidol 5mg IM - most extensive evidence base since 1973, comparable effectiveness to benzodiazepines 2, 6
• Olanzapine 10mg IM - faster onset, greater efficacy, and fewer adverse effects than haloperidol or lorazepam for schizophrenia and bipolar mania-associated agitation 7, 6
• Ziprasidone IM - significant calming effects within 30 minutes, well-tolerated, but avoid in patients with QTc prolongation risk 6

Option C: Combination Therapy (For Rapid Sedation)

• Lorazepam + Haloperidol produces more rapid sedation than monotherapy in acutely agitated psychiatric patients 2, 6
• For cooperative patients: oral lorazepam + oral risperidone preferred over haloperidol 2

Step 3: Physical Restraints (Last Resort Only)

Use restraints only when 5:

• Preventing imminent dangerous behavior to self or others
• Preventing serious disruption of treatment program or property damage
• Less restrictive options have failed or are impractical 5

Never use restraints for 5:

• Punishment
• Staff convenience
• Compensating for inadequate staffing
• Where prohibited by state guidelines

Special Population Considerations

Pediatric and Adolescent Patients

• Implement anger management, problem-solving, and psychoeducational programs for those with history of aggressive behavior 5
• Treatment planning must include strategies to prevent aggressive behavior and de-escalate before restrictive interventions needed 5
• All controlled medication trials were conducted in adults; pediatric dosing is extrapolated 5

Substance-Related Agitation

• Assess cognitive function individually rather than relying solely on blood alcohol level 1, 2
• Screen for intoxication as it can mimic psychiatric symptoms 1

Critical Pitfalls to Avoid

• Never assume psychiatric cause without medical workup - reversible medical causes must be identified first 1
• Do not use antipsychotics in anticholinergic toxicity - they worsen agitation 1
• Do not prescribe antidepressants without screening for bipolar disorder - risk of precipitating mania 1
• Avoid combining olanzapine IM with other CNS depressants - eight fatalities reported; follow strict prescribing guidelines 6
• Monitor QTc with haloperidol and ziprasidone - though haloperidol typically doesn't exceed 500ms threshold, caution warranted 2, 6
• Exercise caution with haloperidol in anticholinergic or sympathomimetic toxicity - may exacerbate agitation due to side effects 2

Context-Specific Modifications

For Psychotic Agitation

• Antipsychotics (haloperidol, olanzapine, ziprasidone) are more appropriate than benzodiazepines alone 6, 8

For Alcohol Withdrawal or Benzodiazepine Withdrawal

• Benzodiazepines are preferred over antipsychotics 8

For Geriatric Patients with Delirium/Dementia

• Management should be guided by underlying etiology 8
• Olanzapine IM has shown efficacy in dementia-related agitation 6