Bipolar Symptom Psychomotor Agitation, Mixed Moods and Suicide
Last year, I wrote an article on psychomotor agitation at HealthyPlace. Psychomotor agitation (or retardation) is a symptom of bipolar (and unipolar) depression as well as hypomania/mania and very little information about it is available (in spite of the fact that it is listed in the Diagnostic and Statistical Manual of Mental Illness (DSM-5)).
Most definitions for psychomotor agitation include the words, “inner restlessness.” I don’t know about you, but “inner restlessness” reminds me of a 22-year-old who can’t find himself and so is backpacking across the country. It really doesn’t sound like a mental illness symptom – let alone like a serious one.
What is Psychomotor Agitation?
If you’ve ever suffered from psychomotor agitation you can attest to the fact that it is very unpleasant. Psychomotor agitation feels like a grinding of sandpaper against your bones that produces a need for useless movement such as hand-wringing, pacing or toe-tapping. It is annoyance in its highest form. It’s something that cannot be ignored or denied. Psychomotor agitation really takes over the consciousness when it’s pronounced. You can’t rest when psychomotor agitation is present. Your body and mind just can’t seem to calm themselves (thus the “psycho” and “motor” of psychomotor agitation).
Psychomotor Agitation and Mixed Bipolar Episodes
Mixed moods in bipolar disorder occur when both manic/hypomanic and depressive symptoms occur at the same time, and many people consider them the worst of what bipolar disorder has to offer. And while psychomotor agitation turns out to be highly correlated with bipolar mixed episodes. In the study, Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes, it was found that psychomotor agitation was the second most prevalent subsyndromal manic symptom in depressed patients (irritation was the first) and was experienced by 39% of people with bipolar disorder. The authors call this indicative of a subtle form of a mixed depressive episode,
. . . the presence of any concurrent subsyndromal manic symptom(s) during bipolar MDEs [major depressive episodes] represents a subtle form of mixed depressive state. Key clinical correlates, such as greater severity of the intake episode, instability of polarity, and heightened suicidality, are similar to those reported for full manic mixed states.
Mixed depression: clinical features and predictors of its onset associated with antidepressant use found that psychomotor agitation was the most common symptom associated with mixed bipolar episodes with 97% of people with bipolar disorder experiencing it.
And what we know about mixed bipolar episodes is that they put the sufferer at great risk for a suicide attempt.
This is borne out with the correlation the study found between psychomotor agitation and suicidal history and suicidal acts. The study found that psychomotor agitation was correlated with:
- Increased severity of depression
- Suicidal ideation
- Prevalence of suicidal acts both current and long-term
The presence of psychomotor agitation just means that everything is worse (people suffering with psychomotor agitation probably could have told you that).
What Psychomotor Agitation Means for Treatment
What we know is that people who have manic/hypomanic symptoms present during a depressive episode should not be treated with an antidepressant. In the study, they note that when people with two or more concurrent manic symptoms were treated with antidepressants and mood stabilizers they had significantly higher manic symptom severity at a three-month follow-up.
In fact, the International Society for Bipolar Disorder Task Force released new recommendations last year for the use of antidepressants in bipolar disorder and they specifically state that antidepressants are not to be used (even adjunctively) when (among other things):
- Psychomotor agitation is present in bipolar I or bipolar II
- During mixed episodes
Additionally, being that psychomotor agitation is linked with suicidal ideation and behavior, special care should be taken with patients who are experiencing this symptom.
Treating Psychomotor Agitation
Antipsychotics (low dose) are typically used to treat psychomotor agitation. From what I’ve seen, antipsychotics all seem to reduce psychomotor agitation but haloperidol plus promethazine and ziprasidone may be more effective than haloperidol plus midazolam or olanzapine (in an acute, hospital setting).
For my part, I might suggest taking up meditation or relaxation exercises to help with psychomotor agitation. Of course, psychomotor agitation comes in many severities and I can’t promise that it will help with all severity levels but I do think it’s worth a try. After all, that method can reduce overall stress and anxiety levels without side effects and that’s a pretty good deal all around.
No matter what you do, though, make sure you report this symptom to your doctor and take it seriously.