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.
But, as it turns out, psychomotor agitation is serious, highly indicative of a bipolar mixed episode and correlated with suicidal acts.
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.
Psychomotor Agitation and Suicide
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.
I’m so relieved to find out there’s a name for this and I’m not alone with my twitchy legs and facial muscles all tensed up! I think the very worst part of PMA is how extra-self-conscious I am cos I know I look strange…its like my inner-craziness has escaped and the disguise I worked so hard to develop has just melted away. Gah!
Hi Debbie
Benzo’s like valium which have a long half life are a possible alternative to antipsychotics. They’re a minor tranquilizer as opposed to antipsychotics which fall into the relm of major tranquilizers. The only problem with benzo’s is that they are highly addictive and for that reason most doctors don’t like to prescribe them. They are also painful to come off of. But another suggestion, if you are so inclined, could be cannabis. Depending on where you live, cannabis may be legal.
The above coupled with various forms of meditation might help to reduce some of the symptoms
I have psychomotor agitation but whenever I take any antipsychotic, phenergan, benadryl, or even reglan I develop severe neuroleptic-induced akathisia. Artane does not relieve the agitation. It’s so severe I become suicidal. So it’s difficult being bipolar and dealing with the potential for psychosis. At least I haven’t been psychotic in almost two years, but because of frequent mixed episodes of hypomania and depression I need an antipsychotic.
Natasha, I’ve had the PMA since late adolescence. I also did a huge amount of traveling then when I couldn’t sit still. Still have it sometimes now (sometimes often). When I was physically able to jump around the US and the world I thought it was wanderlust etc. which it may have very well have been. What’s the difference anyway between the two.
It’s a bit like drinking too much coffee etc. When you have money to spend and a place to go it feels good. When old, disabled, poor and so on it becomes something else. Just sayin’. WN
If you don’t know the difference between wanderlust and PMA then you’ve had neither. I don’t remember ripping my clothes off during wanderlust.
Thanks for this! I suffer from severe psychomotor agitation during depressive and manic/hypomanic episodes. It sucks. That it makes treating my depression almost impossible is the icing on the cake. I meditate and try to move but sometimes the blanket is too thick.
Looks like my cat eleven years ago when she was a kitten. WN
Hi, I was diagnosed bipolar in 1995. Now I was also diagnosed via PET scan as having early onset Alzheimer’s two years ago. Still on the lithium, now Aricept and I also take Ambien to sleep. I am having very bad agitation now, just like described. My new psychiatrist of one month has diagnosed me with agitated depression and put me on Cymbalta 20 mg. Agitated depression has also been described in the literature as melancholia agitata, I believe.
Have you read the new rat study on the immune system that was recently published in a reputable journal from Duke University on the immune system. If I were you I would be reading it VERY carefully. Just Google it or use another browser and you will easily find it.
Most research points to the plaque and/or tenticles (sp.) theory’s I believe, I know there has been past research about it into the immune system. This looks at it in a new way though and may have even (I think) stopped or prevented it’s beginning or onset completely in rats using treatement against the immune system of rats.
This was all from memory of what I read quickly a couple months or so so please please look into it yourself. Looks VERY promising to me. If you can’t find any info I’ll look it up and send you any links I can to the article I read (I’ve been meaning to look into it myself anyway) and to the actual text of the journal article if I can find it. Good luck and I’m very sorry for the diagnosis and if were me I’d be getting some things in order with someone I GREATLY trusted for my future just in case.
Also never read of any BP etc. link at least in what you mention including drugs etc. in anyway that was groundbreaking research or anything, but I am not a neuro-scientist so what do I know. Just keep reading and studying as long as you can about your illnesses. That alond with any WELL spent money or help is all you can really do I suppose. Again, all the best your really getting hit. WN
Here goes,the downward spiral.
To make a long uber boring story relatively condensed…..
Damn my brain feels full of novocaine,before things were cruising along ok then getting slightly more than just ok
The cleaning products got out,hours of housework…
I felt uncomfortable in my own skin…then arguing,with just about everyone…
Not just a bit of a raised tone SCREAMING….
Not sleeping…
Then having to grocery shop on 2 nites next to no sleep,fun…
Hell on earth.
Then BOOM…depressed..
Adding to the mix my BFF in the psych ward emailing ME….many times p/ day
Money issues….
Deathly HEADACHES,plus lovely comment from neighbour oh how lovely & thin I USED TO BE…NOW… AM I
DIABETIC?
Nearly collapsed,instead cried…
Then,worst of them ALL FOR ME HIT October 3….would’ve been my fathers birthday….
I’m so low I believe he would’ve been 84………
I’m going to take my bedtime meds……to say I’m sick & tired of being sick & tired of riding the roller coaster…..is a
trivial ignorant statement……OUCH.
my past life was so sorrowful,,, there were some very sad incident happen in my life,, i want to forget all those incident,, but i cant,,, by thinking about all of that incident my present life is hampering … help me,, how can i forget about my past life… please help me…
Don’t understand Rosy. Maybe if you can be clearer I can help. I just can’t understand. Sorry. I hope whatever happened you can feel a little better. WN
So, I’m greatful to have come across this website. I have been struggling with BP for over a decade now. I am on medication, but I don’t take as I should according to schedule. I used to. but lately, I just don’t give a “F”. I’m so depressed I keep hoping the next morning i’ll be happy–never happens. I’m tired of the mental fight. I read an article written by Natasha I believe about “having fun.” Yea, I do not like “having fun.” I have to “pretend” like I am having fun, because having fun puts me at a state of fear…I am never happy, and to be happy is uncomfortable. But, I think I need to attend church tomorrow. maybe He is what I am missing. whatever it is, I better find out what the missing link is, or else I just might blow up like a bomb.
I would love it if you would also write about psychomotor retardation in the future. It is a hallmark of my son’s depressions and I’ve hardly been able to find any information about it. Thanks for your excellent writing!
I am so happy to be reading abt mixed states as this is generally my flip side of depression. I would frankly rather be depressed.I have also found it hard to treat. I try to go to the gym but that isn’t always possible since I might hurt someone or even myself(drive the car into the tree type stuff).Tried many atypicals but I can’t function. I now take a benzo when necessary, with my pdocs blessing. It doesn’t make it stop but it smoothed out some of the pointier edges so I can do less damage.
While I have yet to be diagnosed, (severe social anxiety keeps me from being able to seek help, but I’m working on that) I know that I’m bipolar. I just wanted to let you know that finding your blog has been such a wonderful thing for me. It’s helped me to piece together all the things that are “wrong” with me and to see that they are all connected. I suffer greatly from psychomotor agitation and it is, indeed, a living hell. I’ve explained it as feeling the need to escape my own body. There’s nothing worse than feeling an episode coming and knowing that you’re going to spend at least the next few hours in extreme pain. And not knowing what it will escalate to is very scary.
I want to thank you for you blog. I’ve been writing things down so that, once I get to the doctor, I’ll have a good starting point. I want to make sure I receive the best care and I think, with some of the things I’ve learned here, that might be attainable.
Actually,I heard my psychiatrist ( the one who finally correctly diagnosed me say in front of his resident watch the
Intense psychomotor agitation in her)
That,I will never forget.
I used to,before my feet were injured walk 2-3 hours,the messiah walk..
Like I was driven to do so.
As for mixed episodes,hello!
I spend a lot of time there,yuck.
Wicked witch of west/ or Good witch of East.
As for the confusion,I’d describe myself as a ball of confusion,absolutely.
As well as chaos.
The times when I say I’m middling…meaning as stable as I can for the time being…
Being rapid cycler,even w meds,coping tools,healthy lifestyle…..
We all have triggers,inevitable.
That’s just life.
I get frustrated with my progress,how hard/ stubborn it or I or vice versa becomes.
Do feel many times want to give up…today was one of crying jags.
But went out anyway to get groceries after all,I refuse to let my illness effect my cat….
She truly is my world.
As she loves me for me,unconditionally.
No boundaries like,others.
To me,that is not real love.
Though,others may disagree.
I too,see similarities in most of these posts.
Yes,I’ve too received the chemical straitjacket as they so lovely termed it here ,more than once.
Sad,painful stuff.
Hopefully,one day,someone will experience something something less traumatic……
Cheers to one & all,w / out alcohol …( for me,anyway)
Oops, sorry I spelled your name wrong.
I definitely relate, I am much more likely to consider self harm during mixed episodes. My brain and body just won’t let me alone, yet I am exhausted, sad, etc. Mixed moods, for me, lead to a swing to either depression or mania, sometimes I don’t know which it’s going to be. I bounce the legs, sway back and forth, pace for hours on end and think about EVERYTHING, over and over and over. I wonder why the psych profession doesn’t put more emphasis on mixed episodes, they seem just as serious as dep. and mania. Like many of you I have played medication roulette but I have also tried to be proactive in trying other techniques. I’m working very hard to make meditation work for me and I am trying out blue light blocking after 6PM. Too soon to report any results but I do think I am sleeping more regular. Off topic question, has anyone else found CBT to be almost impossible during a mood episode ? It’s been pushed on my often and it works great when I’m feeling well but when those brain chemicals throw a curve it’s not my behavior that’s causing it. Just curious. Natashia you are the best, since finding your blog I no longer wonder if my symptoms are common or not, seems like we all have similar experiences. That, believe it or not, offers me some comfort.
Akatesia. Torture sometimes induced by psychiatrist in a situation giving them almost unlimited power. A person who should receive the same when given the situation. A female psychiatrist in Philadelphia who knew what she was doing due to political, professional, financial and other reasons. Formally known as chemical restrains. Modern technology has added to this the most unpleasant feeling a human being can tolerate in the name of “Treatment”. Otherwise known by the US gov. as enhanced interrogation techniques. WN.
in my life i have felt a lot of deep deep depression ! i have felt that anxiety. anger and hopeless and desire to not want to live in a world where i just live day to day trying to live second to second with out going insane. right now I feel a numbness like I just don’t care. i feel a hopeless feeling or a sence of why does it matter to continue on if the rest of my life is going to be a fight to get out of a depression that seems like a hopeless cause, a fight for more and more loneliness .Im know we have those we should live for but dont
they really need a mother a wife who is not lazy,lacking in joy and creativity and the love they deseve to help them grow. my example to them through out there life hasnst been the best just ask they they have a lot of negitive to say a bout me.If i could be promised that this numbness and fear and frustrastion would go away and the scripture man are that they might have joy ways true my view would change. My mind is so confused right now I can seem to get my thoughts down the way I want them but a confused mind is probally something simillar for all of us!
So, as I wipe the tears from my eyes, I’m able to clearly see what I type in response to your blog. I must say, I feel 100% what you feel as posted. I needed to read what you wrote in which I am replying to. BP sucks! And I am at that breaking point in my life where I feel like giving up cause it’s an Everyday f-ing fight. But, thank you. I needed to feel that I am not alone.
Akathisia is a common effect of psychotropics, including and especially neuroleptics (antipsychotics.) Depending on its severity, it may constitute an emergency. If the psychotropic can’t be discontinued, an additional drug must be added to calm the akathisia. Also, receiving haloperidol intramuscular injections in a hospital setting would not be a feasible treatment for the average person suffering from akathisia. I notice there is a related 2011 citation: “Rapid tranquilization for agitated patients in emergency psychiatric rooms: a randomized trial of olanzapine, ziprasidone, haloperidol plus promethazine, haloperidol plus midazolam and haloperidol alone.” Hopefully this isn’t something a doctor would approve, or something you’d want to do to yourself, except during a short term emergency.
Haldol? I wouldn’t give it to a rabid rat. -40 mils of valium is fine w/ me. Actually .. I wish I could bag myself w/ a versade/demerol drip. aahh
PS: wait till I get so pent up and agitated that I start pacing, in a circle, round and round and round… I will find myself, quite often… just pacing, faster and faster, around and around in a circle…. or rocking to and fro, while sitting
all to hide what lurks inside.. which is ironic cause all the pacing, or bouncing, or rocking to and fro… isn’t really hiding anything, is it?
Understated subject. “annoyance in it’s highest form” –if these are your words–you are brilliant.
and–you’ve nailed it. Not only have I had it, but I’ve looked tirelessly for relatable info about it, and other than to dope myself out of the episode, the immediacey of the misery, I knew not much else to do.
I wondered. why there wasn’t more info, more detailed explanations, more SOMETHNG about mixed moods.? Pyschomotor agitation. I can’t even look at those two words together w/o cringing.
When t happens to me, I’m actually screaming out loud for help.
As I’m suffering in the throes, I’m describing what I am able to in those minutes, to my husband.
I have to know he’s there, or I’d have to shoot myself in the mouth. It’s that bad.
Maybe the mother who’s just been told her child was hit and killed by a car, and her husband died on the way home too, could possibly…..possibly…., describe, the angst, the uber painful thoughts, hot red poker hellish thought moments, like being forced to French kiss satan—associated with’ what I feel when I’m having one.
I have yet to hear a proper description of it–but yours comes painfully close. “Annoyance it it’s highest form” you could even possibly substitute ‘torture’ for annoyance.
But no, yours is pretty much spot on.
I get it, I’ve had them, –no long drawn out stories here. They immensely suck.
We MUST find an easier way OUT of them for those of us who suffer them.
It can most certainly be a matter of life or death. It makes me understand why people kill themselves.
Hi Stevie,
Those are, indeed, my words. I put quotes when it’s someone else’s. I’m glad you like them.
– Natasha Tracy
I find that I find myself, at “heightened” times of stress – anxiety – depression… that my legs just bounce and bounce and bounce, when I sit.
Like at work, sitting in the cubicle and I’m agitated or highly anxious or trying to “hide” my bipolar insides… my legs just bounce and bounce, or I get the finger tapping or my speech starts speeding to where my words are garbled.
It’s like time is running short and the pressure is building and I can’t get rid of it and I can’t let go of it and I can’t show it… so, legs bounce, speech goes fast and garbled; I even eat too fast and the agitation….
yes, mixer
very much a mixer
cause while I have all this pent up and “bouncing” energy that is causing seemingly unrelenting agitation…
I just want to lay down
and stop