Acute behavioural disturbance in mania

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Acute behavioural disturbance describes an urgent pattern of agitation, aggression, disorganisation or loss of behavioural control; it is not a diagnosis. In a person with mania, overstimulation, persecutory interpretation, sleep deprivation, intoxication, fear and frustrated goals may amplify escalation. The same behaviour can also be produced by delirium, hypoxia, hypoglycaemia, pain, brain injury or withdrawal. Begin medical and psychiatric formulation together and avoid attributing all abnormal observations to mental illness.

Create conditions for de-escalation. Reduce crowding, noise, bright light and unnecessary demands. Use one trained communicator, introduce roles, maintain non-threatening posture and acknowledge emotion without endorsing delusions. Offer clear choices, time, a quieter space and basic needs. Ask what has helped before and check advance statements. A professional interpreter is safer than relatives for complex consent or risk communication, provided delay does not expose anyone to immediate harm.

Assess the incident dynamically. Identify the behaviour, target and imminence of harm; triggers; weapons or environmental hazards; intoxication; and who may be vulnerable. Observe attention, consciousness, motor pattern, speech, thought and psychosis. Record what the person said and what staff observed. Decision-specific capacity may fluctuate, and refusal is not by itself proof of incapacity. Non-consensual treatment or deprivation of liberty requires the applicable current legal basis for the UK jurisdiction and careful documentation.

If de-escalation and preventive strategies fail and harm is otherwise likely, use the least restrictive intervention that can safely work. Only trained staff should apply manual restraint. Avoid taking the person to the floor where possible; if floor restraint is unavoidable, supine is preferred and any prone position should be as brief as possible. Never obstruct airway, breathing or circulation. Continuously monitor distress and physiological compromise and terminate the intervention as soon as its purpose is achieved.

Rapid tranquillisation means parenteral medicine when oral treatment is not possible or appropriate and urgent sedation is required. Select between the NICE adult options from known previous response, current medicines, total dose, physical disease, pregnancy, intoxication, ECG and patient preference. The aim is safe calming, not unconsciousness. Review each single dose before another, monitor at guideline frequency, provide resuscitation capability and complete both immediate and later post-incident review.

Key points

First action is simultaneous safety and medical triage: acute agitation can arise from hypoxia, hypoglycaemia, delirium, intoxication, withdrawal, pain, head injury or mania.
Use one calm lead communicator, personal space, simple choices, reduced noise and stimulation, access to food, fluid and toilet, and known preferences or advance statements.
Verbal de-escalation and acceptable oral medication are preferred; as-needed medication alone is not a complete de-escalation strategy.
Restrictive intervention is justified only after preventive strategies fail and harm is likely without action; continue communication and use the least restrictive proportionate option.
For adult rapid tranquillisation, NICE recommends intramuscular lorazepam alone or intramuscular haloperidol with intramuscular promethazine after individual contraindication and exposure review.
If information is insufficient, the person is antipsychotic-naive, cardiovascular disease or prolonged QT is present, or no ECG has been done, NICE favours intramuscular lorazepam.
Prescribe the initial rapid-tranquillisation medicine as one dose and do not repeat until its clinical effect, observations, adverse effects and total daily exposure are reviewed.
After rapid tranquillisation, monitor pulse, blood pressure, respiratory rate, temperature, hydration and consciousness at least hourly, or every fifteen minutes in specified high-risk circumstances.
Debrief the patient and staff after containment, assess injury and emotional impact, document the legal and clinical rationale and revise the personalised prevention plan.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Manic escalation

Sleep loss, grandiosity, frustration, psychosis and overstimulation can progressively narrow behavioural control during an acute bipolar episode.

Medical or toxic driver

Hypoxia, hypoglycaemia, delirium, pain, brain injury, intoxication and withdrawal can produce identical outward agitation and may coexist with mania.

Environmental and relational triggers

Crowding, coercive communication, trauma reminders, unmet basic needs and unclear boundaries can amplify threat perception and accelerate an avoidable incident.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Threat-arousal amplification
Perceived threat activates sympathetic arousal and motor readiness, while rapid interpretation and poor inhibitory control reduce the opportunity to reconsider action.
2
Exertional physiological load
Continuous struggle increases oxygen demand, heat production and metabolic stress; positional restriction or sedatives can then impair compensatory breathing and circulation.
3
Drug-related respiratory depression
Parenteral sedatives act rapidly and can compound alcohol, opioids, frailty or respiratory disease, requiring observation of breathing and consciousness.
4
QT and arrhythmia risk
Antipsychotic exposure, electrolyte disturbance, cardiac disease and interacting medicines can delay repolarisation and make regimen selection and ECG information clinically important.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Escalating arousal

Increasing pacing, volume, intrusion, threats, scanning or motor agitation signals rising distress and creates an opportunity for early de-escalation.

Imminent harm

Specific threats, weapon access, assaultive movement or inability to disengage makes the behaviour an emergency rather than merely disruptive.

Delirium phenotype

Fluctuating attention, altered arousal, disorientation and acute physiological change direct assessment toward brain dysfunction and an underlying medical cause.

Manic driver

Reduced sleep need, grandiosity, pressured speech, increased activity and psychotic or irritable mood support mania within the wider differential.

Physiological exhaustion

Hyperthermia, profuse sweating, breathlessness, reduced responsiveness or collapse during prolonged exertion indicates urgent medical compromise.

Red flags requiring action

Stridor, respiratory depression, cyanosis, collapse, chest pain, severe hyperthermia, seizure or reduced consciousness requires immediate ABCDE management and resuscitation support.
Fluctuating attention, disorientation, fever, autonomic change, focal neurology or abrupt onset suggests delirium, intoxication, withdrawal or another acute medical cause.
Access to weapons, escalating threats, command hallucinations, persecutory fear or behaviour that creates imminent serious harm requires a coordinated emergency safety response.
Prolonged physical struggle, prone positioning, pressure on the neck or chest, obesity, intoxication and respiratory disease increase restraint-related physiological risk.
Pregnancy, frailty, older age, head injury, unknown medication exposure or absent ECG materially changes medicine and restrictive-intervention choices.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Immediate ABCDE assessmentFirst step
Why
Detect airway, respiratory, circulatory, neurological, glucose, temperature and exposure emergencies during disturbance.
Interpretation and limitations
Instability takes priority over psychiatric interview. Reassess after sedation or restraint because deterioration can be treatment-related or initially concealed.
02
Focused behavioural and mental-state assessment
Why
Define escalation, threats, psychosis, affect, cognition, insight, capacity and likely triggers.
Interpretation and limitations
Separate direct observation from reported experience; agitation is nonspecific and must be linked to the evolving medical and psychiatric formulation.
03
Medication and substance reconciliation
Why
Identify prescribed, as-needed and emergency doses, alcohol, illicit drugs, withdrawal and interaction risks.
Interpretation and limitations
Total daily exposure, respiratory depressants and QT-prolonging combinations directly affect rapid-tranquillisation choice and monitoring intensity.
04
ECG and targeted tests
Why
Evaluate cardiac, metabolic, toxicological, infectious or neurological hypotheses when safe and clinically relevant.
Interpretation and limitations
Absence of an ECG is itself relevant to avoiding intramuscular haloperidol with promethazine; testing must not delay immediate lifesaving care.
05
Post-intervention physical review
Why
Identify injury, aspiration, oversedation, arrhythmia, restraint harm, dehydration and emotional trauma.
Interpretation and limitations
Normal initial observations do not end monitoring after parenteral sedation; frequency follows physiological state and NICE high-risk criteria.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Delirium

Acute fluctuation, impaired attention, altered consciousness and physiological disturbance indicate brain dysfunction needing urgent cause finding and medical treatment.

Intoxication or withdrawal

Alcohol, stimulants, hallucinogens, sedatives and withdrawal syndromes can cause agitation, psychosis, autonomic change or seizures and alter sedation risk.

Primary psychosis or mania

Mood, sleep, thought form and longitudinal course help distinguish manic activation from schizophrenia-spectrum illness, although initial emergency care may be shared.

Pain or neurological emergency

Head injury, seizure, encephalitis, stroke, urinary retention and other painful or neurological conditions may present behaviourally when communication is impaired.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01First actionDe-escalate while excluding emergencyFirst stepEscalationA person with suspected mania becomes increasingly agitated but communication remains possible.

1Call appropriate support, remove hazards and bystanders, reduce stimulation and nominate one calm communicator with safe personal space.
2Offer simple choices, oral treatment and basic needs while checking ABCDE, cognition, injury, substances and the immediate harm scenario.
3EscalationReview the person's crisis plan and preferences and escalate only if preventive strategies fail and significant harm is otherwise likely.

02Rapid tranquillisationChoose one guideline-supported regimenUrgent sedation is necessary because oral treatment is impossible or inappropriate and serious harm remains likely.

1Review previous response, pregnancy, cardiovascular and respiratory disease, ECG, intoxication, current medicines, total daily dose and advance preferences.
2Use intramuscular lorazepam alone or intramuscular haloperidol with promethazine according to NICE and the current BNF and local emergency protocol.
3AlternativeWrite a single initial dose, ensure resuscitation capability and assess clinical effect and observations before any further dose or alternative.

03After restrictive interventionMonitor, debrief and prevent recurrenceManual restraint, seclusion or parenteral sedation has been used to contain an incident.

1Monitor physiological observations and consciousness at least hourly, increasing to every fifteen minutes when any NICE high-risk criterion applies.
2Examine the patient and staff for injury, address emotional impact and complete an immediate debrief once danger is contained.
3Document indication, sequence, duration, legal basis, medicine doses and response and revise triggers, communication preferences and preventive actions collaboratively.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Restraint-related injury

Airway or circulatory restriction, positional asphyxia, fracture, soft-tissue injury and psychological trauma can occur during poorly controlled physical intervention.

Sedation toxicity

Respiratory depression, aspiration, hypotension, arrhythmia and reduced consciousness may follow parenteral medication, especially with intoxicants or cumulative doses.

Missed medical illness

Diagnostic overshadowing can delay treatment of delirium, infection, hypoglycaemia, head injury or toxicity and convert a reversible cause into major harm.

Therapeutic rupture

Humiliating or unexplained coercion can reinforce trauma, mistrust and avoidance, undermining future help-seeking and collaborative relapse prevention.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

During escalation, continuously reassess airway, breathing, circulation, temperature, consciousness, injury, access to means and the immediacy of harm.
After rapid tranquillisation, record pulse, blood pressure, respiratory rate, temperature, hydration, consciousness and adverse effects at least hourly until concern resolves.
Use fifteen-minute observations when the patient is asleep or sedated, has used alcohol or illicit drugs, has physical illness, has been harmed during restraint or the BNF maximum was exceeded.
Review all prescribed, regular, as-needed and emergency doses before repetition and ensure the combined daily total has not inadvertently exceeded the authorised maximum.
Complete immediate debrief and later collaborative review, including the patient's experience, trauma impact, early triggers and changes that could prevent another restrictive intervention.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Behaviour is not diagnosis

The same shouting or pacing can arise from fear, mania, delirium, pain or intoxication, so mechanism remains an active question.

Calming is the target

Rapid tranquillisation aims to reduce dangerous arousal sufficiently for safety and assessment, not to render the person unconscious.

No ECG changes choice

NICE specifically advises avoiding intramuscular haloperidol with promethazine when an ECG has not been performed and using lorazepam instead.

Restraint changes physiology

Struggle, position and sedatives can produce new compromise, making repeated physical observation part of treatment rather than administrative surveillance.

Debrief restores collaboration

A structured review can identify harm, preserve dignity and convert the incident into personalised prevention and communication preferences.

11Common pitfallsFrequent interpretation and management errors.

01
Assuming every agitated person with a psychiatric history is experiencing mania rather than delirium or medical illness.
02
Crowding the patient with multiple staff giving competing instructions and escalating stimulation.
03
Using as-needed medication alone and calling it de-escalation without relational or environmental intervention.
04
Choosing intramuscular haloperidol with promethazine when there is no ECG or cardiovascular and QT risk is present.
05
Writing repeat rapid-tranquillisation doses without reviewing the effect of the preceding single dose.
06
Failing to increase monitoring to fifteen-minute intervals for sedation, intoxication, physical illness or restraint harm.
07
Treating restraint as the end of the incident and omitting injury assessment, debrief, documentation and prevention review.