Agitation presents as a complex symptom that can greatly affect a client's well-being and treatment results. While some may see it as merely disruptive behavior, agitation needs careful assessment and attuned interventions.

When therapists accurately identify agitation, they can create more effective treatment plans and monitor client progress over time.

This article guides therapists in understanding agitation as a multidimensional symptom, and integrating it into treatment approaches based on evidence. We'll examine the ICD-10 codes and diagnoses often linked to agitation and discuss assessment strategies, treatment considerations, and best practices for documentation.

ICD-10 Codes Commonly Associated with Agitation

Agitation does not have a standalone ICD-10 code but appears as a specifier or symptom within broader diagnoses:

• F41.1 – Generalized Anxiety Disorder (with psychomotor agitation)
• F31-F33 – Bipolar and Major Depressive Disorders (with anxious or agitated features)
• F20-F29 – Schizophrenia spectrum and other psychotic disorders (agitated states in acute exacerbation)
• R45.1 – Restlessness and agitation as a symptom code

Clinical Presentations and Differential Diagnoses

Agitation shows itself through various physical, behavioral, and emotional signs. Common presentations include:

• Psychomotor Agitation: Pacing, hand wringing, finger tapping, muscle tension, increased heartbeat, physical tremors, and sudden, unexplainable movements.
• Irritability and Restlessness: Feelings of severe restlessness, mental distress, crankiness, impatience, and stubborn behavior.
• Disruptive Behavior: As agitation increases, it may lead to violent behavior, excitement, hostility, poor impulse control, and unhelpfulness.
• Emotional Signs: Tension, anxiety, and uneasiness often accompany agitation.

When assessing agitation, mental health professionals need to consider differential diagnoses and potential underlying causes:

• Substance Intoxication or Withdrawal: Agitation can result from substance use or occur during withdrawal.
• Delirium or Dementia: Confusion or environmental factors may trigger agitation in individuals with cognitive impairments.
• Mania vs. Acute Psychosis: Distinguishing between manic episodes and acute psychotic states is important for accurate diagnosis and treatment.
• PTSD-Related Hyperarousal: Agitation may be a manifestation of hyperarousal symptoms in post-traumatic stress disorder.
• Medical Causes: Ruling out medical conditions such as thyroid dysfunction, infections, pain, or electrolyte imbalances is necessary for comprehensive assessment.

Identifying the specific clinical presentation and considering differential diagnoses allows therapists to develop targeted interventions and work with other healthcare providers when necessary.

Assessment Strategies for Agitation

To thoroughly assess agitation, evaluate various aspects of the client's mental status and behavior over time. The mental status examination should focus on:

• Affect: Observe and document the client's emotional state, noting any signs of heightened arousal, irritability, or lability.
• Motor Activity: Pay attention to psychomotor agitation, restlessness, pacing, or other abnormal movements.
• Speech: Note any changes in speech patterns, such as pressured speech, rapid talking, or verbal aggression.
• Impulse Control: Assess the client's ability to regulate their impulses and maintain behavioral control.
• Appearance and Behavior: Observe for signs of distress such as clenched fists, tense posture, scanning the environment, or aggressive gestures. Note disheveled appearance or signs of self-neglect that may indicate escalating agitation or decompensation.
• Mood: Ask the client to describe their internal emotional state. Agitated individuals may report feeling “on edge,” angry, overwhelmed, or unable to calm down.
• Thought Process: Evaluate for disorganized, tangential, or racing thoughts, which can contribute to agitation. Be alert for perseveration or intrusive thoughts that seem to drive the agitation.
• Thought Content: Explore the presence of persecutory ideation, delusions, or preoccupations with themes of injustice or threat, which may fuel agitation.
• Perception: Assess for hallucinations—especially command or threatening auditory hallucinations—that may provoke agitation or aggressive behavior.
• Insight and Judgment: Determine whether the client is aware of their agitation and its potential consequences. Poor insight or impaired judgment can increase risk of escalation or impulsive actions.

Behavioral observation over time plays an important role in tracking the intensity, frequency, and context of agitation episodes. This information helps identify triggers, patterns, and how the client responds to interventions. Consider using a behavioral log or chart to systematically document agitation episodes.

Several tools can help in assessing agitation:

• Agitation Scales: Validated scales, like the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) or the Behavioral Activity Rating Scale (BARS), provide standardized methods for quantifying agitation severity.
• Symptom Logs: Encourage clients to maintain a log, such as the DBT Diary Card to record their emotional states and any associated agitation symptoms throughout the day.
• Caregiver Reports: In geriatric or pediatric settings, gather information from caregivers or family members who can provide valuable insights into the client's behavior and any changes in their daily functioning due to agitation.

When assessing agitation, consider the client's overall clinical presentation and rule out any underlying medical conditions that may contribute to the symptoms. Work with medical professionals when necessary to ensure a thorough evaluation.

Treatment Considerations Based on Underlying Diagnosis

Addressing agitation effectively requires a treatment plan that suits the underlying cause and the individual’s specific needs. Combining therapy, medication, and changes to the environment can help manage agitation in different clinical situations.

Therapeutic approaches are important in supporting individuals to build coping skills and manage their emotions:

• Dialectical Behavior Therapy (DBT): DBT offers mindfulness techniques and distress tolerance skills that assist individuals in handling intense emotions and decreasing agitation.
• Somatic Approaches: Body-based therapies help clients tune into physical sensations and regulate physiological arousal. Techniques like breathwork, grounding, and movement support emotional regulation and can reduce agitation rooted in nervous system dysregulation.
• Trauma-Focused Therapies: For those with agitation stemming from past trauma, grounding techniques and containment strategies can help manage hyperarousal symptoms and foster a sense of safety.

If agitation remains severe or does not improve through therapy alone, psychiatric evaluation and medication management might be necessary. Medications prescribed by a psychiatrist or psychiatric nurse practitioner can address specific symptoms and lessen the severity of agitation.

Changing the environment also plays a significant role in managing agitation:

• Sensory Regulation: Creating a calming sensory environment with soothing colors, lighting, and sounds can decrease overstimulation and encourage relaxation.
• Stimulus Control: Identifying and reducing environmental triggers, such as noise or crowding, can prevent agitation from worsening.
• Structured Routine: Establishing a predictable daily routine with a balance of activities and rest can provide stability and lower stress.

Managing agitation effectively requires teamwork, involving the individual, their support system, and a team of mental health professionals. Regularly monitoring and adjusting the treatment plan based on the individual’s response and progress is key for the best outcomes.

Documentation and Ethical Use of ICD-10 Codes

Accurate and ethical documentation of agitation is important for providing quality care and staying compliant with legal standards. When recording agitation in progress notes, make sure to describe the specific behaviors, intensity, and duration of the symptoms. Connect the agitation to any functional impairments or disruptions in the client's daily life to justify the need for treatment and support.

In cases where the underlying diagnosis is unclear, work with other members of the treatment team to assess the client’s symptoms and impairments to determine the best-fitting provisional diagnosis for that moment. 

If a provisional diagnosis is given, document how the agitation symptoms match the diagnostic criteria and the plan for confirming the diagnosis.: Include any consultations or referrals to other professionals, like psychiatrists or medical specialists, in the note and discussion around differential diagnosis.

When documenting agitation, be careful to avoid language that pathologizes normal emotional responses or culturally specific expressions of distress. Consider the following:

• Cultural Sensitivity: Understand that agitation may appear differently across cultures and that certain behaviors may be culturally normal rather than pathological.
• Trauma-Informed Approach: Recognize the potential impact of trauma on an individual's emotional regulation and behavior, and avoid labeling agitation as inherently problematic.
• Person-Centered Language: Use respectful, person-centered language that separates the individual from their symptoms (e.g., "a person experiencing agitation" rather than "an agitated person").

Be mindful that implicit bias can shape how agitation is interpreted and documented, particularly when intersecting with race, gender, and cultural identity. For instance, a Black man expressing frustration may be perceived as more threatening or unstable compared to a white client displaying the same behaviors, especially by clinicians from dominant cultural groups. This can lead to over-pathologizing or mislabeling normative emotional responses as dangerous or disordered. Clinicians should actively reflect on their own cultural lenses and seek supervision or consultation when unsure, aiming to document behaviors with neutrality, accuracy, and cultural humility.

Maintaining ethical documentation practices also involves ensuring patient confidentiality, obtaining informed consent, and providing care that prioritizes doing good and avoiding harm. Regularly review documentation to ensure it meets legal and ethical standards, and seek consultation when needed to handle complex cases.

Special Considerations for High-Risk Populations

Agitation can present unique challenges in high-risk populations, requiring therapists to adapt their assessment and intervention strategies. Let's look at some important considerations for working with youth, older adults, and individuals in acute psychiatric crisis.

When assessing agitation in youth, it's important to differentiate it from developmentally appropriate behaviors, such as hyperactivity or irritability. Consider the following:

• Developmental Context: Look at the child's behavior in relation to their developmental stage, as what may seem like agitation could be age-appropriate restlessness or emotional reactivity.
• Family Dynamics: Examine the family system and parenting styles to identify any environmental factors contributing to the child's agitation, such as inconsistent discipline or high levels of stress.
• Trauma History: Consider any history of trauma or adverse childhood experiences that may be influencing the child's emotional regulation and behavior.

For older adults, agitation may be complicated by age-related changes, medication side effects, or cognitive impairments. Keep these factors in mind:

• Medical Comorbidities: Refer the client to a medical doctor to rule out any underlying medical conditions or medication interactions that may be causing or worsening agitation, such as pain, infections, or polypharmacy.
• Cognitive Impairment: Look for signs of cognitive decline or dementia, as agitation may be a symptom of these conditions. Use simple, clear communication and create a calming environment to reduce confusion and overstimulation.
• Fall Risk: Be aware of the increased risk of falls and injuries in agitated older adults, especially those with mobility issues or visual impairments. Ensure a safe environment and provide appropriate support.

When working with involuntary clients or those in acute psychiatric crisis experiencing agitation, focus on safety and stabilization:

• Rapport Building: Establish trust and rapport with the client, using a calm, non-confrontational approach. Validate their emotions and concerns while setting clear boundaries and expectations.
• De-escalation Techniques: Use verbal de-escalation strategies, such as active listening, offering choices, and redirecting the client's attention to calming activities. Avoid power struggles or arguments that may escalate agitation.
• Collaborative Care: Work closely with the client's support system, including family members, healthcare providers, and community resources, to ensure a coordinated and comprehensive treatment plan.

Managing agitation in high-risk populations requires a person-centered, trauma-informed approach that prioritizes safety, empathy, and collaboration. Seek supervision and specialized training to improve your skills in working with these vulnerable populations.

Resources and Ongoing Support for Clinicians

Keeping up with the latest research, treatment approaches, and diagnostic considerations is important for mental health professionals working with clients experiencing agitation. Several resources offer guidance and support for clinicians:

• ICD-10 Code Updates: The World Health Organization (WHO) provides regular updates to the ICD-10 coding system, including any changes to codes related to agitation. Checking these updates ensures that your diagnostic coding remains accurate and current.
• Diagnostic Manuals: Refer to the most recent versions of diagnostic manuals, such as the DSM-5 and ICD-11, for the latest specifiers and criteria related to agitation in various mental health disorders.
• Professional Organizations: Join professional organizations, like the American Psychiatric Association or the National Association of Social Workers, to access resources, publications, and continuing education opportunities focused on managing agitation in clinical settings.

Participating in ongoing training and education helps develop and maintain the skills needed to effectively manage high-arousal states in therapy and crisis situations. Look for workshops, webinars, and courses that cover topics such as:

• De-escalation techniques and crisis intervention strategies
• Trauma-informed approaches to managing agitation
• Pharmacological interventions for acute agitation
• Cultural considerations in assessing and treating agitation

Supervision and peer consultation provide valuable support for therapists working with challenging cases involving agitation. Consider the following:

• Individual or Group Supervision: Regularly discuss your high-agitation caseload with a qualified supervisor who can offer guidance, support, and feedback on your clinical approach.
• Peer Consultation Groups: Join or form a peer consultation group with colleagues who have experience working with agitated clients. Meet regularly to share insights, strategies, and self-care practices.

Reflective Practice: Engage in reflective practice, such as journaling or self-assessment, to process your own emotions and reactions when working with agitated clients. This can help prevent burnout and maintain empathy and compassion.