Since bipolar disorder is classified as a psychiatric illness, people might often overlook the fact that there are very real physical characteristics of the disorder as well. Some of these are physical illnesses that may be associated with, but not caused by, bipolar disorder like heart disease, type II diabetes, thyroid disorders and metabolic syndrome. There are also physical manifestations of the disorder itself. One of those symptoms is called “psychomotor agitation,” basically physical restlessness.
When we think of restlessness with bipolar disorder, it’s usually about mental restlessness. There are racing thoughts where the mind just can’t shut down. In mania these may manifest as a constant flow of creative ideas for projects, for example. In depression, it’s often racing thoughts of about guilt, worthlessness and suicide.
For physical restlessness, psychomotor agitation is medically defined as:
“A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions.”
One “other condition” is bipolar disorder. Psychomotor agitation can occur in both mania and depression. In mania it often manifests when patients actually carry out the projects and ideas they thought of during periods of racing thoughts. Patients also tend to have rapid speech and carry on multiple conversations at once.
There is a psychological urge to move, possibly as a way to relieve the excess thoughts, anxiety or tension in the mind. There are symptoms like pacing, rocking motions, driving too fast, bouncing your knee up and down while you sit, hand-wringing, finger tapping or fidgeting in general. Unfortunately, the movements don’t relieve either the desire to move or the psychological agitation. These are not only common in mania, but can also appear with depression.
When psychomotor agitation happens in depression, it’s often part of what’s called a “mixed state” where a person is currently in a depressive episode, but is experiencing some symptoms of mania or hypomania like irritability, racing thoughts or risky behavior.
More than 75% of all bipolar patients experience these subsyndromal manic symptoms. It happens at the same rate for both bipolar I and bipolar II. Psychomotor agitation occurs in about 40% of patients. How drastic the physical restlessness is generally depends on the severity of the mood episode.
With severe episodes, sometimes there are emergency situations tied to psychomotor agitation. It’s possible for the urge for movement to manifest in violence. Patients can feel the urge to lash out or pick fights. The possibility of situations like these increases significantly with substance abuse, which about 60% of the bipolar disorder population deals with at some point, or psychosis.
Suicide is also a major risk when subsyndromal manic symptoms, like psychomotor agitation, are present. Suicidal tendencies and serious attempts double with mixed states as compared to pure depression. This is possibly due to the urge to attempt to rid excess mental energy coming out as self-harm. Racing thoughts of worthlessness and guilt, when combined with impulsive behavior found in mixed states provide fertile ground for suicidal ideation and attempts.
As far as treatment, reducing external stimulation or relaxation practices like yoga, meditation or exercise may provide temporary relief, but are unlikely to work long-term. The underlying manic or depressive episode has to be addressed. In emergency situations, typical antipsychotics and benzodiazepines help to de-escalate the situation quickly. However, a combination of mood stabilizers and atypical antipsychotics seems to work best to reduce agitation in maintenance treatment.
Image credit: Ramona Caníbal