This is a severe form of aggressiveness. During this stage, patient will be irrational, uncooperative, delusional and assaultive.


  • Organic psychiatric disorders like delirium, dementia, Wernicke-Korsakoff’s psychosis.
  • Other psychiatric disorders like schizophrenia, mania, agitated depression, withdrawal from alcohol and drugs, epilepsy, acute stress reaction, panic disorder and personality disorders.


  • An excited patient is usually brought tied up with a rope or in chains. The first step should be to remove the chains. A large proportion of aggression and violence is due to the patient feeling humiliated at being tied up in this manner.
  • Talk to the patient and see if he responds. Firm and kind approach by the nurse is essential.
  • Usually sedation is given.
  • Once the patient is sedated, collect history carefully from relatives; rule out the possibility of organic pathology. In particular check for history of convulsions, fever, recent intake of alcohol, fluctuations of consciousness
  • Carry out complete physical examination
  • Send blood specimens for hemoglobin, total cell count etc.,
  • Look for evidence of dehydration and malnutrition. If there is severe dehydration, IV drip may be started.
  • Have less furniture in the room and remove sharp instruments, ropes, glass items, ties, strings, match boxes etc., from patient’s vicinity
  • Keep environmental stimuli, such as lighting and noise levels to a minimum; assign a single room; limit interaction with others
  • Remove hazardous objects and substances. Caution the patient when there is possibility of an accident
  • Stay with the patient as hyperactivity increases to reduce anxiety level and foster a feeling of security.
  • Redirect violent behavior with physical outlets such as exercise, outdoor activities
  • Encourage the patient to ‘talk out’ his aggressive feelings, rather than acting them out
  • If the patient is not calmed by talking down and refuses medication, restraints may become necessary
  • Following application of restraints, observe patient every 15 minutes to ensure that nutritional and elimination needs are met. Also observe for any numbness, tingling or cyanosis in the extremities. It is important to choose the least restrictive alternative as far as possible for these patients
  • Guidelines for self-protection when handling an aggressive  patient:
    • Never see a potentially violent person alone
    • Keep a comfortable distance away from the patient (arm length)
    • Be prepared to move, a violent patient can strike out suddenly
    • Maintain a clear exit route for both the staff and patient
    • Be sure that the patient has no weapons in his possession before approaching him
    • If patient is having a weapon ask him to keep it on a table or floor rather than fighting with him to take it away
    • Keep something like a pillow, mattress or blanket wrapped around arm between you and the weapon
    • Distract the patient momentarily to remove the weapon (throwing water in the patient’s face, yelling etc.,)
    • Give prescribed antipsychotic medications