Chapter 10 Anger, Hostility, and Aggression

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Chapter 10 Anger, Hostility, and Aggression
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Anger, Hostility, and Aggression

• Anger is a normal human emotion that is a
  strong, uncomfortable, emotional response to a
  provocation, either real or perceived. It results
  when one is frustrated, hurt, or afraid and
  energizes the body for defense (fight-or-flight).

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Anger-Encourage Verbalization

• Denying or suppressing angry feelings can lead to
  physical or emotional problems.
• Anger that is expressed inappropriately can lead
  to hostility and aggression.
• Appropriate expression of anger involves
  assertive communication skills that lead to
  problem-solving or conflict resolution.
• Client who can verbalize angry feelings are less
  likely to become physically aggressive.
• Assertive communication I feel angry when you
  walk away when Im talking.

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Anger (contd)

• Venting angry feelings by engaging in safe but
  aggressive activities (punching bag, yelling) is
  called catharsis. However, research has shown
  that catharsis may increase rather than alleviate
  angry feelings.
• Clients with depression may have anger attacks
  when they feel emotionally trapped.

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Hostility and Aggression

• Hostile and aggressive behavior may occur
  suddenly without warning, but often stages or
  phases can be identified
• Triggering
• Escalation-clenched fist, face flushed, yelling,
  swearing
• Crisis
• Recovery
• Postcrisis

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Hostility and Aggression (contd)

• Hostility is an emotion expressed by verbal
  abuse, lack of cooperation, violation of rules or
  norms, and threatening behavior (verbal
  aggression).

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Related Disorders

• Most psychiatric clients are not aggressive, but
  some exhibit angry, hostile or aggressive
  behavior
• Paranoid delusions
• Auditory (command) hallucinations
• Dementia, delirium
• Head injury

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Related Disorders (contd)

• Intoxication with alcohol or drugs
• Antisocial and borderline personality disorders

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• Intermittent Explosive Disorder Rare
  psychiatric diagnosis involving discrete episodes
  of aggressive impulses resulting in serious
  injury or property damage. Episodes are out of
  proportion to any provocation and the person is
  remorseful and embarrassed afterward.

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• Acting Out
• An immature defense mechanism in which the
  person deals with emotional conflict or stress by
  actions rather than reflection or feelings the
  person is trying to feel less powerless or
  helpless by acting out.

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Etiology

• Neurobiologic theories decreased serotonin,
  increased dopamine and norepinephrine structural
  damage to limbic system, damage to frontal or
  temporal lobes
• Psychosocial theories failure to develop impulse
  control and ability to delay gratification

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Cultural Considerations

• In certain cultures, expressing anger may be
  seen as rude or disrespectful some culture-bound
  syndromes involve aggressive, agitated, or
  violent behavior.

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Treatments and Medications

• Treatment is often aimed at the underlying or
  comorbid diagnosis to eliminate aggressive
  behavior.

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Aggressive Clients

• Lithium for bipolar disorder, conduct disorder,
  or mental retardation
• Carbamazepine (Tegretol) or valproate (Depakote)
  for dementia or personality disorders
• Atypical antipsychotics for dementia, brain
  injury, mental retardation, personality disorders
• Benzodiazepines-used potentially aggressive
  client-use with caution

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Aggressive Psychotic Clients

• Medication (often haloperidol Haldol and
  lorazepam Ativan) can be given to aggressive,
  psychotic clients by the chaser method (doses of
  lorazepam at time of behavior, 30 to 60 minutes
  later, and 1 to 2 hours later, until sedated) or
  the cocktail method (lorazepam and haloperidol at
  time of behavior, 30 to 60 minutes later, and 1
  to 2 hours later).
• Short-term use of seclusion or restraint may be
  required during the crisis phase if the client is
  injuring others. Many legal and ethical
  safeguards govern the use of seclusion and
  restraint (see cChapter 9).
• The single best predictor of aggressive behavior
  history of violence

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Application of the Nursing Process

• Assessment
• Early assessment and intervention needed when
  clients are angry or hostile to avoid physically
  aggressive episodes
• Nurse must assess both individual clients and the
  therapeutic milieu or environment.
• Assessment and intervention are based on five
  phases of aggression.

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• Data Analysis
• Risk for Other-Directed Violence
• Ineffective Coping
• EX Observe 2 clients arguing-one client huddle
  in a corner and the other follows continue to
  verbal abuse. The nurse would Engage the
  attention of the client still yelling and ask
  what is happening.

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• Outcome Identification
• The client will
• Not harm self or threaten others
• Refrain from intimidating or frightening
  behaviors
• Describe feelings and concerns without aggression
• Comply with treatment

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Intervention

• Interventions are most effective and least
  restrictive when implemented early in the cycle
  of aggression.
• Managing the milieu includes
• Having planned activities informal discussions
• Scheduled one-to-one interactions EXgt Angry
  client yelling-best response from nurse You seem
  angry. Tell me more about what you are
  feeling. letting clients know what to expect
• Helping clients with conflicts to solve their
  problems, including expression of angry feelings.
  Give the client permission to be angry.

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Managing Aggressive Behavior

• Triggering phase approach in nonthreatening,
  calm manner-(use brief, clear, simple short
  statements to obtain information) convey
  empathy listen encourage verbal expression of
  feelings suggest going to a quieter area, or use
  of PRN medications physical activity such as
  walking

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Managing Aggressive Behavior (contd)

• Escalation phase Take control provide
  directions in firm, calm voice direct client to
  room or quiet area for time out offer medication
  again let client know aggression is unacceptable
  and nurse or staff will help maintain/regain
  control if needed. (Do not explain consequences
  the client will face if loses control) If
  ineffective to that point, obtain assistance from
  other staff (show of force) to get client to take
  time out or take medication.
• IF YOU FEEL VIOLENT OUTBURST IS IMMINENT-CALL FOR
  HELP!!!

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Managing Aggressive Behavior SAFETY OF CLIENT,
STAFF, AND OTHER CLIENT A MUST!!!

• Crisis phase staff must take control of
  situation as determined by facility or agency
  policy (trained in techniques for behavioral
  management) use restraint or seclusion only if
  necessary
• Recovery phase as client regains control talk
  about the situation or trigger, help client relax
  or sleep, explore alternatives to aggressive
  behavior, provide documentation of any injuries,
  staff debriefing

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Managing Aggressive Behavior(contd)

• Postcrisis phase client is removed from any
  restraint or seclusion and rejoins the milieu
  calm discussion of behavior, no lecturing or
  chastising, return to activities, groups, and so
  forth focus is on appropriate expression of
  feelings, resolution of problems or conflicts in
  nonaggressive manner

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Evaluation

• ? Important to discuss situations involving
  aggression to improve methods of dealing with
  behavior of this type.
• The nurse sees this as progress when the client
  can say Im getting really angry.

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Self-Awareness Issues

• How nurse handles own angry feelings
• Comfort with expression of anger from others
• Ability to be calm, nonjudgmental
• Nurse must have assertive communication skills,
  conflict resolution skills, ability to see that
  clients behavior/anger is not personal or a sign
  of nurses failure, and ability to deal with own
  fear when clients are aggressive or threatening