Anger, Hostility, and Aggression Lecture Notes

Anger, Hostility, and Aggression

• Adaptive Handling of Anger:
  • Can be a force of good.
  • Helps resolve conflicts, solve problems, and make decisions.
• Fight or Flight Response:
  • The body activates this response when anger occurs.
  • Sympathetic nervous system releases norepinephrine, preparing for self-defense.
• Maladaptive Responses to Anger:
  • Examples include punching a wall or someone else to release norepinephrine.
  • Focus is on how anger is handled, as suppressing it is also maladaptive.
• Suppression of Anger:
  • Considered an ego defense mechanism where anger is held in and not dealt with positively.
  • Suppression can lead to headaches, ulcers, and coronary artery disease.
• Inappropriate Expression of Anger:
  • Negative projection: Denying anger while displaying it through voice and body language.
  • Displacement: Expressing anger towards someone other than the cause (e.g., mad at the boss but displaying anger elsewhere).
• Adaptive Ways to Deal with Anger:
  • Assertive communication: Using "I" statements.
  • Engaging in adaptive activities like walking or talking.
• Hostility:
  • Manifests as a lack of cooperation.
  • Can be a form of intimidation and a predictor of physical aggression.
• Physical Aggression:
  • Involves behavior where a person attacks or injures.
• Cathartic Activities:
  • Activities like punching a punching bag.
  • May increase rather than decrease angry feelings in a clinical setting.
  • Non-aggressive activities like walking or talking are preferred in psychiatric facilities.
• Consequences of Suppressed Anger:
  • Migraines, ulcers, cardiac heart disease, and emotional problems like depression.
• Ego Defense Mechanisms:
  • Suppression, denial, projection, and displacement are inappropriate ways to deal with anger.
• Role Play:
  • Can be used to practice assertive communication.
• Cultural Considerations:
  • In the US, women were traditionally discouraged from expressing anger openly.
  • Some cultures, like Asian and Native American, have different norms for expressing anger.

Assertive Communication and Clinical Interventions

• Assertive Communication Skills:
  • Lead to problem-solving and conflict resolution.
  • Involves expressing positive and negative ideas/feelings openly, honestly, and directly.
• Intervention Strategies:
  • Encouraging verbalization is a helpful intervention.
  • Validating feelings: Acknowledge the client's emotions to encourage expression.

Phases of Aggression and Nursing Interventions

• Textbook Guidance:
  • Refer to textbook for phases, definitions, signs, symptoms, behaviors, and nursing actions.
• Managing Aggressive Behavior (page 182):
  • Facilities may offer enclosed areas for activities like pacing.
• Triggering Phase:
  • Encourage verbal expression of anger feelings.
  • Use clear, simple, short statements.
  • Give the client time to express themselves.
• Escalation Phase:
  • Approach the client calmly and firmly.
  • Direct the client to take a time out in a quiet area.
  • Explain that aggressive behavior is unacceptable.
  • Offer PRN medications if refused earlier.
  • Utilize de-escalation techniques.
• Crisis Phase:
  • Nurse decides to use seclusion or restraint based on facility protocols and standards.
  • Prioritize safety for everyone involved.
  • Obtain a physician's order as soon as possible after initiating restraint or seclusion.
  • Restraint requires four to six staff members.
  • Nurse supervises the restraint, ensuring client safety and monitoring breathing and circulation.
  • Administer PRN sedation medications during restraint.
• Restraint and Seclusion:
  • Inform the client of release criteria, emphasizing safety and regaining control.
• Recovery Phase:
  • Offer help such as verbal support, encouragement.
  • Help the client explore alternatives to aggression and how they could have behaved differently.
  • Assess throughout the crisis.
• Post Crisis Phase:
  • The patient expresses what they did because they are moving towards a normal level of functioning.
  • Evaluate staff members.
• Prevention:
  • Proactive planning and training can prevent escalation.
  • All staff should be trained in de-escalation and restraint/seclusion techniques.

Risk Factors and Triggers for Aggression

• Identifying High-Risk Individuals:
  • History of aggression is a major predictor.
  • Other conditions: head injuries, substance abuse, organic brain disease (e.g., dementia), PTSD, bipolar disorder, and schizophrenia.
• Assessment:
  • Assess for risk of violence and plan interventions early.
• Triggers:
  • Identify individual triggers through observation and questioning (e.g., "What are your triggers?").
• Elderly Clients:
  • UTIs can cause confusion and violence.
• Key Point:
  • Never take anger or aggression personally.

Psychiatric Conditions and Aggression

• Common Psychiatric Conditions:
  • Paranoid delusions and auditory command hallucinations (schizophrenia), bipolar type one with psychosis.

Theories of Aggression

• Neurobiological Theory:
  • Serotonin inhibits aggressive behavior; decreased serotonin or increased norepinephrine is associated with increased impulsive behavior.
  • Damage to the limbic system, frontal, and temporal lobes may decrease the ability to modulate aggression.
• Psychosocial Theories:
  • Aggression is related to a failure to develop impulse control.
  • Dysfunctional families and inconsistent responses to behavior increase the risk of aggression.
  • Interpersonal rejection can lead to anger and aggression.
  • Aggressive behavior may be seen as a means to re-establish control.

Medications for Aggression

• Medications:
  • Antipsychotics for schizophrenia with delusions/hallucinations.
  • Lithium, carbamazepine, valproate, or benzodiazepines for bipolar type one with mania/psychosis/irritability.
  • Caution with benzodiazepines in older adults with dementia (paradoxical effect).
  • Haldol, lorazepam, and Benadryl (B52) often used in the ER.

Milieu Management and Nursing Diagnoses

• Factors Reducing Aggression:
  • Strong leadership, clear staff roles, planned activities (group).
  • Adherence to program schedules, sufficient rest, privacy.
• Nursing Diagnoses:
  • Risk for other-directed violence.
  • Ineffective coping.
  • Noncompliance.
• Effective interventions:
  • The the ones that are the least restrictive measure being restraint and medication

Therapeutic Milieu

• Key Aspects:
  • Well-managed environments are therapeutic.
  • Aesthetically pleasing, clean units with appropriate temperature and lighting.
  • Avoid excessive stimulation.
  • Assess for anger, triggers, and escalation.
  • Help clients learn to cope adaptively.
• Nurse's Role:
  • Respond with a firm, calm voice; do not react with anger.
  • Encourage other clients to express feelings (without discussing the specific client involved).
• Post Restraint:
  • Explain the reasonings for the incident after such cases occur.

Post-Crisis Phase and Etiology of Aggression

• Post-Crisis Phase Focus:
  • Encouraging expression of feelings, resolution, and reconciliation.
• Theories with Etiology:
  • Neurobiological theories: structural damage to the limbic system (key point).

Patient Assessment and Workplace Considerations

• Patient Assessment:
  • Brief statements and questions to obtain information.
• Workplace Hostility:
  • Undermines safety, increases errors and healthcare costs, and reduces personnel retention.
  • Joint Commission standards: code of conduct for acceptable/unacceptable behaviors.
• Personal Reflection:
  • How do you manage your own anger?
• Anger Management:
  • Groups are available to help clients deal with anger adaptively.

Trauma and Violence: A National Health Concern

• Effects of Violence:
  • Statistics regarding violence in the home and abuse in acute settings are alarming.
  • Psychological injuries: depression, dissociative disorders, addiction, PTSD.
  • Physical abuse results in agitation and a number of problems.
• Long term psychological effects:
  • Suppressed anger/resentment, shame/guilt, low self-esteem, depression, PTSD.

Impact on Children and Safety Measures

• Impact on Children:
  • Believe they are at fault for the abuse, more likely to miss school, less likely to attend college, and continue to have problems through adolescence and adulthood.
• Safety Measures in the Hospital Setting:
  • Nurses should ensure clients feel safe, secure, and in control, including maintaining personal space, assessing anxiety, and seeking permission before touching.

Understanding the Origins and Dynamics of Abuse

• Origins of Abuse:
  • Intergenerational transmission: Abusive men often come from violent homes; women who grew up in violent homes are like to expect violence in their own relationships.
• Characteristics:
  • Abuse is about power and control (typically possession).
• Screening:
  • Has your partner threatened or abused you or your children?
• Emergency Planning and Appropriate Advice:
  • Safety is key; help them find a safe place to go to.

Bullying and Psychiatric Problems Related to Trauma

• Bullying Overview:
  • Adolescent suicide stems from bullying.
• Early Intervention:
  • This is vital, getting them there to hopefully change or work through any psychiatric problems related to trauma.
• Disorders Related to Trauma:
  • PTSD: Memories (distressing memories, recurrent dreams, flashbacks), Startled response, Concentration problems, sleep Disturbances.

Dissociative Identity Disorder and Other Outcomes

• Hallmark:
  • A person has at least two or more distinct identities that each take control of their behavior.
• Treatment:
  • Don't touch the patients without their permission.
• Possible Outcomes:
  • Moving to client expressing feeling about self.
  • Be reading the care plan in the book for every disorder.