Week 4: Anger, Hostility, and Aggression

Behavioral Strategies to Maintain a Safe Clinical Environment

  • Author: Videbeck

  • Publisher: Wolters Kluwer

Learning Objectives

  • Discuss anger, hostility, and aggression.

  • Describe psychiatric disorders associated with increased risk of hostility and physical aggression in clients.

  • Describe signs, symptoms, and behaviors associated with the five phases of aggression.

  • Discuss appropriate nursing actions for clients during the five phases of aggression.

  • Describe important issues for nurses when working with angry, hostile, or aggressive clients.

Test Your Knowledge

  • Question: Which response indicates the nurse has working knowledge of aggression?

    • Anger is an abnormal emotion and should not be expressed. (False: anger is a normal emotion.)

    • A history of victimization increases an individual's likelihood of exhibiting aggressive behavior. (True: victimization can lead to self-protective aggression.)

    • Acting out is a defense mechanism reflecting feelings. (False: it is an immature mechanism dealing with conflicts through actions.)

    • Most clients with mental illnesses are aggressive. (False: they are more likely to harm themselves.)

Introduction to Anger, Hostility, and Aggression

  • Anger

    • Normal human emotion is characterized as a strong, uncomfortable response to real or perceived provocation.

    • Results from frustration, hurt, or fear.

    • Has both positive (problem-solving) and negative (destructive) aspects.

  • Hostility (also known as verbal aggression)

    • Expressed through verbal abuse, lack of cooperation, violations of rules, or threatening behavior.

      • Lack of cooperation can be a factor in workplace violence.

    • Often occurs when feeling threatened or powerless; aims to intimidate or cause emotional harm.

  • Physical Aggression

    • Involves attacking or injuring another person or destroying property.

    • Intention is to harm, punish, or force compliance.

Onset and Clinical Course of Anger

  • Anger is a healthy reaction when situations are unfair or personal rights are not respected.

  • Assertion of anger can lead to problem-solving or conflict resolution.

    • Anger might propel you to find a solution.

  • Public Perception: Often viewed negatively; many feel uncomfortable expressing anger directly.

Assertive Communication

  • Techniques include:

    • Use “I” statements to express feelings (e.g., "I feel angry when you interrupt me").

      • “You” statements can make people feel accusatory and make them more defensive. Additionally, it can escalate conflicts.

    • Benefits: leads to productive discussions and reduces anger.

  • Catharsis: Engaging in non-aggressive activities (e.g., walking or talking) is more effective than aggressive ones (e.g., hitting).

    • Cathartic: energy release.

  • Cognitive-behavioral therapy techniques: Include distraction, communication skills, problem-solving, and reframing.

    • Linking thoughts to behaviors and emotions.

    • People may black out when getting angry, therefore, not acknowledging this emotion.

Phases of Aggressive Incidents

  • Five-Phase Aggression Cycle (prevent this early on, in the triggering phase):

    1. Triggering Phase

      • Definition: An event that initiates the client's response (anger or hostility).

      • Signs: restlessness, anxiety, irritability, pacing, muscle tension.

    2. Escalation Phase

      • Definition: Increased loss of control.

      • Signs: pale/flushed face, yelling, swearing, agitation, hostility.

    3. Crisis Phase

      • Definition: Loss of emotional and physical control.

      • Signs: throwing objects, kicking, inability to communicate.

    4. Recovery Phase

      • Definition: Regaining control.

      • Signs: clearer communication, physical relaxation.

    5. Postcrisis Phase

      • Definition: Reconciliation and return to normal functioning.

      • Signs: remorse, quiet behavior.

Nursing Actions for Managing Hostility and Aggression

  • Establishing trust with clients helps decrease fears and facilitates communication.

  • Recognizing signs of increasing agitation is critical (e.g., restlessness, threats).

    • Ex. Treating some in a manic episode (from BPD). Priority in this scenario is safety, as this client may be entering the crisis phase.

  • Helping clients express feelings non-destructively using communication techniques or physical exercise.

    • It is ok to be angry, but not violently or destructively.

  • Maintain control and a calm demeanor to provide reassurance to clients.

  • Assure clients of control without threats to prevent lowering self-esteem.

  • Side note: if the client is involuntarily admitted, medications cannot be given against someone’s wishes UNLESS they are a harm to self and others (physically threatening).

    • Anhedonia: the loss of interest in hobbies.

Summoning Outside Assistance

  • Recognize limitations: Avoid personal risk; delegate responsibilities to authorities when necessary.

    • Least restriction, most effective.

    • Give medication to calm the client and manage their feelings.

    • Do not put them in seclusion for long (no more than 3 days).

  • Respect the client’s personal space; do not trap or threaten.

  • Decrease stimulation by lowering lights, reducing noise, or moving to quieter areas.

  • Communicate clearly using simple, direct speech.

  • Set firm limits and expectations to prevent bargaining.

Managing Restraints and Seclusion

  • Communicate clearly about actions and reasons during restraint.

  • Provide reassurance regarding safety; alleviate fears.

  • Regularly reassess the necessity for restraint and minimize it as soon as it is safe.

  • Dignity and rights of the client should be respected.

  • Monitor medication effects and address the needs of other clients.

  • Practice drills for ensuring staff safety with two-member teams approaching clients.

Related Disorders

  • Media portrayals often misrepresent mental illness as aggressive.

  • Actual reality: those with psychiatric disorders are more likely to harm themselves.

  • Aggressive behaviors correlate with:

    • Paranoid delusions, auditory hallucinations, dementia, delirium, substance use, and certain personality disorders.

Characteristics of Anger Attacks

  • Sudden intense spells of anger followed by remorse.

  • Triggered by feelings of emotional entrapment, common in children and adolescents with depression.

Intermittent Explosive Disorder (IED)

  • Rare psychiatric diagnosis characterized by discrete episodes of aggressive impulses leading to serious assaults or destruction.

    • Similar to a temper tantrum seen in 3-6 year olds, this is diagnosed in those who are 6 and older.

  • Aggression disproportionate to provocation; often involves a cycle of tension followed by an outburst.

Acting Out as a Defense Mechanism

  • Involves dealing with emotional conflicts through actions rather than verbalization.

  • Temporary relief is gained from feelings of helplessness.

  • Prevalent among children and adolescents, indicating a need for emotional skill development.

Violence and Mental Illness

  • There is bias in reports linking violence directly with mental illness, emphasizing personal perceptions.

  • Not all individuals who commit violent acts have a mental illness.

Etiology of Aggression: Neurobiologic Theories

  • Neurotransmitters play a significant role; low serotonin levels can lead to aggression.

  • Increased dopamine and norepinephrine activity is linked with impulsively violent behavior.

  • Traumatic brain injury can alter aggression modulation due to structural damage in certain brain lobes.

    • Temporal lobe injuries can lead to aggressive behaviors.

Psychosocial Theories of Aggression

  • Developmentally, infants and toddlers show loud emotional expressions.

    • This may be a portrayal of behaviors seen at home.

  • Maturation is associated with impulse control and socially appropriate behavior.

  • Positive relationships serve as protective factors, while dysfunctional family dynamics increase the risk.

  • Interpersonal rejection can drive some to aggressive behavior as a means to regain control or express frustration.

Cultural Considerations in Anger Expression

  • Cultural norms influence how anger is expressed; in the U.S., traditional norms often restrict female expression of anger.

  • Mental health disparities may arise from historical racial and ethnic differences tied to social determinants of health.

  • Acknowledge cultural syndromes related to anger expression (e.g., Hwa-Byung, Bouffe dlirante).

Treatment of At-Risk and Currently Aggressive Clients

  • Accurate assessment prevents aggressive episodes.

  • Early assessment and medication management (judicious/proper use of medications) are crucial for those experiencing aggression.

  • Focus on treating underlying or comorbid psychiatric conditions.

  • Use of seclusion or restraint may be necessary during the crisis phase, governed by legal and ethical regulations.

Medications for Aggressive Clients

  • Mood Stabilizers: Lithium (for bipolar disorder), Carbamazepine, Valproate (for dementia-related aggression).

  • Anxiolytics: Benzodiazepines for agitated older adults.

  • Antipsychotics: Atypical antipsychotics like Clozapine, Risperidone, Olanzapine, are effective for aggressive behavior.

The Six Functions of Clinical Judgment

  1. Recognize cues

  2. Analyze cues

  3. Prioritize hypotheses

  4. Generate solutions

  5. Take action

  6. Evaluate outcomes

The Nursing Process

  1. Assessment

  2. Analysis

  3. Planning

  4. Implementation

  5. Evaluation

Assessment Data and Cues

  • Factors influencing aggression include psychiatric leadership and structured interactions.

  • Assess clients for history of violence, personal victimization, or substance use; identify cues that may signal impending aggression.

Data Analysis and Priorities

  • Common problems include risk for violence and ineffective coping strategies, especially if the client is intoxicated or psychotic.

Outcome Identification

  • Expected outcomes:

    • Client will not harm or threaten others.

    • Client will express feelings without aggression.

    • Client will engage with treatment plans.

Managing the Environment

  • Implement measures to prevent aggressive behavior through planned activities and supervision.

Managing Aggressive Behavior Phases

  • Approach clients calmly during triggering phases and provide clear direction during escalation phases.

  • Take charge during the crisis; support clients during recovery to explore triggers and reinforce positive behavior in the post-crisis phase.

Evaluation of Outcomes

  • Assess the effectiveness of anger management strategies. Reflect on outcomes achieved and evaluate the performance for future improvements.

Workplace Hostility

  • Recognized disruptive behaviors can lead to errors in healthcare settings, emphasizing the importance of codes of conduct and management processes for addressing unacceptable behaviors.

Community-Based Care

  • Community support and regular follow-up for managing comorbid psychiatric disorders are essential for aggression control.

Self-Awareness Issues

  • Nurses must maintain awareness of their anger management techniques. Seek improvement through observation and practice with experienced roles in handling aggression.

Summary

  • Anger can be a positive force when properly expressed.

  • Hostility and physical aggression serve different functions and are influenced by psychiatric issues.

  • Effective assessment and intervention can lead to improved treatment outcomes for aggression.