Study Notes on Anger, Hostility, and Aggression
Chapter 11: Anger, Hostility, and Aggression
Anger
Definition:
Normal human emotion.
Arises when a person is frustrated, hurt, or afraid.
Can be a positive force if handled appropriately, aiding in conflict resolution, problem-solving, and decision-making.
Physically energizes the body for self-defense through the “fight-or-flight” response.
Inappropriate Expression or Suppression:
Leads to negative outcomes:
Physical or emotional problems.
Interference with relationships.
Hostility and Aggression
Hostility:
Defined as verbal aggression.
Expressed through:
Verbal abuse.
Lack of cooperation.
Violation of rules or social norms.
Threatening behavior.
Often occurs when individuals feel threatened or powerless.
Physical Aggression:
Involves attacks on or injury to another person or property destruction.
Intended to harm or punish another person.
Can be sudden and unexpected, indicating identifiable stages or phases.
Onset and Clinical Course
Anger:
Commonly perceived as a negative feeling.
Denying or attempting to eliminate anger is unhealthy.
Inappropriate expression may escalate to hostility or aggression.
Related concepts:
Catharsis: Emotional release through expression.
Cognitive–Behavioral Therapies: Interventions targeting thinking and behavior patterns.
Suppression is common, particularly among women.
Hostility and Aggression:
May present suddenly and unexpectedly.
Phases of aggression:
Triggering
Escalation
Crisis
Recovery
Postcrisis
Related Disorders
Conditions associated with hostility and aggression:
Paranoid delusions.
Auditory hallucinations.
Dementia, delirium, and head injuries.
Intoxication (alcohol or other drugs).
Antisocial and borderline personality disorders.
Depression.
Intermittent explosive disorder (IED).
Acting out behaviors.
Etiology of Hostility and Aggression
Neurobiologic Theories:
Potential role of neurotransmitters:
Decreased serotonin levels.
Increased dopamine and norepinephrine levels.
Structural damage to the limbic system.
Damage to frontal or temporal lobes of the brain.
Psychosocial Theories:
Inability to develop impulse control.
Inconsistent responses to child behaviors.
Experiences of interpersonal rejection.
Cultural Considerations
Cultural views and values influence the expression of anger.
Ethnic or minority status may affect psychiatric diagnosis and treatment.
Notable culture-bound syndromes related to aggression:
Hwa-Byung: A Korean syndrome associated with suppressed anger.
Bouffée délirante: A syndrome involving episodes of sudden aggression or agitation.
Amok: A syndrome characterized by a sudden, uncontrolled episode of violence.
Treatments
Focus on treating underlying or comorbid psychiatric diagnoses:
Medication Options:
Lithium: For bipolar disorder, conduct disorders, and intellectual disabilities.
Carbamazepine or Valproate: For dementia, psychosis, and various personality disorders.
Atypical antipsychotics: For dementia, brain injury, and personality disorders.
Benzodiazepines: Used in cases of dementia.
Haloperidol and Lorazepam: Administered to reduce agitation or aggression and manage psychotic symptoms.
The Nursing Process: Assessment
Factors influencing aggression in psychiatric environments include:
Client's history of violent or aggressive behaviors.
Client's method of handling anger.
Client's beliefs about anger.
Assess behaviors to determine the phase of the aggression cycle (reference Table 11.1).
The Nursing Process: Data Analysis and Outcome Identification
Data Analysis:
Identify risks:
Risk for other-directed violence.
Ineffective coping strategies.
Outcome Identification:
Client will:
Not harm self or threaten others.
Refrain from intimidating or frightening behaviors.
Describe feelings and concerns without aggression.
Comply with treatment plans.
The Nursing Process: Interventions #1
Effective and least restrictive interventions should be initiated early in the aggression cycle:
Managing the Environment:
Planning activities.
Scheduling one-to-one interactions.
Offering opportunities for problem-solving and conflict resolution.
Ensuring the safety of other patients.
The Nursing Process: Interventions #2
Managing Aggressive Behavior: Triggering Phase:
Approach the client in a nonthreatening and calm manner.
Convey empathy towards the client.
Encourage clients to verbally express angry feelings.
Use clear, simple, and short statements.
Allow clients time for self-expression.
Suggest moving to a quieter area.
Administer PRN medications as ordered.
Propose physical activity such as walking.
The Nursing Process: Interventions #3
Managing Aggressive Behavior: Escalation Phase:
Take control of the situation.
Provide directions in a firm, calm voice.
Direct clients to time-out in a quiet room or area.
Communicate that aggressive behavior is unacceptable.
Offer medication if refused in the triggering phase.
Be prepared for a show of force if necessary.
The Nursing Process: Interventions #4
Management of Aggressive Behavior: Crisis Phase:
Take charge of the situation prioritizing safety.
Restraint:
Only trained staff should administer restraint.
Between four to six trained staff members are necessary for safe restraint practices.
Inform the client that their behavior is out of control and that staff is taking measures for safety.
The Nursing Process: Interventions #5
Management of Aggressive Behavior: Recovery Phase:
Discuss the situation or trigger with the client.
Assist client in relaxing or sleeping.
Help the client explore alternatives to aggressive behavior.
Assess and document any injuries sustained during the episode.
Debrief staff involved in the incident.
Encourage other clients to talk about their feelings without discussing the aggressive client in detail.
The Nursing Process: Interventions #6
Management of Aggressive Behavior: Postcrisis Phase:
Remove the patient from restraint or seclusion as soon as criteria have been met.
Calmly discuss the behavior with the client without lecturing or chastising.
Provide feedback to the client regarding regaining control.
Reintegrate the client into the community as soon as they are prepared to participate.
The Nursing Process: Evaluation
Care is most effective when anger is defused in the earlier stages of aggression.
The goal is to teach angry, hostile, and potentially aggressive clients to express their feelings verbally and safely without threats, harm to others, or destruction of property.
Workplace Hostility #1
Recognize that intimidating and disruptive behaviors are a sentinel event alert according to The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2008).
Overt Actions:
Examples include verbal outbursts and physical threats.
Passive Activities:
Examples include refusing to perform assigned tasks or exhibiting an uncooperative attitude.
Document the occurrence of disruptive and intimidating behaviors.
Workplace bullying was added as a concern by the JCAHO in 2016.
Workplace Hostility #2
New standards of leadership should include:
Established code of conduct defining acceptable and unacceptable behaviors.
A systematic process for managing disruptive or unacceptable behavior.
Educational programs on expected professional behavior.
Zero tolerance policies ensuring all individuals are held accountable.
Community-Based Care
Effective management of comorbid conditions involves:
Regular follow-up appointments.
Adherence to prescribed medications.
Participation in community support programs.
Anger management groups assist clients in expressing their feelings while learning problem-solving and conflict-resolution techniques.
Relevant studies focus on client assaults against staff in community settings and occurrences of assaults in community residences.
Self-Awareness Issues
Important for healthcare professionals to be aware of their own management of anger.
Practicing and gaining experience in restraint and seclusion before engaging in such measures is crucial.
Maintain a calm, nonjudgmental, and nonpunitive demeanor.
Observe and learn from experienced nurses in managing hostile or aggressive clients effectively.