24 Anger, Aggression, and Violence: Clinical Management and Neurobiology

Learning Objectives and Core Nurse Competencies

• Discuss the interplay between neurobiology, medical history, past history, and sociological/demographic issues contributing to violence risks.

• Promote safety by demonstrating physical indicators of a patient escalating out of control (QSEN: Safety).

• Provide patient-centered care by comparing interventions for angry/loud patients in pre-escalation vs. those in aggressive phases (QSEN: Patient-Centered Care).

• Identify specific safety measures for deescalating aggressive individuals (QSEN: Safety).

• Plan patient-centered care for patients in seclusion (QSEN: Patient-Centered Care).

• Describe evidence-based use of communication and procedures for placing individuals in restraints (QSEN: Evidence-Based Practice).

• Discuss the importance of teamwork and collaboration when applying seclusions or restraints (QSEN: Teamwork and Collaboration).

• Explain how quality improvement develops from critical incident debriefing (QSEN: Quality Improvement).

• Document examples of required written information when violence occurs or is averted.

• Identify calming communication and optimum milieu management (QSEN: Evidence-Based Practice).

Defining Anger, Aggression, and Violence

• Culture: Defined as a pattern of shared attitudes, beliefs, norms, and roles among those speaking a specific language or living in a region. Cultures that support intimidation reinforce violence as an acceptable way to solve problems or achieve social status.

• Anger: A normal, not always logical, human emotion. It varies in intensity from mild irritation to intense fury/rage. It is often an unplanned reaction to a stressor (hurt, fear, vulnerability, or threats to needs).

  • Constructive Anger: Channeled through assertive communication and reasoning to meet needs safely.

  • Unhealthy Anger: Interferes with functioning/relationships or risks others.

• Aggression: Behavior aimed at harming others physically or psychologically.

  • Overt: Hitting, yelling, breaking things.

  • Covert: Belittling, shaming, or placing misplaced blame.

  • Adaptive: Protective behavior (e.g., a parent protecting a child).

• Violence: The expression of hostility and rage with the intent to injure or damage people or property through physical force. It is harmful to both victim and aggressor, potentially causing brain changes related to depression and anxiety.

Bullying in the Health Care Environment

• Definition: Offensive, intimidating, malicious, or condescending behavior designed to humiliate and terrorize. It involves persistent, systemic violence.

• Lateral Bullying: Bullying between those of equivalent status (nurse to nurse).

• Statistics:

  • $21\%$ of nurses in an ANA survey reported a significant risk for violence at work.

  • $25\%$ to $50\%$ experienced bullying.

  • $50\%$ experienced peer aggression; $42\%$ experienced aggression from authority figures.

  • $85\%$ of nurses have been verbally abused by a fellow nurse.

  • One in three nurses quits because of bullying.

  • By $2022$, the US Bureau of Labor Statistics projects a shortfall of $1.05\,million$ nurses primarily due to bullying rather than wages.

• Common Bullying Behaviors:

  • Unwanted/invalid criticism or excessive monitoring.

  • Gossiping, rumors, or derogatory nicknames.

  • Blocking career pathways or taking credit for others' work.

  • Eye rolling, dismissive body language, sarcasm, and ridicule.

  • Allocating unrealistic workloads without support.

  • Breaking confidences.

Prevalence and Predictive Factors of Violence

• High-Risk Units: Psychiatric units, emergency departments (EDs), waiting rooms, and geriatric units. ED nurses experience the highest rates of violence.

• Predictors:

  • History of Violence: The single strongest predictor of future violent incidents.

  • Medical/Neurocognitive Disorders: Brain tumors, Alzheimer’s, delirium, TBI, temporal lobe epilepsy, and Tourette’s syndrome.

  • Demographics: Male gender, young age ($15$ to $24$ years), lower socioeconomic status, and family history of violence.

  • Substances: Alcohol/drug intoxication or withdrawal (especially amphetamines, cocaine, and sedative-hypnotics).

• Mental Health Note: Only $3\%$ to $5\%$ of violent acts are attributed to the seriously mentally ill; they are $10\text{ times}$ more likely to be victims than perpetrators.

Neurobiological and Genetic Factors

• Brain Structures:

  • Limbic System: Mediates primitive emotions (survival). Includes the hypothalamus, hippocampus, and amygdala.

  • Amygdala: A vital nexus supporting aggression; responds to perceived threats.

  • Hypothalamus: Stimulated by anger to trigger the fight-or-flight response.

  • Temporal Lobe: Integrates memory of previous insults into threat appraisal; complex partial seizures here lead to aggression.

  • Prefrontal Cortex: Modulates aggressive impulses. MRI shows reduced prefrontal gray matter in violent individuals; PET scans show decreased blood flow/metabolism.

• Neurotransmitters:

  • Serotonin ($5-HT$): Functions as a modulator to lessen impulsive/violent behavior. Low levels of the metabolite $5-hydroxyindoleacetic\,acid\,(5-HIAA)$ in CSF correlate with impulsivity and suicide history.

  • Norepinephrine ($NE$): Enhances vigilance; may play a role in episodic violence.

  • Dopamine: Involved in reward processing. Higher storage in the striatum and midbrain correlates with lower aggressive responses.

• Genetics: Twin and adoption studies suggest a genetic component, though no specific chromosomal abnormality is exclusively linked to aggression.

The Nursing Process: Assessment and Diagnosis

• Subjective Data: Gather history of previous violence, coping skills, and perceptions of current issues. Ask: "Have you ever thought of harming someone? What is the most violent thing you have ever done?"

• Objective Data (Predictive Signs):

  • Hyperactivity: The most important predictor of imminent violence (pacing, restlessness, door slamming).

  • Physical Signs: Clenched jaw/fists, rigid posture, sweating, rapid pulse ($tachycardia$), and mumbling.

  • Verbal Cues: Profanity, argumentativeness, loud or strained soft voice.

  • Eye Contact: Intense staring or complete avoidance.

• Nursing Diagnoses:

  • Risk for violence (directed at self or others).

  • Impaired impulse control.

  • Difficulty coping (overwhelmed or maladaptive).

  • Risk for stress overload.

  • Ineffective family coping.

Implementation: Deescalation and Safety Measures

• General Safety Rules:

  • Maintain at least one arm’s length of space from the patient.

  • Do not wear dangling earrings, necklaces, or lanyards without breakaway features.

  • Position self between the patient and the door, but not directly in front of the exit (avoid trapping the patient).

  • Choose a spokesperson; avoid multiple staff talking at once.

• Deescalation Techniques (Preassaultive Stage):

  • Respond as early as possible.

  • Stand at an angle (non-confrontational).

  • Speak softly in a nonjudgmental manner.

  • Use empathic statements: "It sounds like you are in pain."

  • Use a 45-degree seating angle to allow breaks in eye contact.

• Setting Limits (Box 24.2):

  • Set limits only for protection from harm.

  • Establish realistic/enforceable consequences.

  • Communicate limits clearly and politely before incidents occur.

  • Consistent application by all staff is mandatory.

Assaultive Stage Interventions: Seclusion and Restraint

• Definitions:

  • Seclusion: Involuntary confinement in a room the patient is prevented from leaving. Only for management of violent/self-destructive behavior.

  • Restraint: Manual methods, devices, or drugs (chemical restraint) that restrict movement and are not standard treatment for the condition.

• Legal/Procedural Requirements:

  • Requires a physician’s order (verbal, written, or telephone).

  • Evaluation by a physician/LIP must occur within $1\,hour$ of initiation.

  • Face-to-face observation every $15\,minutes$.

  • Patients age $14$ or younger require constant face-to-face observation.

• Trauma-Informed Principles: Safety, Trust/Transparency, Peer Support, Collaboration, Empowerment, and Cultural/Gender issues.

• The Recovery Model: Encourages "comfort rooms" (managing sensory input) and trauma-informed approaches to reduce the use of coercive measures.

Postassaultive Stage and Documentation

• Critical Incident Debriefing: Reviewing the incident to ensure quality care, evaluate team response, handle staff feelings (fear/anger), and prevent long-term psychological sequelae.

• Reintegration: Gradual progression from restraints to seclusion, then to time-outs in quiet areas with fewer patients.

• Documentation Requirements:

  • Exact reason for seclusion/restraint.

  • Assessment of preassaultive behaviors (with time).

  • List of all nursing interventions and patient responses.

  • Detailed description of assaultive behavior.

  • Names of persons notified/orders received.

  • Documentation of food, toileting, vitals, and verbatim statements every $15$ to $30\,minutes$.

  • Injury reports and reintegration process.

Special Populations: Neurocognitive Deficits

• Catastrophic Reaction: Severe agitation/aggression resulting from overwhelming fear and inability to process stimuli.

• Intervention Steps (Box 24.3):

  • Face patient within $2\,feet$.

  • Say name, gain eye contact, and smile.

  • Use gentle touch and a soft voice.

  • Use short, simple sentences; avoid complex explanations.

  • Decrease environmental sensory stimulation.

• Validation Therapy: Instead of reorienting a disoriented patient (which causes distress), reflect back the feelings. (e.g., if a woman wants to go home to care for babies, ask her to tell you more about her children).

Psychopharmacology for Aggression

• Acute Aggression:

  • Benzodiazepines: Often first choice for episodic dyscontrol.

  • Antipsychotics: IM ziprasidone or olanzapine (orally disintegrating) for emergencies.

• Chronic Aggression:

  • Anticonvulsants ($Valproic\,Acid$, $Carbamazepine$): Labile mood, poor impulse control.

  • Antipsychotics ($Risperidone$, $Quetiapine$): Disorganized behavior.

  • Anti-hypertensives ($Clonidine$, $Propranolol$): Anxiety, agitation.

  • Lithium: Labile mood, suicidality.

  • SSRIs ($Sertraline$, $Fluoxetine$): Agitation associated with depression.

Questions & Discussion

• Duty to Warn: A psychiatric resident/nurse has the duty to warn intended victims if a patient makes a specific threat. In the vignette, an RN called the wife and police after a schizoaffective patient threatened violence (Duty to Warn guidelines).

• Environmental Factors: Overcrowding, staff inexperience, or arbitrary revocation of privileges (staff inconsistency) are milieu characteristics that provoke violence.

• Predictors Check: A history of setting fires or cruelty to animals in childhood is strongly linked to adult violent behavior.