Anger, Hostility, and Aggression Notes

Anger, Hostility, and Aggression

Anger: A Normal Human Emotion

  • Anger arises when a person feels frustrated, hurt, or afraid.
  • When handled appropriately, anger can serve as a positive force to:
    • Resolve conflicts.
    • Solve problems.
    • Make decisions.
  • Anger physiologically energizes the body for self-defense, triggering the fight or flight response via the sympathetic nervous system.
  • Inappropriate expression or suppression of anger can lead to:
    • Physical problems.
    • Emotional problems.
    • Relationship interference.
  • Healthy reaction to:
    • Unfair or unjust situations.
    • Situations where personal rights are not respected.
    • Situations where realistic expectations are not met.

Negative Reactions to Anger

  • Denial.
  • Suppression.
  • Inappropriate expression, potentially leading to hostility or aggression.

Hostility

  • Also known as verbal aggression.
  • Expressed through:
    • Verbal abuse.
    • Lack of cooperation.
    • Violation of rules or norms.
    • Threatening behavior.
  • Often arises when a person feels threatened or powerless.

Aggression

  • Physical aggression involves:
    • Attacking or injuring another person.
    • Destroying personal property.
  • Both hostility and aggression are intended to:
    • Harm or punish another person.
    • Force compliance.

Onset and Clinical Course

  • Anger is often perceived as a negative feeling.
  • It's unhealthy to deny or try to eliminate anger.
  • Inappropriate expression of anger can lead to hostility and aggression.
  • Suppression is especially common in women.
  • Catharsis and cognitive-behavioral therapies can be helpful.

Suppression of Anger

  • Common in women.
  • Manifests through somatic complaints and psychological problems.
  • Expression of anger is vital for growth and development.

Hostility and Aggression: Onset and Clinical Course

  • Can occur suddenly and unexpectedly, but often has identifiable phases:
    • Triggering Phase
    • Escalation Phase
    • Crisis Phase
    • Recovery Phase
    • Post-crisis Phase

Related Disorders

  • Most psychiatric clients are not aggressive, but some exhibit angry, hostile, or aggressive behavior caused by:
    • Paranoid delusions
    • Auditory (command) hallucinations
    • Dementia, delirium
    • Head injury
    • Intoxication with alcohol or drugs
    • Antisocial and borderline personality disorders
    • Depression
    • Intermittent explosive disorder (IED)
    • Acting out

Etiology of Hostility and Aggression

  • Associated with:
    • Maternal drug use during pregnancy
    • Structural damage to the limbic system in the brain
    • Long-term use of drugs and alcohol
    • A disruption in the immune system

Neurobiologic Theories

  • Possible role of neurotransmitters:
    • Decreased serotonin
    • Increased dopamine and norepinephrine
  • Structural damage to the limbic system
  • Damage to frontal or temporal lobes

Psychosocial Theories

  • Failure to develop impulse control (ability to delay gratification) due to:
    • Dysfunctional families with poor parenting
    • Inconsistent responses to children’s behaviors
  • Interpersonal rejection

Treatments

  • Focus on treating underlying/comorbid psychiatric diagnoses.
  • Medications:
    • Lithium: bipolar disorder, conduct disorders (in children), intellectual disability
    • Carbamazepine or valproate: aggression associated with dementia, psychosis, personality disorders
    • Atypical antipsychotics (clozapine, risperidone, olanzapine): effective with dementia, brain injury, intellectual disability, personality disorders
    • Benzodiazepines: dementia
    • Haloperidol and lorazepam (combined): decrease agitation or aggression and psychotic symptoms

The Nursing Process: Assessment

  • Early assessment, judicious medication use, and verbal intervention are needed with an angry client to prevent escalation to physical aggression.
  • Nurses must assess individual clients and the therapeutic milieu or environment.
  • Be aware of factors influencing aggression in the psychiatric environment/unit milieu.
  • Individual clients:
    • History of violent or aggressive behavior in the past.
    • How the client handles anger.
    • Beliefs about anger.
    • Assess behavior to determine phase of aggression cycle (see Table 11.1).

The Best Intervention is Prevention

  • Assess history of prior aggression; head injuries, substance abuse, organic brain disease, PTSD, Bipolar, schizophrenia
  • Assess for risk of becoming violent - then plan intervention
  • Know what anger “looks like”
  • Your powers of observation are essential.

The Nursing Process: Data Analysis and Priorities

  • Common Nursing Diagnoses:
    • Risk for Violence
    • Ineffective Coping
  • Outcome Identification: Client will:
    • Not harm self or threaten others
    • Refrain from intimidating/frightening behaviors
    • Describe feelings and concerns without aggression
    • Comply with treatment

The Nursing Process: Actions #1

  • Most effective and least restrictive when implemented early in the cycle of aggression.
  • Managing the milieu/environment:
    • Group and planned activities
    • Scheduled one-to-one interactions
    • Problem-solving or conflict resolution
  • Considering safety and security of other clients

The Nursing Process: Actions #1 (Continued)

  • Milieu Management, cont’d
    • Helping clients with conflicts to solve their problems, including expression of angry feelings
    • Color, noise, heat, over crowding, boredom, space, excessive stimulation
    • Assess source of anger – who/what & the target of anger, the likelihood of escalation

Appropriate Expression of Anger

  • Walking or talking with another person
  • Controlling intensity of anger
  • Use of “I” statements
    • “I feel really hurt when you leave without letting me know.”
  • Lead to problem-solving and anger reduction

The Nursing Process: Actions #2

  • Managing aggressive behavior: Triggering phase:
    • Approach in nonthreatening, calm manner
    • Convey empathy
    • Listen
    • Encourage verbal expression of angry feelings
    • Use clear, simple, short statements
    • Allow client time for self-expression
    • Suggest going to a quieter area
    • Offer PRN medications if ordered
    • Suggest physical activity such as walking

The Nursing Process: Actions #3

  • Managing aggressive behavior: Escalation phase:
    • Take control
    • Provide directions in firm, calm voice
    • Direct client to room or quiet area for time out
    • Offer medication if refused in triggering phase
    • Let client know aggression is unacceptable and nurse or staff will help maintain/regain control if needed
    • If ineffective to that point, obtain assistance from other staff (show of force) to get client to take time out or take medication

The Nursing Process: Actions #4

  • Management of aggressive behavior: Crisis phase:
    • Take control of situation as determined by facility or agency policy (trained in techniques for behavioral management)
    • Use restraint or seclusion only if necessary
    • Only staff with training should participate in restraint
    • Four to six trained staff members are needed
    • Inform client that behavior is out of control and staff is taking measures for safety

The Nursing Process: Actions #5

  • Management of aggressive behavior: Recovery phase
    • Talk about the situation or trigger
    • Help client relax or sleep
    • Help client explore alternatives to aggressive behavior
    • Assess and document any injuries
    • Debrief staff

The Nursing Process: Actions #5 (Continued)

  • Management of aggressive behavior: Postcrisis phase
    • Remove client from any restraint or seclusion as soon as criteria are met
    • Calmly discuss behavior (no lecturing or chastising)
    • Give client feedback for regaining control
    • Reintegrate client as soon as they are able to participate
    • Focus is on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner

The Nursing Process: Evaluation

  • Was the client’s anger defused in an early stage?
  • Did the angry, hostile, and potentially aggressive client learn to express feelings verbally and safely without threats or harm to others or destruction of property?
  • Appropriate expression of anger involves assertive communication skills that lead to problem-solving or conflict resolution

Workplace Hostility

  • Sentinel event alert concerning intimidating and disruptive behaviors (The Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2008)
    • Overt actions: verbal outbursts, physical threats
    • Passive activities: refusing to perform assigned tasks, uncooperative attitude
  • Occurrence of disruptive and intimidating behaviors
  • In 2016, the JCAHO added workplace bullying.
  • New standards of leadership
  • Code of conduct defining acceptable and inappropriate/unacceptable behaviors
  • Process for managing disruptive/unacceptable behavior
  • Education on expected professional behavior
  • Zero tolerance = all are held accountable

Community-Based Care

  • Effective management of comorbid conditions
  • Regular follow-up appointments
  • Compliance with prescribed medication
  • Participation in community support programs
  • Anger management groups to help clients express their feelings and learn problem-solving and conflict-resolution techniques
  • Studies on client assaults of staff in community
  • Assaults by clients in community residences

Self-Awareness Issues

  • Be aware of your own management of anger.
  • Practice and gain experience in restraint/seclusion before using.
  • Be calm, nonjudgmental, and nonpunitive.
  • Learn from watching experienced nurses deal with hostile or aggressive clients.
  • Nurses must have:
    • Assertive communication skills
    • Conflict resolution skills
    • Ability to see that client’s behavior/anger is not personal or a sign of nurse’s failure
    • Ability to deal with own fear when clients are aggressive or threatening

Self Awareness Discussion

  • Discuss personal attitudes regarding caring for an aggressive client with the potential for violence.
  • Discuss the importance of being aware of self-awareness as a nurse when dealing with angry clients.