Anger, Hostility, and

Aggression
Nursing 225
Psychiatric Mental Health Nursing
Spring 2010
 Anger
 Anger is a normal human emotion.
 It is a positive emotion that can motivate a
person to resolve conflicts, solve problems,
and make decisions.
 Anger can also energize the body for self-
defense (fight or flight response).
 Anger arousal is a personal signal of threat
or injustice against the self. The signal elicits
coping responses to deal with the stress.
 Anger
 Anger is constructive when it provides
a feeling of control over a situation
and the individual is able to
assertively take charge of a situation.
 Anger is constructive when it is
expressed assertively, serves to
increase self-esteem, and leads to
mutual understanding and forgiveness
 ANGER
 Anger is a strong, uncomfortable,
emotional response to a
provocation, either real or
perceived.
 Hostility and Aggression are
inappropriate expressions of
anger.
 Anger
 Inappropriate expressions of anger may
result in impulsive behavior, disregarding
possible negative consequences.
 Communicated aggressively, conflict
escalates, and the problem that created
the conflict goes unresolved.
 Anger can lead to aggression when the
coping response is displacement (kick the
cat)
*Denying or suppressing angry
feelings can lead to physical or
emotional problems.
*Depression is sometimes
described as anger turned inward.
*Appropriate expression of anger
involves assertive communication
skills leading to problem solving or
conflict resolution.
 Factors that Contribute to
Aggressive Behavior
 Attitudes about work
 Level of education
 Religious choices
 Exposure to the media
 Population problems, overcrowding,
limited resources
 Unavailability of community resources
 Hostile Behavior
 Several studies have demonstrated that
significant immune mediated changes
occur in people who displayed hostile or
negative behaviors.
 Blood Pressure changes occur in people
who display hostile or negative behaviors
during periods of conflict.
 Hostility and Aggression
Thehostile aggressive
behavior may occur
suddenly without warning,
but often times stages or
phases can be identified.
 1. Triggering
 Definition-An event Behavior
 Restlessness
or circumstances in
 Anxiety
the environment
 Irritability
initiates the client’s  Pacing
response which is  Muscle Tension
often either anger  Rapid Breathing
or hostility.  Perspiration
 Loud Voice
 Anger
(Full Metal Jacket)
 Predictors for Violent Behavior
 The strongest risk factor for violent
behavior is a previous history of violent
behavior
 It is sometimes helpful to ask the client to
assess his/or her own potential for
violence-some clients on the unit will
verbalize to you that they feel angry
enough to hit someone
 Violent Aggressive Behavior
 Contract with the client to use nonviolent
methods to control anger
 Be prepared to use seclusion if escalation
with potential for violence exists
 Nursing Implications
 Approach in a calm, nonthreatening
manner
 Convey empathy for their anger or
frustration as appropriate
 Encourage the client to verbalize feelings
 Use clear, simple, short statements
 Suggest moving to a quiet area and move
other clients to decrease stimulation
 Nursing Implications
 Offer PRN medication as ordered.
 Physical activity such as walking may help
the client to relax and become calmer.
 (In the triggering phase, remember we
still have the ability to communicate with
the client-we are still in the talking phase)
 2. Escalation
Behavior indicates a  Pale/Flushed Face
movement toward  Yelling/Swearing
loss of control. The  Agitated
client has lost the  Threatening
ability to problem  Demanding
solve or think  Clenched fists
clearly  Hostility
 Nursing Implications
 The nurse must take control of the
situation
 Provide directions in a calm, firm, voice
 Direct client to a time out or cooling off
period in a quiet area or in their room
 Emphasize to the client that aggressive
behavior is not acceptable and the nurse
is there to help them regain control
Time Out to Cool Off!!
 Nursing Implications
 If the client refused PRN medication
during the triggering phase, offer it again
at this time
 If they are unwilling to take a time out,
obtain assistance from several other staff
members who will be within sight, but not
as close as the primary staff member who
is dealing directly with the patient. (Show
of force)
 Nursing Implications
 This is known as a “show of force” and
sometimes (hopefully) the client will take
meds and a timeout. This also reinforces
to the client that the staff is in control and
will control the situation if the client is
unable to do so.
 3. Crisis
The client Behaviors
Throwing
completely loses
Kicking
physical and Screaming
emotional control Biting
We have passed Scratching
Spitting
the talking stage
Inability to
communicate clearly
 Nursing Implications
 ONLY STAFF WITH SPECIALIZED
TRAINING SHOULD PARTICIPATE IN
THE RESTRAINT OF A PHYSICALLY
AGGRESSIVE CLIENT
 The students’ role is to remove the
“audience” i.e. escort other patients to
their rooms or community room and close
the door until the situation is under
control.
 Nursing Implications
 When restraint or seclusion is used, the
nurse must then phone the physician and
obtain the order. Requirements can vary
from state to state and facility to facility as
to the time frame in which the physician
must evaluate the patient.
 Aggressive children, females, and elderly
clients can be just as difficult to restrain as
adult males can be.
 Nursing Implications
 PRN Medication should be given (if not
already administered) as soon as the
patient is safely restrained.
 The patient is closely observed in
seclusion and the nurse documents the
patients behavior
 4. Recovery
Client regains Behaviors
physical and  Lowering of voice
emotional control  Decreased muscle
tension
 Clearer, more rational
communication
 Physical relaxation
 Nursing Implications
 As the client regains control during the
recovery phase, encourage discussion
about the situation or triggers that led up
to the aggressive behavior
 Encourage rest, relaxation, and sleep
 Assist the client to explore alternatives to
the aggressive behavior
 Assess staff members for injuries, and
debrief with the staff and evaluate how
the situation was handled.
 5. Postcrisis
Attempts reconciliation Behaviors
with others and  Remorse
returns to previous  Apologies
level of functioning
before the incident
 Crying
 Quiet, withdrawn
behavior
 Nursing Implications
 Restraints are removed as per protocol
 DO NOT lecture or chastise but instead
discuss the behavior in a calm rational
manner.
 Reintegrate the patient into the unit and
unit activities as soon as they are ready to
participate.
 DO NOT discuss the incident in detail with
the other clients on the unit.
 Core Concept-Anger
 Anger is an emotional state that
varies in intensity from mild
irritation to intense fury and rage.
It is accompanied by physiological
and biological changes, such as
increases in heart rate, blood
pressure, and levels of the
hormones epinephrine and
norepinephrine (APA, 2006a).
 Core Concept-Aggression
 Aggression is a behavior intended to threaten
or injure the victim’s security or self-esteem. It
means to “go against,” “to assault,” or “to
attack.” It is a response that aims at inflicting
pain or injury on objects or persons. Whether
the damage is caused by words, fists, or
weapons, the behavior is virtually always
designed to punish. It is frequently
accompanied by bitterness, meanness, and
ridicule. An aggressive person is often vengeful
(Warren, 1990).
 Related Disorders
 About 90 percent of psychiatric patients
are portrayed in the media as violent, but
in reality only about 10 percent exhibit
angry, hostile, or aggressive behavior.
 Clients with psychiatric disorders are much
more likely to harm themselves than
others.
 Causes
 Clients with paranoid delusions are attempting
to protect themselves from self-perceived
threats.
 Clients with auditory or command hallucinations
telling them to hurt someone or someone is
going to hurt them
 Clients with dementia, delirium, head injury,
and intoxication with ETOH/drugs
 Antisocial and borderline personality disorder
patients
 Younger males
 Causes
 Clients with depression may have outbursts of
anger due to feelings of being emotionally
trapped.
 These outbursts are verbal only-no threats of
physical aggression.
 The outburst is uncharacteristic of the client’s
personality, inappropriate to the situation, and
followed by remorse.
 Often related to irritable mood, overreaction to
minor annoyances, and decreased coping skills
 Important to Note
 Psychiatric patients who tend to be more
aggressive are those whose illness is
more symptomatic and possess a
marked lack of insight (the ability to
understand the true nature of one’s
situation and accept some responsibility
for that situation) and judgment (the
ability to interpret one’s environment and
situation correctly and to adapt one’s
behavior and decisions accordingly.
 Important to note
 The highest rates of aggression and
hostility among psychiatric patients tend
to be older males with schizophrenia and
younger males and females with
personality disorders.
 All patients and visitors throughout the
hospital have the potential to become
hostile and aggressive. It is a response
when one feels powerless
 Intermittent Explosive Disorder
 Rare psychiatric diagnosis involving
discrete episodes of aggressive impulses
resulting in serious injury or property
damage
 Episodes are out of proportion to any
provocation, and the person is remorseful
and embarrassed afterward.
 (IED)
 Intermittent explosive disorder is characterized
by repeated episodes of aggressive, violent
behavior in which you react grossly out of
proportion to the situation. Road rage,
domestic abuse, and angry outbursts or
temper tantrums that involve throwing or
breaking objects may be signs of intermittent
explosive disorder
 Client is nonviolent between episodes
 Acting Out
 An immature defense mechanism
 The person uses actions (verbal or
physical aggression) rather than
reflections or feelings to deal with
emotional conflicts or stressors
 Serves to help the person feel less
helpless or powerless
 Often used by children and adolescents
 Etiology of Hostility and
Aggression
 Neurobiological theories: decreased serotonin,
increased dopamine and norepinephrine;
structural damage to limbic system, damage to
frontal or temporal lobes
 Hormonal (testosterone)
 Psychosocial theories: failure to develop impulse
control and ability to delay gratification, Monkey
See Monkey Do
 General lack of social and personal accountability
 Cultural Considerations
 In certain cultures, expressing anger may
be seen as rude or disrespectful (certain
Asian cultures/Native Americans); some
culture-bound syndromes (West
Africa/Haiti) involve aggressive, agitated,
or violent behavior
 Some cultures view cause of physical
illness to be unexpressed anger
Treatments and Medications
 Treatment often focuses on treating the
underlying or comorbid psychiatric
diagnosis such as schizophrenia or bipolar
disorder. If the individual is having angry
outburst due to low serotonin for example,
use of SSRIs such as Prozac or Paxil will
often assist the patient controlling
inappropriate behavior in social situations.
 Pharmacology for Aggressive
Clients
 Lithium for bipolar disorder, conduct disorder, or mental
retardation
 Carbamazepine (Tegretol) or Valproate (Depakote) for
dementia, psychosis, or personality disorders
 Atypical antipsychotics such as Clozapine (Clozaril),
Risperidone (Risperdal), and Olanzapine (Zyprexa) for
dementia, brain injury, mental retardation, and
personality disorders
 Benzodiazepines e.g. Xanax for dementia
 Ziprasidone (Geodon), Haloperidol (Haldol) and
lorazepam (Ativan) for clients with psychoses
 Common nursing diagnoses:
 Risk for Other-Directed Violence
 Ineffective Coping
 Expected Goals/Outcomes
The client will:
 Not harm self or harm/threaten others
 Refrain from intimidating or frightening
behaviors
 Describe feelings and concerns without
aggression
 Comply with treatment
 Interventions
 Different for each phase of the aggression
cycle as we discussed earlier when we
defined them individually.
 Pages 182-185 has a detailed care plan for
aggressive behavior.
 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?
 Tips for Controlling Anger
 Take a 'timeout.' Although it may seem cliché, counting
to 10 before reacting really can defuse your temper.
 Get some space. Take a break from the person you're
angry with until your frustrations subside a bit.
 Once you're calm, express your anger. It's healthy to
express your frustration in a nonconfrontational way.
Stewing about it can make the situation worse.
 Get some exercise. Physical activity can provide an
outlet for your emotions, especially if you're about to
erupt. Go for a brisk walk or a run, swim, lift weights or
shoot baskets.
 Think carefully before you say anything. Otherwise,
you're likely to say something you'll regret. It can be
helpful to write down what you want to say so that you
can stick to the issues. When you're angry, it's easy to
get sidetracked.
 Tips for Controlling Anger
 Identify solutions to the situation. Instead of focusing on what
made you mad, work with the person who angered you to
resolve the issue at hand.
 Use 'I' statements when describing the problem. This will help
you to avoid criticizing or placing blame, which can make the
other person angry or resentful — and increase tension. For
instance, say, "I'm upset you didn't help with the housework
this evening," instead of, "You should have helped with the
housework."
 Don't hold a grudge. If you can forgive the other person, it will
help you both. It's unrealistic to expect everyone to behave
exactly as you want.
 Use humor to release tensions. Lightening up can help diffuse
tension. Don't use sarcasm, though — it's can hurt feelings and
make things worse.
 Practice relaxation skills. Learning skills to relax and de-stress
can also help control your temper when it may flare up. Practice
deep-breathing exercises, visualize a relaxing scene, or repeat a
calming word or phrase to yourself, such as "Take it easy."
Other proven ways to ease anger include listening to music,
writing in a journal and doing yoga.
 Post Discharge/Community Based
Care
 Regular follow-up appointments, individual and
group psychotherapy, compliance with
prescribed medication, and participation in
community support programs help the client to
achieve stability
 Anger management groups are available to
help clients express their feelings and learn
problem-solving and conflict-resolution
techniques
 Self-Awareness Issues
 How nurse handles own angry feelings
 Level of comfort with expression of anger from
others
 Ability to be calm, nonjudgmental
 Nurse must have assertive communication
skills, conflict resolution skills, ability to see
that client’s behavior/anger is not a personal
attack or a sign of nurse’s failure, and ability to
deal with own fear when clients are aggressive
or threatening
 BEHAVIORAL APPROACHES
Aggressive, violent clients
Avoid isolating yourself or being alone
with a client who has a potential for
violence. Remember that a history of
violence is the best predictor of future
violent episodes. If a client becomes
aggressive while you are with him or
her, give the client space and keep
some distance away – DO NOT move
closer to or touch the client.
 BEHAVIORAL APPROACHES for
Increased Agitation/Anxiety
Do not turn your back on the client.
Use a calm, quiet tone of voice, and
encourage the client to verbalize
feelings instead of acting them out.
Avoid threatening or expressing a
judgmental, punitive attitude
 Behavioral Approaches
Increased Agitation/Anxiety
 Use nonthreatening body language
– Arms visible at sides-palms outward
– Keep distance-arms length or
greater
– Avoid body contact-do not touch
client at this time
 Behavioral Approaches
Escalation to Violence
 Intercede early to diffuse the situation as
quickly as possible
 Continue nonthreatening behavior
 If restraint or seclusion is warranted enlist the
assistance of at least four qualified staff
members. (Follow policy)
 Move in organized, calm manner, stating you
wish to help the client and you will not permit
him/her to harm self or others
 BEHAVIORAL APPROACHES

 Call
for nursing staff assistance as
soon as possible if a client
becomes increasingly agitated or
begins acting out in any way.
 Aggression: Escalation Phase
 Clinical Vignette
– John
Identify risk factors for violence
 Risk Factors for Violence
 Schizophrenic
– Hearing voices that the staff are trying to kill
him. (Self preservation/survival is one of our
most basic instincts). John feels threatened-
real or perceived threat
– Off meds for two weeks (altered thought
processes) Schizophrenia is a disorder of
thought.
 Risk factors for violence
 Younger males (hormone-testosterone)
are more prone to aggression
 Behaviors-Verbal and Nonverbal
 Pacing in the hall (Triggering Phase)
 Muttering to himself (Triggering Phase)
 Avoiding close contact with anyone else (Trig)
 Yells “I can’t take it” “I can’t stay here” (Esc.)
 Fists are “clenched” (Esc.)
 Appears very “agitated” (Esc.)
 (The above behaviors indicate we are still in
the talking phase and the nurse can attempt to
diffuse the situation)
 Attempted Interventions by the
Nurse
 Approaches John at a safe distance (six feet)
 Nurse says “John, tell me what is
happening.”
 Nurse correctly-Recognized signs of
impending violence, spoke calmly with
nonthreatening body language, and
attempted to help John verbalize feelings
 Signs Indicating Client has Moved
to Crisis Phase
 John runs to the end of the hall and will
no longer talk to the nurse (Loss of
emotional and physical control)
 Note-the nurse once again tries to get
John to agree to take prn meds and a
time-out.
 John refuses but now John picks up
objects from a nearby table (nurse
recognizes that violence is imminent.
 Crisis Phase
 During a period of emotional and physical
crisis, the client loses control.
 Signs, symptoms, and behaviors include
loss of emotional and physical control,
throwing objects, kicking, hitting, spitting,
biting, scratching shrieking, screaming,
and/or inability to communicate clearly
 Nsg. Interventions during the
Crisis Phase
 When John began to pick up objects to
obviously throw at the nurse, the nurse
then summoned assistance from other
staff members. Four to six staff should
remain ready and in sight, but not as close
as the primary nurse. This technique is
known as a “show of force” and indicates
to the client that if he is unable to control
himself, then there are those who will
assist him in regaining control
 Review Questions
