Patients with Aggressive Behaviour Zamzaliza Abdul Mulud

Learning Objectives Discuss the aetiological basis of aggression Compare the interventions used in pre-assaultive stage with those used in assaultive stage Describe various de-escalation techniques Describe the procedures of seclusion and restraint

Introduction Anger is an emotional response to frustration of desires or needs. Aggression is a harsh verbal or physical action that reflects rage, hostility and a potential toward destruction or intent to cause harm.

This may be directed towards objects, others or self. Violence, however, refers to destructive human behaviours and responses and is marked by physical aggression by one person against another.

Stages of Violence Cycle Pre-assaultive stage During this stage the patient is restless, agitated and may report increasing tension and irritability. Assaultive stage The patient is physically and/or verbally aggressive and may be destructive. Post-assaultive stage After the aggressive outburst is over and the patient returns to his baseline behaviour.

Comorbidity Incidents of aggression or violence occur in all clinical diagnostic categories and are not limited to any particular psychiatric disorder. Various psychiatric disorders associated with aggression: Psychosis with positive symptoms Mania Depression

Comorbidity (cont.) Post-traumatic stress disorder Antisocial and borderline personality disorders Substance-use related disorders Alzheimer’s disease

Etiology i. Psychosocial factors Learning theory Bandura: Children learn aggression by imitating others and repeat those behaviours that are rewarded or the ones that go without punishment. Similarly, children who grow up in angry families respond to frustration with anger.

Cognitive theory This theory explains how a person’s perception of an event, expectations and self-talk mediate between stimuli and aggression.

Etiology (cont.) ii. Biological factors The role of genetic factors is suggested by the fact that the aggressive temperament and violent reactions run in families. Low levels of serotonin in the brain are associated with violent and aggressive behaviour. Alzheimer’s disease, brain tumours, temporal lobe epilepsy and injury to certain parts of the brain result in personality changes including aggressive reactions.

Nursing Assessment Anger and aggression are the last two stages of the violence cycle that often starts with feelings of vulnerability and then helplessness. Patients often convey their anxiety before an aggressive response. Nursing interventions begin at these early stages with accurate assessment. Taking an accurate history and usual coping skills provide the necessary information to plan intervention strategies

Nursing Assessment (cont.) Assessment of Risk Factors for Violence Predisposition : Hyperactivity, easy irritability of impulsivity increases the risk of violence Socio-demographic : Male, age 15–25 years Risk factors : Unemployed, low income group and poor social support

Nursing Assessment (cont.) Past history of violence is the best predictor of future violence Limited coping skills Active plans to harm someone—wish, plan and means to harm. Current triggers, e.g. limit-setting in the ward, overcrowding, inexperienced staff, and demanding and controlling staff

Nursing Assessment (cont.) Indicators of Impending Violence Recent aggressive outbursts Alcohol or drug intoxication Signs preceding violence: Hyperactivity Argumentativeness, verbal abuses and profanities Loud voice

Nursing Assessment (cont.) Increasing anxiety and tension, rigid posture, clenched fists and jaw and tense facial muscles Staring into others’ eyes or avoidance of eye contact Absolute silence and unwillingness to talk Carrying a weapon or an object such as knife, fork or rock

Nursing Diagnosis Various relevant nursing diagnoses include: violence towards self or others poor impulse control ineffective coping and responses to psychopathology (e.g. delusions, hallucinations)

Nursing Outcomes Aggression self-control is the diagnosis with the highest priority. Short-and long-term goals include the following: The patient will report of urges to harm self or others and will seek help from staff. The patient will discuss the feelings of anger, anxiety and aggression as well as other such impulses secondary to delusions and hallucinations and learn constructive ways to control aggression.

Nursing Outcomes (cont.) The patient will refrain from acting on aggressive impulses. The patient will become aware of various provoking factors and learn positive ways of coping and problem solving. The patient will learn assertive communication skills.

Nursing Planning and Implementation The plan of care and intervention is based on the assessment of risk factors and indicators of violence. It is also important to take into consideration the stages of the violence cycle.

Implementation (cont.) Nursing Planning and Implementation (cont.) i. Pre-assaultive stage Some of the de-escalation/intervention techniques: Move the patient to a quiet and safe place. Be with the patient and encourage him to stay in control. Medication (e.g. benzodiazepines) may be used at this stage.

Implementation (cont.) Nursing Planning and Implementation (cont.) Listen carefully and actively about the patient’s feelings as well as his perception of the situation and expectations. Maintain the personal space so that the patient does not perceive you as intrusive. Do not rush the patient. Use verbal techniques of de-escalation. Assure your own safety

Implementation (cont.) Nursing Planning and Implementation (cont.) ii. Assaultive stage If the patient’s anger progresses to the assaultive stage, the staff must respond quickly. A team approach is advisable. One leader speaks to the patient and instructs members of the team. Interventions include use of pharmacological agents, physical restraints and seclusion of the patient.

Implementation (cont.) Nursing Planning and Implementation (cont.) Use of seclusion and restraint Definition of seclusion and restraint “Seclusion is the involuntary confinement of a patient to a room or an area, which the patient is not allowed to leave”. It can be: open seclusion, e.g. quiet time alone in an unlocked room or in a partitioned area; or locked seclusion, e.g. in a locked room designed specifically for this purpose. Restraint is a human or mechanical action that restricts freedom of movement or normal access to one’s body.

Implementation (cont.) Nursing Planning and Implementation (cont.) Restraints can be: Mechanical (physical) This is when a device, material or equipment, is attached to the patient’s body to restrict freedom of movement. Chemical In this form of restraint, drugs are used to control and restrict the patient’s freedom of movement Restraint or seclusion can be used individually or together.

Implementation (cont.) Nursing Planning and Implementation (cont.) Indications for seclusion and restraint Prevention of imminent harm to self or others Failure of alternative or other less restrictive measures to ensure the safety Prevention of substantial damage to the physical environment Decrease overstimulation in agitated or violent patients At the patient’s request

Implementation (cont.) Nursing Planning and Implementation (cont.) Contraindications to Seclusion and Restraint Suicidal and self-mutilating tendencies Medical problems needing constant and close supervision Delirium or dementia (understimulation may worsen the condition) For the convenience of staff To punish a patient or as a coercion Patient with epilepsy Patient with mental retardation

Implementation (cont.) Nursing Planning and Implementation (cont.) Guidelines for Implementing Seclusion and Restraint The doctor should order seclusion and restraint in writing. Reason for seclusion and restraint should be clearly stated. Time period of the seclusion/restraint should be clearly specified (e.g. 2 hours).

Implementation (cont.) Nursing Planning and Implementation (cont.) Frequency of review (e.g. every 15 minutes) is specified and each review should be documented. If seclusion and restraint needs to be extended, the whole procedure of authorization and nature of seclusion and restraint should be documented.

Implementation (cont.) Nursing Planning and Implementation (cont.) iii. Post-assaultive stage Once the patient has calmed down and does not need seclusion and restraint, the staff should review the incident with the patient. This helps the patient to learn from the incident, to identify the provoking and precipitating factors and to learn alternative ways of coping with stresses.

Evaluation While evaluating the nursing care of an aggressive patient, the following indicators should be considered: Did the seclusion/restraint prevent harm to the patient or to others? Was the safety of staff maintained? Was the hospital guidelines and policy regarding seclusion and restraint followed?

Evaluation (cont.) Was the patient’s care, safety and dignity maintained? Did the patient learn to handle his aggressive impulses constructively? Was the underlying cause for the behaviour leading to aggression assessed and effectively controlled?