1. Copyright © 2013 by Elsevier Inc. All rights reserved.
Chapter 25
Anger and Aggression
Copyright © 2013 by Elsevier Inc. All rights reserved.

2. Copyright © 2013 by Elsevier Inc. All rights reserved.
Learning Objectives
Explain the differences among anger, aggression, and assertiveness.
Describe how anger is expressed by children, adolescents, young adults, and older adults.
Examine the impact of anger and aggression on society.
Compare three theories that attempt to explain the causes of aggression.
Describe each of the five stages of the assault cycle.
Copyright © 2013 by Elsevier Inc. All rights reserved.

3. Copyright © 2013 by Elsevier Inc. All rights reserved.
Learning Objectives
Explain the main characteristics for three mental health disorders that relate to anger or aggression.
Outline the process for assessing clients who are angry or aggressive.
Develop four therapeutic interventions for clients who are experiencing anger or acting aggressively.
Consider seven techniques for recognizing and coping with your own anger.
Copyright © 2013 by Elsevier Inc. All rights reserved.

4. Anger and Aggression (p. 284)
Anger is a normal emotional response to a perceived threat, frustration, or distressing event.
Can be focused on the self or others
Associated with anxiety and loss of control
Can be used as a coping mechanism
Aggression is a forceful attitude or action that is expressed physically, symbolically, or verbally.
Assertiveness is the ability to directly express one’s feelings or needs in a way that respects the rights of other people yet retains one’s dignity.
Explain the differences among anger, aggression, and assertiveness.
Anger may result when basic needs are not met.
Like the self-concept continuum discussed in the Chapter 24, the continuum of anger responses are learned behaviors.
The manner in which a person expresses anger depends on impulse control.
Copyright © 2013 by Elsevier Inc. All rights reserved.

5. Anger and Aggression in Society (p. 284)
Cultural expressions of anger differ.
Gender aggression
Ancient and well-accepted beliefs that men were superior led to values that supported the abuse of women.
Gender aggression and abuse still are practiced everywhere.
Copyright © 2013 by Elsevier Inc. All rights reserved.

6. Anger and Aggression in Society cont’d. (p. 286)
Aggression throughout the life cycle
Expressions of anger begin in infancy and end with death.
Infants express unmet needs through diffuse rage reactions.
Toddlers engage in temper tantrums.
Children in the early school-age years assault or hit each other frequently.
In adolescence, fighting is organized, controlled, and purposeful.
After 45 years of age, few people engage in physical aggression.
Crying is how infants talk. They let you know when they are happy (coo and babble) or need something (cry). Crying can also signal anger when the infant’s needs are not met.
In toddlers, the most aggressive acts occur over toys. To adults, it looks like fighting, but to toddlers it is learning how to get along. They have not yet learned how to say, “Let’s play.”
Children from 2 to 5 years of age decrease their physical aggression as they begin to use words to communicate needs. Knowing what to expect from normally developing children is critical.
Copyright © 2013 by Elsevier Inc. All rights reserved.

7. Anger and Aggression in Society cont’d. (p. 287)
Scope of the problem today
Aggression and violence are worldwide concerns.
In the United States, 4,266,000 violent crimes were reported in 1999.
Helping others focus their aggression into more effective (and less violent) ways of coping is the task of the health care provider.
What is the impact of anger and aggression on society?
Copyright © 2013 by Elsevier Inc. All rights reserved.

8. Theories of Anger and Aggression (p. 287)
Biological theories
Models that see the cause of aggression and violence as physical or chemical differences are called biological or individual theories.
Charles Darwin
Animal model stated that aggression strengthened human beings through natural selection
Sigmund Freud
Believed that the greater the death wish, the greater is the need for aggressive behavior.
List and analyze the theories that attempt to explain the causes of aggression.
Copyright © 2013 by Elsevier Inc. All rights reserved.

9. Theories of Anger and Aggression cont’d. (p. 287)
Psychosocial theories
Psychosocial theories of aggression state that aggressive behaviors are learned responses.
Sociocultural theories
Cultural theories state that aggressive or violent acts are a product of cultural values, beliefs, norms, and rituals.
Functional model
Conflict theories
Resource theory
General systems model
Compare the theories that attempt to explain the causes of aggression.
Copyright © 2013 by Elsevier Inc. All rights reserved.

10. The Cycle of Assault (p. 288)
Assault is aggressive behavior that violates another person or a person’s property.
Studies have shown that assault and violence occur in a predictable pattern of emotional responses.
Each response pattern is called a stage.
The five stages in the assault cycle consist of
Trigger
Escalation
Crisis
Recovery
Depression
Describe each of the five stages of the assault cycle.
Copyright © 2013 by Elsevier Inc. All rights reserved.

11. Stages of the Assault Cycle (p. 288)
Trigger stage
A stress-producing event elicits anger, fear, anxiety, or a similar response.
The client chooses coping mechanisms in an attempt to achieve control.
The client’s ability to solve problems or use nonviolent behavior decreases as aggressive feelings escalate.
For lack of effective coping options, assaultive behavior becomes automatic.
Crisis interventions are very successful if begun early in this stage.
Helping a client to identify the triggers and learn alternative coping behaviors is a goal when clients seek treatment.
What is the best way for the care provider to stage a crisis intervention at this point?
Copyright © 2013 by Elsevier Inc. All rights reserved.

12. Stages of the Assault Cycle cont’d. (p. 288)
Escalation stage
Building stage—each behavior moves the client a step closer to total loss of control.
Aggressive behaviors become increasingly ineffective in regaining control.
Frustration and anger increase.
Intense emotions also make aggression escalate.
Intervention is crucial at this stage if violence is to be prevented.
When a client is under the influence of drugs or alcohol, this enhances the loss of control and makes intervention more difficult.
Copyright © 2013 by Elsevier Inc. All rights reserved.

13. Stages of the Assault Cycle cont’d. (p. 288)
Crisis stage
Potential for danger increases.
Assaultive behavior occurs.
Acting out takes many forms: doing physical harm to others, abuse or torture of animals, or destruction of property
Verbal abuse: screaming, shouting, and cursing
At this stage clients are unable to listen to reason, follow directions, or engage in mental exercises.
Rational thinking is clouded by the intense emotional reactions to the situation.
What is the best intervention at this stage? (to protect the individual and others from physical harm)
Copyright © 2013 by Elsevier Inc. All rights reserved.

14. Stages of the Assault Cycle cont’d. (p. 288)
Recovery stage
Cooling-down period
Client slowly calms and returns to normal behavioral responses and actions.
Interventions include assessing for injury or trauma and providing a safe, quiet environment where the client can recover.
Depressive stage
The client experiences guilt and attempts to reconcile with others.
The assailant may offer loving care to the victim.
As time passes, the assaultive event is slowly “placed in the past.”
A client in the recovery stage can be both physically and emotionally drained.
In the case of domestic violence against a woman, the depressive stage is particularly confusing and dangerous for the victim. At this stage, the assailant is now displaying regret and promises never to repeat his actions.
Copyright © 2013 by Elsevier Inc. All rights reserved.

15. Anger Control Disorders (p. 288)
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) lists three categories of disorders related to aggressive behaviors:
Conduct disorders
Most often occur in childhood
Impulse control disorders
Usually develop later in life
Adjustment disorders
Can occur at any time
What are the characteristics of the three mental health disorders that are related to anger or aggression?
Copyright © 2013 by Elsevier Inc. All rights reserved.

16. Anger Control Disorders cont’d. (p. 289)
Aggressive behavioral disorders of childhood
Conduct disorder
Pattern of behavior whereby the basic rights of others or major age-appropriate societal norms or rules are violated
Oppositional defiant disorder
Pattern of negative, aggressive behaviors that focuses on authority figures in the child’s life
Young people who have not learned how to deal with frustrations effectively are more prone to experiment or abuse drugs and alcohol as a release for their internal conflict.
What are some signs the care provider should look for in a client with a conduct disorder?
Copyright © 2013 by Elsevier Inc. All rights reserved.

17. Anger Control Disorders cont’d. (p. 289)
Impulse control disorders
Individuals fail to resist an impulse, drive, or temptation to perform an act that is harmful to themselves or to others.
Intermittent explosive disorder
Individuals fail to resist aggressive impulses that result in the destruction of property or assault on another individual.
What are the five types of impulse control disorders? What type of behavior is prominent in all of them?
Copyright © 2013 by Elsevier Inc. All rights reserved.

18. Anger Control Disorders cont’d. (p. 289)
Adjustment disorders
Emotional or behavioral problems that develop in response to an identifiable source
Individuals have difficulty adapting to a new situation.
Suicide attempts occur more frequently in persons who are having trouble adjusting to new situations.
Although a person may experience more than one episode of an adjustment disorder in their lifetime, it is usually a short-term problem, lasting about 6 months.
Copyright © 2013 by Elsevier Inc. All rights reserved.

19. Guidelines for Intervention (p. 290)
Assessing anger and aggression
Mental status assessment:
General appearance
Activity
Behaviors
Attitude
Verbal communication
Mood
Affect
Perceptions
Thought
Judgment
Insight reliability
Copyright © 2013 by Elsevier Inc. All rights reserved.

20. Guidelines for Intervention cont’d. (p. 290)
Psychosocial assessment:
Coping skills
Relationships
Cultural
Spiritual
Occupational
Value and belief system
Reactions
Behaviors
Attitudes
Copyright © 2013 by Elsevier Inc. All rights reserved.

21. Guidelines for Intervention cont’d. (p. 292)
Therapeutic interventions
Interventions for aggressive or potentially aggressive client behaviors occur on three levels:
Level one interventions focus on the prevention of violence.
Level two interventions focus on protecting the client and others from potential harm.
Level three interventions are reserved for those clients who are out of control.
Therapeutic interventions include establishing good communication, learning to identify the signs of potential violence, and providing a safe environment when a client is out of control.
Copyright © 2013 by Elsevier Inc. All rights reserved.

22. Guidelines for Intervention cont’d. (p. 293)
Interventions for caregivers focus on learning to effectively control their own feelings of anger.
Even the most therapeutic care provider experiences anger.
Learning to cope with personal feelings of anger and aggression allows caregivers to be more successful in working with the angry emotions of others.
What coping techniques can caregivers use when recognizing and coping with their own anger?
Copyright © 2013 by Elsevier Inc. All rights reserved.

23. Copyright © 2013 by Elsevier Inc. All rights reserved.
Question 1
The nurse is taking care of a client who consistently pulls out her hair, resulting in noticeable hair loss. The client’s behavior is known as what?
Trichotillomania
Pyromania
Agarobiamania
Kleptomania
Correct Answer: 1
Copyright © 2013 by Elsevier Inc. All rights reserved.

24. Copyright © 2013 by Elsevier Inc. All rights reserved.
Question 2
The assault cycle consists of five stages. A stress-producing event occurs during which stage?
Trigger stage
Escalation stage
Crisis stage
Recovery stage
Correct Answer: 1
Copyright © 2013 by Elsevier Inc. All rights reserved.

25. Copyright © 2013 by Elsevier Inc. All rights reserved.
Question 3
The potential for danger is at its peak during which stage of the assault cycle?
Escalation stage
Crisis stage
Recovery stage
Depression stage
Correct Answer: 2
Copyright © 2013 by Elsevier Inc. All rights reserved.

26. Copyright © 2013 by Elsevier Inc. All rights reserved.
Question 4
The nurse is taking care of someone who has a history of violence and aggression. He is participating in level one intervention. What is the goal of this level?
Protecting the client and others from harm
Obtaining a history from the client about his violence and aggression
Establishing and maintaining a trusting and therapeutic relationship
Securing the environment from harmful weapons or devices
Correct Answer: 3
Copyright © 2013 by Elsevier Inc. All rights reserved.

27. Copyright © 2013 by Elsevier Inc. All rights reserved.
Question 5
The care provider is trying to deal with an angry male client. She takes a deep breath, remains calm, and introduces herself to the client. She also should do all of the following as well, except:
Listen actively
Identify emotions
Explore options
Acknowledge the anger with the client
Correct Answer: 4
Copyright © 2013 by Elsevier Inc. All rights reserved.