1. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 10 Anger, Hostility, and Aggression

2. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Anger Is a Normal Human Emotion Anger can be a positive force It can help a person to resolve conflicts, solve problems, and make decisions Anger energizes the body physically for self-defense It activates the “fight-or- flight” response mechanisms of the sympathetic nervous system Anger can be expressed inappropriately or suppressed It can cause physical or emotional problems It can interfere with relationships

3. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Hostility (verbal aggression) is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior Physical aggression is behavior in which a person attacks or injures another person or that involves destruction of property Anger Is a Normal Human Emotion (cont’d)

4. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Anger Appropriate expression of anger involves assertive communication skills that lead to problem-solving or conflict resolution Anger that is expressed inappropriately can lead to hostility and aggression Venting angry feelings by engaging in safe but aggressive activities (punching bag, yelling) is called catharsis; however, research has shown that catharsis may increase rather than alleviate angry feelings Clients with depression may have anger attacks when they feel emotionally trapped

5. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Hostility and Aggression Hostile and aggressive behavior may occur suddenly without warning, but often stages or phases can be identified: –Triggering –Escalation –Crisis –Recovery –Postcrisis

6. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Paranoid delusions Auditory hallucinations Dementia, delirium, head injuries Intoxication with alcohol or other drugs Antisocial and borderline personality disorders Depression Intermittent explosive disorder

7. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Acting Out An immature defense mechanism in which the person deals with emotional conflict or stress by actions rather than reflection or feelings –The person is trying to feel less powerless or helpless by acting out

8. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Etiology of Hostility and Aggression Neurobiologic theories –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 and ability to delay gratification

9. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Cultural Considerations In certain cultures, expressing anger may be seen as rude or disrespectful Some culture-bound syndromes involve aggressive, agitated, or violent behavior

10. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatments and Medications Treatment often focuses on treating the underlying or comorbid psychiatric diagnosis –Lithium –Carbamazepine (Tegretol) or valproate (Depakote) –Atypical antipsychotics: clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) –Benzodiazepines –Haloperidol (Haldol) and lorazepam (Ativan)

11. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Application of the Nursing Process Assessment –Early assessment and intervention needed when clients are angry or hostile to avoid physically aggressive episodes –Nurse must assess both individual clients and the therapeutic milieu or environment –Assessment and intervention are based on five phases of aggression

12. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Data analysis –Common nursing diagnoses: oRisk for other-directed violence oIneffective coping Application of the Nursing Process (cont’d)

13. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Outcome identification –The client will: oNot harm self or threaten others oRefrain from intimidating or frightening behaviors oDescribe feelings and concerns without aggression oComply with treatment Application of the Nursing Process (cont’d)

14. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Managing the milieu includes: –Having planned activities; informal discussions –Scheduled one-to-one interactions; letting clients know what to expect –Helping clients with conflicts to solve their problems, including expression of angry feelings Interventions are most effective and least restrictive when implemented early in the cycle of aggression Application of the Nursing Process (cont’d)

15. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention Managing aggressive behavior includes: –Triggering phase oApproach in nonthreatening, calm manner oConvey empathy oListen oEncourage verbal expression of feelings oSuggest going to a quieter area, or use of PRN medications oPhysical activity such as walking

16. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention (cont’d) Escalation phase –Take control –Provide directions in firm, calm voice –Direct client to room or quiet area for time out –Offer medication again –Let client know aggression is unacceptable and that the 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

17. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention (cont’d) Crisis phase –Staff must take control of situation (trained in techniques for behavioral management) –Use restraint or seclusion only if necessary

18. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention (cont’d) Recovery phase as client regains control –Talk about the situation or trigger –Help client relax or sleep –Explore alternatives to aggressive behavior –Provide documentation of any injuries –Staff debriefing

19. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Intervention (cont’d) Postcrisis phase –Client is removed from any restraint or seclusion and rejoins the milieu –Calm discussion of behavior, no lecturing or chastising, return to activities and groups, etc. –Focus is on appropriate expression of feelings and resolution of problems or conflicts in nonaggressive manner

20. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Application of the Nursing Process Evaluation phase –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?

21. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Community-Based Care Regular follow-up appointments, 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

22. Copyright © 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues How nurse handles own angry feelings 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 personal or a sign of nurse’s failure, and ability to deal with own fear when clients are aggressive or threatening