CHAPTER 11: ANGER, HOSTILITY, AND AGGRESSION

Chapter 11: Anger, Hostility, and Aggression

Key Terms:
o Acting Out: an immature defense mechanism by which the person deals with emotional conflicts or
stressors through actions rather than through reflection or feelings
o Anger: a normal human emotion involving a strong, uncomfortable, emotional response toa real or
perceived provocation
o Catharsis: activities that are supposed to provide a release for strong feelings such as anger or rage
o Crisis Phase: when client becomes physically aggressive, staff must take charge of the situation for the
safety of the client, staff, and other clients; during an emotional and physical crisis, client looses control
o Escalation Phase: period when client builds toward loss of control
o Hostility: also called verbal aggression; an emotion expressed through verbal abuse, lack of cooperation,
violation of rules or norms, or threatening behavior; also called verbal aggression
o Impulse Control: the ability to delay gratification and to think about ones behavior before acting
o Physical Aggression: behavior in which a person attacks or injures another person or that involves
destruction of property
o Post Crisis Phase: when client is removed from restraint or seclusion as soon as he or she meets the
behavioral criteria; client attempts reconciliation with others and returns to the level of functioning before
the aggressive incident, and antecedents
o Recovery Phase: client regains control physically and emotionally
o Triggering Phase: incident or situation that indicated aggressive response; an event or circumstances in
the environment initiates the clients response, which is often anger or hostility
Objectives:
o Discuss anger, hostility, and aggression
Anger:
Normal, often perceived as a negative feeling
Can be a normal and health reaction when situations or circumstances are unfair or
unjust, personal rights are not respected, or realistic expectations are not met
Becomes negative when the person denies it, suppresses it, or expresses it
inappropriately; possible consequences are physical problems such as migraine
headaches, ulcers, or CAD and emotional problems such as depression and low self
esteem
Activities that are not aggressive, such as walking or talking with another person, are
more likely to be effective in decreasing anger
High hostility and anger are associated with increased risk of CAD and HTN
Anger suppression us especially common in women who have been socialized each
others and to avoid the expression of so-called negative unfeminine emotions such as
anger
Hostility and Aggression:
Hostile and aggressive behavior can be sudden and unexpected
Stages or phases can be identified in aggressive incidences: triggering phase, escalation
phase, crisis phase, recovery phase, post crisis phase
o Describe psychiatric disorders that may be associated with an increased risk of hostility and physical
aggression in clients
Media gives a great deal of attention to people with mental illness who commit aggressive acts
Clients with psychiatric disorders are much more likely to hurt themselves than other people
Related Disorders:
Paranoid Delusion: may believe others are out to get them; believing they are protecting
themselves, they relate with hostility or aggression
Auditory Hallucinations: command them to hurt others
Dementia, Delirium, Head Injuries
Intoxication with Alcohol or Other Drugs
Antisocial, Borderline Personality Disorders

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CHAPTER 11: ANGER, HOSTILITY, AND AGGRESSION
Depression: have anger attacks, may be related to irritable mood, overreaction to minor
annoyances, and decreased coping abilities
Intermittent Explosive Disorder: a rare psychiatric diagnosis characterized by discrete
episodes of aggressive impulses that result in serious assaults of destruction of property;
dx is made only if client has other comorbid psychiatric disorders; develops between late
adolescents and third decade of life ; typically large men with dependent personality
features who respond to feelings of uselessness or ineffectiveness with violent outbursts
Acting-out Behaviors:
Violent patients tend to be more symptomatic, have poorer functioning, and a marked lack of
insight compared with nonviolent patients
o Describe the sign, symptoms, and behaviors associated with the five phases of aggression
Triggering: restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration,
loud voice, anger
Escalation: pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched
fists, threatening gestures, hostility, loss of ability to solve the problem or thing clearly
Crisis: loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting,
scratching, shrieking, screaming, inability to communicate clearly
Recovery: lowering of voice; decreased muscle tension; clearer, more rational communication;
physical relaxation
Postcrisis: remorse; apologies; crying; quiet, withdrawn behavior
o Discuss appropriate nursing interventions for the client during the five phases of aggression
Engaging the hostile person in dialogue is most effective to prevent the behavior from escalating
to physical aggression
Most effective, least restrictive when implemented early in cycle of aggression
Environmental Management:
Planned actives; informal discussions
Scheduled one-to-one interactions (letting patients know what to expect)
Assistance with problem solving or conflict resolution to avoid expression of anger
Safety of other patients
Triggering Phase:
Approach in nonthreatening, calm manner to de-escalate emotions and behavior
Convey empathy; listening
Encourage verbal expression of feeling
Suggest patient go to a quitter area to decrease stimulation
Suggest physical activity such as walking to help client relax and become calmer
Escalation Phase:
Take control; provide directions in firm, calm voice
Direct patient to room or quiet area for time-out
Offer medication again if it was refused
Let patient know aggression is unacceptable; nurse or staff will help maintain/regain
control
If in effect, obtain help from other staff (show of force) usually 4-6 other staff members
within sight of client but not as close as primary nurse
Crisis:
Inform patient that behavior is our of control, and staff is taking control to provide safety
and prevent injury of client, other clients, and staff
Use of restraint or seclusion only if necessary
o 4-6 trained staff are needed to retrain an aggressive client
o 4 staff members each take a limb, one supports the head, another torso if needed
o Transported by gurney or carried to seclusion room
o Restrains are applied to each limb and fastened to bed frame
o If PRN meds were refused, may obtain an order for IM medication in this type
of emergency situation
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CHAPTER 11: ANGER, HOSTILITY, AND AGGRESSION
Recovery:
Talk about situation or trigger that led to aggressive behavior
Help patient relax or sleep to return to a calmer state
Explore alternatives to aggressive behavior by asking what the client or staff can do next
time to avoid an aggressive episode
Provide documentation of any injuries
Debrief staff to discuss aggressive episode, how it was handled, what worked well or
needed improvement, and how the situation could have been defused more effectively
Postcrisis:
o Remove patient from any restraint or seclusion to rejoin milieu
o Calmly discuss behavior (no lecturing or chastising); allow patient to return to
activities, groups, and so on
o Focus on appropriate expression of feelings, resolution of problems or conflicts
in nonaggressive manner
o Describe important issues for nurses to be aware of when working with angry, hostile, or aggressive
clients
Methods for handling own angry feelings
Use of assertive communication skills, conflict resolution
Comfort with expression of anger from others
Not taking others anger or aggression personally or as measure of effectiveness as nurse
Ability to be calm and nonjudgmental
Discuss situations or the care of potentially aggressive clients with experienced nurses
o Additional content such as neurobiologic and psychosocial theories, cultural considerations, and treatment
Neruobiologic Theories:
Possible role of neurotransmitters
Decreased serotonin may lead to increased aggressive behavior
Increased dopamine and norepi in brain is associated with increased impulsively violent
behavior
Structural damage to limbic system and damage to frontal or temporal lobes may alter
persons ability to modulate aggression and lead to aggressive behavior
Psychosocial Theories:
Failure to develop impulse control
Inability to delay gratification
Cultural Considerations:
In certain cultures, expressing anger is seen as rude or disrespectful
Some culture-bound syndromes involving aggressive, agitated, or violent behavior:
o Hwa-Byung: a culture-bound syndrome that literally translates as anger
syndrome or fire illness, attributed to the suppression of anger
Seen in Korea
Predominantly in women
Characterized by sighing, abdominal pain, insomnia, irritability, anxiety,
and depression
Western psychiatrist would likely dx as depression or somatization
disorder
o Bouffee delirante: condition observed in West Africa and Haiti; characterized by
a sudden outburst of agitated and aggressive behavior, marked confusion, and
paranoid ideation that resembles brief psychotic episodes
o Amok: s dissociative episode characterized by an outburst of violent, aggressive,
or homicidal behavior directed at other people and objects
Behvair precipitated by a perceived slight or insult and is seen only in
men

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CHAPTER 11: ANGER, HOSTILITY, AND AGGRESSION
Originally reported in Malaysia, similar behavior patterns found in Laos,
Philippines, Papua New Guinea, Polynesia (cafard), Puerto Rico (mal de
pelea) and among Navajo (iichaa)
Treatment:
Often focuses on treating the underlying or comorbid psychiatric diagnosis such as
schizophrenia or bipolar disorder
Lithium: effective in treating aggressive clients with bipolar disorder, conduct disorders
(in children) and mental retardation
Carbamazepine (Tegretol) and valproate (Depakote): used to treat aggression associated
with dementia, psychosis, personality disorders
Atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal) and
olanzapine (Zyprexa) effective in treating aggressive clients with dementia, brain injury,
mental retardation, and personality disorders
Benzodiazepines: can reduce irritability and agitation in older adults with dementia but
can result in loss of social inhibition for other aggressive clients, thereby increasing rather
than reducing aggression
Haloperidol (Haldol) and lorazepam (Ativan): commonly used in combination to
decrease agitation or aggression and psychotic symptoms; those who are agitated and
aggressive but not psychotic benefit from Ativan most, given in 2mg doses every 45-60
minutes
Atypical antipsychotics are more effective than conventional antipsychotics for
aggressive psychotic clients

UNIT 3: CUURENT SOCIAL AND EMOTIONAL CONCERNS