Chapter 11 Anger, Hostility, & Violence Flashcards
Discuss anger, hostility, and aggression. Describe psychiatric disorders that may be associated with an increased risk of hostility and physical aggression in clients. Describe the signs, symptoms, and behaviors associated with the five phases of aggression. Discuss appropriate nursing actions for the client during the five phases of aggression. Describe important issues for nurses to be aware of when working with angry, hostile, or aggressive clients.
Anger
A normal human emotion, is a strong, uncomfortable, emotional response to a real or perceived provocation
Results when a person is frustrated, hurt, or afraid
Can be constructive or destructive
Constructive Anger
If there is an unfair or wrong situation or self-defense
Destructive Anger
When denied, suppressed, or expressed inappropriately
Increases risk of health problems (e.g., HTN, ulcers, CAD
Effects of Anger When Handled Appropriately & Expressed Assertively
Can be a positive force that helps a person resolve conflicts, solve problems, and make decisions.
Anger energizes the body physically for self-defense when needed by activating the “fight-or-flight” response mechanisms of the SNS
Effects of Anger When Handled Inappropriately or Suppressed
Can cause physical or emotional problems or interfere w/relationships
Hostility
AKA Verbal Aggression
An emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior
May express hostility when they feel threatened or powerless
What is the intention behind hostility?
Intended to intimidate or cause emotional harm to another, and it can lead to physical aggression
Physical Aggression
Behavior in which a person attacks or injures another person or destroys property
What is the intention behind physical aggression?
Both verbal and physical aggression are meant to harm or punish another person or to force someone into compliance
Some clients with psychiatric disorders display hostile or physically aggressive behavior that represents a challenge to nurses and other staff members.
(T/F) True or False: Anger is a negative feeling and should be repressed.
FALSE!!
Anger or angry feelings are not bad or wrong. It is not healthy to deny or try to eliminate ever feeling angry. It is essential for good health to recognize, express, and manage angry feelings in a positive manner.
When does anger become negative?
When the person denies it, suppresses it, or expresses it inappropriately
- A person may deny or suppress (i.e., hold in) angry feelings if they are uncomfortable expressing anger.
Possible consequences are physical problems such as:
- Migraine headaches
- Ulcers,
- CAD
Emotional problems such as depression and low self-esteem.
Assertive Communication
Uses “I” statements that express feelings and are specific to the situation
Ex) “I feel angry when you interrupt me,”
Ex) “I am angry that you changed the work schedule without talking to me.”
This allows appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger
Catharsis
Activities that are supposed to provide a release for strong feelings such as anger or rage
Can increase instead of alleviate angry feelings
CONTRAINDICATION for angry patients
Activities that are non-violent tend to be more effective:
- Walking
- Drawing
- Talking w/ another person
Example of Catharsis
Hitting a punching bag or yelling
Cognitive Behavioral Techniques (CBT) to Alleviate Anger
Distraction, problem-solving, reframing one’s perspective
High hostility and anger are associated w/…
…increased risk of CAD & HTN
Hostility can lead to angry outbursts that are NOT effective for anger expression
Simply suppressing or attempting to ignore angry feelings may adversely affect control of hypertension
Controlling one’s temper or managing anger effectively should not be confused with suppressing angry feelings
Anger-related personality traits and social inhibition are associated with the presence and severity of coronary artery disease
Anger Suppression in Women
Anger suppression is more common in women than men
Women have been socialized to maintain and enhance relationships with others and to avoid the expression of the so-called negative or unfeminine emotions such as anger
Often results when:
- People deny them power or resources
- Treat them unjustly
- Behave irresponsibly toward them
School-age girls report experiences of disrespect, dismissal, and denial of the right to express anger
Offenders are usually their closest intimates
Manifestations of anger suppression through somatic complaints and psychological problems are more common among women than men
Hostile & aggressive behavior can be…
…sudden & unexpected
What are the stages of an aggressive incident?
1) Triggering Phase
2) Escalation Phase
3) Crisis Phase
4) Recovery Phase
5) Postcrisis Phase
Triggering Phase
An incident or situation that initiates an aggressive response
Signs, Symptoms, & Behaviors
- Restlessness
- Anxiety
- Irritability
- Pacing
- Muscle tension
- Rapid breathing
- Perspiration
- Loud voice
- Anger
Escalation Phase
The client’s responses represent escalating behaviors that indicate movement toward a loss of control.
Signs, Symptoms, & Behaviors
- Pale or flushed face
- Yelling, swearing
- Agitation
- Threatening, demanding
- Clenched fists, threatening gestures
- Hostility
- Loss of ability to solve the problem or think clearly
Crisis Phase
During an emotional and physical crisis, the client loses control.
Signs, Symptoms, & Behavior
- Loss of emotional and physical control
- Throwing objects
- Kicking, hitting, spitting, biting, scratching, shrieking, screaming
- Inability to communicate clearly
Recovery Phase
The client regains physical and emotional control.
Signs, Symptoms, & Behavior
- Lowering of voice
- Decreased muscle tension
- Clearer, more rational communication
- Physical relaxation
Postcrisis Phase
The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents.
Signs, Symptoms, & Behavior
- Remorse; apologies
- Crying
- Quiet, withdrawn behavior
Related Disorders
Clients with paranoid delusions may believe others are out to get them
- Believing they are protecting themselves, they retaliate with hostility or aggression.
Some clients have auditory hallucinations that command them to hurt others.
Aggressive behavior is also seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders
Violent patients tend to be more symptomatic, have poorer functioning, and show a marked lack of insight compared with nonviolent patients
Anger Attacks in Depression
Sudden intense spells of anger typically occur in situations in which the depressed person feels emotionally trapped
Involve verbal expressions of anger or rage but no physical aggression
Clients describe these anger attacks as uncharacteristic behavior that is inappropriate for the situation and followed by remorse
The anger attacks seen in some depressed clients may be related to:
- Irritable mood
- Overreaction to minor annoyances
- Decreased coping abilities
Intermittent Explosive Disorder (IED)
A rare psychiatric diagnosis characterized by discrete episodes of aggressive impulses that result in serious assaults or destruction of property
The aggressive behavior the person displays is grossly disproportionate to any provocation or precipitating factor
Diagnosis made only if the client has no other comorbid psychiatric disorders, as previously discussed
Describes a period of tension or arousal that the aggressive outburst seems to relieve.
- Afterward, however, the person is remorseful and embarrassed, and there are no signs of aggressiveness between episodes
Develops between late adolescence and the third decade of life
Clients w/ IED are frustrated and are often men who respond to feelings of uselessness or ineffectiveness with violent outburst
Acting Out
An immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings
Engages in acting-out behavior, such as verbal or physical aggression, to feel temporarily less helpless or powerless.
Children and adolescents often “act out” when they cannot handle intense feelings or deal with emotional conflict verbally
To understand acting-out behaviors, it is important to consider the situation and the person’s ability to deal with feelings and emotion
Neurobiologic Theories
Serotonin plays a major inhibitory role in aggressive behavior
- Low serotonin levels may lead to increased aggressive behavior
- This finding may be related to the anger attacks seen in some clients with depression
Increased activity of dopamine and norepinephrine in the brain is associated w/ increased impulsively violent behavior
Structural damage to the limbic system and the frontal and temporal lobes of the brain may alter the person’s ability to modulate aggression-> can lead to aggression
Psychosocial Theories
Infants and toddlers express themselves loudly and intensely, which is normal for these stages of growth and development.
- Temper tantrums are a common response from toddlers whose wishes are not granted.
As a child matures, they are expected to develop impulse control and socially appropriate behavior.
= Positive relationships with parents, teachers, and peers; success in school; and the ability to be responsible for oneself foster the development of these qualities.
Children in dysfunctional families w/ poor parenting, children who receive inconsistent responses to their behaviors, and children whose families struggle with social determinants of health are at increased risk for failing to develop socially appropriate behavior
- Can result in a person who is impulsive, easily frustrated, and prone to aggressive behavior.
The relationship between interpersonal rejection and aggression can also be the basis for long-term problems regulating and managing emotions, including anger as well as others.
- Rejection can lead to anger and aggression when that rejection causes the individual emotional pain or frustration or is a threat to self-esteem.
Aggressive behavior is seen as a means of reestablishing control, improving mood, or achieving retribution, all of which fail to achieve those ends
Impulse Control
The ability to delay gratification
Characteristics Predictive of Aggression
History of violence/rage or aggressive behavior
Involuntary hospitalization
Suspiciousness
Impulsivity
Anxiety
Hyperactivity (e.g., pacing that indicates increased agitation, restlessness)
Staring and eye contact or glaring as a way of intimidation, or no eye contact at all
Easily offended; hypersensitivity
Unit Characteristics Predictive of Aggression
Busy, noisy, crowded
Rigid unit rules
Lack of patient privacy and space (psychological or physical)
Lack of patient autonomy (locked doors, restraints)
Strict hierarchy of authority
Lack of meaningful, planned and predictable ward activities
Lack of patient control over the treatment plan
Boundary violations
Staff Behavior Characteristics Predictive of Aggression
Denial of patient requests or privileges; limit setting
Insufficient staff assistance with ADLs and other needs
Rude or patronizing staff behavior
Unclear staff roles
Power struggles related to medications
Failure of staff to listen or to convey empathy
What are the 3 categories of anger/aggression?
1) Pre-assaultive
2) Assaultive
3) Post-assaultive
Pre-Assaultive Category of Anger/Aggression
Patient
- Begins to become angry
- Exhibits increasing anxiety, tension, hyperactivity, and verbal abuse
Examples of Nurse Responses
- Use therapeutic de-escalation, calm limit setting, and clear options
- Engage in dialogue; convey empathy
- Physical activity and relaxation techniques
- Decrease stimulation in environment
- Offer PRN meds as ordered
Assaultive Category of Anger/Aggression
Patient
- Commits an act of violence
Examples of Nurse Responses
- “Show of force” as appropriate
- Implement seclusion or physical or chemical restraints only as a last resort
Post-Assaultive Category of Anger/Aggression
Patient
- Is encouraged by staff to talk about what triggered and escalated the aggression
Examples of Nurses Responses
- Review incident with the patient; discuss ways for patient to keep control & how staff can help
- Reassess milieu
- Debrief involved staff
- Talk to other clients
Nursing Interventions to Promote Safety
Provide a safe environment – closely monitor patients with potential for violence
Establish therapeutic nurse-patient relationships
- Respond empathetically
- Validate the patient’s experience and concerns
When possible, offer patient concrete choices
Provide “teachable moments”; teach assertive communication techniques
Jointly develop prevention strategies and an early detection plan
Make behavioral limits and consequences clear
- Consistently apply them
Maintain calmness and personal control (e.g., self-awareness; mindfulness techniques)
Remain with patients when they are angry; respect personal space; sit or stand at same level
Nursing Interventions to Promote Safety in Milieu
Maintain a structured and respectful therapeutic milieu; planned and predictable activities
Scheduled 1:1 interactions with patients
Create a culture of nonviolence
Reduce stimulation
Create a comfort room or multisensory environment room (e.g., Snoezelen® room)
Use multisensory behavior therapy to reduce apathy and agitation in older adults with dementia
Permit processing of conflicts (e.g., in daily meetings)
Which medication has the most severe side effects?
Haloperidol (Haldol)
Olanzapine (Zyprexa)
Class: Atypical Antipsychotic
Used for (1) schizophrenia spectrum disorders, (2) psychotic episodes induced by levodopa, and (3) relief of psychotic manifestations of other disorders
Atypical antipsychotics are the medication of choice for clients (1) receiving initial treatment, or (2) experiencing breakthrough episodes while taking typical antipsychotics
Relieve positive and negative symptoms
Has fewer adverse effects than typical antipsychotics
Olanzapine (Zyprexa) Side Effects & Contraindications
Adverse Effects:
Low risk of extrapyramidal symptoms (EPS)
High risk for diabetes mellitus
Weight gain
Dyslipidemia
Other adverse effects include:
- Sedation
- Orthostatic hypotension
- Anticholinergic effects.
Contraindications:
Contraindicated for elderly clients with dementia
Use cautiously in clients with cardiovascular or cerebrovascular disease, seizures, or diabetes mellitus
Nursing Considerations for Olanzapine (Zyprexa)
Avoid alcohol
Obtain fasting blood glucose on clients with diabetes mellitus, and carefully monitor blood glucose
Ziprasidone (Geodon)
Class: Atypical Antipsychotic
Used for (1) schizophrenia spectrum disorders, (2) psychotic episodes induced by levodopa, and (3) relief of psychotic manifestations of other disorders
Works by blocking serotonin, and to a lesser degree dopamine, receptors
Can be used for clients with concurrent depression
Atypical antipsychotics are the medication of choice for clients (1) receiving initial treatment, or (2) experiencing breakthrough episodes while taking typical antipsychotics
Relieves positive and negative symptoms
Ziprasidone (Geodon) Adverse Effects & Contraindications
Low risk of extrapyramidal symptoms (EPS)
Diabetes mellitus, and dyslipidemia
- Low risk for weight gain
Other adverse effects include orthostatic hypotension, anticholinergic effects, rash, and prolonged QT intervals
Does not cause weight gain; non-sedating
Contraindicated for elderly clients with dementia
Nursing Considerations for Ziprasidone (Geodon)
Avoid CNS depressants, levodopa and other dopamine receptor agonists, and medications that prolong the QT interval
Haloperidol (Haldol)
Class: Conventional Antipsychotic
Primarily used for schizophrenia spectrum disorders
Goals: (1) suppress acute episodes, (2) prevent acute recurrence, and (3) maintain the highest possible level of functioning
Mainly controls positive symptoms
- e.g., hallucinations, delusions, bizarre behavior of psychotic disorders
- Likely due to blockage of dopamine receptors in the brain
Reserved for clients who (1) are using them successfully and can tolerate the side effects, or (2) are violent or aggressive
Haloperidol (Haldol) Adverse Effects & Contraindications
Very high extrapyramidal side effects (acute dystonia, tardive dyskinesia, Parkinsonism, Akathisia,)
Anticholinergic effects
Neuroleptic malignant syndrome
Neuroendocrine effects
Seizures
Photosensitivity
Orthostatic hypotension
Agranulocytosis
Prolonged QT
Sedation, sexual dysfunction
Contraindicated in clients w/:
- Dementia
- Severe depression
- Parkinson’s
- Prolactin-dependent breast cancer
- Severe hypotension, or those in a coma
Use cautiously with seizure or heart disorders or liver or kidney disease
Nursing Considerations for Haloperidol
Avoid OTC meds with anticholinergic agents (e.g., sleep aids)
Avoid CNS depressants
Avoid levodopa and other dopamine receptor agonists
Community-Based Care after Discharge
Treat underlying or comorbid psychiatric diagnoses and contributing factors
- Address cultural issues
- Address alcohol and other drug use
Regular follow-up appointments; assess access to services and adherence with meds
Cognitive and behavioral interventions
Stress management/relaxation techniques (e.g., mindfulness)
Community support programs
Anger management groups
Couples counseling
12-step groups
Workplace Hostility
Lateral or horizontal violence/bullying (among healthcare providers in the workplace)
Intimidating, disruptive, threatening, and/or humiliating behaviors; verbal abuse; work interference/sabotage
Numerous potential negative outcomes
The Joint Commission has standards that address this issue
- Urges organizations to establish a safety culture
- Zero tolerance for unacceptable behaviors – all persons are held accountable
Facilities must have Code of Conduct policies, with processes to handle unacceptable behavior
Self-Awareness Issues
Be aware of your own management of anger.
Practice and gain experience in restraint/seclusion before using.
Be calm, nonjudgmental, and nonpunitive.
Learn from watching experienced nurses deal with hostile or aggressive clients
