MENTAL HEALTH: CHAPTER 11: ANGER, HOSTILITY, AGGRESSION:

Atypical antipsychotics:

(second generation) - Are made effective than typical (first generation) for aggressive psychotic clients

Aggressive Behavior Seen In:

- Aggressive behavior can be seen in those with schizophrenia, bipolar, dementia, head injury, delirium, intoxication of drugs/alcohol, antisocial, BPD

Aggressive Behavior & Strong Leadership:

- Aggressive behavior is less common on a unit with strong leadership

Intermittent Explosive Disorder:

- Discrete episodes of aggression and impulses that result in serious assaults/aggression of property. - Afterwards, the person is remorseful/embarrassed (Develops in late adolescence --> 3rd decade of life in large men)

Five-Phase Aggression Cycle: Crisis:

- During an emotional and physical crisis, the client loses control. - Signs & Symptoms: Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly

Application Of The Nursing Process: Other Identification:

- Expected outcomes for aggressive clients may include the following: 1. The client will not harm or threaten others. 2. The client will refrain from behaviors that are intimidating or frightening to others. 3. The client will describe his or her feelings and concerns without aggression. 4. The client will comply with treatment.

Catharsis:

- Expressing anger in aggressive but safe method (ex. hitting a punching bag or yelling) - This can actually end up increasing angry behavior

Aggression Cycle: Crisis:

- Loss of emotional/physical control - Hitting - Kicking - Throwing objects

Aggression Cycle: Post-crisis:

- Remorse - Apology - Crying

1. Which is an example of assertive communication? a."I wish you would stop making me angry." b."I feel angry when you walk away when I'm talking." c."You never listen to me when I'm talking." d."You make me angry when you interrupt me."

b."I feel angry when you walk away when I'm talking."

Recovery Phase:

- Management of aggressive behavior: recovery phase o Talk about situation or trigger o Help client relax or sleep o Help client explore alternatives to aggressive behavior o Assess and document any injuries o Debrief staff o Encourage other clients to talk about feelings §Do not discuss aggressive client in detail with other clients

Escalation Phase:

- Managing aggressive behavior: escalation phase o Take control o Provide directions in a firm, calm voice o Direct client to time-out in quiet room or area o Communicate that aggressive behavior is not acceptable o Offer medication if refused in triggering phase o Show of force

Triggering Phase:

- Managing aggressive behavior: triggering phase o Approach in a nonthreatening, calm manner o Convey empathy o Encourage verbal expression of angry feelings o Use clear, simple, short statements o Allow client time for self-expression o Suggest client go to a quieter area o Offer PRN medications if ordered o Suggest physical activity, such as walking

Applications Of The Nursing Process: Data Analysis:

- Nursing diagnoses commonly used when working with aggressive clients include: •Risk for other-directed violence •Ineffective coping - If the client is intoxicated, depressed, or psychotic, additional nursing diagnoses may be indicated.

Myth:

- People with mental illness are aggressive, should be feared, and more likely to hurt others (actually, they're more likely to hurt themselves)

At Risk For Aggression:

- Poor parenting - Inconsistent response to behavior - Low socioeconomic status

Hostility:

- Also called verbal aggression, is an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior - A person may express hostility when he or she feels threatened or powerless. - Hostile behavior is intended to intimidate or cause emotional harm to another, and it can lead to physical aggression.

Onset & Clinical Course: Anger:

- Although anger is normal, it is often perceived as a negative feeling. - Many people are not comfortable expressing anger directly. - Nevertheless, anger can be a normal and healthy reaction when situations or circumstances are unfair or unjust, personal rights are not respected, or realistic expectations are not met. - If the person can express his or her anger assertively, problem-solving or conflict resolution is possible. - Anger or angry feelings are not bad or wrong. It isn't 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. - Anger becomes 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 he or she is uncomfortable expressing anger. - Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease, and emotional problems such as depression and low self-esteem. - Anger that is expressed inappropriately can lead to hostility and aggression. - The nurse can help clients express anger appropriately by serving as a model and by role-playing assertive communication techniques. - Assertive communication uses "I" statements that express feelings and are specific to the situation, for example, "I feel angry when you interrupt me," or "I am angry that you changed the work schedule without talking to me." - Statements such as these allow appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger. - Some people try to express their angry feelings by engaging in aggressive but safe activities such as hitting a punching bag or yelling. - Such activities, called catharsis, are supposed to provide a release for anger. - However, catharsis can increase rather than alleviate angry feelings. - Therefore, cathartic activities may be contraindicated for angry clients. - Activities that are not aggressive, such as walking or talking with another person, are more likely to be effective in decreasing anger. - Cognitive behavioral therapy techniques, such as distraction, problem-solving, and changing one's perspective or reframing can be effective in managing situations or problems that provoke angry feelings - High hostility and anger are associated with increased risk of coronary artery disease and hypertension. - Hostility can lead to angry outbursts that are not effective for anger expression. - Effective methods of anger expression, such as using assertive communication to express anger and mindfulness techniques, should replace angry aggressive outbursts of temper such as yelling or throwing things. - 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, which can lead to the problems described earlier. - Anger-related personality traits and social inhibition are associated with the presence and severity of coronary artery disease - Anger suppression is especially common in women, who 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. - Women's anger often results when people deny them power or resources, treat them unjustly, or behave irresponsibly toward them. - School-age girls report experiences of disrespect, dismissal, and denial of the right to express anger. The offenders are not strangers, but are usually their closest intimates. - Manifestations of anger suppression through somatic complaints and psychological problems are more common among women than men. - Women must recognize that anger awareness and expression are necessary for their growth and development.

Five-Phase Aggression Cycle: Triggering:

- An event or circumstances in the environment initiates the client's response, which is often anger or hostility. - Signs & Symptoms: Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, perspiration, loud voice, anger

Anger Becoming Negative:

- Anger becomes negative when person denies it, suppresses it, or expresses it inappropriately

Anger In Women:

- Anger suppression in common in women

Anger:

- Anger, a normal human emotion, is a strong, uncomfortable, emotional response to a real or perceived provocation. - Anger results when a person is frustrated, hurt, or afraid. - Handled appropriately and expressed assertively, anger 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 mech

Asians & Native Americans:

- Asians and Native Americans avoid expressing anger at all costs bc it's viewed as rude

ASAP:

- Assaulted Staff Action Program (ASAP) help staff victims cops with psychological stress of assaults by clients in community-based programs

Ways To Express Anger:

- Assertive communication - Problem solving - Conflict resolution - Distraction - Challenging one's perspective

Nursing Interventions:

- Build a trusting relationship with patient ASAP, well in advance of aggression episode - Develop/practice consistent techniques of restraint - Always maintain control of you/your emotions: remain calm - Provide control if client cannot himself but never threaten client - Notify the charge nurse/supervisor ASAP for an aggressive situation - Keep something between you and the weapon the client has - If necessary to remove the weapon, kick it out of client's hand; Do not reach with your hand - Don't trap client; potentially violent people have a body space 4x more than regular people so you need to stay further away from them not to feel threatned - When a decision has been made to restrain/seclude a client, tell them in a matter-of-fact tone and DON'T allow for any bargaining - Never strike the client - Do NOT help restrain the client if you're angry yourself - If possible, don't let other clients watch another being restrained - Talk with client after situation has resolved

Evaluation:

- Care is most effective when the client's anger can be defused in an earlier stage, but restraint or seclusion is sometimes necessary to handle physically aggressive behavior. - The goal is to teach angry, hostile, and potentially aggressive clients to express their feelings verbally and safely without threats or harm to others or destruction of property.

Treatment Of Aggressive Behavior:

- Clients usually focuses on treatment of underlying or comorbid psychiatric diagnosis

Intervention: Managing The Environment:

- It is important to consider the environment for all clients when trying to reduce or eliminate aggressive behavior. - Group and planned activities such as playing card games, watching and discussing movies, or participating in informal discussions give clients the opportunity to talk about events or issues when they are calm. - Activities also engage clients in the therapeutic process and minimize boredom. - Scheduling one-to-one interactions with clients indicates the nurse's genuine interest in the client and a willingness to listen to the client's concerns, thoughts, and feelings. - Knowing what to expect enhances the client's feelings of security. - If clients have a conflict or dispute with one another, the nurse can offer the opportunity for problem-solving or conflict resolution. - Expressing angry feelings appropriately, using assertive communication statements, and negotiating a solution are important skills clients can practice. - These skills will be useful for the client when he or she returns to the community. - If a client is psychotic, hyperactive, or intoxicated, the nurse must consider the safety and security of other clients, who may need protection from the intrusive or threatening demeanor of that client. - Talking with other clients about their feelings is helpful, and close supervision of the client who is potentially aggressive is essential.

Low Serotonin:

- Low serotonin, damage to frontal/temporal lobes can lead to increased aggressive behavior

Community-Based Care:

- For many clients with aggressive behavior, effective management of the comorbid psychiatric disorder is the key to controlling aggression. - Regular follow-up appointments, compliance with prescribed medication, and participation in community support programs help the client achieve stability. - Anger management groups are available to help clients express their feelings and to learn problem-solving and conflict resolution techniques. - Studies of client assaults on staff in the community become increasingly important as more clients experience rapid discharge from inpatient or acute care settings. - Assaults by clients in the community were caused partly by stressful living situations, increased access to alcohol and drugs, availability of lethal weapons, and noncompliance with medications. - Episodes of assault were often precipitated by denial of services, acute psychosis, and excessive stimulation. - Flannery (2012) studied assaults by clients in community residences, including physical or sexual assaults, nonverbal intimidation, and verbal threats. - Clients who were assaultive were most likely to be older male clients with schizophrenia and younger clients with personality disorders. - The Assaulted Staff Action Program (ASAP) was established in Massachusetts to help staff victims cope with the psychological sequelae of assaults by clients in community-based residential programs. - In addition, ASAP works with staff to determine better methods of handling situations with aggressive clients and ways to improve safety in community settings. - This program is now available throughout the United States and can be purchased for implementation by any interested staff.

Onset & Clinical Course: Hostility & Aggression:

- Hostile and aggressive behavior can be sudden and unexpected. - Often, however, stages or phases can be identified in aggressive incidents: a triggering phase (incident or situation that initiates an aggressive response), an escalation phase, a crisis phase, a recovery phase, and a post-crisis phase. - As a client's behavior escalates toward the crisis phase, he or she loses the ability to perceive events accurately, solve problems, express feelings appropriately, or control his or her behavior; behavior escalation may lead to physical aggression. - Therefore, interventions during the triggering and escalation phases are key to preventing physically aggressive behavior

The Nursing Process: Intervention:

- Hostility or verbally aggressive behavior can be intimidating or frightening even for experienced nurses. - Clients exhibiting these behaviors are also threatening to other clients, staff, and visitors. - In social settings, the most frequent response to hostile people is to get as far away from them as possible. - In the psychiatric setting, however, engaging the hostile person in dialogue is most effective in preventing the behavior from escalating to physical aggression. - Interventions are most effective and least restrictive when implemented early in the cycle of aggression. - This section presents interventions for the management of the milieu (which benefit all clients regardless of setting) and specific interventions for each phase of the aggression cycle.

Workplace Hostility:

- In July 2008, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a sentinel event alert concerning "intimidating and disruptive behaviors" that undermine a culture of safety and lead to errors, decreased patient satisfactions, preventable adverse outcomes, increased health care costs, and loss of qualified personnel. - These undesirable behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or an uncooperative attitude. - Disruptive and intimidating behaviors are often demonstrated by health care providers in power positions and can manifest as reluctance or refusal to answer questions, return phone calls, or answer pages; condescending or intimidating language or voice tone/volume; and impatience. - In 2016, the JCAHO added workplace bullying, also known as lateral or horizontal violence, to this initiative. Bullying is defined as abusive conduct, such as verbal abuse, threatening, intimidating or humiliating behaviors, and work interference (sabotage), which prevents work from getting done. - This problem prompted the JCAHO to include new standards on leadership effective January 2009 -. Any accredited health care organization must now have a code of conduct that defines acceptable and disruptive and inappropriate behaviors. - Additionally, leaders in these organizations must create and implement a process for managing disruptive and inappropriate behaviors (JCAHO, 2016). Several action steps have been suggested to accomplish this new standard of behavior, including: •A code of conduct outlines acceptable and inappropriate/unacceptable behavior •A process for managers to handle disruptive or unacceptable behavior •Education of all team members on expected professional behavior •Zero tolerance for unacceptable behaviors, meaning all persons are held accountable

Intervention: Managing Aggressive Behavior:

- In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client's emotion and behavior. - Conveying empathy for the client's anger or frustration is important. - The nurse can encourage the client to express his or her angry feelings verbally, suggesting that the client is still in control and can maintain that control. - Use of clear, simple, short statements is helpful. - The nurse should allow the client time to express him or herself. - The nurse can suggest that the client go to a quiet area or may get assistance to move other clients to decrease stimulation. - Medications (PRN, or as needed) should be offered if ordered. - As the client's anger subsides, the nurse can help the client use relaxation techniques and look at ways to solve any problem or conflict that may exist. - Physical activity, such as walking, may also help the client relax and become calmer. - If these techniques are unsuccessful and the client progresses to the escalation phase (the period when the client builds toward loss of control), the nurse must take control of the situation. - The nurse should provide directions to the client in a calm, firm voice. - The client should be directed to take a time-out for cooling off in a quiet area or his or her room. - The nurse should tell the client that aggressive behavior is not acceptable and that the nurse is there to help the client regain control. - If the client refused medications during the triggering phase, the nurse should offer them again. - If the client's behavior continues to escalate and he or she is unwilling to accept direction to a quiet area, the nurse should obtain assistance from other staff members. Initially, four to six staff members should remain ready within sight of the client but not as close as the primary nurse talking with the client. - This technique, sometimes called a "show of force," indicates to the client that the staff will control the situation if the client cannot do so. Sometimes, the presence of additional staff convinces the client to accept medication and take the time-out necessary to regain control. - When the client becomes physically aggressive (crisis phase), the staff must take charge of the situation for the safety of the client, staff, and other clients. - Psychiatric facilities offer training and practice in safe techniques for managing behavioral emergencies, and only staff with such training should participate in the restraint of a physically aggressive client. - The nurse's decision to use seclusion or restraint should be based on the facility's protocols and standards for restraint and seclusion. - The nurse should obtain a physician's order as soon as possible after deciding to use restraint or seclusion. - Four to six trained staff members are needed to restrain an aggressive client safely. - Children, adolescents, and female clients can be just as aggressive as adult male clients. - The client is informed that his or her behavior is out of control and that the staff is taking control to provide safety and prevent injury. - Four staff members each take a limb, one staff member protects the client's head, and one staff member helps control the client's torso, if needed. - The client is transported by gurney or carried to a seclusion room, and restraints are applied to each limb and fastened to the bed frame. - If PRN medication has not been taken earlier, the nurse may obtain an order for intramuscular (IM) medication in this type of emergency situation. - As noted previously, the nurse performs close assessment of the client in seclusion or restraint and documents the actions. - As the client regains control (recovery phase), he or she is encouraged to talk about the situation or triggers that led to the aggressive behavior. - The nurse should help the client relax, perhaps sleep, and return to a calmer state. - It is important to help the client explore alternatives to aggressive behavior by asking what the client or staff can do next time to avoid an aggressive episode. - The nurse should also assess staff members for any injuries and complete the required documentation such as incident reports and flow sheets. - The staff usually has a debriefing session to discuss the aggressive episode, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively. - It is also important to encourage other clients to talk about their feelings regarding the incident. However, the aggressive client should not be discussed in detail with other clients. - In the postcrisis phase, the client is removed from restraint or seclusion as soon as he or she meets the behavioral criteria. - The nurse should not lecture or chastise the client for the aggressive behavior but should discuss the behavior in a calm, rational manner. - The client can be given feedback for regaining control with the expectation that he or she will be able to handle feelings or events in a nonaggressive manner in the future. - The client should be reintegrated into the milieu and its activities as soon as he or she can participate.

Etiology: 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, he or she is expected to develop impulse control (the ability to delay gratification) and socially appropriate behavior. - Positive relationships with parents, teachers, and peers; success in school; and the ability to be responsible for oneself foster development of these qualities. - Children in dysfunctional families with poor parenting, children who receive inconsistent responses to their behaviors, and children whose families are of lower socioeconomic status are at increased risk for failing to develop socially appropriate behavior. - This lack of development 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

Physical Aggression:

- Is behavior in which a person attacks or injures another person or destroys property. - 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.

Aggression Cycle: Recovery:

- Lowering of voice - Decreased muscle tension

Crisis Phase:

- Management of aggressive behavior: crisis phase o Take charge of situation for safety oRestraint § Only staff with training should participate in restraint. § Four to six trained staff members are needed. § Inform client that behavior is out of control and staff is taking measures for safety.

Post-crisis Phase:

- Management of aggressive behavior: postcrisis phase o Remove patient from restraint or seclusion as soon as criteria met o Calmly discuss behavior (no lecturing or chastising) o Give client feedback for regaining control o Reintegrate client as soon as he or she is able to participate

Etiology: Neurobiologic Theories:

- Researchers have examined the role of neurotransmitters in aggression in animals and humans, but have been unable to identify a single cause. - Findings reveal that serotonin plays a major inhibitory role in aggressive behavior; therefore, low serotonin levels may lead to increased aggressive behavior. - This finding may be related to the anger attacks seen in some clients with depression. - In addition, increased activity of dopamine and norepinephrine in the brain is associated with increased impulsively violent behavior. - Further, structural damage to the limbic system and the frontal and temporal lobes of the brain may alter the person's ability to modulate aggression; this can lead to aggressive behavior

Aggression Cycle: Trigger:

- Restlessness - Pacing - Rapid breathing - Perspiration - Offer medication

Five-Phase Aggression Cycle: Postcrisis:

- The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents. - Signs & Symptoms: Remorse; apologies; crying; quiet, withdrawn behavior

Five-Phase Aggression Cycle: Recovery:

- The client regains physical and emotional control. - Signs & Symptoms: Lowering of voice; decreased muscle tension; clearer, more rational communication; physical relaxation

Five-Phase Aggression Cycle: Escalation:

- The client's responses represent escalating behaviors that indicate movement toward a loss of control - Signs & Symptoms: Pale or flushed face, yelling, swearing, agitation, threatening, demanding, clenched fists, threatening gestures, hostility, loss of ability to solve the problem or think clearly

Related Disorders:

- The media gives a great deal of attention to people with mental illness who commit aggressive acts. - This gives the general public the mistaken idea that most people with mental illness are aggressive and should be feared. - In reality, clients with psychiatric disorders are much more likely to hurt themselves than other people. - Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. - 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 - Some clients with depression have anger attacks. - These sudden intense spells of anger typically occur in situations in which the depressed person feels emotionally trapped. - Anger attacks 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, and decreased coping abilities. Intermittent explosive disorder (IED) is 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. - This diagnosis is made only if the client has no other comorbid psychiatric disorders, as previously discussed. - The person 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 - IED develops between late adolescence and the third decade of life. - Clients with IED are often are men with dependent personality features who respond to feelings of uselessness or ineffectiveness with violent outbursts. - Acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings. - The person 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 emotions. - There are numerous reports of violence toward both individuals and groups in the United States. - The identified suspects or perpetrators are often described as having unresolved anger or a mental illness. - It is important to remember that such reports may originate from family or neighbors and are their own personal perceptions of the situation. - Sometimes, others may speculate about the causes of these violent actions. - Just because an individual commits a seemingly incomprehensible act doesn't mean that person has a mental illness.

Self-Awareness Issues:

- The nurse must be aware of how he or she deals with anger before helping clients do so. - The nurse who is afraid of angry feelings may avoid a client's anger, which allows the client's behavior to escalate. - If the nurse's response is angry, the situation can escalate into a power struggle, and the nurse loses the opportunity to "talk down" the client's anger. - It is important to practice and gain experience in using techniques for restraint and seclusion before attempting them with clients in crisis. - There is a risk of staff injury whenever a client is aggressive. - Ongoing education and practice of safe techniques are essential to minimize or avoid injury to both staff and clients. - The nurse must be calm, nonjudgmental, and nonpunitive when using techniques to control a client's aggressive behavior. Inexperienced nurses can learn from watching experienced nurses deal with clients who are hostile or aggressive.

Application Of The Nursing Process: Assessment:

- The nurse should be aware of factors that influence aggression in the psychiatric environment or unit milieu. - Aggressive behavior is less common on psychiatric units with strong psychiatric leadership; clear staff roles; and planned and adequate events such as staff-client interaction, group interaction, and activities. - Conversely, when predictability of meetings or groups and staff-client interactions is lacking, clients often feel frustrated and bored, and aggression is more common and intense. - A lack of psychological space—having no privacy, being unable to get sufficient rest—may be more important in triggering aggression than a lack of physical space. - In addition to assessing the unit milieu, the nurse needs to assess individual clients carefully. - A history of violent or aggressive behavior is one of the best predictors of future aggression. - Determining how the client with a history of aggression handles anger and what the client believes is helpful is important in assisting him or her in controlling or nonaggressively managing angry feelings. - Clients who are angry and frustrated and believe no one is listening to them are more prone to behave in a hostile or aggressive manner. - In addition to a past history of violence, a history of being personally victimized and/or one of substance abuse increases a client's likelihood of aggressive behavior. - Individual cues can help the nurse recognize when aggressive behavior is imminent. - Clients who believe their hallucinated voices to be all-powerful, malevolent, and irresistible are more likely to be aggressive. - These cues include what the client is saying; changes in the client's voice (volume, pitch, speed); changes in the client's facial expression; and changes in the client's behavior. - The nurse should assess the client's behavior to determine which phase of the aggression cycle he or she is in so that appropriate interventions can be implemented. - Assessment of clients must take place at a safe distance. - The nurse can approach the client while maintaining an adequate distance so that the client does not feel trapped or threatened. - To ensure staff safety and exhibit teamwork, it may be prudent for two staff members to approach the client.

Treatments:

- The treatment of aggressive clients often focuses on treating the underlying or comorbid psychiatric diagnosis such as schizophrenia or bipolar disorder. - Successful treatment of comorbid disorders results in successful treatment of aggressive behavior. - Lithium has been effective in treating aggressive clients with bipolar disorder, conduct disorders (in children), and intellectual disability. - Carbamazepine (Tegretol) and valproate (Depakote) are used to treat aggression associated with dementia, psychosis, and personality disorders. - Atypical antipsychotic agents such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) have been effective in treating aggressive clients with dementia, brain injury, intellectual disability, and personality disorders. - Benzodiazepines can reduce irritability and agitation in older adults with dementia, but they can result in the loss of social inhibition for other aggressive clients, thereby increasing rather than reducing their aggression. - Haloperidol (Haldol) and lorazepam (Ativan) are commonly used in combination to decrease agitation or aggression and psychotic symptoms. - Patients who are agitated and aggressive but not psychotic benefit most from lorazepam, which can be given in 2-mg doses every 45 to 60 minutes. - Atypical antipsychotics are more effective than conventional antipsychotics for aggressive, psychotic clients - Use of antipsychotic medications requires careful assessment for the development of extrapyramidal side effects, which can be quickly treated with benztropine (Cogentin). - Although not a treatment per se, the short-term use of seclusion or restraint may be required during the crisis phase of the aggression cycle to protect the client and others from injury. - Many legal and ethical safeguards govern the use of seclusion and restraint

Cultural Considerations:

- What a culture considers acceptable strongly influences the expression of anger. - The nurse must be aware of cultural norms to provide culturally competent care. - In the United States, women traditionally were not permitted to express anger openly and directly because doing so would not be "feminine" and would challenge male authority. - That cultural norm has changed slowly during the past few decades. - Some cultures, such as Native American and Asian cultures, see expressing anger as rude or disrespectful and avoid it at all costs. - In these cultures, trying to help a client express anger verbally to an authority figure would be unacceptable. - Ethnic or minority status can play a role in the diagnosis and treatment of psychiatric illness. - Patients with dark skin, regardless of race, are sometimes perceived as more dangerous than light-skinned patients, and therefore more likely to experience compulsory hospitalizations, increased use of restraints, higher doses of medication, and so forth. - People of color are overrepresented in interpersonal violence episodes. - However, when studies controlled for socioeconomic factors, race was not the significant factor; rather poverty, and other socioeconomic factors explained the difference - Education to develop cultural competence is needed to provide quality care to immigrants and minority group patients. - Hwa-Byung or hwabyeong is a culture-bound syndrome that literally translates as anger syndrome or fire illness, attributed to the suppression of anger (Lee et al., 2018). - It is seen in Korea, predominately in women, and is characterized by sighing, abdominal pain, insomnia, irritability, anxiety, and depression. - Western psychiatrists would be likely to diagnose it as depression or somatization disorder. - Two other culture-bound syndromes involve aggressive behavior. - Bouffée délirante, a condition observed in West Africa and Haiti, is characterized by sudden outbursts of agitated and aggressive behavior, marked confusion, and psychomotor excitement. - These episodes may include visual and auditory hallucinations and paranoid ideation that resemble brief psychotic episodes. - Amok is a dissociative episode characterized by a period of brooding followed by an outburst of violent, aggressive, or homicidal behavior directed at other people and objects - This behavior is precipitated by a perceived slight or insult and is seen only in men. - Originally reported in Malaysia, similar behavior patterns are seen in Laos, the Philippines, Papua New Guinea, Polynesia (cafard), Puerto Rico (mal de pelea), and among the Navajo (iich'aa).

Anger Positive:

- When handled appropriately, anger can be a positive force

Aggression Cycle: Escalation:

- Yelling - Swearing - Threatning - Here the nurse has to take control of situation - Recommend moving to a quiet area and offer medication

Inappropriate Expression Or Suppression:

- negative force o Physical or emotional problems o Interference with relationships

Is the following statement true or false? Hostility and aggression are terms that can be used interchangeably.

False - Rationale: Hostility and aggression are two different terms. o Hostility means verbal aggression. Physical aggression involves attack on or injury to another person or destruction of property.

2. Which statement about anger is true? a.Expressing anger openly and directly usually leads to arguments. b.Anger results from being frustrated, hurt, or afraid. c.Suppressing anger is a sign of maturity. d.Angry feelings are a negative response to a situation.

b.Anger results from being frustrated, hurt, or afraid.

3. Which type of drugs requires cautious use with potentially aggressive clients? a.Antipsychotic medications b.Benzodiazepines c.Mood stabilizers d.Lithium

b.Benzodiazepines

During which phase does staff debriefing occur? A. Escalation phase B. Crisis phase C. Recovery phase D. Postcrisis phase

C. Recovery phase - Rationale: Staff debriefing occurs during the recovery phase to allow for discussion of the event, how it was handled, what worked well or needed improvement, and how the situation could have been defused more effectively.

Is the following statement true or false? A client with a history of violent or aggressive behavior is more likely to exhibit similar behavior in the future

True - Rationale: A history of violent or aggressive behavior is one of the best predictors of future aggression.

5. The nurse observes a client muttering to himself and pounding his fist in his other hand while pacing in the hallway. Which principle should guide the nurse's action? a.Only one nurse should approach an upset client to avoid threatening the client. b.Clients who can verbalize angry feelings are less likely to become physically aggressive. c.Talking to a client with delusions is not helpful, because the client has no ability to reason. d.Verbally aggressive clients often calm down on their own if staff members don't bother them.

b.Clients who can verbalize angry feelings are less likely to become physically aggressive.

4. A client is pacing in the hallway with clenched fists and a flushed face. She is yelling and swearing. In which phase of the aggression cycle is she? a.Anger b.Triggering c.Escalation d.Crisis

c.Escalation