MH C 15 Anger and Aggression Management

■ Violence occurs when individuals lose control of their anger.

■ Anger is viewed as an emotional response to one's perception of a situation.

Modeling

-Role modeling is one of the strongest forms of learning. Children model their behavior at a very early age after their primary caregivers, usually parents. How parents or significant others express anger becomes the child's method of anger expression.

Aggression may be differentiated as reactive versus proactive.

-Reactive aggression is defined as fear-based and impulsive -proactive aggression is described as predatory and calculated.

Novitsky and associates describe a prodromal syndrome characterized by

anxiety and tension, verbal abuse and profanity, and increasing hyperactivity. These escalating behaviors usually do not occur in stages but most often overlap and sometimes occur simultaneously.

Anger

"an emotional state that varies in intensity from mild irritation to intense fury and rage," Anger is accompanied by physiological and biological changes, such as increases in heart rate, blood pressure, and levels of the energy hormones adrenaline and noradrenaline

Planning and Implementation

-Cognitive behavior therapy (CBT) as a strategy for anger management and aggression reduction is an evidence-based treatment that, especially when incorporated in treatment for children and adolescents, has demonstrated effectiveness in reducing maladaptive aggression

Assessment

-Nurses must be aware of the risk factors and symptoms associated with anger and aggression in order to make an accurate assessment.

Aggression

-When describing aggression as a behavioral response to anger, aggression has been defined as a behavior intended to threaten or injure the victim's security or self-esteem. It means "to go against," "to assault," or "to attack." It is a response that aims at inflicting pain or injury on objects or persons -Aggression may include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control.in general, may range from a self-protective response to a destructive, violent act.

Predisposing Factors to Anger and Aggression

A number of factors have been implicated in the way an individual expresses anger. Some theorists view aggression as purely biological, and some suggest that it results from individuals' interactions with their environments. It is likely a combination of both.

OBJECTIVES

1. Define and differentiate between anger and aggression. 2. Identify when the expression of anger becomes a problem. 3. Discuss predisposing factors to the maladaptive expression of anger. 4. Apply the nursing process to patients expressing anger or aggression. a. Assessment: Describe physical and psychological responses to anger. b. Diagnosis/Outcome Identification: Formulate nursing diagnoses and outcome criteria for patients expressing anger and aggression. c. Planning/Intervention: Describe nursing interventions for patients demonstrating maladaptive expressions of anger. d. Evaluation: Evaluate achievement of the projected outcomes in the intervention with patients demonstrating maladaptive expression of anger.

The following three factors have been identified as important considerations in assessing for potential violence:

1. Past history of violence 2. Client diagnosis 3. Current behavior

An example of learning by negative reinforcement follows:

A mother asks the child to pick up her toys, and the child becomes angry and has a temper tantrum. If, when the temper tantrum begins, the mother thinks, "Oh, it's not worth all this!" and picks up the toys herself, the anger has been negatively reinforced (the child was rewarded by not having to pick up her toys).

In both cases, there is intent to harm another, but the motives differ. Intent is a requisite in the definition of aggression. It refers to behavior that is intended to inflict harm or destruction.

Accidents that lead to unintentional harm or destruction are not considered aggression.

Aggression

Aggression can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness.

Aggression is a behavior intended to threaten or injure the victim's security or self-esteem.

Aggression can be physical or verbal, but it is virtually always designed to punish.

Anger generates a physiological arousal comparable to the stress response discussed in Chapter 1, "The Concept of Stress Adaptation."

Aggression is one way in which individuals express anger.

aggression may include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control.

Aggressive behaviors can be classified as mild (e.g., sarcasm), moderate (e.g., slamming doors), severe (e.g., threats of physical violence against others), or extreme (e.g., physical acts of violence against others).

Assessing Risk Factors

Prevention is the key issue in management of aggressive or violent behavior

Most assaultive behavior is preceded by a period of increasing hyperactivity.

Behaviors associated with the prodromal syndrome should be considered emergent and demand immediate attention. Keen observation skills and background knowledge for accurate assessment are critical factors in predicting the potential for violent behavior.

Individuals may be genetically predisposed to aggression related to genetic variants that control levels of serotonin in the central and peripheral nervous systems

Consequently, administration of selective serotonin re-uptake inhibitors (SSRIs) has been associated with increased frontal cortex activity and decreased aggression

CBT is an evidence-based treatment strategy for reducing maladaptive aggression, especially in the treatment of aggression in children and adolescents.

END OF CHAPTER

Prevention is a key issue in the management of aggressive or violent behavior.

Elements identified as key risk factors in the potential for violence among acute psychiatric inpatients include (1) male gender, (2) substance use, (3) past history of violence, and (4) a diagnosis of schizophrenia.

When anger is unresolved, this physiological arousal can be the predisposing factor to several health problems

Even if the situation that created the anger is removed by miles or years, it can be replayed through the memory, reactivating the sympathetic arousal when this occurs.

Role models are not always in the home

Evidence supports the role of television and video violence as a predisposing factor to later aggressive behavior (APA, 2013). Whether modeling occurs in the home, community, or popular media, its role in the development of aggression has been well supported.

Example of Hormones Affecting

For example, in one controlled study where anabolicandrogenic steroids were given to normal subjects, the participants reported both positive and negative mood symptoms; the latter included anger, hostility, and violent feelings

Anger is often described as a secondary emotion.

For example, it may be a response to unresolved grief, depression, fear, anxiety, or unresolved post-traumatic stress. Anger is also one of the stages of the normal grief process and thus is an expected emotion.

Anger responses can be learned through operant conditioning.

For example, when a child wants something and has been told no by a parent, he or she might have a temper tantrum. If the parent then gives the child an ice cream cone, the anger displayed during the temper tantrum has been positively reinforced (or rewarded).

Socioeconomic Factors

High rates of violence exist within the subculture of poverty in the United States. Exposure to violence has been identified as having an impact on future tendencies toward aggression.

Aggression is one way individuals express anger.

In virtually all instances, aggression is a negative function or destructive use of anger.

Anger is not always a negative expression.

It is a normal human emotion that, when handled appropriately and expressed assertively, can provide an individual with a positive force to solve problems and make decisions concerning life situations. Anger becomes a problem when it is not expressed or when it is expressed aggressively.

SUMMARY & KEY POINTS

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The Nursing Process in Anger Management

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"Any factors which increase the activity or reactivity of the brainstem (e.g., chronic traumatic stress, testosterone, disregulated serotonin or norepinephrine systems) or decrease the moderating capacity of the limbic or cortical areas (e.g., neglect) will increase an individual's aggressivity, impulsivity, and capacity to display violence.

Loss of function in the frontal cortex (and subsequently decreased moderating capacity) can also occur as a result of many pathological processes, including stroke, dementia, alcohol intoxication, and traumatic brain injuries, and has been associated with increased aggression.

Some possible predisposing factors include role modeling, operant conditioning, neurophysiological disorders (e.g., brain tumors, trauma, or diseases), biochemical factors (e.g., increased levels of androgens or other alterations in hormone levels and neurotransmitter involvement), socioeconomic factors (e.g., living in poverty), and environmental factors (e.g., physical crowding, uncomfortable temperature, use of alcohol or drugs).

Nurses must be aware of the symptoms associated with anger and aggression in order to make an accurate assessment.

Operant Conditioning

Operant conditioning occurs when a specific behavior is reinforced. Positive reinforcement is a response to a specific behavior that is pleasurable or offers a reward. Negative reinforcement is a response to a specific behavior that prevents an undesirable result from occurring

Outcome Criteria

Outcome criteria include short- and long-term goals. Timelines are individually determined.

Although aggression is modulated by several hormonal systems, testosterone is identified as playing a key role, and deficits in serotonin have been associated with an increase in impulsivity

Oxytocin administration has been associated with decreasing activation in the amygdala and decreasing aggression in men

Past history of violence is widely recognized as a major risk factor for violence in a treatment setting. Assaultive behavior is also highly correlated with specific diagnoses

Substance abuse (alone or in combination with a mental illness) is the single most important risk factor for violence;

An ongoing controversy exists as to whether economic inequality or absolute poverty is most responsible for aggressive and violent behavior within this subculture.

That is, does violence occur because individuals perceive themselves as disadvantaged relative to other persons, or does violence occur because of the deprivation itself? These concepts are not easily understood and are still under investigation.

Anger creates a state of preparedness by arousing the sympathetic nervous system.

The activation of this system results in increased heart rate and blood pressure, increased secretion of epinephrine (resulting in additional physiological arousal), and increased levels of serum glucose, among others.

Diagnosis and Outcome Identification

The following nursing diagnoses may be considered for patients demonstrating inappropriate expression of anger or aggression: ■ Ineffective coping ■ Risk for self-directed or other-directed violence

In a meta-analysis of prevalence and risk factors for violence by psychiatric acute inpatients (Iozzino et al., 2015), the researchers found that close to 1 in 5 patients may commit an act of violence.

The highest risk factors were male sex, a diagnosis of schizophrenia, substance use, and a history of violence. The best intervention is prevention, so risk factors for assessing violence potential are also presented.

Biochemical Factors

The impact of hormones, particularly testosterone, in aggression has been the focus of animal research, and although it has been associated with increased aggression in animals and correlation studies in humans, the effects of testosterone administration have yielded mixed results

Neurophysiological Factors

The neurophysiology of aggression is extremely complex and only partially understood despite years of research.

Environmental Factors

Three environmental factors that have been shown to increase risks for aggression are crowding, temperature, and noise

The following criteria may be used for measurement of outcomes in the care of the patient needing assistance with management of anger and aggression.

The patient: ■ Recognizes when he or she is angry and seeks out staff/support person to talk about his or her feelings ■ Takes responsibility for own feelings of anger ■ Demonstrates the ability to exert internal control over feelings of anger ■ Demonstrates the ability to diffuse anger before losing control ■ Uses the tension generated by the anger in a constructive manner ■ Causes no harm to self or others ■ Uses steps of the problem-solving process rather than becoming violent as a means of seeking solutions

All three of these environmental factors increase stress, which has a multitude of effects on mood and behavior. Past experiences and current behavior also influence aggressive expression

The three best predictors of violent behavior in this context are a history of childhood abuse, a history of violent acts with criminal activity or arrests, and alcohol intake

■ Aggression is a negative function or destructive use of anger.

Various predisposing factors to the way individuals express anger have been implicated. Some theorists suggest that the etiology is purely biological, whereas others believe it depends on psychological and environmental factors.

Anger is a normal, healthy emotion that serves as a warning signal and alerts us to potential threat or trauma. It triggers energy that sets us up for a good fight or quick flight and can range from mild irritation to rage.

Warren (1993) outlines some fundamental points about anger: ■ Anger is not a primary emotion, but it is typically experienced as an almost automatic inner response to hurt, frustration, or fear. ■ Anger is physiological arousal. It instills feelings of power and generates preparedness. ■ Anger and aggression are significantly different. ■ The expression of anger is learned. ■ The expression of anger can come under personal control.

When expressed inappropriately, anger commonly interferes with interpersonal relationships.

When anger is suppressed, it often turns to resentment.

Tumors in the brain, particularly in the areas of the limbic system and the temporal lobes; trauma to the brain resulting in cerebral changes; and diseases such as encephalitis (or medications that may effect this syndrome),

have all been implicated in the predisposition to aggression and violent behavior.

What other substances of abuse have been associated with aggression ?

methamphetamines and amphetamines, bath salts, anabolic steroids, synthetic marijuana, PCP, and alpha PVP (also known as flakka).

Anger is a very powerful emotion. When it is denied or buried, it can precipitate a number of physical problems such as

migraine headaches, ulcers, colitis, and even coronary heart disease. When turned inward on oneself, anger can result in depression and low self-esteem. When it is expressed inappropriately, it commonly interferes with relationships. When suppressed, anger may turn into resentment, which often manifests in negative, passive-aggressive behavior.

Behaviors usually do not occur in stages but most often overlap and sometimes occur simultaneously. Behaviors associated with this prodromal stage include

rigid posture; clenched fists and jaws; grim, defiant affect; talking in a rapid, raised voice; arguing and demanding; using profanity and threatening verbalizations; agitation and pacing; and pounding and slamming.

Anger Management

use of various techniques and strategies to control responses to anger-provoking situations. The goal of anger management is to reduce both the emotional feelings and the physiological arousal that anger engenders.

Anger is often manifested in the following ways:

■ Frowning facial expression -Clenched fists -Low-pitched verbalizations forced through clenched teeth -Yelling and shouting -Intense eye contact or avoidance of eye contact -Hypersensitivity, easily offended -Defensive response to criticism -Passive-aggressive behaviors -Lack of control or overcontrolled emotions -Intense discomfort; continuous state of tension -Flushed face -Anxious, tense, angry facial expression (affect)

Aggression may be associated with (but not limited to) the following defining characteristics:

■ Pacing, restlessness ■ Threatening body language ■ Verbal or physical threats ■ Loud voice, shouting, use of obscenities, argumentative ■ Threats of homicide or suicide ■ Increase in agitation, with overreaction to environmental stimuli ■ Panic anxiety, leading to misinterpretation of the environment ■ Suspiciousness and defensive posturing ■ Angry mood, often disproportionate to the situation ■ Destruction of property ■ Acts of physical harm toward another person

■ When denied or buried, anger can precipitate several psychophysiological disorders.

■ When anger is turned inward on the self, it can result in depression.

■ Anger, a normal human emotion, is not necessarily a negative response.

■ When used appropriately, anger can provide positive assistance with problem-solving and decision making in everyday life situations.