Anger, Hostility, and Aggression
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| Hostility | Verbal aggression, emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior
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| Anger | Human emotion. Perceived as a negative feeling; 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.
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| Catharsis | alleviate or increase feeling of anger
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| Physical Aggression | Attack or injury to another person; destruction of property; both to harm or punish another person or force into compliance. Sudden, unexpected
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| Intermittent Explosive Disorder | Rare psychiatric dx; discrete episodes of aggressive impulses that result in serious assaults or destruction of property. Grossly disproportionate to any provocating or precipitating factor. Diagnosis made if no other comorbid psychiatric disorders
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| Neurobiologic Theories | Possible role of neurotransmitters; decreased serotonin; increased dopamine, norepiniphrine. Structural damage to limbic system; damage to frontal or temporal lobes. Low serotonin levels may lead to increased aggressive behavior
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| Psychosocial Theories | Failure to develop impulse control; Inability to delay gratification
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| Impulse Control | Ability to delay gratification and socially appropriate behavior
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| Rejection | Can lead to anger and aggression when that rejection causes the individual emotional pain or frustration. Is a threat to self-esteem
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| Acting Out | Immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings
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| Five-Phase Aggression Cycle | Triggering Phase, Escalation, Crisis, Recovery, Post Crisis
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| Triggering Phase | Event or circumstances in the environment initiates the client's response which is often anger or hostility
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| Escalation | Responses represent escalating behaviors that indicate movement toward a loss of control
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| Crisis | During a period of emotional and physical crisis, client loses control
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| Recovery | Client Regains Physical and emotional control
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| Post Crisis | Attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents
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| Haloperidol and lorazepam | decrease agitation or aggression and psychotic symptoms
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| Benzodiazepines | Irritability and agitation in older adults with dementia
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| Atypical antipsychotics | (Clozapine, risperidone, and olanzapine) for dementia, brain injury, mental retardation, personality disorders
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| Carbamazepine and valproate | dementia, psychosis, personality disorder
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| Interventions | Most effective, lease restrictive environment when implemented early in cycle of aggression. Offer opportunity for problem-solving or conflict resolution
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| Environmental management | Planned activities, informal discussions, scheduled one-to-one interactions, assistance with problem solving or conflict resolution to avoid expression of anger, safety of other patients
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| Aggression management: triggering phase | Approach in non-threatening, calm manner. Convey empathy, listening, encourage verbal expression of feelings, suggest patient go to a quieter area, use PRN medications (offer), suggest physical activity such as walking, use clear, short, simple statements
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| Aggression management: escalation phase | Take control; provide directions in firm, calm voice; Direct pt to room or quiet area for time-out; offer meds again. Aggression is unacceptable; nurse or staff will help manage/regain control. If ineffective, obtain help from other staff. "show of force"
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| Aggression management: crisis phase | Inform patient that behavior is out of control, and staff is taking control to provide safety and prevent injury. Use of restraints or seclusion only if necessary based on facility protocol and standards
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| Aggression management: recovery phase | Talk about situation or trigger; help pt relax or sleep; explore alternatives to aggressive behavior. provide documentation of any injuries; debrief staff
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| Aggression management: post crisis phase | Remove patient from any restraint or seclusion to rejoin milieu. Calmly discuss behavior, allow patient to return to activities, groups and so forth. Focus on appropriate expression of feelings, resolution of problems or conflicts in nonaggressive manner
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| Evaluation | Goal is to teach angry, hostile, and potentially aggressive clients to express feelings verbally and safely without threats or harm to others or destruction of property
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| Effective management of comorbid conditions | Regular follow-up appts, compliance with prescribed meds, participation in community support programs, anger management groups to help client express feelings and learn problem solving and conflict resolution techniques
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