ANGER, HOSTILITY AND AGGRESSION

(Combative- Aggression Behaviour)

- Acting out feeling of frustration, anger, anxiety, etc. through physical or verbal
behaviour.

ACTING OUT – is an immature defense mechanism by which the person deals with emotional
conflicts or stressors through actions rather than through reflection of feelings.

ANGER

- Normal human emotion is a strong, uncomfortable, emotional response to real or

perceived provocation.
- Often received as a negative feeling.
- Becomes negative when the person denies it, suppresses it, or expresses it
inappropriately at leads to hostility and aggression.

*Effective methods of anger expression.

- using assertive communication (tell indirectly frankly) to replace aggressive outburst of
temper such as yelling/throwing things
- controlling one’s temper
- managing anger effectively

*Effective methods of anger expression:

- using assertive communication (tell individual frankly) to replace aggressive outburst of
temper such as yelling / throwing things.
- controlling one’s temper
- managing anger effectively

***Anger suppression is common in women.

CATHARSIS – expressing angry feelings by engaging in aggressive but safe activities.

Ex. Hitting punching bag
Yelling

HOSTILITY / VERBAL EXPRESSION

- emotion expressed through verbal abuse, lack of cooperation, violation of rules or
norms of threatening.

5 PHASES OF AGGRESSION CYCLE (T, E, C, R, P)

1) TRIGGERING PHASE

- Event or circumstances in the environment initiates the patient’s anger or hostility.

S/S – restlessness, anxiety, irritability, pacing, muscle tension, loud voice, rapid breathing,
perspiration.

2) ESCALATION PHASE

- movement towards a loss of control

SIS Behaviors:

- pale or flushed face

- yelling, demanding clenched fist
- threatening gestures
- loss the ability to solve the problem.

3) CRISIS PHASE

- the patient loses control

S/S - loss of environmental and physical control, throwing objects, kicking, screaming, biting,
spitting, hitting, inability to communicate clearly.

4) RECOVERY PHASE

- the patient regains physical and environmental control.

S/S

- lowering of voice
- decreased muscle tension
- physical relaxation
- rational communication

5) POST – CRISIS PHASE

- patient attempts reconciliation with others and returns to the level of functioning before the
aggressive incident.

- What to do with an aggressive pt.?

A.) Maintain a distance of about 6 feet but still try to calm down the patient.
S/S

- remorse
- apologies
- crying, quiet, withdrawn behaviour

ETIOLOGY:

1) Neurological theories

Factors that lead to increased aggressive behaviour:

- low serotonin level maybe r/t anger attack in some patient with depression.
- Increased dopamine and NE is associated with increased impulsively violent behaviour.
- Damage to the limbic system and the frontal and temporal lobes of the brain.

2) Psychosocial Theories

- children in dysfunctional family with poor parenting.

- children who received inconsistent responses to their behavior.

- Lower economic status

- rejection

3) Cultural Considerations

HWA- BYUNG or HWABYEONG – seen in Korea, predominantly in women, is a culture bound

syndrome that literally translates as anger syndrome or fire-illness attributed to the
suppression of anger.

BOUFFEE DELIRANTE

- West African and Haiti

- Sudden outburst of agitated behavior, marked confusion, and psychomotor excitement.
- Visual and auditory hallucinations and paranoid ideation that resemble brief psychotic
episode.

AMOK

- Dissociative episode characterized by a period of brooding followed by an outburst of

violent, aggressive, or homicidal behavior directed at other people and objects.
- Precipitated by a perceived slight or insult
- Seen only in men
POLYNESIA: Cafard

PUERTO RICO: Mal de Pelea

NAVAJO: Iich’aa

INTERVENTION

Managing the environment to reduce or eliminate aggressive behavior

- Plan group activities such as card games, watching and discussing movies
- One-on-one interaction
- Expressing angry feeling appropriately
- Close observation of the client

MANAGING AGGRESSIVE BEHAVIOR

TRIGGERING PHASE (ACEUR)

A – approach patient in a NON-THREATENING, calm manner

C – convey empathy

E – encourage client to express his/ her angry feeling

U - use clear simple, short statement which are helpful

R- use of relaxation techniques

- medications be offered (PRN or as needed)

- physical activities (walking)

ESCALATION PHASE

- Take control of the situation by:

o Providing directions to the client in a calm, firm voice
o Direct patient to take a time-out for cooling off in a quiet area
o Inform client that aggressive behavior is not acceptable
o If PRN meds was previously declined, offer again.
o If client’s behavior continuous “show or force” be done.

CRISIS PHASE
 - The staff takes charge of the situation for the safety of the client, staff and other clients.
- Only trained staff shall participate in the restraint of a physically aggressive client.
- Reminder: use of seclusion and restraint should be based on the facility protocols.

RECOVERY PHASE

- Encourage client to talk about the situation/triggers that led to the aggressive behavior.
- Help client relax, perhaps sleep and return to a calmer state.
- Help client explore alternatives to aggressive behavior
- Encourage client to talk about the incident
- Among the staff, debriefing session be done for any needed improvement in handling
some situation in the future.

POST CRISIS

- After removal from seclusion, discuss with the client, the behavior in a calm, rational
manner.
- Client be reintegrated into the milieu and activities as soon as the client can participate.

COMBAT

C – control immediate situation

- Set their attention

- Remove harmful object
- Maintain distance (6 ft. between self and client)
- Remain neutral

O – out of situation

- Remove client from the environment to de-escalate combative behavior

M – maintain calmness

- Do not hurry
- Channel the agitated behavior

B – be firm and set limits

- Be consistent and prevent overt aggression

A- avoid restraints

- Use restraints as last interventions

T – try consequences

- Positive consequences for positive behavior

TREATMENT
- Often focuses on treating the underlying or comorbid psychiatric dx.

LITHIUM
- effective in treating aggressive clients with bipolar disorder, conduct disorder with
children mental retardation.

TEGRETOL AND DEPAKOTE

- dementia, psychosis, personality disorder

- are mood stabilizers

LITHIUM

L – Levels

- lithium serum levels should be between 0.5 – 1.2 mEq/L (maximum of 1.5 mEq/L)
- blood test be done weekly (initially) then 1-2 month
- blood should be drawn in the morning 8 – 12 hrs. after the last dose.
- be taken on regular basis, same time, daily with meals or milk (DO NOT CRUSH, CHEW
OR BREAK the extended-release or film coat tablets)

I – inconvenience

- Or polyuria (side effect)

T – thyroid/thirst

- Polydipsia (abnormal intense thirst)

- Report sign of hypothyroidism
- Lab studies of the thyroid hormone and periodic palpation of the thyroid gland
- Symptom is reversible when lithium is discontinued and supplemental thyroid is
provided.

H – hand tremors

- Fine hand tremors or jaw tumors may occur in early treatment of mania or sometimes
persist throughout therapy
- Symptoms subside with the reduction of dose.
I – increase fluids

- Fluid intake of 3 L / day (1 glass = 250 ml)

- Assess clients who are at high risk to develop toxicity (postoperative, DHN,
hyperthyroidism, renal disease, or those taking diuretics)
(Remember: Diuretics decrease lithium excretion increases risk for toxicity)

U – Unsteady gait

- Neuromuscular reaction

M – Manic / morton’s salt

- Diet should contain normal amount of salt.

Other Nursing Consideration with anti-manic drug

normal carbamazepine levels: 4 – 12 ug/ml

- agranulocytosis (adverse effect of carbamazepine)

- Severe acute deficiency of neutrophils (result of damage to the bone marrow by toxic
drugs or chemicals)
- Metallic taste – side effect of lithium
- If dietary Na increases, lithium level decreases
- Interaction with antipsychotic-mask early sign of lithium toxicity (nausea/v)
- Takes 7-10 days to effect
- NO ANTIDOTE of Lithium toxicity

MAJOR TRANQUILIZER / ANTIPSHYCHOTIC

Traditional Antipsychotic Atypical Antipsychotic

HIGH-POTENCY: Clozapine (Clozaril)
Fluphenazine (Prolixin) Pirperidone (Pisperdal)
Haloperidol (Haldol) Olanzapine (Zypexa)
Thiothixine (Navane) Ziprasidone (Zeldox)
Trifluperazine (Stelazine)

MODERATE – POTENCY:
Loxapine (Loxitane)
Molindone (Moban)
Perphenazine (Trilafon)

LOW – POTENCY:
Chloropromazine (Thorazine)
Thioridazine (Mellavil)

Actions:

- Improve thought processes and behavior of psychotic clients

- Traditional types are dopamine blockers, thereby reducing psychotic symptoms.
- Chlorpromazine will serve as prototype
- Blocks chemoreceptors trigger zone and vomiting center, producing antiemetic effect
- Phenothiazines (thorazine) lower seizure threshold
- Enters CNS rapidly for tranquilizing effect but only a fraction of it enters because it is
bound to plasma proteins and accumulates in fatty tissue
- Half-life of 10-30 hrs.
- Atypical types are dopamine agonist, serotonin blockers.

Indications: Schizophrenic patients

Contraindication: Elderly and decreased WBC count

UNDESIRABLE (ADVERSE) EFFECTS OF ANTIPSYCHOTICS

STANCE

S – sedation (sleepiness)
- Sunlight sensitivity
T - Tardive dyskinesia
- An irreversible effect that charges the stance because it changes the head
A – Anticholinergic (makes client’s mouth dry and cause constipation)

- Agranulocytosis

***report SORE THROATS/ SIGNS OF SEPSIS

N – neuroleptic malignant syndrome (NMS)

C – cardiac effect

- Orthostatic hypertension

E – extrapyramodal (akathisia)

Extrapyramidal Symptoms:

1) PARKINSONISM (tremors, masklike faces, rigidity, shuffling gait)

2) DYSTONIA (facial grinning, abnormal or involuntary eye movement)

3) AKATHESIA (restlessness, combat moving about)

4) TARDIVE DYSKINESIA – (protrusion of tongue, chewing motion, involuntary movement of

body extremities)

NMS

- a potentially fatal syndrome (but rare) commonly occurs at initiation of therapy,

increase of dosage, change of meds or combined.

Assessment:
1. Dyspnea or tachypnea
2. Tachycardia or irregular pulse
3. Fever, increased or decreased blood pressure
4. Increased sweating, loss of bladder control

*Never combine L and antipsychotic!

5. Skeletal muscle rigidity, pale skin
6. Excessive weakness or fatigue
7. Altered LOC, seizures
8. Severe EPS
9. Dysphagia, excessive salivation, dyskinesia
10. Increased WBC, increased liver function tests

INTERACTIONS

1) If with:

SSRI – increased EPS

Amphetamines – decreased antipsychotic effect

Anticholinergic – increased anticholinergic effects

Barbiturates – causes respiratory depression

Benzodiazepines - increased sedation

 Insulin – weakened control of

Narcotics – further hypotension and sedation

Lithium – decreased antipsychotic effect, neurotoxicity

Tricyclies – possible ventricular arrythymias

Important nursing considerations:

1. Monitor for compliance

2. Check for “cheeking” or “hoarding”
3. Daily therapy for 3-6 weeks or more maybe needed before a drug’s effectiveness
4. Give anti-parkinson or antihistamine drugs for dystonias
5. Routinely take temperature for NMS
6. Avoid immersion in hot water – may cause further hypotension
7. Avoid abrupt withdrawal of medication
8. Monitor for blood dyscrasias

ABUSE AND VIOLENCE

Characteristics of a healthy family:

1) Reassuring/supportive by helping each other in developing competence / skills.

2) Sets clear boundaries between the older and younger family members.

3) Allows each member to express disagreement but still be accepted and loved.

4) Honesty is encouraged.

5) Gives realistic expectations and values the contribution of each family.

6) Reality is focused, able to recognize each member’s contributions in dysfunctional problem

and does not blame the individual.

Characteristics of violent families:

1) Social isolation

2) Abuse of power and control

3) Alcohol and other drug abuse

4) Intergenerational transmission process

FAMILY VIOLENCE

- Family members tolerate abusive and violent behavior from relatives they would never
accept from strangers.
- The home, which normally is a safe haven of love and protection, may be the most
dangerous place for the victims.

BATTERED WIFE / PARTNER ABUSE

Domestic violence – refers to violence occurring between partners in an ongoing relationship.

Battering – is not simply physical violence, and it is not just a conflict between two people. It is
rather, a systematic pattern of domination and control.

Battered wife – any woman over the age of 16 with evidence of physical abuse or at least one
occasion at the hands of an intimate partner.

Battered Wife Syndrome

- A complex syndrome wherein a woman experiences repeated and deliberate pattern of

abuse, with injury ranging from severe bruising to more serious injuries.

PATTERN OF INTIMATE PARTNER VIOLENCE

1) Psychological Abuse (Emotional Abuse)

- the abuser establishes total control over the victim (partner)
- name calling, belittling, screaming, yelling, making threats, destroying properties, ignoring the
victim.

2) Physical Abuse
- an act that results in non-accidental physical injury to the partner.

3) Sexual Abuse
- forcing a woman to perform sexual acts against her will, physically attacking the sexual parts
of the body and treating her like a sex object.

4) Financial / Economic Abuse

- Unilaterally restricting her access to financial resources by forcing her to ask money, giving her
allowances and taking her own money.