Anger, Hostility and Aggression
Facilitator:
Uzma Rafique
BSN-RN
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Learning Objectives:
After reading this chapter, you should be able to:
1. Discuss anger, hostility, and aggression.
2. Describe psychiatric disorders that may be associated
with an increased risk for hostility and physical
aggression in clients.
3. Describe the signs, symptoms, and behaviors
associated with the five phases of aggression.
4. Discuss appropriate nursing interventions for the
client during the five phases of aggression.
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Anger
• ANGER, A NORMAL HUMAN EMOTION, is a
strong, uncomfortable, emotional response to a real or
perceived provocation.
• Anger is “a strong, uncomfortable emotional response
to a provocation that is unwanted and incongruent
with one’s values, beliefs, or rights”.
(Thomas,
2001)
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• Anger results when a person is frustrated, hurt, or afraid.
• Anger can be a positive force, if held properly, that helps a
person to resolve conflicts, solve problems, and make
decisions.
• Anger energizes the body physically for self-defense.
• When expressed inappropriately or suppressed can cause
physical or emotional problems or interfere with
relationships.
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Hostility
• Hostility, also called verbal aggression, is an emotion
expressed through verbal abuse, lack of cooperation,
violation of rules or norms, or threatening behavior.
(Schultz & Videbeck,
2009)
• 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.
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Aggression
• Physical aggression is behavior in which a person
attacks or injures another person or that involves
destruction of property.
• Both verbal and physical aggression are meant to harm
or punish another person.
• Some clients with psychiatric disorders display hostile or
physically aggressive behavior that represents a
challenge to nurses and other staff members.
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Onset and clinical course
• Although anger is normal, it often is perceived as a
negative feeling.
• Anger becomes negative when the person denies it,
suppresses it, or expresses it inappropriately.
• Anger that is expressed inappropriately can lead to
hostility and aggression.
• Possible consequences are physical problems such as
migraine headaches, ulcers, or coronary artery disease
and emotional problems such as depression and low self-
esteem.
• The nurse can help clients express anger appropriately
by serving as a model and by roleplaying assertive
communication techniques.
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• 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.
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Style Characteristic Behaviors
Anger suppression Feeling anxious, Acting as though
nothing happened, Withdrawing
from people, Conveying anger
nonverbally by body language
Sulking, pouting, or ruminating
Unhealthy outward anger expression Expressing anger in an attacking or
blaming way Yelling, saying nasty
things, Calling the other person
names, Using fists rather than words
to express angry feelings
Constructive anger discussion Discussing the anger, Approaching
the person with whom one is
angry and discussing the concern
directly Using “I” language to
describe feelings and request
changes in
another’s behavior
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Hostility and Aggression
Hostile and aggressive behavior can be sudden
and unexpected.
Stages of Aggression Cycle
Stages or phases can be identified in aggressive
incidents:
1) Triggering phase (incident or situation that
initiates an
aggressive response)
2) Escalation phase
3) Crisis phase
4) Recovery phase
5) Post-crisis phase
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Related Disorders and
Anger, Hostility, or
Aggression
❖ Paranoid delusions
❖ Auditory hallucinations
❖ Dementia, delirium
❖ Intoxication with alcohol
❖ Antisocial, borderline PD
❖ Depression
❖Intermittent explosive disorder: (discrete episodes
of aggressive impulses that result in serious assaults
or destruction of property)
❖ Acting-out behaviors: children and adolescents
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Etiology of Hostility and
Aggression
1. Neurobiological theories
• Possible role of neurotransmitters: decreased serotonin;
increased dopamine, norepinephrine
• Structural damage to limbic system; damage to frontal
or temporal lobes
2. Psychosocial theories
• Failure to develop impulse control
• Inability to delay gratification-impulse control (the
ability to delay gratification)
• Rejection of any kind
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Treatment
Underlying/comorbid psychiatric diagnosis
• Lithium: bipolar and conduct disorders; mental
retardation
• Carbamazepine or valproate: dementia, psychosis,
personality disorders
• Atypical antipsychotics: clozapine, risperidone, and
lanzapine: dementia, brain injury, mental
retardation, personality disorders
• Benzodiazepines: irritability and agitation in older adults
with dementia
• Haloperidol and lorazepam: decrease agitation
or aggression and psychotic symptoms
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Treatment
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.
Video Link:
https://youtu.be/12OoEaYN
sL8
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Applying Nursing
Process-Assessment
• Nurse should be aware of factors that influence
aggression
• Individual patients (history of violent or
aggressive behavior in past and how patient
handles anger)
• Patient’s behavior to determine phase of aggression
cycle
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The Nursing Process: Data
Analysis and Outcome
Identification
Data analysis
• Risk for other-directed violence
• Ineffective coping
Outcome identification:
patient will
• Not harm self or threaten others
• Refrain from intimidating/frightening behaviors
• Describe feelings, concerns without aggression
• Comply with treatment
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The Nursing Process:
Interventions
Most effective, least restrictive when implemented early in
cycle of aggression.
Environmental management;
• Planned activities; informal discussions
• Scheduled one-to-one interactions (letting patients
know what to expect)
• Assistance with problem solving or conflict resolution
to avoid expression of anger
• Safety of other patients
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The Nursing Process:
Interventions
Aggression management: triggering phase
• Approach in nonthreatening, calm manner
• Convey empathy; listening
• Encourage verbal expression of feelings
• Suggest patient go to a quieter area
• Use PRN medications
• Suggest physical activity such as walking
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The Nursing Process:
Interventions
Aggression management: escalation phase
• Take control; provide directions in firm, calm voice
• Direct patient to room or quiet area for time-out
• Offer medication again
• Let patient know aggression is unacceptable; nurse or staff
will help maintain/regain control
• If ineffective, obtain help from other staff (show of force)
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The Nursing Process:
Interventions
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 restraint or seclusion only if necessary
Aggression management: recovery phase
• Talk about situation or trigger
• Help patient relax or sleep
• Explore alternatives to aggressive behavior
• Provide documentation of any injuries
• Debrief staff
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The Nursing Process:
Interventions
Aggression management: post-crisis
phase
• Remove patient from any restraint or seclusion to
rejoin milieu.
• Calmly discuss behavior (no lecturing or chastising);
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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The Nursing Process:
Evaluation
• Was patient’s anger defused in an early stage?
• Did angry, hostile, and potentially aggressive patient
learn to express feelings verbally and safely
without threats or harm to others or destruction of
property?
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Reference:
V. L. Sheila. Psychiatric–Mental Health Nursing.
5th edition
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