ANGER A normal human emotion

Strong, uncomfortable, emotional response to a real or perceived provocation.

Results when a person is frustrated, hurt, or afraid.
Energizes the body physically for self-defense, when needed, by activating the fight-or-flight
response mechanisms of the sympathetic nervous system.
HOSTILITY An emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or
threatening behavior.
PHYSICAL AGGRESSION 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 or to force
someone into compliance.
Onset a nd c linic al c our se: ang er

Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately.
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.
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, it can increase rather than alleviate angry
feelings.
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.
Hostile and aggressive behavior can be sudden and unexpected.
Stages or phases can be identified in aggressive incidents:
1. triggering phase
2. escalation phase
3. crisis phase
4. recovery phase
5. postcrisis phase
PHASE DEFINITION S/SX
TRIGGERING An event or circumstances in the Restlessness, anxiety, irritability, pacing,
environment initiates the clients response, muscle
which is often anger or hostility. tension, rapid breathing, perspiration, loud
voice, anger.
ESCALATION Clients responses represent escalating Pale or flushed face, yelling, swearing,
behaviors that indicate movement toward a agitated, threatening, demanding, clenched
loss of control. fists, threatening gestures, hostility, loss of
ability to solve the problem or think clearly.
CRISIS During a period of emotional and physical Loss of emotional and physical control,
crisis, the client loses control. throwing
objects, kicking, hitting, spitting, biting,
scratching, shrieking, screaming, inability to
communicate clearly.
RECOVERY Client regains physical and emotional Lowering of voice; decreased muscle tension;
control. clearer, more rational communication;
physical relaxation.
POST-CRISIS Client attempts reconciliation with others Remorse; apologies; crying; quiet, withdrawn
and returns to the level of functioning before behavior
the aggressive incident and its antecedents.
ANGER ATTACKS Sudden intense spells of anger that typically occur in situations in which the depressed person
feels emotionally trapped.
It involve verbal expressions of anger or rage but no physical aggression. It is described as
an 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 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.
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.

Intermittent explosive disorder develops between late adolescence and the third decade of
life.

ACTING OUT
ETIOLOGY: NEUROBIOLOGIC THEORIES
Clients with intermittent explosive disorder typically are large men with dependent
personality features who respond to feelings of uselessness or ineffectiveness with violent
outbursts.
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 persons ability to deal with feelings and emotions.

Low serotonin levels may lead to increased aggressive behavior

increased activity of dopamine and norepinephrine in the brain is associated with increased impulsively violent behavior
structural damage to the limbic system and the frontal and temporal lobes of the brain may alter the persons ability to modulate
aggression; this can lead to aggressive behavior.
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 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, those who receive inconsistent responses to their behavior, and those whose
families are of lower socioeconomic status are at increased risk for failing to develop socially appropriate behavior, thus, resulting in a
person who is impulsive, easily frustrated, and prone to aggressive behavior.
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 was often seen as a means of re-establishing control, improving mood, or achieving retribution.
CULTURAL CONSIDERATIONS
HWA-BYUNG is a culture-bound syndrome that literally translates as anger syndrome or fire illness,
attributed to the suppression of anger.
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.
BOUFFE DELIRANTE is a condition observed in West Africa and Haiti. It is characterized by a sudden outburst of
agitated and aggressive behavior, marked confusion, and psychomotor excitement.
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.
Precipitated by a perceived slight or insult and is seen only in men.
Originally reported from Malaysia, similar behavior patterns are seen in Laos, the
Philippines, Papua New Guinea, Polynesia, Puerto Rico, and among the Navajo.
TREA TMENT
Lithium has been effective in treating aggressive clients with bipolar disorder, conduct disorder and mental retardation.
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, mental retardation, and personality disorders.
Benzodiazepines can reduce irritability and agitation in older adults with dementia.
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 were 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.
MA N A GING AGGRESSIVE BEH A VIOR
In the triggering phase, the nurse should approach the client in a nonthreatening, calm manner in order to de-escalate the clients
emotion and behavior.
Conveying empathy for the clients 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 himself or herself.
PRN Medications should be offered, if ordered.
As the clients anger subsides, the nurse can help the client to use relaxation techniques and look at ways to solve any problem or
conflict that may exist.
Physical activity, such as walking, also may help the client relax and become calmer.
During the escalation phase, 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 clients 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.
When the client becomes physically aggressive during the crisis phase, the staff must take charge of the situation.
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.
Four to six trained staff members are needed to restrain an aggressive client safely. Four staff members each take a limb, one staff
member protects the clients head, and one staff member helps control the clients 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.
N ur si ng c ar e plan: aggr es si ve beha vi or
Build a trust relationship with this client as soon as possible, ideally well in advance of aggressive episodes.
Be aware of factors that increase the likelihood of violent behavior or agitation. Use verbal communication or PRN medication to
intervene before the clients behavior reaches a destructive point and physical restraint becomes necessary.
If the client tells you (verbally or nonverbally) that he or she feels hostile or destructive, try to help the client express these feelings in
nondestructive ways.
Be aware of PRN medication and procedures for obtaining seclusion or restraint orders.
Be familiar with restraint, seclusion, and staff assistance procedures and legal requirements.
Always maintain control of yourself and the situation; remain calm. If you do not feel competent in dealing with a situation, obtain
assistance as soon as possible.
Calmly and respectfully assure the client that you will provide control if he or she cannot control himself or herself, but do not threaten
the client.
If you are not properly trained or skilled in dealing safely with a client who has a weapon, do not attempt to remove the weapon.
Keep something (like a pillow, mattress, or a blanket wrapped around your arm) between you and the weapon.
If it is necessary to remove the weapon, try to kick it out of the clients hand. (Never reach for a knife or other weapon with your hand.)
Distract the client momentarily to remove the weapon (throw water in the clients face, or yell suddenly).
Remain aware of the clients body space or territory; do not trap the client.
Allow the client freedom to move around (within safe limits) unless you are trying to restrain him or her.
Talk with the client in a low, calm voice. Call the client by name, tell the client your name, where you are, and so forth.
Tell the client what you are going to do and what you are doing. Use simple, clear, direct speech. Do not threaten the client, but state
limits and expectations.
Do not use physical restraints or techniques without sufficient reason.
Do not strike the client.
Do not help to restrain or subdue the client if you are angry.
Do not restrain or subdue the client as a punishment.
Do not recruit or allow other clients to help in restraining or subduing a client.
Poi nts to c o nsider w hen wor ki n g wi th a ngr y, hosti l e, or ag gr e ssive c lients
Identify how you handle angry feelings; assess your use of assertive communication and conflict resolution. Increasing your skills in
dealing with your angry feelings will help you to work more effectively with clients.
Discuss situations or the care of potentially aggressive clients with experienced nurses.
Do not take the clients anger or aggressive behavior personally or as a measure of your effectiveness as a nurse.