Anger, Hostility, and Aggression

 Anger is a normal human emotion.

 Hostility and aggression are inappropriate expressions of
anger.
 Anger is a strong, uncomfortable, emotional response to a
provocation, either real or perceived.
 It results when one is frustrated, hurt, or afraid and
energizes the body for defense (fight or flight).
 Denying or suppressing angry feelings can lead to physical
or emotional problems.
 Anger that is expressed inappropriately can lead to
hostility and aggression
 Appropriate expression of anger involves assertive
communication skills that lead to problem solving or conflict
resolution
 Venting angry feelings by engaging in safe but aggressive
activities (punching bag, yelling) is called catharsis.
However, research has shown that catharsis may increase
rather than alleviate angry feelings
 Clients with depression may have anger attacks when
they feel emotionally trapped

Hostility and Aggression

Hostile and aggressive behavior may occur suddenly without
warning, but often stages or phases can be identified:
• Triggering
• Escalation
• Crisis
• Recovery
• Postcrisis

 Hostility is an emotion expressed by:

 Verbal abuse
 Lack of cooperation
 Violation of rules or norms
 Threatening behavior (verbal aggression)
 Related Disorders
 Most psychiatric clients are not aggressive, but some
exhibit angry, hostile, or aggressive behavior caused by:
– Paranoid delusions
– Auditory (command) hallucinations

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 – Dementia, delirium
– Head injury
– Intoxication with alcohol or drugs
– Antisocial and borderline personality disorders
Acting Out
An immature defense mechanism in which the person deals
with emotional conflict or stress by actions rather than
reflection or feelings; the person is trying to feel less powerless
or helpless by acting out.

Etiology of Hostility and Aggression

⇒ Neurobiologic theories:
– Decreased serotonin
– Increased dopamine and norepinephrine
– Structural damage to limbic system
– Damage to frontal or temporal lobes
⇒ Psychosocial theories:
– Failure to develop impulse control and ability to delay
gratification
– Cultural Considerations
 In certain cultures, expressing anger may be
seen as rude or disrespectful; some culture-bound
syndromes involve aggressive, agitated, or violent
behavior.

Treatments and Medications

Treatment often focuses on treating the underlying or comorbid
psychiatric diagnosis such as schizophrenia or bipolar disorder.

Aggressive Clients
• Lithium for bipolar disorder, conduct disorder, or mental
retardation
• Carbamazepine (Tegretol) or valproate (Depakote) for
dementia, psychosis, or personality disorders
• Atypical antipsychotics such as clozapine (Clozaril),
risperidone (Risperdal), and olanzapine (Zyprexa) for dementia,
brain injury, mental retardation, and personality disorders
• Benzodiazepines for older adults with dementia
• Haloperidol (Haldol) and lorazepam (Ativan) for clients with
psychoses

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Application of the Nursing Process
Assessment:
1. Early assessment and intervention needed when clients
are angry or hostile to avoid physically aggressive episodes
2. Nurse must assess both individual clients and the
therapeutic milieu or environment
3. Assessment and intervention are based on five phases of
aggression

Data Analysis:
Common nursing diagnoses:
1. Risk for Other-Directed Violence
2. Ineffective Coping

Outcome Identification:
The client will:
1. Not harm self or threaten others
2. Refrain from intimidating or frightening behaviors
3. Describe feelings and concerns without aggression
4. Comply with treatment

Intervention:
Interventions are most effective and least restrictive when
implemented early in the cycle of aggression.
1. Managing the milieu includes:
 Having planned activities; informal discussions
 Scheduled one-to-one interactions; letting clients
know what to expect
 Helping clients with conflicts to solve their problems,
including expression of angry feelings
2. Managing aggressive behavior includes:
a- Triggering phase:
1. Approach in nonthreatening, calm manner
2. Convey empathy
3. Listen
4. Encourage verbal expression of feelings
5. Suggest going to a quieter area, or use of PRN
medications
6. Physical activity such as walking
b- Escalation phase:

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 1. Take control
2. Provide directions in firm, calm voice
3. Direct client to room or quiet area for time out
4. Offer medication again
5. Let client know aggression is unacceptable and nurse
or staff will help maintain/regain control if needed
6. If ineffective to that point, obtain assistance from
other staff (show of force) to get client to take time out or
take medication
c- Crisis phase:
1. Staff must take control of situation as determined by
facility or agency policy (trained in techniques for
behavioral management)
2. Use restraint or seclusion only if necessary

d- Recovery phase : as client regains control:

1. Talk about the situation or trigger
2. Help client relax or sleep
3. Explore alternatives to aggressive behavior
4. Provide documentation of any injuries
5. Staff debriefing

e. Postcrisis phase:
1. Client is removed from any restraint or seclusion and
rejoins the milieu
2. Calm discussion of behavior; no lecturing or
chastising; return to
activities, groups, and so forth
3. Focus is on appropriate expression of feelings,
resolution of problems or conflicts in nonaggressive
manner

Evaluation
1. Was the client’s anger defused in an early stage?
2. Did the angry, hostile, and potentially aggressive
client learn to express feelings verbally and safely without
threats or harm to others or destruction of property?
3. Was the client’s anger defused in an early stage?
4. Did the angry, hostile, and potentially aggressive
client learn to express feelings verbally and safely without
threats or harm to others or destruction of property?