Chapter 11 Anger, Hostility, & Violence

Question 1

Anger

Answer 1

A normal human emotion, is a strong, uncomfortable, emotional response to a real or perceived provocation

Results when a person is frustrated, hurt, or afraid

Can be constructive or destructive

Question 2

Constructive Anger

Answer 2

If there is an unfair or wrong situation or self-defense

Question 3

Destructive Anger

Answer 3

When denied, suppressed, or expressed inappropriately

Increases risk of health problems (e.g., HTN, ulcers, CAD

Question 4

Effects of Anger When Handled Appropriately & Expressed Assertively

Answer 4

Can be a positive force that helps a person resolve conflicts, solve problems, and make decisions.

Anger energizes the body physically for self-defense when needed by activating the “fight-or-flight” response mechanisms of the SNS

Question 5

Effects of Anger When Handled Inappropriately or Suppressed

Answer 5

Can cause physical or emotional problems or interfere w/relationships

Question 6

Hostility

Answer 6

AKA Verbal Aggression

An emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior

May express hostility when they feel threatened or powerless

Question 7

What is the intention behind hostility?

Answer 7

Intended to intimidate or cause emotional harm to another, and it can lead to physical aggression

Question 8

Physical Aggression

Answer 8

Behavior in which a person attacks or injures another person or destroys property

Question 9

What is the intention behind physical aggression?

Answer 9

Both verbal and physical aggression are meant to harm or punish another person or to force someone into compliance

Some clients with psychiatric disorders display hostile or physically aggressive behavior that represents a challenge to nurses and other staff members.

Question 10

(T/F) True or False: Anger is a negative feeling and should be repressed.

Answer 10

FALSE!!

Anger or angry feelings are not bad or wrong. It is not healthy to deny or try to eliminate ever feeling angry. It is essential for good health to recognize, express, and manage angry feelings in a positive manner.

Question 11

When does anger become negative?

Answer 11

When the person denies it, suppresses it, or expresses it inappropriately
- A person may deny or suppress (i.e., hold in) angry feelings if they are uncomfortable expressing anger.

Possible consequences are physical problems such as:
- Migraine headaches
- Ulcers,
- CAD

Emotional problems such as depression and low self-esteem.

Question 12

Assertive Communication

Answer 12

Uses “I” statements that express feelings and are specific to the situation
Ex) “I feel angry when you interrupt me,”
Ex) “I am angry that you changed the work schedule without talking to me.”

This allows appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger

Question 13

Catharsis

Answer 13

Activities that are supposed to provide a release for strong feelings such as anger or rage

Can increase instead of alleviate angry feelings

CONTRAINDICATION for angry patients

Activities that are non-violent tend to be more effective:
- Walking
- Drawing
- Talking w/ another person

Question 14

Example of Catharsis

Answer 14

Hitting a punching bag or yelling

Question 15

Cognitive Behavioral Techniques (CBT) to Alleviate Anger

Answer 15

Distraction, problem-solving, reframing one’s perspective

Question 16

High hostility and anger are associated w/…

Answer 16

…increased risk of CAD & HTN

Hostility can lead to angry outbursts that are NOT effective for anger expression

Simply suppressing or attempting to ignore angry feelings may adversely affect control of hypertension

Controlling one’s temper or managing anger effectively should not be confused with suppressing angry feelings

Anger-related personality traits and social inhibition are associated with the presence and severity of coronary artery disease

Question 17

Anger Suppression in Women

Answer 17

Anger suppression is more common in women than men

Women have been socialized to maintain and enhance relationships with others and to avoid the expression of the so-called negative or unfeminine emotions such as anger

Often results when:
- People deny them power or resources
- Treat them unjustly
- Behave irresponsibly toward them

School-age girls report experiences of disrespect, dismissal, and denial of the right to express anger

Offenders are usually their closest intimates

Manifestations of anger suppression through somatic complaints and psychological problems are more common among women than men

Question 18

Hostile & aggressive behavior can be…

Answer 18

…sudden & unexpected

Question 19

What are the stages of an aggressive incident?

Answer 19

1) Triggering Phase
2) Escalation Phase
3) Crisis Phase
4) Recovery Phase
5) Postcrisis Phase

Question 20

Triggering Phase

Answer 20

An incident or situation that initiates an aggressive response

Signs, Symptoms, & Behaviors
- Restlessness
- Anxiety
- Irritability
- Pacing
- Muscle tension
- Rapid breathing
- Perspiration
- Loud voice
- Anger

Question 21

Escalation Phase

Answer 21

The client’s responses represent escalating behaviors that indicate movement toward a loss of control.

Signs, Symptoms, & Behaviors
- Pale or flushed face
- Yelling, swearing
- Agitation
- Threatening, demanding
- Clenched fists, threatening gestures
- Hostility
- Loss of ability to solve the problem or think clearly

Question 22

Crisis Phase

Answer 22

During an emotional and physical crisis, the client loses control.

Signs, Symptoms, & Behavior
- Loss of emotional and physical control
- Throwing objects
- Kicking, hitting, spitting, biting, scratching, shrieking, screaming
- Inability to communicate clearly

Question 23

Recovery Phase

Answer 23

The client regains physical and emotional control.

Signs, Symptoms, & Behavior
- Lowering of voice
- Decreased muscle tension
- Clearer, more rational communication
- Physical relaxation

Question 24

Postcrisis Phase

Answer 24

The client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and its antecedents.

Signs, Symptoms, & Behavior
- Remorse; apologies
- Crying
- Quiet, withdrawn behavior

Question 25

Related Disorders

Answer 25

Clients with paranoid delusions may believe others are out to get them - Believing they are protecting themselves, they retaliate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggressive behavior is also seen in clients with dementia, delirium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders Violent patients tend to be more symptomatic, have poorer functioning, and show a marked lack of insight compared with nonviolent patients

Question 26

Anger Attacks in Depression

Answer 26

Sudden intense spells of anger typically occur in situations in which the depressed person feels emotionally trapped Involve verbal expressions of anger or rage but no physical aggression Clients describe these anger attacks as 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 - Decreased coping abilities

Question 27

Intermittent Explosive Disorder (IED)

Answer 27

A 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 Diagnosis made only if the client has no other comorbid psychiatric disorders, as previously discussed 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 Develops between late adolescence and the third decade of life Clients w/ IED are frustrated and are often men who respond to feelings of uselessness or ineffectiveness with violent outburst

Question 28

Acting Out

Answer 28

An immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings 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 person’s ability to deal with feelings and emotion

Question 29

Neurobiologic Theories

Answer 29

Serotonin plays a major inhibitory role in aggressive behavior - Low serotonin levels may lead to increased aggressive behavior - This finding may be related to the anger attacks seen in some clients with depression Increased activity of dopamine and norepinephrine in the brain is associated w/ increased impulsively violent behavior Structural damage to the limbic system and the frontal and temporal lobes of the brain may alter the person’s ability to modulate aggression-> can lead to aggression

Question 30

Psychosocial Theories

Answer 30

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, they are 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 the development of these qualities. Children in dysfunctional families w/ poor parenting, children who receive inconsistent responses to their behaviors, and children whose families struggle with social determinants of health are at increased risk for failing to develop socially appropriate behavior - Can result in a person who is impulsive, easily frustrated, and prone to aggressive behavior. The relationship between interpersonal rejection and aggression can also be the basis for long-term problems regulating and managing emotions, including anger as well as others. - 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 is seen as a means of reestablishing control, improving mood, or achieving retribution, all of which fail to achieve those ends

Question 31

Impulse Control

Answer 31

The ability to delay gratification

Question 32

Characteristics Predictive of Aggression

Answer 32

History of violence/rage or aggressive behavior Involuntary hospitalization Suspiciousness Impulsivity Anxiety Hyperactivity (e.g., pacing that indicates increased agitation, restlessness) Staring and eye contact or glaring as a way of intimidation, or no eye contact at all Easily offended; hypersensitivity

Question 33

Unit Characteristics Predictive of Aggression

Answer 33

Busy, noisy, crowded Rigid unit rules Lack of patient privacy and space (psychological or physical) Lack of patient autonomy (locked doors, restraints) Strict hierarchy of authority Lack of meaningful, planned and predictable ward activities Lack of patient control over the treatment plan Boundary violations

Question 34

Staff Behavior Characteristics Predictive of Aggression

Answer 34

Denial of patient requests or privileges; limit setting Insufficient staff assistance with ADLs and other needs Rude or patronizing staff behavior Unclear staff roles Power struggles related to medications Failure of staff to listen or to convey empathy

Question 35

What are the 3 categories of anger/aggression?

Answer 35

1) Pre-assaultive 2) Assaultive 3) Post-assaultive

Question 36

Pre-Assaultive Category of Anger/Aggression

Answer 36

Patient - Begins to become angry - Exhibits increasing anxiety, tension, hyperactivity, and verbal abuse Examples of Nurse Responses - Use therapeutic de-escalation, calm limit setting, and clear options - Engage in dialogue; convey empathy - Physical activity and relaxation techniques - Decrease stimulation in environment - Offer PRN meds as ordered

Question 37

Assaultive Category of Anger/Aggression

Answer 37

Patient - Commits an act of violence Examples of Nurse Responses - “Show of force” as appropriate - Implement seclusion or physical or chemical restraints only as a last resort

Question 38

Post-Assaultive Category of Anger/Aggression

Answer 38

Patient - Is encouraged by staff to talk about what triggered and escalated the aggression Examples of Nurses Responses - Review incident with the patient; discuss ways for patient to keep control & how staff can help - Reassess milieu - Debrief involved staff - Talk to other clients

Question 39

Nursing Interventions to Promote Safety

Answer 39

Provide a safe environment – closely monitor patients with potential for violence Establish therapeutic nurse-patient relationships - Respond empathetically - Validate the patient’s experience and concerns When possible, offer patient concrete choices Provide “teachable moments”; teach assertive communication techniques Jointly develop prevention strategies and an early detection plan Make behavioral limits and consequences clear - Consistently apply them Maintain calmness and personal control (e.g., self-awareness; mindfulness techniques) Remain with patients when they are angry; respect personal space; sit or stand at same level

Question 40

Nursing Interventions to Promote Safety in Milieu

Answer 40

Maintain a structured and respectful therapeutic milieu; planned and predictable activities Scheduled 1:1 interactions with patients Create a culture of nonviolence Reduce stimulation Create a comfort room or multisensory environment room (e.g., Snoezelen® room) Use multisensory behavior therapy to reduce apathy and agitation in older adults with dementia Permit processing of conflicts (e.g., in daily meetings)

Question 41

Which medication has the most severe side effects?

Answer 41

Haloperidol (Haldol)

Question 42

Olanzapine (Zyprexa)

Answer 42

Class: Atypical Antipsychotic Used for (1) schizophrenia spectrum disorders, (2) psychotic episodes induced by levodopa, and (3) relief of psychotic manifestations of other disorders Atypical antipsychotics are the medication of choice for clients (1) receiving initial treatment, or (2) experiencing breakthrough episodes while taking typical antipsychotics Relieve positive and negative symptoms Has fewer adverse effects than typical antipsychotics

Question 43

Olanzapine (Zyprexa) Side Effects & Contraindications

Answer 43

Adverse Effects: Low risk of extrapyramidal symptoms (EPS) High risk for diabetes mellitus Weight gain Dyslipidemia Other adverse effects include: - Sedation - Orthostatic hypotension - Anticholinergic effects. Contraindications: Contraindicated for elderly clients with dementia Use cautiously in clients with cardiovascular or cerebrovascular disease, seizures, or diabetes mellitus

Question 44

Nursing Considerations for Olanzapine (Zyprexa)

Answer 44

Avoid alcohol Obtain fasting blood glucose on clients with diabetes mellitus, and carefully monitor blood glucose

Question 45

Ziprasidone (Geodon)

Answer 45

Class: Atypical Antipsychotic Used for (1) schizophrenia spectrum disorders, (2) psychotic episodes induced by levodopa, and (3) relief of psychotic manifestations of other disorders Works by blocking serotonin, and to a lesser degree dopamine, receptors Can be used for clients with concurrent depression Atypical antipsychotics are the medication of choice for clients (1) receiving initial treatment, or (2) experiencing breakthrough episodes while taking typical antipsychotics Relieves positive and negative symptoms

Question 46

Ziprasidone (Geodon) Adverse Effects & Contraindications

Answer 46

Low risk of extrapyramidal symptoms (EPS) Diabetes mellitus, and dyslipidemia - Low risk for weight gain Other adverse effects include orthostatic hypotension, anticholinergic effects, rash, and prolonged QT intervals Does not cause weight gain; non-sedating Contraindicated for elderly clients with dementia

Question 47

Nursing Considerations for Ziprasidone (Geodon)

Answer 47

Avoid CNS depressants, levodopa and other dopamine receptor agonists, and medications that prolong the QT interval

Question 48

Haloperidol (Haldol)

Answer 48

Class: Conventional Antipsychotic Primarily used for schizophrenia spectrum disorders Goals: (1) suppress acute episodes, (2) prevent acute recurrence, and (3) maintain the highest possible level of functioning Mainly controls positive symptoms - e.g., hallucinations, delusions, bizarre behavior of psychotic disorders - Likely due to blockage of dopamine receptors in the brain Reserved for clients who (1) are using them successfully and can tolerate the side effects, or (2) are violent or aggressive

Question 49

Haloperidol (Haldol) Adverse Effects & Contraindications

Answer 49

Very high extrapyramidal side effects (acute dystonia, tardive dyskinesia, Parkinsonism, Akathisia,) Anticholinergic effects Neuroleptic malignant syndrome Neuroendocrine effects Seizures Photosensitivity Orthostatic hypotension Agranulocytosis Prolonged QT Sedation, sexual dysfunction Contraindicated in clients w/: - Dementia - Severe depression - Parkinson’s - Prolactin-dependent breast cancer - Severe hypotension, or those in a coma Use cautiously with seizure or heart disorders or liver or kidney disease

Question 50

Nursing Considerations for Haloperidol

Answer 50

Avoid OTC meds with anticholinergic agents (e.g., sleep aids) Avoid CNS depressants Avoid levodopa and other dopamine receptor agonists

Question 51

Community-Based Care after Discharge

Answer 51

Treat underlying or comorbid psychiatric diagnoses and contributing factors - Address cultural issues - Address alcohol and other drug use Regular follow-up appointments; assess access to services and adherence with meds Cognitive and behavioral interventions Stress management/relaxation techniques (e.g., mindfulness) Community support programs Anger management groups Couples counseling 12-step groups

Question 52

Workplace Hostility

Answer 52

Lateral or horizontal violence/bullying (among healthcare providers in the workplace) Intimidating, disruptive, threatening, and/or humiliating behaviors; verbal abuse; work interference/sabotage Numerous potential negative outcomes The Joint Commission has standards that address this issue - Urges organizations to establish a safety culture - Zero tolerance for unacceptable behaviors – all persons are held accountable Facilities must have Code of Conduct policies, with processes to handle unacceptable behavior

Question 53

Self-Awareness Issues

Answer 53

Be aware of your own management of anger. Practice and gain experience in restraint/seclusion before using. Be calm, nonjudgmental, and nonpunitive. Learn from watching experienced nurses deal with hostile or aggressive clients