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AGGRESSION

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AGGRESSION

can be

verbal(sarcasm,insults, threats) orphysical(propertydamage, slapping,hitting)

behaviors or attitudesthat reflect rage,hostility, and thepotential for physical

or verbaldestructiveness

HOSTILITY

also called verbalaggression

an emotionexpressed throughverbal abuse, lack of

cooperation, violationof rules or norms, orthreatening behavior

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involves overt

behavior intendedto hurt, belittle, takerevenge, or achievedomination andcontrol

usually occurs if theperson believessomeone is goingto do him or her

harm

Hostile behavior is

intended to intimidateor cause emotionalharm to another, andit can lead to

physical aggression

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ITISMARKEDBY:

Sarcasm, verbal/physical threats, change in voice tone

(raised or quivering voice tone and pitch; rapid hesitantspeech)

Degrading comments, pacing throwing or hitting objectsor people, suspiciousness, suicidal/homicidal ideation,

Self-mutilation, invasion of personal space, increase inagitation or irritability,

Disturbed thought process or perception (illusion,hallucination or delusions)

Anger disproportionate to the event

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Aggressive behavior are seen in clients with:

DementiaDelirium

Paranoid delusions

Auditory hallucination

Head injuries

Intoxification with alcohol or drugs

Antisocial and borderline personalitydisorder

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ETIOLOGYOF AGGRESSION

Biologic Theories

An aggression-related gene,(monoamine oxidaseA), which affects norepinephrine, serotonin, anddopamine, may play a significant role in the

violence enacted by abused children ,especiallyboys

Serotonin- major neurotransmitter involved inmood, sleep, and appetite

Low serotonin levels- associated not only withdepression, but also with irritability, increased painsensitivity, impulsiveness and aggression

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5-hydroxyindoleacetic acid(5-HIAA) the major

metabolite for serotonin

Increased dopamine and norepinephrine-

associated with increased aggressively violentbehavior

Brain structures most frequently associated withaggressive behavior are the limbic system and thecerebral cortex, particularly the frontal and temporallobes

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Psychological Theories

Freud identified aggression as a separate instinct:

Cathexis(filling)

Catharsis(release)

Catharsis - safe yet aggressive activities that areused to express anger

ex: hitting a punching bag, yelling

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NOTE:Catharsis can increase anger feelingcathartic activities may be contraindicated toangry patients

Instead of catharsis, non-aggressive activities(walking or talking to another person) can be usedto alleviate or decrease anger

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Psychosocial Theories

Failure to developimpulse control (theability to delay gratification) and failure todevelop socially appropriate behaviors

children in dysfunctional families with poorparenting

children who receive inconsistent responses to theirbehavior

children whose families are of lower socioeconomicstatus

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TYPESOFAGGRESSION

Verbal Aggression or abuseare verbally aggressive attacks on others that

tend to have a repetitive pattern and signify a majorwarning sign of assault

Passive- Aggression

indirect expression of anger and underminingothers in various subtle and evasive ways. People

reacting this way tend to deny anger and its sourceeven when confronted about their behaviors.

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AGGRESSION CYCLE

A. Triggeringthe stress-producing event occurs,initiating the stress response

RestlessnessAnxiety

IrritabilityPacing

muscle tension,rapid breathing

perspirationvoice qualitychanges (loud voice)

fingers tappingsuspiciousness

tremorsglaring

repeatedverbalizations

noncomplianceanger

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NURSING INTERVENTION OF TRIGGERING

Provide & convey empathic support

Encourage deep breathing

Use clear, calm, simple statementsAsk the patient to maintain control

Facilitate problem solving: alternative solutions

PRN: quiet area and oral meds

Provide safe tension reduction measures

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B. Escalation-responses represent escalatingbehaviors that indicate movement towards loss of

control

Pale or flushedfaceYelling/ screaming

SwearingAgitatedThreatening

demanding

clenched fiststhreateninggestures

threateninggestureshostility

loss of ability tosolve the problem orthink clearly

diaphoresis

hypersensitivityeagerness toretaliateanger

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NURSING INTERVENTION OF ESCALATION

Take charge and provide calm and firmdirections

Give patient time out in a quiet roomGive prn meds as ordered

Standby staff at a distance

Prepare for show of determination or show of

force to acquire control

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C. Crisis- period of emotional and physical crisis,loss of control occurs

NURSING INTERVENTION OF CRISIS PRN involuntary seclusion, restraints, or

medications as ordered

Provide intensive nursing care

Loss of emotionaland physical controlThrowing objectsKicking

HittingSpittingBiting

RageFightingScratchingShrieking

ScreamingInability tocommunicate clearly

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D. Recoverycool down period, regains emotionaland physical control

NURSING INTERVENTION OF RECOVERY Assess patient and staff injuries

Process incident with staff and other patients

Voice lowersDecreased bodytension

Conversational contentchanges

AccusationsMore normalresponses

RelaxationClear and more rationalcommunication

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E. Post Crisisattempts to reconciliateandreturns to level of functioning before the incident

CryingApologiesReconciliatory effortsRemorseQuietWithdrawn behaviorsRepression of assaultive feeling (later

appears as hostility or passive aggression)

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NURSING INTERVENTION OF POST-CRISIS

Process the incident with the patients

Discuss alternatives to situations and feelings

Gradually reduce the degree of restraints andseclusion

Facilitate reentry to the unit

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RISK FACTORS

Actual or potentialphysical acting out of

violenceDestruction of propertyHomicidal or suicidal

ideationPhysical danger to selfor othersHistory of assaultive

behavior or arrestsNeurologic IllnessDisordered thoughts

Agitation orrestlessnessLack of impulsivecontrolDelusions,

hallucinations, or otherpsychotic symptoms

Manic symptomsConduct disorder

Posttraumatic stressdisorderSubstance abuse

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MANAGEMENTFOR AGGRESSION:

BIOLOGIC:

Administer psychotropic agents.

Monitor hepatic functions.

Encourage proper nutrition.Administer vitamins, such as thiamine and

niacin.

Reduce intake of caffeinated beverages.

Modify environmental stimuli.Anticipate need for bladder and bowel

elimination.

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SOCIAL:

Develop family support groups.

Use restraints and seclusion only as last result.

Encourage use of resources for informationand support.

Reduce stimulation.

Reassign roommates or caregivers.

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PSYCHOLOGICAL:

Use past experience to normalize and validatepatients experiences.

Explore beliefs about expressing aggression.

Assist with taking charge of situation.

Explain behavioral limits and consequencesclearly.

Develop written contracts.

Plan to prevent escalation.

Allow choices if possible.

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TREATMENTFOR AGGRESSION

Drugs used in the management of aggressivebehavior:

Atypical antipsychotic-risperidone(Risperdal)

-dozapine(Clozaril)

-olanzapine(Zyprexa)

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SSRI

-flouxetine(Prozac)

-paroxetine(Paxil)

Anxiolytic Medications

-excert a calming effect by increasing brain levels ofGABA.

-alprazolam(Xanax)

-lorazepam(Ativan)

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Beta-adrenergic receptor blockers

-propranolol(Inderal)

-has an effect in decreasing the peripheralmanifestations of rage that associated withexcitement of the sympathetic nervous system.

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Lithium Carbonate

-has been effective in treating explosive andaggressive behavior associated with head injury.

Divalproex Sodium(Depakote)

-carbamazepine(Tegretol)

-oxcarbazepine(Trileptal)

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NURSING DIAGNOSIS

Risk for Self-Directed

ViolenceRisk for Other- Directed

Violence

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RELATED DISORDERS

Intermittent explosive disorder- a rare psychiatric

diagnosis characterized by discrete episodes ofaggressive impulses that results in serious assaultsor destruction of property

Before episodes:

Head pressure palpitations

Chest tightness

Tingling

Tremors

Sounds or echo

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During episodes:

Adrenaline rushOut of proportion expression of aggression

Typically begins in childhood,adolescence, or early

adulthood

Impulsiveness, chronic anger, and less destructiveaggression can occur between explosive episodes

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Acting out- immature defense mechanism by whichthe person deals with emotional conflicts or

stressors through actions rather than throughreflection or feelings

Bouffe delirancecharacterized by a sudden

outburst of agitated and aggressive behavior,marked confusion and psychomotor excitement

Amok- dissociative episode characterized by a

period of brooding followed by an outburst of violent,aggressive, or homicidal behavior directed at otherpeople and objects