AGGRESSION

AGGRESSION can be verbal(sarcasm, insults, threats) or physical(property damage, slapping, hitting) behaviors or attitudes that reflect rage, hostility, and the potential for physical or verbal destructiveness

HOSTILITY also called verbal aggression an emotion expressed through verbal abuse, lack of cooperation, violation of rules or norms, or threatening behavior

 involves

overt behavior intended to hurt, belittle, take revenge, or achieve domination and control

Hostile behavior is intended to intimidate or cause emotional harm to another, and it can lead to physical aggression

usually

occurs if the person believes someone is going to do him or her harm

IT IS MARKED BY:

Sarcasm, verbal/physical threats, change in voice tone (raised or quivering voice tone and pitch; rapid hesitant speech) Degrading comments, pacing throwing or hitting objects or people, suspiciousness, suicidal/homicidal ideation,

Self-mutilation, invasion of personal space, increase in agitation or irritability,

Disturbed thought process or perception (illusion, hallucination or delusions) Anger disproportionate to the event

Aggressive behavior are seen in clients with: Dementia Delirium Paranoid delusions Auditory hallucination Head injuries Intoxification with alcohol or drugs Antisocial and borderline personality disorder

ETIOLOGY OF AGGRESSION

Biologic Theories An aggression-related gene,(monoamine oxidase A), which affects norepinephrine, serotonin, and dopamine, may play a significant role in the violence enacted by abused children ,especially boys Serotonin- major neurotransmitter involved in mood, sleep, and appetite Low serotonin levels- associated not only with depression, but also with irritability, increased pain sensitivity, impulsiveness and aggression

5-hydroxyindoleacetic acid(5-HIAA) the major metabolite for serotonin Increased dopamine and norepinephrineassociated with increased aggressively violent behavior Brain structures most frequently associated with aggressive behavior are the limbic system and the cerebral cortex, particularly the frontal and temporal lobes

Psychological Theories

Freud identified aggression as a separate instinct: Cathexis (filling) Catharsis (release)

Catharsis - safe yet aggressive activities that are used to express anger ex: hitting a punching bag, yelling

NOTE: Catharsis can increase anger feeling cathartic activities may be contraindicated to angry patients
Instead of catharsis, non-aggressive activities (walking or talking to another person) can be used to alleviate or decrease anger

Psychosocial Theories Failure to develop impulse control (the ability to delay gratification) and failure to develop socially appropriate behaviors children in dysfunctional families with poor parenting children who receive inconsistent responses to their behavior children whose families are of lower socioeconomic status

TYPES OF AGGRESSION

Verbal Aggression or abuse are verbally aggressive attacks on others that tend to have a repetitive pattern and signify a major warning sign of assault Passive- Aggression indirect expression of anger and undermining others in various subtle and evasive ways. People reacting this way tend to deny anger and its source even when confronted about their behaviors.

AGGRESSION CYCLE

A. Triggering the stress-producing event occurs, initiating the stress response Restlessness Anxiety Irritability Pacing muscle tension, rapid breathing perspiration voice quality changes (loud voice) fingers tapping suspiciousness tremors glaring repeated verbalizations noncompliance anger

NURSING INTERVENTION OF TRIGGERING Provide & convey empathic support Encourage deep breathing Use clear, calm, simple statements Ask the patient to maintain control Facilitate problem solving: alternative solutions PRN: quiet area and oral meds Provide safe tension reduction measures

B. Escalation- responses represent escalating behaviors that indicate movement towards loss of control

Pale or flushed face Yelling/ screaming Swearing Agitated Threatening demanding clenched fists threatening gestures

threatening gestures hostility loss of ability to solve the problem or think clearly diaphoresis hypersensitivity eagerness to retaliate anger

NURSING INTERVENTION OF ESCALATION Take charge and provide calm and firm directions Give patient time out in a quiet room Give prn meds as ordered Standby staff at a distance Prepare for show of determination or show of force to acquire control

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

Loss of emotional and physical control Throwing objects Kicking Hitting Spitting Biting Rage Fighting Scratching Shrieking Screaming Inability to communicate clearly

NURSING INTERVENTION OF CRISIS PRN involuntary seclusion, restraints, or medications as ordered Provide intensive nursing care

D. Recovery cool down period, regains emotional and physical control

Voice lowers Decreased body tension Conversational content changes Accusations More normal responses Relaxation Clear and more rational communication

NURSING INTERVENTION OF RECOVERY Assess patient and staff injuries Process incident with staff and other patients

E. Post Crisis attempts to reconciliate and returns to level of functioning before the incident

Crying Apologies Reconciliatory efforts Remorse Quiet Withdrawn behaviors Repression of assaultive feeling (later appears as hostility or passive aggression)

NURSING INTERVENTION OF POST-CRISIS Process the incident with the patients Discuss alternatives to situations and feelings Gradually reduce the degree of restraints and seclusion Facilitate reentry to the unit

RISK FACTORS
Actual or potential physical acting out of violence Destruction of property Homicidal or suicidal ideation Physical danger to self or others History of assaultive behavior or arrests Neurologic Illness Disordered thoughts Agitation or restlessness Lack of impulsive control Delusions, hallucinations, or other psychotic symptoms Manic symptoms Conduct disorder Posttraumatic stress disorder Substance abuse

MANAGEMENT FOR 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.

 SOCIAL:

Develop family support groups. Use restraints and seclusion only as last result. Encourage use of resources for information and support. Reduce stimulation. Reassign roommates or caregivers.

PSYCHOLOGICAL: Use past experience to normalize and validate patients experiences. Explore beliefs about expressing aggression. Assist with taking charge of situation. Explain behavioral limits and consequences clearly. Develop written contracts. Plan to prevent escalation. Allow choices if possible.

TREATMENT FOR AGGRESSION

Drugs used in the management of aggressive behavior:

Atypical

antipsychotic -risperidone(Risperdal) -dozapine(Clozaril) -olanzapine(Zyprexa)

SSRI -flouxetine(Prozac) -paroxetine(Paxil) Anxiolytic Medications -excert a calming effect by increasing brain levels of GABA. -alprazolam(Xanax) -lorazepam(Ativan)

Beta-adrenergic receptor blockers -propranolol(Inderal) -has an effect in decreasing the peripheral manifestations of rage that associated with excitement of the sympathetic nervous system.

Lithium Carbonate -has been effective in treating explosive and aggressive behavior associated with head injury.

Divalproex Sodium(Depakote) -carbamazepine(Tegretol) -oxcarbazepine(Trileptal)

NURSING DIAGNOSIS
Risk

for Self-Directed Violence Risk for Other- Directed Violence

RELATED DISORDERS

Intermittent explosive disorder- a rare psychiatric diagnosis characterized by discrete episodes of aggressive impulses that results in serious assaults or destruction of property Before episodes: Head pressure palpitations Chest tightness Tingling Tremors Sounds or echo

During episodes: Adrenaline rush Out of proportion expression of aggression Typically begins in childhood,adolescence, or early adulthood Impulsiveness, chronic anger, and less destructive aggression can occur between explosive episodes

Acting out- immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings
Bouffe delirance characterized 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 other people and objects