Management of Anger, Aggression & Violence lecture 2011
Management of Anger, Aggression & Violence Lecture Notes 1Objectives: Poor anger control is demonstrated in increased conflicts at1. Explore healthy & unhealthy styles of anger management. work, frequent job changes, increased risk taking, and have2. Review factors that influence aggressive & violent more accidents that people with adaptive anger behavior. behaviors.3. Identify behaviors & actions that escalate & de-escalate What exactly is “ANGER?” violent behaviors.4. Discuss risks related to “nurse abuse.” Descriptors are imprecise & confusing. Cultural influences5. Apply the nursing process to the management of anger, exist. aggression & violence in patients. Anger: strong, uncomfortable emotional response relatedThis handout is an interactive guide to assist you in your provocation that is unwanted and incongruent with one’sstudies of the Management of Anger, Aggression & Violence values, belief & rights. Anger is an internal affective state andas it relates to Psychiatric Nursing. My intention is for this may not be expressed in overt behavior. Anger and be healthyguide to serve as an adjunct learning aid for material and not or unhealthy.as a substitute. You are responsible for reviewing andunderstanding the course objectives and the objectives for this Aggression: involves overt behavior to hurt, belittle,chapter for testing purposes. The additional material is to help revengeful, achieve domination or control. Well-adjustedsolidify your understanding of the concepts presented in the patients are able to prevent themselves from expressingtext and to provide you with practical application of this aggression.material. Violence: Can be predatory or reactive, the use of force withLECTURE OUTLINE the intent of harm.Violence in our society is so pervasive that we can see it in the Anger is one of six emotions recognized in all cultures! (Fear,news everyday. Thomas indicated in her chapter bullying anger, sadness, happiness, surprise, and disgust). It’soccurs in school age children every 71/2 minutes and 160,000 expression is expressed differently cross-culturally. Verbalchildren miss school everyday due to the fear of violence. verses nonverbal cues. Cultural nonverbal cues. It is all in how it is displayed.Have you encountered violence with school-aged childreneither at home or on a professional level? Think about how loss is expressed and how anger is apart of that expression.Nursing students and nurses create their own form of violence-Nurses That Eat There Own It is healthy to expression anger adaptively; relationships are actually stronger when mates argue, so the research says!The practical concept of managing-up or managing-down yourpeers. Physiologic Experience of Cerebral Cortex AngerAnger cannot be viewed on a continuum: On the left- anger as Amygdala- processing ofa healthy response to the violation of one’s integrity and to the emotionsright- maladaptive anger that is detrimental to one’s psycheand well-being. Sympathetic Response Fight or FlightMaladaptive anger linked to: Adrenal MedullaDepression Epi & NorepiStrong correlations to Medical conditions: CAD Adrenal Cortex CortisolSuppressed anger- correlations to arthritis, breast & corectalCA, HTN, predictor early mortality. Physiologic response is universal- to what extent, how the body interprets & how weThe caveat: Conflicting research that indicates anger used in a express it is what is unique. Anger arousal can be pleasant orconstructive way reduces HTN, improves general health, unpleasant & scary. Trying to suppression can prolongbetter sense of self, accounts for less depression and decreased physiologic manifestations.prevalence of obesity. Think about the last time you were ANGERY! What symptoms did you feel?
2Assessment of anger in individuals can be challenging, As the For this to be effective, candidates must have some insight toauthors indicated, how one directs there anger may not neatly their problem. Check out Emotional Intelligence & Whofit into a categorize of “anger-in” or Anger-out”. The goal to Hijacked My Amygdalaanger assessment in a controlled clinical setting is to be able toassess anger in various situations, frequency, intensity of Violenceexpression, and triggers. Our environment, social issues, Violence is not random, senseless and can be understood!occupation or lack of, level of intimacy in relationships andthe presents of coping skills all have effects on how we Predictors for violence are very sensitive. Practical Tool-express anger. listen to your instincts!In a very controlled setting with a client that is not presently De-escalation skill sets are an extremely valuable tool in youranger, questionnaire can be used as assessment tools. success as a nurse! Spielberger State Trait Anger Expression Inventory- measures propensity to be angry, feelings of anger & What is the difference in approach by police verses healthcare anger styles. providers in managing a violent individual? Diagnostic & Statistical Manual of Mental Disorders- Anger Disorder, Intermittent Explosive Disorder Those that commit acts of violence have frequently (seen in teens) experienced childhood abandonment, physical brutality, sexual abuse & confinement.Can one predict violence from the display of anger?Johns Hopkins Shooter Event Models of Anger, Aggression & ViolenceCulture & Gender Considerations Not one models explains all. I find all models apply- all theHistorical trajectories (experiences), religion, language & time!customs affect anger behavior. Biologic TheoriesA random act by a stranger in one culture can be perceived as Developmental deficitsinsulting and in another culture simply dismissed. Remember AnoxiaPresident George Bush having the shoe thrown at him during a Malnutritionpressing meeting! Toxins TumorsGender role socialization- appropriateness of owning angry Neurodegenerative diseasesemotionality and revealing it to others. Head Injury- Look up Phineas P. Gage Injury to cerebral cortex- increased Western Cultures- Promote more aggressive behavior impulsivity, decreased inhibition &in males and conciliatory behavior in females. The caveat: decreased judgment.generalizations may not apply to marginalized individuals or Neurocognitive impairmentethnic minorities. Social history of abuse, family violence Eastern Cultures- disapproves of anger expression by Aggression gene: Monoamine Oxidase A- affects Norepi,both genders when the culture(s) emphasize connectedness serotonin & dopamine (seen in male children with history ofrather than individualism. abuse)Anger Management Sex hormones- violent male offenders have high testosterone,Psychoeduactional intervention in persons whose behavior is violent females commit crimes during low progesterone phasedysfunctional, but not violent. of menstrual cycle.Court Mandated for violent individuals has limited success. Combining risk factors dramatically increase risk of violence:Anger Management Intervention does not modify violent History, medical noncompliance, substance abuse, selectivebehavior. Greater benefit when used with other psychiatric diagnoses, police involvement, pain & emotion.psychotherapies. Set up as a group therapy, ran by a coach,and targets interventions on modulating the arousal of anger in Cognitive Neuroassociation Modelindividuals, alter irrational thoughts and modified maladaptive Adverse event triggers primitive negative response, peripheralbehaviors. Those with personality disorders, paranoia and receptors communicate response to spinal cord toorganic disorders need not to apply. hypothalamus, synthesizes input to limbic system and drives primitive emotion- flight or flight
Management of Anger, Aggression & Violence Lecture Notes 3 obtain that status. Example is men and women in the WesternNo cognitive appraisal in assessing rudimentary feelings and society.higher order cognitive processing goes wild. Brain associatesstimulus to other similar physiologic sensations, memories, Interactional Theoryideas, past experiences and previously experienced expressive This is a really prevalent assertion in the psychiatricmotor reactions. Think of a body builder running away from a community. Viewing violence and aggression with asmall, harmless snake that he just touched. biologically or psychological basis excuses the behavior. Violence is violence no matter what setting and should beTake a look at the Neurostructural Model and the Emotional considered a social problem. Individuals with interactiveCircuit. The focus of this model is how the meaning is styles that were argumentative or coercive (chip on thereperceived, influenced by physiologic capabilities, how to shoulder) where more likely to be aggressive or violent.prioritize competing stimuli and interpret messages in relation Antecedent variables: history of violence, psychiatricto stored ideas, beliefs & memories. disorders, hospitalizations and the mediating variable of interactional style are the primary reasons for behavior.Neurochemical Model & Low Serotonin SyndromeRole of Serotonin in mood, sleep & appetite well researched. How Do Nurses Mange Anger & Aggression in Patients?Low Serotonin associated with depression, irritability,increased pain sensitivity, impulsiveness & aggression. Prevention is key. The right staffing mix, enough staff, safeSerotonin sensitive to dietary intake tryptophan- found in high environment, having structured routine, respectful milieu,carbohydrate foods (wheat, flour, corn, milk and eggs). timing of admissions/discharges, uses of space/personnel andRelationship of Tryptophan depletion and aggressive behavior. the conviction of understanding the meaning of the behavior.Psychological Theories What do patients gain by acting out?Psychoanalytic Theories- emotions viewed as instinctual A rigid view of “my way” without a flexible self-awareness isdrive. Early work done by Freud. Contemporary sure to get any nurse in trouble. Can you keep your Amygdalapsychoanalysts- focus on patient having grater insight onto the from being HIJACKED? Threats never work. If the patient isunconscious processes of their feelings/actions to develop able to understand the explanation, explain to process andgreater insight for better adoptive behavior. consequences. Be careful here!! Look for the opportunity to debrief the experience with peers and later with the patient.Behavioral Theories- Anger was viewed as a learned response.Social Learning Theory as a classic model of this model. Predictors of ViolenceMaladaptive behavior learned from parents. Treatment basedin avoidance of provoking stimuli, self monitoring, response The research is all over the place! History is universallydisruption and guided practice of effective anger behavior. agreed to be a reliable predictor.Cognitive Theories Better Predictors Poor PredictorsHow do people transform internal and external stimuli into Suspiciousness Age, gender & race- notuseful information. Socratic Questioning is used to challenge Impulsivity good predictorsdistorted cognitions. Socratic Questioning seeks to get a Agitation Time of dayperson to answer the question by making them think and draw Noncompliance with Mixed Predictorout the answer. Examples of questions: Why are you saying rules Adequate staffingthat?, What else could we assume? & Can you give me an Involuntary Specific diagnosesexample of that? Change behavior by altering irrational beliefs hospitalization related to poor impulse(unrealistic expectations) and identify workable alternatives. Crowding & high density Dual diagnosis withUse of role play is prevalent. Cognitive & Cognitive during high patient substance abuseBehavioral Therapies are the most researched. The patient has census Temporal lobe epilepsyhave a level of self awareness and motivation to change Previous episodes of rage Barbiturates- increasebehavior. Escalating irritability violence Intruding angry thought Mood Stabilizers- lessSociocultural Theories Fear of losing control violenceThe pursuit of status produces inequities in relationships, oneperson is superior and the other is subordinate. A hazardinherent to the pursuit of status is the view of the “entitled There are no infallible tools. No tool that has reasonableperson” and this person has the right to use whatever means to success is Nurses Observation Scale for Inpatient Evaluation (NOSIE). My experience is that pertinent positives and
4pertinent negatives are assessed and risk is stratified from thatassessment. RMEMBER- not all violence is because of anger Beta-blockers Decreasing sympathetic response to angerViolence can be the result of predatory behavior, forsecondary gain or as a result of delusions. Lithium Carbonate- Depakote or Tegretol Intermediate effect and can poorly interact with other agentsPlanning & Implementing Interventions NutritionPatient needs to be a partner in the process! Thiamine is blocked by ETOH abuse and caffeine is a stimulant.When the patient is unable to participate, then the Nurse musttake charge. Anticipating Needs Toileting is frequently responsible for agitation in older adultsStepped approach, that escalates and is patient specific-Blanket interventions don’t work. Psychological Domain & Assessment/Intervention Disturbance in thought process- both psychiatric andThose who act out violence or aggression, can assume substance abuse related. Chronic medical condition also play aresponsibility. part in this.Intervention is NEVER punitive!!! Altered Perceptions Patients may misinterpret events and objects. IllusionsPersonal riskBody language is critical DelusionsRespect personal space False or unreasonable beliefs- cause here: poorly manage thisSpatial awareness is absolutely the responsibility of the Nurse- discussion with a patient and it may precipitate aggression andalways have an out and never left anybody or anything dissuading patients usually ineffective.interfere with egressPlenty of support and team oriented approach The goal for psychological interventions is to help the patientClothing gain control over their loss of control.Speak softly, only one person gets to speakListen a lot & embrace a calm presents Affective Interventions: validating, listening to the experience & exploring beliefsCrisis Intervention- discussed in class Cognitive Interventions: Giving Commendations, OfferingInterventions based on Biopsychosocial Interventions. See Information, Thought Stopping, Contracting & Providingpage 829, figure 38.2 Education. A contract can be both written & verbal.Biologic Domain & Assessment/Intervention Behavioral Interventions: Assigning Behavioral Tasks,Biochemical imbalance may exacerbate aggression Bibliotherapy, Interrupting Patterns & Providing Choices.(hypoglycemia, ETOH intoxication or withdrawal,premenstrual dysphoric disorder). Social Doman & Assessment/Interventions Factors are all about the stressors!Sensory ImpairmentImpairment in communication is seen in older males. Reducing StimuliAdministering Medications & Monitoring for Effects- critical Seclusion & Restraint- nobody wins when this is the lastAtypical Antipsychotics- Resperidone & Zyprexa option. All other options tried and failed or clear & compellingMechanism not fully understood, minimal extrapyramidal side reason to immediately escalate. There are ALWAYSeffects, used of intermediate intervention consequences to this intervention. Extremely regulated, requires continual training, carries risk before, during andSelective Serotonin Reuptake Inhibitors- Prozac & Paxil after. Adverse events prevalent.Gradual onset of action, antidepressant effects Assault Against NursesAnxiolytics- Ativan 70% of mental health professionals report assault and orGreat for immediate sedation and can be used with other battery during their care of patients.agents for synergistic effects
Management of Anger, Aggression & Violence Lecture Notes 5Workplace violence: prevalence and risk factors in the safeat work study. Campbell JC, Messing JT, Kub J, Agnew J,Fitzgerald S, Fowler B, Sheridan D, Lindauer C, Deaton J,Bolyard R.Almost one-third (30%) of nurses/nursing personnelexperienced WPV. Risk factors included being a nurse, white,male, working in the emergency department, older age, longeremployment, childhood abuse, and intimate partner violence.Nurses- largest healthcare provider group and greaterincidence of assaultTheme to assaults- patient perceives the nurse restrictingaction, controlling, or aggressive. Verbal or physicalEmergency NursesRates of Violence against Emergency Department Nurses AreHigh, Remain Steady, According to New Study, But RemediesExist on a weekly basis 8-13% ED Nurses assaulted ~60% reported violence within the last 7 days of the survey ~75% of the nurses that were assault- reported not receiving assistance from there employer 97% of those committing assault and/or battery- patients & family Nurses performing triage had equal incidence to nurse physically restraining patients for assault rate Young male nurse- highest occurrence