Anger/Aggression Management slideshare

ANGER/ AGGRESSION
MANAGEMENT
PRESENTED BY:
Ms. Priyanka Kumari
M.Sc. Nursing ( Mental Health Nursing)

SPECIFIC OBJECTIVES
Define and differentiate between anger and aggression and violence.
Explain theories of aggression.
Enlist types of anger.
Discuss the predisposing factors to the maladaptive expression of
aggression.
Explain the phases of aggression.
Recognize the signs/symptoms of aggression/anger.
Explain the nurses’ response to patient aggression.
Explain about the management of anger/aggression.
Apply the nursing process for the person who expressing anger or
aggression.

ANGER
Anger is a normal, healthy emotion that serves as a warning
signal and alerts us to potential threat or trauma.
Warren(1990) outlined some fundamental points about anger:
 It Is physiological arousal.
 Anger and aggression are significantly different.
 Expression of anger is learned.
 Expression of anger can come under personal control.

DEFINITION
Anger is an emotional state that varies in intensity from
mild irritation to intense fury and rage. It is accompanied
by physiological changes, such as increase in heart rate,
blood pressure and level of the hormones epinephrine and
norepinephrine.
– American Psychological Association, 2010

Aggression is behavior intended to threaten or injure the
victim’s security or self-esteem. It means “to go”, “to
attack”.
 In Psychology, the term aggression refers to a range of
behaviors that can result in both physical and
psychological harm to oneself, other or objects in the
environment.

Social psychologists define aggression as behavior that is
intended to harm another individual who does not wish to be
harmed.
(Baron & Richardson, 1994)
Violence is defined as “a physical act of force intended to
cause harm to a person or an object and to convey the
message that the perpetrator’s point of view is correct and not
the victim’s.”
(Harper-Jaques and Reimer, 1992)

Aggression is verbal statement that are intended to
threaten. Aggression and violent behavior represent a
continuum from suspicious behavior to extreme actions
that threaten the safety of others or result in injury or
death.

THEORIES ON AGGRESSION
Biological theory
Psychological theory
Humanistic theory
Social learning theory

BIOLOGICAL THEORY
Current neurobiological research has focused on three areas
of the brain believed to be involved in aggression: the limbic
system, frontal lobe, hypothalamus.
 Neurotransmitters also have been suggested as having a role
the expression or suppression of anger or aggressive behavior.

LIMBIC SYSTEM (Amygdala, Frontal lobes and
limbic system):
Stimulation of the amygdala results in augmented
aggressive behavior, while lesions of this area greatly reduce
one's competitive drive and aggression.

FRONTAL LOBE: dysfunctions of frontal lobe will alter
neurochemistry, neurometabolism.
 Impaired function of the prefrontal cortex leads to
aggression.
Lesions in the frontal cortex are characterized by
aggression, irritability and short tempers.
Damage to the frontal lobes can result in impaired
judgement, personality changes, problems in decision
making, inappropriate conduct of aggressive outburst.

HYPOTHALAMUS: regulatory role. The hypothalamus
causes aggressive behavior when electrically stimulated,
but also has receptors that determine aggression levels
through the neurotransmitters serotonin and vasopressin.

Stress raises the level of steroids, the hormone secreted by adrenal
gland. Nerve receptors for these hormones become less sensitive
in an attempt to compensate, and the hypothalamus tells the
pituitary gland to release more steroids.
After repeated stimulation, the system may respond more
vigorously to all provocation. That may be one reason why
traumatic stress in childhood may permanently enhance one’s
potential for violence.

Testosterone has been shown to correlate with aggressive
behavior in mice and in some humans.
Progesterone, LH, and Prolactin increase aggression.
Estrogen decreases aggression.
Thyroid hormones: increase aggression.
Serotonin: Low serotonin could contribute to aggressive
behavior.
Alcohol disinhibits an individual. Over half of all acts of
rape occur while the aggressor is under the influence of
alcohol.

PSYCHOANALYTICAL THEORIES
Sigmund Freud is well known as the father of
psychoanalysis. In his early theory, Freud asserts that human
behaviors are motivated by sexual and instinctive drives
known as the libido, which is energy derived from the Eros, or
life instinct. Thus, the repression of such libidinal urges is
displayed as aggression.

Later, Freud added the concept of Thanatos, or death force, to
his Eros theory of human behavior. Contrary to the libido
energy emitted from the Eros, Thanatos energy encourages
destruction and death.
In this conflict between Eros and Thanatos, some of the
negative energy of the Thanatos is directed toward others, to
prevent the self-destruction of the individual. Thus, Freud
claimed that the displacement of negative energy of the
Thanatos onto others is the basis of aggression.

According to Freud: Aggression may be due to impaired
mother-child relationship (children of punitive parents are
more aggressive)
Aggression is developed during the oral stage when the
pleasure of biting is added to that of sucking. Fixation on the
oral stage of psychosexual development may lead to sadistic
personality.

Aggression may be due to impaired development of
superego.
Aggression may be due to defense mechanisms:
 Projection
 Narcissism
 Repression

LORENZ THEORY- THE EVOLUTIONARY
THEORY OFAGGRESSION
Lorenz looked at instinctual aggressiveness as a product of
evolution.
Aggressiveness is beneficial and allows for the survival,
territory protection and success of populations of
aggressive species since the strongest animals would
eliminate weaker ones and over the course of evolution,
the result would be a stronger, healthier population.

Adler’s view:
Aggression is due to the striving for superiority and
perfection.
Mc Dougall’s view:
Aggression is an instinct.
A civilized man modifies and replaces physical aggression
and destruction with sarcastic smiles, polished insulting
words.
Only when these methods fail, may the individual regress to
the primitive and childish way of behavior.

HUMANISTIC THEORY
Aggression is a drive (basic concept). It arises from
deprivation of basic needs (Abraham Maslow)
The drive theory attributes aggression to an impulse
created by an innate need.
In this theory, frustration and aggression are linked in a
cause and effect relationship. Frustration is the cause of
aggression and aggression is the result of frustration.
Frustration may cause apathy, depression, anxiety, etc…

SOCIAL LEARNING THEORY
Albert Bandura and his colleagues were able to demonstrate one
of the ways in which children learn aggression. Bandura's theory
proposes that learning occurs through observation and interaction
with other people
The experiment involved exposing children to two different adult
models, an aggressive model and a non-aggressive one.

He predicted that children who observed an adult acting
aggressively would be likely to act aggressively.
Aggression is initially learned from social behavior and
maintained by reward, which encourages the further display
of aggression.
Aggressive responses are acquired so they are evitable
(optimistic).

Media violence:
Although most young people who are exposed to violence in
TV and movies and playing violent video games do not become
violent criminals, they can become more open to acts of violence.
However, media violence is explicitly not considered a causal
influence of aggression, but in a combination with genetic and early
social influences could have an influence.

TYPES:
Instrumental Aggression
Hostile Aggression
Relational Aggression

Instrumental aggression:
Aggression aimed at obtaining an object, privilege or
space with no deliberate intent to harm another person.
Typically of toddlers.

Hostile aggression:
Aggression intended to harm another person such as
hitting, kicking or threating to beat up someone.

Relational aggression:
It is intended to harm others through deliberate
manipulation of their social standing and relationships.
According to Daniel Olweus it is a type of bullying.

Is harming others through purposeful manipulation and
damage of their peer relationships or social status.
It can be proactive (planned and goal oriented) and reactive (in
response to perceived threats, hostility or anger).

OTHER TYPES:
Verbal aggression.
Physical aggression against others.
Physical aggression against property or objects.
Physical aggression against self.

PREDISPOSING FACTORS OF
ANGER/AGGRESSION:
Modeling
Operant conditioning
Neurophysiological disorders
Biochemical factors
Socioeconomic factors
Environmental factors

MODELING
Children model their behavior at a very early age after their
primary caregivers, usually parents.
How parents or significant others express anger becomes the
child’s method of anger expression.
Whether role modeling is positive or negative depends on the
behavior of the models.

OPERANT CONDITIONING:
A positive reinforcement is a response to the specific behavior
that is pleasurable or produces the desired results.
A negative reinforcement is a response to the specific behavior
that prevents an undesirable result from occurring.
Anger responses can be learned through operant conditioning.

NEUROPHYSIOLOGICAL DISORDERS
Tumors in the brain, particularly in the areas of the limbic
system and the temporal lobes; trauma to the brain, resulting in
cerebral changes; and diseases, such as encephalitis, have all
been implicated in the predisposition to aggression and violent
behavior.

BIOCHEMICAL FACTORS
Violent behavior may be associated with hormonal
dysfunction caused by Cushing’s disease or
hyperthyroidism
Some research indicates that various neurotransmitters
(e.g., epinephrine, norepinephrine, dopamine,
acetylcholine, and serotonin) may play a role in the
stimulation and inhibition of aggressive impulses.

SOCIOECONOMIC FACTORS
An ongoing controversy exists as to whether economic
inequality or absolute poverty is most responsible for
violent behavior within this subculture.

ENVIRONMENTAL FACTORS
Moderately uncomfortable temperature appears to be
associated with an increase in aggression, while extremely hot
temperatures seem to decrease aggression.
A number of epidemiological studies have found a strong link
between use of alcohol and violent behavior.
Other substances, including cocaine, amphetamines,
hallucinogens, and anabolic steroids, have also been associated
with violent behavior.

PHASES OF AGGRESSION
Triggering
phase
Escalation
phase
Crisis
phase
Recovery
phase
Post crisis
phase
Phases Of
Aggression

Triggering phase:
An event or circumstances in the environment initiates the
client’s response, which is often anger or hostility.
This is a circumstances where a person is still on a non-
threatening manner. Which can be managed easily and
without any hostile or aggressive behavior.

Escalation phase:
The client’s responses represent escalating behaviors that
indicate movement toward a loss of control.
Here a man with a very high anger level will result to a
pale or flushed face, yelling, agitated, showing threatening
gestures such as clenching fist and even the ability to think
clearly is loss.

Crisis phase:
During this stage the man will loss his control and will
react to the environment by:
Kicking,
Punching,
Screaming,
Throwing objects and he will have loss the ability to
communicate clearly.

Recovery phase:
As the person regains physical and emotional control the
man is showing a more relaxed state by lowering his
voice, has a decreased muscle tension and has more
rational communication with others.

Post crisis phase:
The man will attempt reconciliation for everything he has
done.
He will be very emotional that they apologize in a quiet
yet crying behavior.
In here the man can now be reintegrated to the
environment to be more relaxed and emotionally stable.

SIGN AND SYMPTOMS OF AGGRESSION:
IN TRIGGERING PHASE-
Restlessness
Anxiety
Irritability
Muscle tension
Rapid breathing
Perspiration
Loud voice.

IN ESCALATION PHASE-
Pale or flushed face
Yelling
Agitated
Threatening
Demanding
Clenched fists
Hostility, loss of ability to solve problems.

IN CRISIS PHASE-
Loss of emotional and physical control
Throwing objects
Kicking, Hitting
Spitting
Biting, scratching
Screaming
Inability to communicate clearly.

IN RECOVERY PHASE-
Lowering of voice
Decreased muscle tension
Clearer
More rational communication and Physical relaxation.

IN POST CRISIS PHASE-
Remorse
Apologies
Crying
Quiet
Withdrawn behavior.

NURSES’ RESPONSE TO ASSAULT:
Response types are:
 Affective
 Cognitive and behavioral
 Physiologic

Affective:
Personal –
 Irritability
 Depression
 Anger
 Anxiety
 Apathy

Professional-
 Erosion of feelings of complete, leading increase anxiety
and fear.
 Feelings of guilt or self-harm.
 Fear of potentially violent patient.

Cognitive and behavioral:
Personal-
 Suppressed thoughts of assault
 Social withdrawal.
Professional-
 Reduced confidence in judgement.
 Consideration of job change.

 Possible hesitation in responding to other violent situation.
 Possible over-controlling.
 Possible hesitation to report future assault.
 Possible withdrawal from colleagues.
 Questioning of capabilities by coworker.

Physiologic:
Personal-
 Disturbed sleep
 Headache
 Stomach aches
 Tension
Professional-
 Increase absenteeism.

MANAGEMENT
 The goal of anger management is to reduce both the
emotional feelings and the physiological arousal that anger
engenders.

General Principles of Management
The safety of patient, clinician, staff, other patients and
potential intended victims.
The doors should be open outwards and not be lockable
from inside or capable of being blocked from inside.
One must take care to reduce accessibility to patients of
movable objects, earrings, eyeglasses, lamps and pens.
Adequate caregiver training.

Availability of appropriate supervision.
Constant Observation in a calm and firm but respectful
manner.
Putting space between self and patient.
Avoiding physical or verbal threats, false promises and
build rapport with client.
Training in basic self-defense techniques and physical
restraint techniques are useful.

Environmental management: violence prevention
Remove potential weapons from the environment.
Search environment routinely to maintain it as hazard free.
Search patient and belongings for weapons or potential
weapons during admission.
Monitor the safety of items.

Assign single room to patient.
Place the patient in a room near a nursing station.
Place patient in least restrictive environment.
Provide plastic, rather than metal, clothes hanger as
appropriate.

NURSING PROCESS:
Assessment
Anger
Anger can be associated with a number of typical
behaviors, including (but not limited to) the following:
 Frowning facial expression.
 Clenched fists.
 Low-pitched verbalizations forced through clenched teeth.
 Yelling and shouting.

 Intense eye contact or avoidance of eye contact.
 Easily offended.
 Defensive response to criticism.
 Passive–aggressive behaviors.
 Emotional over-control with flushing of the face.
 Intense discomfort; continuous state of tension.

Anger has been identified as a stage in the grieving process.
Individuals who become fixed in this stage may become
depressed.
Because of the negative connotation to the word anger, some
clients will not acknowledge that what they are feeling is
anger. These individuals need assistance to recognize their
true feelings and to understand that anger is a perfectly
acceptable emotion when it is expressed appropriately.

Aggression
Aggression can arise from a number of feeling states,
including anger, anxiety, guilt, frustration, or suspiciousness.
Aggressive behaviors can be classified as:
 Mild (e.g., sarcasm)
 Moderate (e.g., slamming doors)
 Severe. (e.g., threats of physical violence against others)
 Extreme (e.g., physical acts of violence against others).

Aggression may be associated with (but not limited to) the
following defining characteristics:
 Pacing, restlessness.
 Tense facial expression and body language.
 Verbal or physical threats.
 Loud voice, shouting, argumentative.
 Threats of homicide or suicide.

 Increase in agitation, with over-reaction to environmental
stimuli.
 Panic anxiety, leading to misinterpretation of the
environment.
 Disturbed thought processes; suspiciousness.
 Angry mood, often disproportionate to the situation.

Assessing Risk Factors
Past history of violence.
Client diagnosis.
Current behavior.

DIAGNOSIS
Ineffective coping related to negative role modeling and
dysfunctional family system evidenced by yelling, name
calling, hitting others, and temper tantrums as expressions of
anger.
Risk for self-directed or other-directed violence related to
having been nurtured in an atmosphere of violence; history
of violence

OUTCOME IDENTIFICATION
The client:
Is able to recognize when he or she is angry, and seeks out
staff/support person to talk about his or her feelings.
Is able to take responsibility for own feelings of anger.
Demonstrates the ability to exert internal control over
feelings of anger.
Is able to diffuse anger before losing control.

Uses the tension generated by the anger in a constructive
manner.
Does not cause harm to self or others.
Is able to use steps of the problem-solving process rather
than becoming violent as a means of seeking solutions.

NURSING INTERVENTION
Remain calm when dealing with an angry client.
Set verbal limits on behavior. Clearly delineate the
consequences of inappropriate expression of anger and
always follow through:
 Have the client keep a diary of angry feelings, what triggered
them, and how they were handled.
 Avoid touching the client when he or she becomes angry.
 Help the client determine the true source of the anger.
 It may be constructive to ignore initial derogatory remarks by
the client.

 Help the client find alternate ways of releasing tension,
such as physical outlets, and more appropriate ways of
expressing anger, such as seeking out staff when feelings
emerge.
 Role model appropriate ways of expressing anger
assertively.

Observe client for escalation of anger (called the
prodromal syndrome):
 Increased motor activity.
 Pounding.
 Slamming.
 Tense posture, defiant affect.
 Clenched teeth and fists, arguing,
 Demanding, and challenging or threatening staff.

When these behaviors are observed, first ensure that
sufficient staff are available to help with a potentially
violent situation. Attempt to defuse the anger beginning
with the least restrictive means.
Techniques for dealing with aggression include:
 Talking down. (Ensure that client does not position
self between door and nurse.)
 Physical outlets.

Medication:
If agitation continues to escalate, offer client choice of
taking medication voluntarily. If he or she refuses, reassess the
situation to determine if harm to self or others is imminend.
 Acute agitation and aggression:
 Antipsychotics Eg. Ziprasidone IM.
 Haloperidol- 0.5 to 10 mg IM.
 Risperidone 0.5mg-1mg- In dementia and schizophrenia.

 Trazodone – 50-100mg . In older clients with sun downing
syndrome and aggression.
 Benzodiazepines Most commonly lorazepam, oral or
injection.
 Other sedating agents used include Valproate, chloral
hydrate and diphenhydramine.

 Chronic aggression:
When client continues to exhibit aggression more than
several weeks’ choice of medication is based on underlying
condition. I.e., if related to:
 Antipsychotic- schizophrenia.
 Anxiolytics- Buspirone
 Carbamazepine and valproate to treat bipolar associated
aggressive behaviour.
 Antidepressants –trazodone in aggression associated with
organic mental disorder.
 Anti-hypersensitive medication – Propanolol to treat
aggression related to organic brain syndrome.

Restraints: If client is not calmed by “talking down” or
by medication, use of mechanical restraints and/or
seclusion may be necessary. Be sure to have sufficient
staff available to assist.
 Physical restraints are any manual methods or physical or
mechanical device attached to or adjacent to the patient’s body
that she/he cannot easily remove and that restricts freedom of
movement or normal access to one’s body, material or
equipment.

 Chemical restraints are medications used to restrict
patient’s freedom of movement or for emergency control of
behaviour, but it is not a standard treatment for the patient’s
medical or psychiatric condition.

Guidelines for use of restraints:
 Restraints should be applied with care that not to injure a
patient.
 Adequate personnel must be assembled before the patient is
approached.
 Each staff member should be assigned responsibility for
controlling specific body parts.
 Restraints should be available and in working order.
 Padding of cuff restraints helps to prevent skin breakdown.
For the same the patient should be positioned in anatomical
alignment.

 Restraints must not be used to punish a patient or solely
following the convenience of staff or other patients.
 Staff must take into consideration the medical/psychiatric
status of patient.
 Written policy must be followed.
 Physical restraints should be used very sparingly and only
after careful and comprehensive review.

 All mechanical restraints must be padded; proper size and
type must be used.
 Both the patient and restraining device must be checked
frequently.
 A restrained limb should be periodically exercised and, if
possible the patient should be ambulated at reasonable
intervals.
 Attention to need for hydration, elimination, comfort, and
social interaction must be assured.

Observation and documentation: Observe the client in
restraints every 15 minutes (or according to institutional
policy).
Ensure that circulation to extremities is not compromised
(check temperature, color, pulses).
Assist client with needs related to nutrition, hydration, and
elimination.
Position client so that comfort is facilitated and aspiration can
be prevented.
Document all observations.

Ongoing assessment: As agitation decreases, assess
client’s readiness for restraint removal or reduction. With
assistance from other staff members, remove one restraint
at a time, while assessing client’s response. This
minimizes the risk of injury to client and staff.

Staff debriefing: It is important when a client loses
control for staff to follow-up with a discussion about
the situation.
Debriefing is an important part of terminating the use of
seclusion or restraints.
Debriefing is a therapeutic intervention that includes
reviewing the facts related to an event and processing the
response to them.
It provides the staff and patient with an opportunity to clarify
the rational for seclusion, offer mutual feedback.
Identify alternative, methods of coping that might help the
patient avoid seclusion in the future.

Communication strategies
The nurse should have to:
 Present a calm appearance
 Speak softly
 Speak in a non proactive and non judgmental manner
 Speak in a neutral and concrete way
 Put space between yourself and patient
 Show respect to the patient
 Avoid intense direct eye contact

 Demonstrate control over the situation without assuming
an overly authoritarian stance.
 Facilitate the patient’s stance.
 Listen to the patient
 Avoid early interpretations
 Do not make promises that cannot keep.

EVALUATION
The following type of information may be gathered to
determine the success of working with a client exhibiting
inappropriate expression of anger:
 Is the client able to recognize when he or she is angry now?
 Can the client take responsibility for these feelings and keep
them in check without losing control?

 Does the client seek out staff/support person to talk about
feelings when they occur?
 Is the client able to transfer tension generated by the anger
into constructive activities?
 Has harm to client and others been avoided?
 Is the client able to solve problems adaptively without
undue frustration and without becoming violent?

RESEARCH ARTICLE
Anger Management among Medical Undergraduate
Students and Its Impact on Their Mental Health and
Curricular Activities
by: Gayathri S. Prabhu,
Department of Anatomy, Melaka Manipal Medical
College, Manipal University, 12 July 2016

ABSTRACT
Background: This study was intended to determine the practice of
students in good anger management skills and to what extent their
anger can affect their studies, work, and social interactions.
Variable: In this study the relationship between anger management
and the effects on the mental health of medical students was
evaluated.
Sampling technique: A survey was also done to determine duration
of the feeling of anger which lasts among medical students and its
consequences.
Materials and Methods: A newly developed questionnaire was
utilized which included a simplified version of the Novaco Anger
Scale and Provocation Inventory and the modified Patient Health
Questionnaire 9 (to measure the mental health).

Results: The data suggests that although students with high anger
tendencies display poor mental health, there is no lowering of the
mental health/PHQ-9 score as the anger management technique’s
effectiveness rises. “Friends” was cited as the major triggering
factor for anger, whereby the feelings can last for up to a day and
somewhat affect their concentration on normal activities.
Conclusion: When anger is suppressed and not let out, it can be
an underlying factor for anxiety and depression. Therefore, more
emphasis needs to be placed on educating students on how to
manage their anger especially in a stressful environment away
from home.

SUMMARY
Today we had discussed about anger and aggression, its’s
predisposing factors, various stages, sign and symptoms,
nurse’s response toward aggression and management.

CONCLUSION
Anger is a normal human emotion that is crucial for
individual’s growth. When handled appropriately and
expressed assertively, anger is a positive creative force that
leads to problem solving and productive change.
When channeled inappropriately and expressed as verbal
aggression or physical aggression, anger is destructive and
potentially life threatening force.

Patients admitted to an inpatient psychiatric unit are usually
in crisis, so their coping skills are even less effective.
During these times of stress acts of physical aggression or
violence can occur.
Nurses spends more time in the inpatient unit than any other
disciplines, so they are more at risk of being victims of acts
of violence by patients.
For these reasons, it is critical that psychiatric nurses be able
to assess patients at risk for violence and intervene
effectively with patients before, during and after an
aggressive episode.

BIBLIOGRAPHY
 R Sreevani A Guide to Mental Health and Psychiatry Nursing JAYPEE Publications 2nd edition
page no- 242-243
 Psychiatric Nursing Contemporary Practice Mary Ann Boyd Lippincott Publications 2nd edition
Page no: 950-970
 Psychiatric mental health nursing concepts of care in Evidence-Based practice Mary C.
Townsend JAYPEE Publications 8th edition Page no: 262-271
 Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical
Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers;1998.
 Stuart GW, Laria MT. Principles and Practices of Psychiatric Nursing. Ist ed.
Philadelphia: Mosby Publishers; 2005. Page no- 630-651.
 https://www.hindawi.com/journals/edri/2016/7461570/
 https://www.slideshare.net/MenanRabie/psychology-of-aggression
 https://www.slideshare.net/ > sunilkumar3828/theories-of-aggression-141218680

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