Transcript Anger, Hostility, & Aggression

()= ex in previous
lecture
[]= in both lectures
Current Social and Emotional Concerns
Chapter 10: Anger, Hostility, and Aggression
Chapter 11: Abuse and Violence
Vicki Moceo MSN RN-BC, CA/CP SANE
Learning Outcomes
• Discuss anger, hostility, and aggression
• Describe the signs, symptoms, and behaviors
associated with the phases of aggression
• Identify appropriate nursing interventions in
caring for a patient experiencing anger,
hostility, or aggression
2
Anger
• Normal human emotion(can be a positive force)
• Handled appropriately, a positive force for
resolving conflicts, solving problems, making
decisions
– Body physically energized for self-defense
(activates “flight-or-flight” response)
3
Anger
• Expression inappropriate or suppressed:
negative force
– Physical(incr BP,ulcers) or emotional
problems;[interference with relationships]
– Possible hostility, aggression
• Catharsis: alleviate or increase feeling of anger
4
Anger
• Appropriate expression of anger involves
assertive communication skills that lead to
problem-solving or conflict resolution
• Anger that is expressed inappropriately can
lead to hostility and aggression
• Patients with depression may have anger
attacks when they feel emotionally trapped
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Hostility and Aggression
• Hostility = verbal (abuse)aggression, usually when
feeling threatened or powerless(lack of
cooperation,violation of rules or norms, threatening behavior)
• [Physical aggression: attack on or injury to
another person; destruction of property]
• Sudden, unexpected
• Identifiable stages or phases
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Anger
• Venting angry feelings by engaging in safe but
aggressive activities (punching bag, yelling) is
called catharsis “letting it go”; however research
has shown this may increase rather than
alleviate angry feelings
• Hostile/aggressive behavior may occur
suddenly without warning
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Hostility and Aggression
• Phases of aggression(table 10.1):
- Triggering- what sets them off (incr BP, redness, look
for the physical cues)
- Escalation- representing behaviors that indicate
a loss of control (cursing, threatening gestures)
- Crisis- Explode, lose control (biting, kicking)
- Recovery (starting to calm down (regain of physical
control)
- Postcrisis- Back to normal level of functioning
(apologetic)
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Related Disorders
• Depression
• Paranoid delusionssomeone is out to get
them
• Borderline/antisocialp
ersonality disordersusually in
adolescence/older
adults
• Intermittent explosive
disorder-fight’n drunk
• Alcohol/other drugs
• Auditory hallucinations
• Dementia, delirium,
head injuries
9
Etiology of Hostility and Aggression
• Neurobiologic theories
– Possible role of neurotransmitters: decreased serotonin;
increased dopamine, norepinephrine
– Structural damage to limbic system; damage to frontal or
temporal lobes
• Psychosocial theories
– Failure to develop impulse control
– Inability to delay gratification
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Treatments
• Underlying/comorbid psychiatric diagnosis
– Lithium: bipolar and conduct disorders; mental
retardation
– Carbamazepine or valproate: dementia, psychosis,
personality disorders
– Atypical antipsychotics: clozapine, risperidone, and
olanzapine: dementia, brain injury, mental
retardation, personality disorders
11
Treatments and Medications
• Treatment focuses on the underlying
psychiatric diagnosis:
Lithium “mood stabilizer”
Tegretol “anti-seizure and anger management”
Depakote “treatment of major depressive disorder” anti-depressant
and Mood stabilizer
Benzodiazepines “sedatives”
Haldol “tranquilizing med”
Atypical Antipsychotics “2nd generation antipsychotics”
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Treatments
• Continued
– Benzodiazepines: irritability and agitation in older
adults with dementia
– Haloperidol and lorazepam: decrease agitation or
aggression and psychotic symptoms
13
The Nursing Process: Assessment
• Factors influencing aggression in psychiatric
environment/unit milieu(scene)
• Individual patients (history)
• Patient’s behavior to determine phase of
aggression cycle (Table 10.1)
•
•
•
Early assessment/intervention needed to avoid physical aggression
Assess both PT and milieu (scene)
Assessment and intervention based on phases of aggression
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The Nursing Process:
Data Analysis and Outcome Identification
• Data analysis
– Risk for other-directed violence
– Ineffective coping
• Outcome identification( patient will):
– Not harm self or threaten others
– Refrain from intimidating/frightening behaviors
– Describe feelings, concerns without aggression
– Comply with treatment
15
The Nursing Process: Interventions
• Most effective, least restrictive when
implemented early in cycle of aggression
• Environmental management(managing the Milieuenvironment in psychological setting)-controlling the environment
– Having Planned activities; informal discussions
– Scheduled one-to-one interactions (letting
patients know what to expect)
– Assistance with problem solving or conflict
resolution to avoid expression of anger
– Safety of other patients
16
The Nursing Process: Interventions
• Aggression management: Triggering phase
– Approach in nonthreatening, calm manner
– [Convey empathy; listening]
– Encourage verbal expression of feelings-have them
speak out
– Suggest patient go to quieter area
– Use PRN medications
– Suggest physical activity such as walking
17
The Nursing Process: Interventions
• Aggression management: Escalation phase
– Take control; provide directions in firm, calm voice
– Direct patient to room or quiet area for time out
– Offer medication again
– Let patient know aggression is unacceptable;
nurse or staff will help maintain/regain control
– If ineffective, obtain help from other staff (show of
force)
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The Nursing Process: Interventions
• Aggression management: Crisis Phase
– Inform patient that behavior is out of control, staff
is taking control to provide safety and prevent
injury
– Use of restraint or seclusion(isolation) only if
necessary
– (Requirement,annually, to have training on how to
”take a person down” and restrain them)
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The Nursing Process: Interventions
• Aggression management: Recovery phase
(pt regains control)
– Talk about situation or trigger
• Help them find other solutions/options
– Help patient relax or sleep
– Explore alternatives to aggressive behavior
• i.e. Jumping jacks
– Provide documentation of any injuries
– Debrief staff
20
The Nursing Process: Interventions
• Aggression management: Postcrisis phase
– Remove patient from any restraint or seclusion to
rejoin milieu
– Calmly discuss behavior; allow patient to return to
activities, groups, and so forth
– Focus on appropriate expression of feelings,
resolution of problems or conflicts in
nonaggressive manner
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The Nursing Process: Evaluation
• Was patient’s anger defused in an early stage?
• Did angry, hostile, and potentially aggressive
patient learn to express feelings verbally and
safely without threats or harm to others or
destruction of property?
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Community-Based Care
• Effective management of comorbid conditions
– Regular follow-up appointments
– Compliance with prescribed medication
– Participate in community support programs
• Anger management groups to help patients
express feelings, learn problem-solving and
conflict-resolution techniques to achieve
stability
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Self-Awareness Issues
• Methods for handling own angry feelings
• Use of assertive communication skills, conflict
resolution
• Comfort with expression of anger from others
– Not taking other’s anger or aggression personally
or as measure of effectiveness as nurse
• Need to have the ability to be calm,
nonjudgmental
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Abuse and Violence
25
Learning Outcomes
• Discuss characteristics, types, and cycles of
abuse/violence
• Describe responses to abuse and violence
• Apply the nursing process to the care of
patients who have survived abuse/violence
• Evaluate your own experiences, feeling,
attitudes, and beliefs about abuse/violence
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Clinical Picture of Abuse and Violence
• Abuse: wrongful use, maltreatment of another
person
• Victims across lifespan: spouses, partners,
children, elders
• Evidence of physical injuries requiring medical
attention
• Psychological injuries with broad range of
responses
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Abuse and Violence
• Victims have both physical and psychological
injuries including:
- Agitation, anxiety, silence
- Shame and guilt, low self-esteem
- Suppressed anger or resentment
- Feelings of being degraded or dehumanized
- Relationship problems, mistrust
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Violence and Trauma
• Violence: the threatened or actual use of
physical force by an individual that results or
has a high likelihood of resulting in
psychological or physical injury or death
• Trauma: a disordered psychic or behavioral
state resulting from mental or emotional
stress or physical injury
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Characteristics of Violent Families
• Family violence: spouse battering, neglect and
physical, emotional or sexual abuse of
children, elder abuse, marital rape
• Common characteristics regardless of type of
abuse (Box 11.1)
– Social isolation
– Abuse of power, control
– Alcohol, other drug abuse
– Intergenerational transmission process
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Cultural Considerations
• Domestic violence spanning families of all
ages and from all ethnic, racial, religious,
socioeconomic, sexual orientation
backgrounds
• Battered immigrant women at particular risk
– Facing increased legal, social, economic barriers
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Intimate Partner Violence
• Mistreatment or misuse of one person by
another in context of emotionally intimate
relationship
• Emotional or psychological: name calling,
belittling, screaming, yelling, destroying
property, threatening, refusing to speak or
ignoring victim
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Intimate Partner Violence
•
•
•
•
Physical: shoving, pushing, battering, choking
Sexual: assaults during sexual relations, rape
Combination (common)
Victims: primarily women (increased rates
during pregnancy)
• 90-95% of domestic violence are women
• Abuse can occur in same sex relationships
• Often perpetrated by husband against will
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Intimate Partner Violence
• Clinical picture
– Abuser’s view of wife as belonging to him; strong
feelings of inadequacy, low-self esteem; poor
problem-solving and social skills
– Increasing violence, abuse with any signs of
independence
– Victim commonly dependent; viewed as unable to
function with husband
– Dependency is the trait most commonly found in
abused wives who stay w/ their husbands
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Intimate Partner Violence
• Cycle of abuse and violence
– Violent episode
tension-building
honeymoon phase
violent episode
35
Spouse or Partner Abuse
• Abuse cycle:
- Initial episode
- Honeymoon period
-Tension-building phase
-Violent episode
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Intimate Partner Abuse
• Identification important; victims commonly
not seeking direct help for problems
• Screening/assessment: SAFE (Box 11.2)
– Stress/safety
– Afraid/abused
– Friends/family
– Emergency plan
• Appropriate techniques (Table 11.1)
37
Intimate Partner Violence
• Treatment and interventions(be aware of diff stories)
– Laws related to domestic violence; arrest
• Laws very among states & not always followed
• Women may stay in abusive relationships for fear of violence to children,incr
violence or death,& financial dependance
– The nurse must never indicate they think the person
should leave the relationship: keep door open for
communication
• Nurse can’t advise, can give info/options & client must make
a decision for themselves
– Restraining order/civil orders of protection
– Provide info to PT about Shelters and services
– Individual psychotherapy/counseling, group therapy,
support and self-help groups
– Treatment for possible PTSD
38
Elder Abuse
• Maltreatment of older adults(Caused by family
members/caretakers)
– Physical, sexual, psychological abuse or neglect
– Self-neglect
– Financial exploitation
– Denial of adequate medical treatment
39
Elder Abuse
• People who abuse elders almost always in
caretaker role or elders depend on them in
some way
• Elders often reluctant to report abuse due to
fear of alternative (nursing home)
• Clinical picture: variable depending on type of
abuse
40
Elder Abuse
• Assessment (potential indicators, Box 11.4)
• Treatment and intervention
– Caregiver stress relief
– Additional resources
– Possible removal of elder or caregiver
41
Rape and Sexual Assault
• Rape: crime of violence, humiliation of victim
expressed through sexual means
• Sexual assault: any other form of forced sexual
contact (from touch to mutilation)
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Rape and Sexual Assault
• Perpetration of act of sexual intercourse against
person’s will and without consent
– Whether will is overcome by force, fear of force,
drugs, or intoxicants
• Also considered rape if person incapable of
exercising rational judgment because of mental
deficiency or when younger than age of consent
– Only slight penetration of vulva needed (full
erection/ejaculation not necessary)
43
Rape and Sexual Assault
• Strangers (approximately 50% of rapes),
acquaintances, married people, people of
same sex
• Date rape (acquaintance rape)
• Highly underreported crime
• Most commonly occurring in woman’s
neighborhood, often inside or near home
44
Rape and Sexual Assault
• Four(4) categories of male rapists
– Sexual sadists (aroused by victim’s pain)
– Exploitive predators (impulsive use of victims for
own gratification)
– Inadequate men (belief that no woman would
voluntarily have sexual relations with them;
obsessed with fantasies about sex)
– Men for whom rape is displaced expression of
anger, rage
45
Rape and Sexual Assault
• Most rapes premeditated
• Male rape significantly underreported
• Severe physical, psychological trauma
– Medical problems
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Rape and Sexual Assault
• Severe physical, psychological trauma
– Physical problems
• Acute injury, pregnancy, STD’s, lingering medical
complaints
– Psychological problems
• Fear, helplessness, shock, disbelief, guilt, humiliation,
embarrassment, (or anger)
• Avoidance of places or circumstances of rape; (loss of
previously pleasurable activities)
• Depression, anxiety, [PTSD], sexual dysfunction,
insomnia, impaired memory, suicidal thoughts
47
Rape and Sexual Assault
• Assessment:
– Physical examination: should occur before victim
has showered, brushed teeth, douched, changed
clothes, or had anything to drink
– Description of what happened
– Preservation of evidence (rape kit/rape protocol
are in most ER settings)
48
Rape and Sexual Assault
• Treatment and intervention
– Do not rush victim through any interview or
examination procedure
• Tell them the process before you do it
• Move interview along at their pace
– Provide immediate support to ventilate fear and
rage
– Give the patient rationales for care
49
Rape and Sexual Assault
• Treatment and intervention
– Give as much control back to victim as possible(to start
the healing process)
– Education (Box 11.6)
– Prophylactic treatment of STDs, pregnancy
– Therapy services(counseling,groups for long-term help) to restore
victim’s sense of control
50
Recovery from Violence/Trauma
• Stages
– Impact- victim can come in and be angry or in shock.
Each indvividual can react differently (ex: sleep problems,
nightmares, lose control of emotions)
– Recoil- starting/struggle to adapt (return to normal ADLs,
starting to open up about event. But victim may regress.)
– Reorganization- May never happen or could take yrs;
its when the pt has returned to normal ADLs w/out
negative SE from event
• Duration and severity of the trauma, victim
resources, and nature of help available during
and immediately after the crime/trauma
influence recovery
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Community Violence
• School violence (homicides, suicides, theft, violent
crimes)
• Bullying
• Hazing
• Effects on children, young adults
• Violence on larger scale (i.e., terrorism)
• Early intervention, treatment for victims
•
Not in prev sem lec
52
Psychiatric Disorders Related to Abuse and
Violence
• Post Traumatic Stress Disorder (PTSD)
– Disturbing behavior resulting from a traumatic event at
least 3 months after event occurred
– 3 clusters of symptoms are present:
• Reliving the event
• Avoiding reminders of the event
• Being on guard, or experiencing hyperarousal
• Not in prev sem lec
53
Psychiatric Disorders Related to Abuse and
Violence
• Symptoms of PTSD include:
- Flashbacks
- Insomnia
- Irritability
- Persistent
nightmares
- Memories
- Hypervigilance
- Angry outbursts
- Emotional
numbness
54
Psychiatric Disorders Related to Abuse and
Violence
• Dissociative disorders:
– Dissociation: subconscious defense mechanism
that helps a person protect the emotional self
from recognizing the full impact of some horrific
or traumatic event by allowing the mind to forget
or remove itself from the painful situation or
memory
– Occurrence both [during and after the event]
• Easier with repeated use
55
Psychiatric Disorders Related to Abuse and
Violence
• Dissociative disorders: disruption in usually
integrated functions of consciousness,
memory, identity, environmental perception
– Dissociative amnesia
– Dissociative fugue
– Depersonalization disorder
– Dissociative identity disorder (formerly multiple
personality disorder)
56
PTSD and Dissociative Disorders
• Treatment and intervention
– Community-based group or individual therapy
– Cognitive behavioral therapy
– Pharmacologic treatment
• Paroxetine, sertraline for PTSD
• Symptomatic treatment for dissociative disorders
(anti-anxiety agents, antidepressants)
57
The Nursing Process: Assessment
• History of trauma or abuse
• General appearance, motor behavior
– Hyperalertness, anxiety, agitation
• Mood, affect(fearful,hyper-alert,anxious,needs large personal space)
– Wide-ranging emotions from passivity to anger
• Thought processes, content
– Nightmares, flashbacks, destructive thoughts or
impulses
58
The Nursing Process: Assessment
• Sensorium, intellectual processes
– Disorientation (during flashbacks), memory gaps
• Judgment, insight
– Impaired decision-making, problem-solving
abilities
• Self-concept
– Low self-esteem
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The Nursing Process: Assessment
• Roles, relationships
– Problems with relationships, work, authority
figures
• Physiologic considerations
– Difficulty sleeping, under-eating or over-eating,
use of alcohol or drugs for self-medication
60
The Nursing Process: Data Analysis
• Common nursing diagnosis
– Risk for self-mutilation
– Ineffective coping
– Post-trauma response
– Chronic low self-esteem
– Powerlessness
61
The Nursing Process: Outcome Identification
• The patient will
– Be physically safe
– Distinguish between sefl-harm ideas and taking
action on those ideas
– Learn healthy ways to deal with stress
– Express emotions nondestructively
– Establish social support network in community
62
The Nursing Process: Intervention
• Promoting patient’s safety
• Helping patient cope with stress, emotions using
grounding techniques
• Helping promote patient’s self-esteem
• Establishing social support
63
The Nursing Process: Evaluation
• Outcomes possibly taking years to achieve
– Learning to protection of self
– Learning to manage to manage stress, emotions
– Ability to function in their daily life
64
Self-Awareness Issues
• Becoming comfortable asking about abuse (SAFE
questions)
• Listening to accounts of abuse from patients, families
• Recognizing patient’s strengths, not just problems
• Working with perpetrators of abuse; dealing with
own feelings about abuse , violence
65