ANGER, HOSTILITY

AND AGGRESSION
ANGER
• a normal human emotion, but often perceived as a negative feeling
• is a strong, uncomfortable, emotional response to a real or perceived
provocation (Thomas, 1998).
• results when a person is frustrated, hurt, or afraid.
• If handled appropriately and expressed assertively, anger can be a
positive force that helps a person to resolve conflicts, solve problems,
and make decisions.
• energizes the body physically for self-defense, when needed, by
activating the “fight-or-flight” response mechanisms of the
sympathetic nervous system.
• When expressed inappropriately or suppressed, however, anger can
cause physical or emotional problems or interfere with relationships
• Example: migraine headaches, ulcers, or coronary artery disease
and emotional problems such as depression and low self-esteem
• Nursing Intervention
• Therapeutic communication techniques
• “I” statements- allow appropriate expression of anger and can lead
to productive problem-solving discussions and reduced anger.
• “I feel angry when you interrupt me,” or “I am angry that you
changed the work schedule without talking to me.”
• Non aggressive activities such as walking or talking with another
person,
• Catharsis
• Aggressive but safe activities such as hitting a punching bag or
yelling
• Not advisable because it can increase rather than alleviate
angry feelings (Bushman and Stack,1999) therefore, may be
contraindicated for angry clients.
HOSTILITY AND AGGRESSION
• also called verbal aggression
• is an emotion expressed through verbal abuse, lack of
cooperation, violation of rules or norms, or threatening
behavior

Physical aggression
• is behavior in which a person attacks or injures another
person or that involves destruction of property.
• Both verbal and physical aggression are meant to harm
or punish another person or to force someone into
compliance.
Acting out
• is an immature defense mechanism by which the person
deals with emotional conflicts or stressors through
actions rather than through reflection or feelings.
• The person engages in acting-out behavior, such as
verbal or physical aggression, to feel temporarily less
helpless or powerless.
• Children and adolescents often “act out” when they
cannot handle intense feelings or deal with emotional
conflict verbally.
• To understand acting-out behaviors, it is important to
consider the situation and the person’s ability to deal
with feelings and emotions.
 Etiology
• Neurorobiologic
• Unknown
• Serotonin- inhibits aggression
• increased activity dopamine and norepinephrine = increased
impulsively violent behavior
• structural damage to the limbic system and the frontal and
temporal lobes of the brain = altered ability to modulate
aggression
• Psychosocial
• Dysfunctional families with poor parenting
• Inconsistent responses to the child’s behavior
• lower socioeconomic status
Treatment
• Lithium- for aggression, bipolar and children with conduct disorder
• Carbamazepine (Tegretol) and valproate (Depakote) aggression
associated with dementia, psychosis, and personality disorders.
• Clozapine(Clozaril), risperidone (Risperdal), and
olanzapine(Zyprexa)- aggressive clients with dementia, brain injury,
mental retardation, and personality disorders
• Benzodiazepine- to reduce irritability and agitation in older adults
with dementia, but can result in loss of social inhibition for other
aggressive clients, thereby increasing rather than reducing their
aggression
• Haloperidol (Haldol) + Lorazepam(Ativan)
• the first dose is given at the time of the aggressive behavior
• second dose is given 30 minutes to 1 hour after the behavior
• third dose is given 1 to 2 hours after the behavior.
Five-Phase Aggression Cycle
Triggering Phase
• An event or circumstances in the environment initiates the
client’s response, which is often anger or hostility.
• Restlessness, anxiety, irritability, pacing, muscle tension,
rapid breathing, perspiration, loud voice, anger
Escalation Phase
• Client’s responses represent escalating behaviors that
indicate movement toward a loss of control.
• Pale or flushed face, yelling, swearing, agitated,
threatening, demanding, clenched fists, threatening
gestures, hostility, loss of ability to solve the problem or
think clearly
Crisis Phase
• During a period of emotional and physical crisis, the client loses
control.
• Loss of emotional and physical control, throwing objects, kicking,
hitting, spitting, biting, scratching, shrieking, screaming, inability to
communicate clearly
Recovery Phase
• Client regains physical and emotional control.
• Lowering of voice, decreased muscle tension, clearer, more rational
communication, physical relaxation
Post-crisis Phase
• Client attempts reconciliation with others and returns to the level of
functioning before the aggressive incident and its antecedents.
• Remorse, apologies, crying, quiet withdrawn behavior
ABUSE AND
VIOLENCE
Abuse
 is the wrongful use and maltreatment of another person
Violence
 is the expression of physical or verbal force against self or
other, compelling action against one's will on pain of
being hurt.
 Usually perpetrated by someone known to the victim like
spouse/partner, child, elderly parent (domestic abuse)
 Often remains undisclosed for months or years because
victims fear their abusers
Victims of abuse and trauma can have both physical and psychological injuries,
including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or dehumanized; low self-esteem, feels
unlovable
• Relationship problems; mistrust of authority figures
• Withdrawn and aloof
Nursing Considerations:
• Be sensitive to the client’s need to feel safe, secure and in control of
his/her body
• Maintain client’s personal space
• Assess anxiety level
• Ask permission before touching him/her
Spouse or Partner Abuse
• Involves the mistreatment of one person by another in
the context of an intimate relationship
• 90% to 95% of domestic violence victims are women
• Pregnancy escalates domestic violence
• Abuse can occur in same-sex relationships
BATTERED WIFE SYNDROME
 cycle of domestic violence characterized by
wife-beating by the husband, humiliation
and other forms of aggression
 The most common trait of abusive men is
low self-esteem
 The most common trait of abused women
is dependence
 Priority Care for Battered Wife: provide
shelter
 Characteristics of Abusive Husband:
 They usually come from abusive
families
 They are Immature, dependent and
non-assertive
 They have strong feelings of inadequacy
 Phases of Battered Wife Syndrome
TENSION-BUILDING PHASE- involves minor battering incidents
ACUTE BATTERING INCIDENT- more serious form of battering
AFTERMATH/HONEYMOON
 husband becomes loving and gives the wife hope
 abuser promises it will never happen again, gives gifts and
flowers, is affectionate
 Tensions begins to build with arguments, silence, complaints
 Violence occurs again
 This cycle repeats over and over
 Assessment
 It is necessary to identify victims of abuse in all settings, since they often
do not seek treatment directly
 SAFE questions can be used to assess:
 Stress/Safety
 Afraid/Abused
 Friends/Family
 Emergency plan
 Treatment and Intervention
 Women may stay in abusive relationships for fear of violence to children,
fear of increased violence or death, financial dependence
 Identifying women in violent situations is a priority.
 Providing women with information about shelters, services, and so forth is
essential
 The nurse must never indicate that he or she thinks the woman should
leave the relationship; keep the door open for further communication
CHILD ABUSE
Child abuse is intentional injury of a child, including:
Physical abuse or injuries/violence
Sexual assault or intrusion
Neglect or failure to prevent harm (failure to provide
adequate physical or emotional care or supervision;
abandonment)
Psychological / emotional abuse
 CHILD ABUSE
 Is what happens when an older adult takes advantage of his authority over a
young child
 PHYSICAL ABUSE
 Abuse in the form of inflicting pain
 EMOTIONAL ABUSE
 Abuse in the forms of insult and undermining one’s confidence
 SEXUAL ABUSE
 Abuse in the form of unwanted sexual contact
 COMMON INDICATORS OF CHILD ABUSE
 S – serious injuries in various stages of healing
 H - healthy hair in various length
 A - apathy, no reaction
 D - depression
 E - excessive knowledge of sex
 S - self-esteem is low
Characteristics of Abusive Parents
• Come from violent families
• Were also abused by their parents
• Have inadequate parenting skills
• Are socially isolated because they don’t trust anyone
• Are emotionally immature
• Have negative attitude towards the management of the abused
• Are incapable of meeting their own needs
• Often raise their children the way they were raised, including
corporal punishment and abuse
• Expect the child to meet all their needs for love and affection
 NURSING CONSIDERATIONS
RA 7610- ANTI-CHILD ABUSE LAW
Law requires reporting of suspected cases to authorities
Report cases to the barangay officials, DSWD, personnel, police
within 48 hours
ELDER ABUSE
Elder abuse is maltreatment of older adults by family members or
caretakers, including:
Physical, sexual, or psychological abuse or neglect
Self-neglect
Financial exploitation
Denial of adequate medical treatment
 60% of perpetrators are spouses, 20% adult children, 20% others
 People who abuse elders are almost always in a caretaker role
 Elders are reluctant to report abuse because they fear the
alternative (nursing home)
 Not all states have mandatory elder abuse reporting laws
Possible indicators of abuse by caregiver:
• Caregiver speaks for the elderly person
• Caregiver shows indifference or anger
• Caregiver blames elderly person for physical problems
• Caregiver shows defensiveness
• Caregiver and client give conflicting accounts
Intervention
• Providing adequate support and break for the
caregivers
• Changing caregiving arrangements
• Moving the elderly person to a safe environment
RAPE / SEXUAL ASSAULT
 Rape is a crime of violence and aggression expressed through
sexual means. The act is against the victim’s will or against
someone who cannot give consent.
 RAPE
 According to RA 8353, rape refers to insertion of penis into the
mouth, vagina, anus of the victim
 Insertion of any object into the mouth, anus or vagina
 Generally considered as an act of hostility, anger or violence
 ESSENTIAL ELEMENTS NECESSARY TO DEFINE AN ACT OF RAPE
Use of threat/force
Lack of consent from the victim
Actual penetration of the penis into the vagina
 KINDS OF RAPE
Power- done to prove one’s masculinity
Anger- done as means of retaliation
Sadistic- done to express erotic feelings
 RAPE TRAUMA SYNDROME (RTS)
Refers to a group of signs and symptoms experienced by a victim
in reaction to rape
 PHASES OF RTS
Acute- characterized by shock, numbness and disbelief
Denial- characterized by the victim’s refusal to talk about the
event
Heightened anxiety- characterized by fear, tension, nightmares
Stage of reorganization- victim’s life normalizes
 PRIORITY CARE: preservation of evidence
 TREATMENT AND INTERVENTION
Immediate support to ventilate fear and rage
Care by persons who believe that the rape happened
Coordination of all needed services in one location
Giving the victim control over choices whenever
possible
Prophylactic treatment for STDs
Referral to therapy services; counseling; and groups for
longer-term help
GRIEF AND LOSS
Grief
 refers to the subjective emotions and affect that are a
normal response to the experience of loss.
Grieving
 also known as bereavement
 Refers to the process by which a person experiences the
grief.
 It involves not only the content (what a person thinks,
says, and feels) but also the process (how a person thinks,
says, and feels).
Anticipatory grieving
 is when people facing an imminent loss begin to
grapple with the very real possibility of the loss or
death in the near future (Zilberfein, 1999).
Mourning
 is the outward expression of grief.
KUBLER-ROSS’S STAGES OF GRIEVING
FIVE STAGES OF GRIEVING
1. Denial is shock and disbelief regarding the loss.
2. Anger may be expressed toward God, relatives, friends, or health
care providers.
3. Bargaining occurs when the person asks God or fate for more
time to delay the inevitable loss.
4. Depression results when awareness of the loss becomes acute.
5. Acceptance occurs when the person shows evidence of coming
to terms with death.
DISENFRANCHISED GRIEF
 is grief over a loss that is not or cannot be
acknowledged openly, mourned publicly, or supported
socially.
 Three categories of circumstances can result in
disenfranchised grief:
A relationship has no legitimacy.
The loss itself is not recognized.
The griever is not recognized.
NURSING RESPONSIBILITIES
observe and listen for cognitive, emotional, spiritual, behavioral, and
physiologic cues.
Maintain an attentive presence, and provide a psychologically safe
environment for deeply intimate sharing
Assess for:
Adequate perception regarding the loss
Adequate support while grieving for the loss
Adequate coping behaviors during the process
B- be physically present
B- be non-judgmental
E- encourage verbalization of feelings
A- allow the patient to cry
R- recognize your own thoughts about death and dying