PSYCHIATRIC

EMENGENCY- AGGRESSION

PRESENTER:
PAMELA .K. MWINDWA
OBJECTIVES
GENERAL OBJECTIVES
By the end of the session students should be
able to acquire knowledge and skills and
apply it in the management of clients with
aggressive behavior
OBJECTIVES
SPECIFIC OBJECTIVES
Define key terms
Describe the theories on causes of aggressive
behavior
 State the types of aggression
Mention characteristics of aggressive
behavior
OBJECTIVES
Discribe the management of a patient with
aggressive behavior
DEFINITION OF TERMS
Aggression
refers to behavior that is intended to cause harm
or pain.
can be either physical or verbal
Assertiveness
Ability to express yourself and your rights
without violating the rights of others (sudah
2011)
DEFINITIONS OF TERMS
Assertiveness includes:
Communicating directly with another person
Saying no to unreasonable demands or
requests
Being able to state your position
Expressing appreciation as appropriate
DEFINITION OF TERMS
Passiveness: Subjecting to an action without
responding or initiating an action in return.
DEFINITION OF TERMS
Anger
A strong uncomfortable emotional response
to provocation that is unwanted and
incongruent with one’s values, beliefs or
rights.
THEORIES ON CAUSES OF AGGRESSION
Biological Theories
Alteration in the brain structure and
function
Alterations in the limbic system especially
the amygdala may increase or decrease the
potential for aggressive behavior
THEORIES ON CAUSES OF AGGRESSION
Damage to the frontal lobe can result into
impaired judgment,
Personality changes, inappropriate conduct
and aggressive outburst
Alterations in the hypothalamus
Leads to over response to stress
THEORIES ON CAUSES OF AGGRESSION
Provocation
Over stimulation of the pituitary makes
people to respond vigorously to all
provocation
Could be one of the reason why children who
experience childhood traumatic stress tends
to permanently become violent
CAUSES OF AGGRESSION
Orbital frontal region
Lesions in this region leads to impulsive
behavior
CAUSES OF AGGRESSION
B. Imbalance in neurotransmitters
Increase or decrease in neurotransmitters
influences behavior by either aggravating or
inhibiting aggression
CAUSES OF AGGRESSION
For instance a decrease in serotonin is
associated with irritability and
hypersensitivity to provocation and rage
Lower levels of serotonin is associated with
acts such as impulsive arson, suicide and
homicide
CAUSES OF AGGRESSION
Other neurotransmitters that have been
associated with aggression include;
Dopamine
Norepinephrine
GABA
Increase in the levels of these
neurotransmitters is linked to impulsive
behavior
THEORIES ON CAUSES OF AGGRESSION
Social Theories
A. Learned behavior
Aggressive behavior is learned
Both internally and externally
Internal learning takes place through
reinforcement
THEORIES ON CAUSES OF AGGRESSION
External learning occurs through observation
of a role model
A role model can either be a peer, parent,
teacher or nurse etc
THEORIES ON CAUSES OF AGGRESSION
B. Sociocultural factors
A norm that reinforces violent behavior will
result in physical expression of anger in a
destructive way.
Norms that supports assertive expression of
anger helps people to deal with anger in a
health manner
THEORIES OF CAUSES OF AGGRESSION
Developmental factors
Organic brain damage
Intellectual disability
Severe emotional deprivation
Overt rejection in childhood
Exposure to violence during childhood
CAUSES OF AGGRESSION
Mental disorders
Patients with delusional disorders
Substance abuse disorders
Co-morbid of psychiatric and substance
abuse disorders
PTSD
TYPES OF AGGRESSION
Instrumental aggression
Aggression aimed at obtaining an object,
privilege or space with no intent to harm
another person
TYPES OF AGGRESSION
Hostile aggression
Aggression intended to harm another person,
such as hitting, kicking, or threatening to beat
up someone.
TYPES OF AGGRESSION
Relational aggression
 A form of hostile aggression that does
damage to another's peer relationships, as in
social exclusion or rumor spreading
CHARACTERISTICS OF AGGRESSIVE
BEHAVIOR
Pacing
Inabilityto sit still
Invasion of personal space
Loud speech
Verbal threats
Clenching or pounding fist
Jaw tightening
CHARACTERISTIC OF AGGRESSIVE
BEHAVIOR
Increased respiration
Anger
Hostility
Irritability disorientation
Delusions
Paranoid
MANAGEMENT OF CLIENTS BEFORE
AGGRESSIVE EPISODE
Preventive strategies
A. Establishing a therapeutic alliance
Involves :
Show unconditional positive regards
Treat client with respect and dignity
MANAGEMENT OF CLIENTS BEFORE EPISODE
OF AGGRESSION
B.Self awareness
 Helps the nurse to communicate effectively
Helps to avoid Countertransference
PREVENTIVE STATEGIES
D. Risk assessment
Assessing all patients for potential risk of
violence
Use an assault and violence assessment tool.
Has scores from 0-9
MANGEMENT BEFORE AGGRESSIVE EPISODE
9 or more – high risk
3-8- moderate risk
0-2 – no precautions
Scoring key:
2 points- high risk factor
1 point- moderate risk
0 point – no precaution
MANAGEMENT BEFORE AGGRESSIVE
EPISODE
Key factors to assess;
History of violence
History of aggression in family
Substance abuse
Impulsivity
Agitation
Sensorium
MANAGEMENT OF CLIENTS BEFORE
AGGRESSIVE EPISODE
OBSERVATIONS
Monitor client’s behavior regularly and
intervene as early as possible
Monitor for signs of escalating violence
Monitor client for signs of hallucination
Monitor client’s behavior for signs of
increased agitation and sensorium
MANAGEMENT OF CLIENTS BEFORE
AGGRESSIVE EPISODE
Assertiveness training
 Helps client to learn the skill through
structured groups or programs through:
Modeling
Role play
 home works
MANAGEMENT OF CLIENTS BEFORE
AGGRESSIVE EPISODE
Aggressive behavior tends to diminish as
clients learn new and more effective social
skills
MANAGEMENT OF CLIENTS BEFORE
AGGRESSIVE EPISODE
 Anger management
Teach client adaptive ways of managing anger
such as:
Change of environment
Writing about one’s feelings
 Cathartic activities
Taking a walk
Listening to soft music
MANAGEMENT BEFORE AGGRESSIVE
EPISODE
Environmental strategies
Involves modifying patient’s environment:
Reducing on stimuli
Ensuring privacy
Lack of personal privacy and loss of control
can foster anger and hostility
MANAGEMENT BEFORE AGGRESSIVE
EPISODE
Room programs
Involves limiting the amount of time the
patient is allowed in the unit milieu.
Allows patients time away from situations
that may increase agitation
Room programs also regulates the amounts
of stimulation the client receives.
MANAGEMENT OF CLIENT BEFORE
AGGRESSIVE EPISODES
Communication strategies
Present in a calm appearance
Do not argue with the patient because
arguing with the client may impede the
development of a trusting relationship
COMMUNICATION STRATEGIES
Strengthening the therapeutic alliance
Talking down the patient
Speaking in a calm and low voice helps to
reduce agitation
Use short and simple sentences
COMMUNICATION STRATEGIES
Avoid laughing and smiling unnecessarily
Communicate expected behavior in a
respectful and encouraging manner.
Helps client to maintain control over their
violent impulses
COMMUNICATION STRATEGIES
Maintain a calm and relaxed posture, good
eye contact
Helps client feel less intimidated
Avoid threatening and nervous postures
Maintain personal space.
Intrusion may be perceived as a threat and
provoke aggression
COMMUNICATION STRATEGIES
Acknowledge patient’s feelings and reassure
them
Allow patient to communicate their concerns
and participate in their care
BEHAVIROL STRATEGIES
Behavioral strategies
A. Limiting setting
Communicating in a calm and respectful
manner
Ensure consistence
BEHAVIROL STRATEGIES
B. Behavioral contracts
Sometimes patients use violence to win
control and make personal gains
To correct such, you withdrawal certain
rewards.
BEHAVIORAL STRATEGIES
Time out
Effective measures for managing agitated
patients
Decreases the need for seclusion and restraints
Involves short time removal of patient from
over stimulating and reinforcing situations
Patient remains there for a few minutes until
they are no longer aggressive
BEHAVIROL STRATEGIES
Token economy
Rewarding of interpersonal and self care
behaviors
Clinical example
 Ms Chota a regressed patient refused to get
out of bed in the morning
BEHAVIROL STRATEGIES
Refused to bath, dress or change clothes
When encouraged to perform these activities,
she become agitated, swore and threatened to
hit anyone who tried to help her
In her contract, ms chota would
BEHAVIROL STRATEGIES
Receive 2 tokens for each of the following
behavior;
Getting out of bed at 7:00
Bathing at 8:00
Dressing before 8:00
Episode of swearing will lead to loss of a
token
BEHAVIROL STRATEGIES
Cathartic activities
Physical and emotional cathartic
Examples of emotional cathartic;
Writing about one’s feelings
Talk about one’s feelings
Deep breathing
Relaxation exercises
BEHAVIROL STRATEGIES
Cathartic activities helps the client to regain
their control and lower feelings of tension and
agitation
MEDICATION
Benzodiazepine eg diazepam or lorezapam
IM for quick relief of symptoms of agitation
Antianxiety eg diazepam, Busiporone
Antidepressants eg SSRIs eg fluoxectine
MEDICATION
mood stabilizers eg sodium volprate,
Carbamazepine
Antipsychotic eg haloperidol IM/IV or
Risperidone or Olanzapine
other drugs: beta blockers e.g. propranolol
NURSING MANAGEMENT DURING A VIOLENT
STATE
Crisis management techniques
Identify crisis team leader
constitute a team
remain calm
Try to talk the client down
CRISIS MANAGEMENT
Notify team members or co-workers
Notify the physician and assess need for prn
medication
Obtain additional security if needed as sign
and show of strength
ENVIROMENTAL MODIFICATION
Create safe environment by removing harmful
objects to prevent client from using them to
harm self or others
Reduce on environmental stimuli
These may worsen the levels of violence
especially in highly suspicious patients
Assign client to a quiet and less traffic part of
the unit
COMMUNICATIONS STRATEGIES
Talking the patient down
Monitor client for verbal and behavioral
signs of escalating violence such as pacing,
clenching or pounding fists, loud pressured
speech, jaw tightening.
COMMUNICATION STRATEGIES
This will help the nurse in assess the
potential danger and providing necessary
interventions that will help the client to
deescalate
COMMUNICATION STRATEGIES
Avoid laughing, whispering or talking where
client can see but cannot hear what is being
said.
Client may have ideas of reference and may
become more aggressive
COMMUNICATION STRATEGIES
Ensure that you speak in a calm low voice to
help reduce client’s agitation.
when nurses use high voices, the client may
perceive it as a competition and hence
escalate feelings of increased violence
COMMUNICATION STRATEGIES
Use short simple sentences
Acknowledge client’s feelings and reassuring
them that the staff are there to help them
Allow client to ventilate
maintain adequate personal space
avoid being judgmental and use of
provocative language
MEDICATION
benzodiazepine e.g. lorezapm IM used for
quick relief of symptoms of agitation
antianxiety e.g. Busiporone
antidepressants e.g. SSRIs such as fluoxetine
CONTAINMENT STRATEGIES
Seclusion or Restraints
to be implemented when other less restrictive
measures proves ineffective
During seclusion and application of
restraints, client’s needs must be meet
Observing for circulation and change of
restraint devices regularly
MANAGEMENT AFTER THE VIOLENT EPISODE
ASSESSMENT
Assess for any physical injuries and manage
appropriately
MSE
Investigate the factors that could have led to the
violent episode and offer the necessary measures

Assign to quiet room

BEHAVIROL THERAPY
Remind client of set limits
Remind client of rewards
Remind client of token economy
PATIENT TECHING
Assertive
skills
Anger management skills
Communication skills
PREVENTION OF AGGRESSION
Settinglimits
Time outs
Room programs
Environment modification
Therapeutic alliance
Self awareness