CHAPTER- III

ANGER / AGGRESSIVE MANAGEMENT

INTRODUCTION:

We live in a world which often seems more violent with every passing day.
Anger is normal, it often is perceived as a negative feeling. Violence occurs
when individuals core control of their anger. Terrorist bombings, school – Yard
measures; war and atrocities fill news headlines. At limits it even seems that
humanity has a collective death wish.

DEFINITION:

Anger:

Anger is a normal human emotion, which is a strong, uncomfortable,

emotional response to a real or perceived provocation.

- Sheila L. Videbeck.

Anger is an emotional state that varies in intensity from mild irritation to

intense fury and range.

- Wikipedia

Aggression:

Aggression refers to a harsh physical or verbal actions intended (either

consciously or unconsciously) to harm or injure another.

BIOLOGY OF AGGRESSION:

Aggression is directed to and often originates from outside stimuli, but has
a very distinct internal character. Using various techniques and experiments,
scientist have been able to explore the relationships between various parts of the
body and aggression.

Aggression in the Brain:

Mary researchers fours on the brain to explain aggression. The areas

involved in aggression in mammals include the amygdale, hypothalamus,

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prefrontal cortex, cingulate cortex, hippocampus, septal nuclei and periaqueductal
gray of the midbrain.

Electrical stimulation of the hypothalamus causes aggression behavior, the

hypothalamus express reception that help determine aggression levels based on
their interaction with the neurotransmitters serotonin and vasopressin.

The amygdale is also critically involved in aggression. Stimulation of the

amygdale results in augmented aggressive behavior in hamsters, while lesions of
an evolutionarily homologous area in the lizard greatly reduce competitive issue
and aggression.

Neurotransmitters and Hormones:

 Various neurotransmitters and hormones have been shown to correlate with

aggressive behavior. The most after mentioned of these is the hormone
testosterone. In one source, it was noted that concentration of testosterone
most clearly correlated with aggressive responses involving provocation.
 Glucocorticoids also play an important role in regulating aggressive
behavior. Glucocorticoids affect development of aggression and
establishment of social hierarchies.
 Dehydroepiandrosterone (DHEA) is the most abundant circulating
androgen and can be rapidly metabolized within target tissues into potent
androgens and estrogens.
 Another chemical messenger with implications for aggression in the
neurotransmitter serotonin.
 Serotonin is negatively correlated with aggression.

PREDISPOSING FACTORS TO ANGER AND AGGRESSION:

A number of factors home been implicated in the way individuals express

anger. Some theorist view aggression as purely biological and some suggest that
it result from individuals interactions with their environments. It is likely a
combination of both.

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 Modeling

Operant conditioning

Neurophysiologic disorders
Predisposing factors
Biochemical factors

Socio-economic factors

Environmental factors

Modeling:

 Role modeling is one of the strangest forms of learning.

 How parents of 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.
 Role models are not always in the home, however. Evidence supports the
role of television violence as a predisposing factor to later aggressive
behavior.

Operant conditioning:

 Operant conditioning occurs when a specific behavior is reinforced.

 A positive reinforcement is a response to the specific behavior that is
pleasurable or produces the derived 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. For eg:
when a child wants something and has been told “no” by parent, he or she
might have a temper tantrum. It when the temper tantrum begins, the
parent lets the child have what is wanted, the anger has been positively
reinforced.

An Eg. Of learning by negative reinforcement follows:

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 A mother asks the child to pick up her toys and the child becomes angry
and has a temper tantrum. If, when the temper tantrum begins, the mother thinks,
“Oh, its’ not worth all this!” and picks up the toys herself, the anger has been
negatively reinforced.

Neurophysiological disorders:

Epilepsy of temporal and frontal lobe

Episodic aggression

Violent behavior

 Tumor in the brain (areas of the limbic system and temporal lobes)

Trauma in the brain

Aggression and violent bahaviour

A study by lee and associates (1998) showed that destruction of the

amygdaloid body in patients with intractable aggression resulted of families,
alienation, discrimination and frustration.

An ongoing controversy exist us to whether economic inequality or

absolute poverty is most responsible for violent behavior within this subculture.

Environmental factors:

 Physical crowding may be related to violence through increased contact

and decreased defensible space.
 A relationship between heat and aggression also has been indicated.
 Moderately uncomfortable temperature appears to be associated with an
increase in aggression, while extremely hot temperatures seems 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 in a reduction in autonomic around levels
and in the number of aggressive outbursts.

Biochemical factors:

Violent behavior may be associated with hormonal dysfunction caused by

curbing’s disease or hyperthyroidism.

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 Studies have not supported a correlation between violence and increased
levels of androgens or alterations in hormone levels associated with
hypoglycemia or premenstrual syndrome.

Various neurotransmitters may play a role in the facilitation and inhibition

of aggressive impulses.

Socio-economic factors:

Culture is a distinctly human factor that plays a role in anger and

aggression.

High rate of violence exist within the subculture of poverty in United

States. This has been attributed to lack of resources, breakup.

CAUSES OF ANGER AND AGGRESSION:

Human anger and aggression has been blamed on many things, including
broken homes, poverty, racism, inequality, chemical imbalances in the brain, toy
guns, TV violence.

Unfulfilled Human Needs and Desirers:

Self-control sometimes breaks down resulting in aggressions ranging from

petty theft – to the columbine massacre to the mass killing fields of Cambodia.

Neurosis – Neurosis consists of irrational thoughts and acts that cause

significant harm to one’s self or others.

Desperation – Destruction of the family by subsidizing children born out

of wedlock.

Destruction of inner-city jobs and businesses by minimum-wage and

licensing laws.

Envy – Envy is not simply an attack on a particular persons wealth or

success, but an attack on wealth and success per re.

Greed – Greed is a obsessive desire for material possessions, irrationally

placing material gain before all other values and being oblivious to the
psychological consequences of such single-minded pursuit of wealth on oneself
and others.

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 Collectivism – Collectivism is the doctrine that the social collective –
called society, the people, the state etc. has rights, needs or moral authority and
apart from the individuals who compromise it.

FUNCTIONS OF ANGER:

The role function of anger is to stop stress: It does this by discharging or

blocking awareness of painful levels of emotional or physical around. They are 4
of stress that anger server to dissipate:

Painful affect: Anger can block off painful emotions so that they are
literally pushed out of awareness. It can also discharge high levels of arousal
experienced during periods of anxiety, hurt, guilt and so on.

Painful sensation: Stress is often experienced as a physical sensation.

The most common form is muscle tension, but stressful arousal may also stem
from physical pain or sympathetic nervous system activity.

Frustrated Drive: Anger can discharge stress that develops when you are
frustrated in the research for something you want. It functions to ventilate high
arousal levels that inevitably grow as drive activities are blocked.

Threat: any perceived threat creates immediate arousal.

Very strong push

Stress reduction activity

Positive functions or constructive use:

 Anger energizes and mobilizes the body for self-defense.

 Anger is a constructive when it is expressed assertively.

Negative functions or destructive uses:

 Anger can be destructive when it marks honest feelings weakens self-

esteem and lead to hostility and rage.

TYPES OF ANGER / AGGRESSION:

Anger:

(i) Behavioral anger  which consist of an aggressive action often

physical, against someone or something.

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 (ii) Passive anger  people who have this type of anger may be silent but it
may be just to avoid the open confrontation. They tend to keep away
from conflicts with situations or people.
(iii) Verbal Anger  It signifies the same that is anger expressed through
words and not actions.
(iv) Self-inflicted anger  self-infecting anger is a way to take out the anger
by punishing oneself.
(v) Volatile anger It just comes and goes; it can either appear out of
nowhere or can explode or even go unnoticed.
(vi) Chronic anger  which is often a prolonged anger, and mostly without
any seasons.
(vii) Judgemental anger  this type of anger is very much related to verbal
anger and the person gets satisfaction by putting g other people down.
(viii) Overwhelmed anger  overwhelming, anger is used as a method to
relieve stress by shouting and fighting.
(ix) Retaliatory anger  Retaliatory anger is the result of often a direct
reaction to someone else fasting out at the person.
(x) Paranoid anger  this type of anger is the direct result of either the
insecurity feeling or jealously. It may be because of feeling intimidated
by others.
(xi) Deliberate anger This anger arises out of frustration or in order to gain
power over the situation or sometimes over a person. This type of anger
often occurs when something does not turn out the way the person
wanted.
(xii) Constructive anger This type of anger is a constructive approach
towards something and is often a response towards injustices.

Aggression:

TYPES EXAMPLES
A) VERBAL
(i) Active-Direct Insulting or derogating another person.
(ii) Active-Indirect Spreading malicious rumours or goring about
another person
(iii) Passive-Direct Defusing to speak to another person, to
answer questions and so on.
(iv) Passive-Indirect Falling to making specific verbal comments.

B) PHYSICAL
(i) Active-Direct Stabbing punching or shooting another
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 TYPES EXAMPLES
person.
(ii) Active-Indirect Setting a body trap for another person, hiring
an assassin to kill an enemy.
(iii) Passive-Direct Physical preventing another person from
obtaining a desired goal or performing a
desired act.
(iv) Passive-Indirect Refusing perform necessary tasks.

Types of Aggression can indicate as

Physical Verbal
Hitting Name calling
Active Don’t shake hands Don’t say Hello
Passive

PHASES OF AGGRESSION CYCLE:

Triggering

Post crisis

Escalation

Recovery

Crisis

I – Triggering – An event or circumstances I the environment initiates the clients

response, which is often anger or hostility.

- Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing,

perspiration, loud voice and anger.

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II – Escalation – clients responses represent escalating behaviours that indicate
movement towards a loss of control.

- Pale or flushed face, felling, swearing agitated, threatening, demanding,

clenched first, threatening gestures, hostility, loss of ability to solve the
problem or think clearly.

III – Crisis – During a period of emotional and physical crisis, the client loses
control.

- Loss of emotional and physical control, throwing objects, killing, hitting,

spitting, biting, inability to communicate clearly.

IV – Recovery – client regains physical and emotional control

- Lowering of voice, decreased muscle tension, clearer, more rational

communication, physical relaxation.

V – Post crisis – client attempts reconciliation with others and returns to the level
of functioning before the aggressive in violent and its antecedents.

- Remorse, apologies, crying, quiet.

CLINICAL MANIFESTATIONS OF ANGER / AGGRESSION:

- Restlessness
- Anxiety
- Irritability
- Pale or flushed face
- Lowering the voice
- Hostility
- Swearing
- Agitated
- Clenched fists
- Rapid breathing

MANAGEMENT OF ANGER AND AGGRESSION:

Anger Management Techniques:

The best way in dealing with anger is to know its cause.

Communication and conflict:

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  Communication and conflict are related to each other in the sense that
communication could lead to conflict as much as conflict could lead to
communication.
 Through communication, a person could also express himself which could
easily diffuse frustration, anger, stress and other emotional trouble.
 Conflict can easily lead to communication, since this is the only way that
two troubled parties could resolve their anger without restoring to physical
violence.

More than Just talk:

 Talking about emotions to avoid conflict is not the right way to diffuse
emotional problems.
 Proper communication is required that each party would have a clear
understanding.
 Need assertive communication.
 Physical aspect when talking to another person for an assertive
communication should also be considered.
 Looking straight to the eye will always convey the message clearly.
 Tone of the voice should also be controlled to prevent the idea that you are
conveying an angry message.

Step-by-step technique:

The following is a recommended strategy on how can effectively convey

message with understanding. When conveying this message, use first person
pronouns (I, we) instead of using 2 nd or 3rd person pronouns (you, they) so that
you do not sound blaming someone else for your troubles.

4 State what you need

3 Reason for emotions

2 Pointing to specific situation

1 The feeling stage

The feeling stage:

The first step in properly conveying your emotion is to tell them how you
feel. This should give your listeners a good idea on your current situation.

Pointing to specific situation:

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 Inform the person what triggers the said emotions. By being specific, you
will also increase understanding since they can easily relate to a specific event.

Reason for emotions:

Emotions are always triggered by events. However, there are underlying

reasons why a person feels this way. By being honest and clear about the reason,
understanding could be achieved.

State what you need:

Close everything by stating what you need to do or what needs to be done

by others. At this point, everyone now understands your situation and would be
glad to help you with your troubles.

Managing Aggression (Ending Aggression)

Three steps would end most of the aggression in the world today.

(i) Create free societies where prosperity is the norm, not the exception.
(ii) Provide rational moral education for young people, explaining that
aggression is almost never in their long-term interest and envy are
irrational.
(iii) Reject the “might of the collective” – the idea that the nation, state or
race has an identity above and apart from the individuals comprising it.

Aggression may never be eliminated entirely, but, it can be reduced to very

low levels by creating societies of freedom, self-awareness and comparison.

THE NURSING PROCESS

Assessment

Evaluation

Nursing Diagnosis

Implementation
Planning

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Assessment:

Nurses must be aware of the symptoms associated with anger and

aggression in order to make an accurate assessment.

 Anger: anger can be associated with a number of typical behaviors,

including the following:
 Frowning facial expression
 Clenched fists
 Low-pitched verbalization forced through clenched teeth
 Yelling and shouting
 Intense contact or avoidance of eye
 Easily offended
 Defensive response to criticism
 Passive aggressive behaviors
 Emotional over control with flushing of the face
 Intense discomfort, continuous state of tension.

Aggression:

Aggression can arise from a number of feeling states, including anger,

anxiety, guilt, frustration, or suspiciousness. Aggression may be associated with
the following defining characteristics:

 Pacing, restlessness
 Tense facial expression and body language
 Verbal or physical threats
 Loud voice, shouting, use of abscenities, argumentive
 Threats of homicide or suicide
 Increase in agitation, with over reaction to environmental stimuli
 Panic anxiety lending to misinteruption of the environment.
 Disturbed thought processes, suspiciousness
 Angry mood, often disproportionate to the situation.

Assessing Risk factors:

Prevention is the key issue in the management of aggressive or violent

behavior. The individual who becomes violent usually feels an underlying
helplessness. Three factors that have been identified as important considerations
in assessing for potential violence include the following.

(i) Past history of violence

(ii) Client diagnosis
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 (iii) Current behavior

Nursing Diagnosis:

- Ineffective coping related to negative role modeling and dysfunctional family

system as evidenced by Yelling, and temper tantrum.
- Risk for self-directed or other-directed violence related to having been
nurtured in an atmosphere of violence.
- High risk for violence, self-directed or directed at others related to manic
excitement; delusional thinking and hallucination.
- Impairment of adaptive behaviours and problem-solving abilities of a person
in meeting life’s demands and roles.

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 Nursing Expected
Nursing Interventions Rationale
Diagnosis outcome
Ineffective coping - Remain calm when dealing with an - Anger expressed by the nurse will Client will
related to angry client. most likely incite increased anger in be able to
negative role - Set verbal limits on behavior. Clearly the client. recognize
modeling and delineate the consequences of - Consisting in enforcing the anger in self
dysfunctional inappropriate expression of anger and consequences is essential if positive in self and
family system as always follow through. outcomes are to be achieved. take
evidenced by - Have the client keep a diary of angry - This provides a more objective responsibilit
yelling, and feelings, what triggered them, and how measure of the problem. y before
temper tantrums. they were handled. losing
- Avoid touching the client when he or she control.
becomes angry. - The client may view touch as
- Help the client determine the true source threatening and could become violent
of the anger. - Many times anger is being displaced
onto a safer object or person. If
resolution is to occur, the first step is
- If may be constructive to ignore initial to identify the source of the problem.
derogatory remarks by the clients. - Lack of feedback often extinguishes
an undesirable behavior.
- Help the client find alternate ways of

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 Nursing Expected
Nursing Interventions Rationale
Diagnosis outcome
releasing tension, such as physical - Client will likely need assistance to
outlets, and more appropriate ways of problem solve more appropriate ways
expressing anger, such as seeking our of behaving.
staff when feelings emerge.
- Role model appropriate ways of
expressing anger assertively.
- Role modeling is one of the stingiest
methods of learning.
Risk for self- - Observe client for escalation of anger. - Violence may be prevented if risks are The client
directed or other- - identified in time. will
directed violence - When these behaviors are observed - It helps to diffuse a potentially violent verbalize
related to having ensure that sufficient staff are available to situation. anger rather
been nurtured in help with a potentially violent situation. than hit
an atmosphere of - Techniques for dealing with aggression - Aggression control techniques others.
violence like talking down, physical outlets, promote safety and reduce risk of
medication, restraints. harm to client and others.
- Remove self and other clients from the - Client and staff safety are of primary
immediate area. concern.
- Reassess the situation to determine if - Provides the least restrictive method

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 Nursing Expected
Nursing Interventions Rationale
Diagnosis outcome
harm to self or others is imminent. of controlling client behavior.
- Maintain positioning. - To facilitate comfort.
High risk for - Maintain low level of stimuli in patients - To minimize anxiety and The patient
violence, self- environment, provide unchallenging suspiciousness. will not be
directed or environment. harm self or
directed at others - Observe patient’s behavior at least every - Early intervention must be taken to others.
related to manic 15 min. ensure patients and other’s safety.
excitement, - Ensure that all sharp objects, glass or - These may be used to harm self or
delusional mirror items, belts, ties, matchboxes have others.
thinking and been removed from patients environment.
hallucinations. - Redirect violent behavior with physical - For reliving pent-up tension and
outlet. hostility.
- Encourage verbal expression feelings. - Your reliving pent-up tension and
hospitality.
- Engage him in some physical exercises - To relieve tension.
like aerobics.
- Maintain and convey a calm attitude to - Anxiety is contagious and can be
the patient. transmitted from staff to patient.
- Talk to the patient in low, calm voice, - It helps to client to do the same.

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 Nursing Expected
Nursing Interventions Rationale
Diagnosis outcome
use clear and direct speech.
- Administer tranquilizing medication. - It helps to reduces anger.
- Have sufficient staff to indicate a show of - This conveys control over the situation
strength to patient if necessary. and provides physical security for the
staff.
- Set and maintain firm limits. - Limits must be established by others
when the client is unable to use
internal controls effectively.
Impairment of - The initial nursing assessment should - It helps to get baseline data. The patient
adaptive include a complete physical assessment, a will be able
behaviours and history of previous complaints and to express
problem – solving treatment. feelings
abilities of a - Minimize the amount of time and - If physical complaints are verbally.
person in meeting attention given to complaints. unsuccessful in giving attention, they
life’s demands should decrease in frequency over
and roles. - Do not argue with the client about his/her time.
somatic complaints. - Arguing with the client still constitutes
- Explore the client feelings of lack of attention, even though it is negative.
control over stress and life events. - The client may have helpers feelings

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Nursing Expected
Nursing Interventions Rationale
Diagnosis outcome
but may not recognize this
independently.
- Talk with the client once per shift. - Regular interest in the client facilitates
the relationship.
- Encourage the client to ventilate feelings - The client may have difficulty
by talking or crying, through physical identifying and expressing feelings
activities, and so forth. directly.

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Evaluation:

Evaluation consists of reassessment to determine if the nursing

interventions have been successful in achieving the objectives of care.
The following type of information may be gathered to determine the
success of working with the 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 occurs?
 Is client is able to transfer tension generated by the anger into
constructive activities?
 Has harm to client and others been avoided?

JOURNAL ABSTRACT:

Paul. A.Klacynski. Department of Psychology, West Viginia

University. U.S.A.

High responders were more likely than other boys to have been
from aggressive group and reported more aggression towards a
hypothetical peer.

CONCLUSION:

Anger is viewed as the emotional response to one’s perception of

a situation. Aggression one way in which individuals express anger.
Nurses must be aware of the symptoms associated with anger and
aggression in order to make accurate assessment. Prevention is the key
issue in the management of aggressive and violent behavior.

BIBLIOGRAPHY:

BOOKS:

 Dr. M.s. Bhatia, “Essentials of Psychiatry”, 4 th edition, 2004,

CBS publishers and distributors, New Delhi, Page.No: 37.3.
 Mary C. Townsend, “Psychiatric Mental Health Nursing”, Jaypee
brothers medical publishers(P) Ltd, Page.No: 240-249.

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  Niraj Ahuja, “A short text book of Psychiatry”, 5 th edition, 2004,
Jaypee brothers medical publishers(P) Ltd, Page.No: 124.
 Sheila L. Videbeck, “Psychiatric mental health nursing”, 3 rd
edition, 2006, Lipincott, Williams and wilkins, Page No: 179-
187.
 R. Sreevani, “A guide to mental health and psychiatric nursing”,
2nd edition, 2007, Jaypee brothers Medical Publishers (P) Ltd.
Page.No: 91.

Journals:

 The journal of child psychology and psychiatry, volume 30, issue

2, published 7.12.2006. Page.No: 309-314.
 American Academic of Neurology 2005, Page.No: 1106-1108.
 Personality and Individual differences, volume 35, issue 5,
October 2003, Page.No: 995-1005.

Electronic Version:

- http://www.findyoutinfo.gov
- neuropsychiatryonline.org
- www.nebi.nim.nih.gov
- www.jneuronic.org

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