Understanding Anger and Aggression

Anger and Aggression

• Anger is a normal human emotion that can be positive when managed well, aiding problem-solving and decision-making.
• Unexpressed or aggressively expressed anger can be problematic.
• Violence arises when anger is not controlled

Statistics

• In 2020, the rate of violent crimes in the U.S. was 398.5 per 100,000 people.
• Aggravated assault made up about two-thirds of these crimes.
• Violent crime rates had been decreasing since the 1990s, but there was an increase in 2020, especially in murder and manslaughter.

Definition and Physiological Changes

• Anger is an emotional state varying from mild irritation to intense fury.
• It is accompanied by increased heart rate, blood pressure, and hormone levels (adrenaline and noradrenaline).

Anger as a Normal Emotion

• Anger serves as a warning signal for potential threats, triggering a "fight or flight" response.

Fundamental Points About Anger

• Anger is not a primary emotion, but a response to hurt, frustration, or fear.
• It involves physiological arousal, instilling power and preparedness.
• Anger is distinct from aggression.
• Expression of anger can be learned and controlled.

Impact of Suppressed or Inappropriately Expressed Anger

• It can cause physical problems like headaches, ulcers, and heart disease.
• It can lead to depression, low self-esteem, relationship issues, resentment, and passive-aggressive behavior.

Physiological Preparedness and Unresolved Anger

• Anger activates the sympathetic nervous system, increasing heart rate, blood pressure, epinephrine, and serum glucose levels.
• Unresolved anger can lead to health problems due to prolonged physiological arousal, which can be reactivated by memories.

Defining Aggression

• Aggression is defined differently based on the situation.
• It is seen as behavior meant to threaten or harm someone's security or self-worth when viewed as a response to anger.
• Involves actions like going against, assaulting, or attacking, with the goal of causing pain or injury to people or objects.
• Aggression can include verbal and physical attacks intended to harm and often shows a desire to dominate or control others.
• Aggression can range from protecting oneself to destructive and violent acts

Positive Functions/Constructive Uses of Anger

• Self-Defense: Anger can provide a boost of energy to protect yourself
• Conflict Resolution: Expressing your anger clearly and respectfully can help solve problems.
• Signal for Coping: Feeling angry can alert you to a threat, prompting you to deal with it.
• Taking Control: Anger can be helpful when it allows you to take charge of a situation.
• Self-Esteem: Expressing anger assertively can boost self-esteem and lead to forgiveness.

Negative Functions/Destructive Uses of Anger

• Impulsive Behavior: Acting on anger without thinking can lead to negative consequences.
• Escalating Conflict: Expressing anger passively-aggressively or aggressively can worsen the situation.
• Displaced Aggression: Anger can lead to aggression when it's directed at the wrong target.
• Intimidation: Using anger to control or intimidate others is destructive.
• Masking Feelings: Hiding true feelings and becoming hostile due to anger is destructive.

Influences on Expressing Anger

• The way people express anger is influenced by many things.
• Some experts believe aggression is purely biological, while others think it comes from how people interact with their environment.
• It's most likely a mix of both biological and environmental factors.

Role Modeling

• Role modeling is a powerful way of learning, especially for children who learn from their parents or caregivers.
• The way these role models behave, whether positively or negatively, influences the child.
• Abused children may become abusive adults due to this learned behavior.
• Role models aren't always family members.

Media Influence

• Television and violent video games can also lead to aggressive behavior.
• Even brief exposure to violent video games can increase aggressive thoughts and actions, especially in boys.
• Role modeling plays a big part in how aggression develops whether in the community, at home or through media.

Operant Conditioning

• Operant conditioning is when a behavior is strengthened through reinforcement.
• Positive reinforcement: Giving something pleasant or a reward in response to a behavior.
• Negative reinforcement: Removing something unpleasant in response to a behavior.

Examples of Reinforcement

• Positive reinforcement: If a child throws a tantrum because they want an ice cream cone and the parent gives in, the tantrum (anger) is positively reinforced because it led to a reward.
• Negative reinforcement: If a child throws a tantrum when asked to pick up toys, and the parent, to avoid the tantrum, picks up the toys themselves, the tantrum is negatively reinforced because it helped the child avoid doing something they didn't want to do.

Neurophysiology of Aggression

• The neurophysiology of aggression refers to how brain functions relate to aggressive behavior, which is complex and not fully understood.
• Factors that increase activity in the brainstem or decrease the control of the limbic or cortical areas can increase aggression, impulsivity, and violence.

Factors Influencing Aggression

• Chronic traumatic stress
• Hormones like testosterone
• Dysregulation of neurotransmitter systems (serotonin or norepinephrine)
• Neglect
• Loss of function in the frontal cortex, which can result from conditions like stroke, dementia, alcohol intoxication, or traumatic brain injuries, is linked to increased aggression.
• Brain tumors (especially in the limbic system and temporal lobes), brain trauma, and diseases like encephalitis can also contribute to aggression and violent behavior.
• Genetics can play a role, particularly genetic variations affecting serotonin levels.
• Selective serotonin reuptake inhibitors (SSRIs) can increase frontal cortex activity and reduce aggression.

Biochemical Factors

• Hormones are significant in aggression.
• Animal research has focused on testosterone's effect on aggression.
• Giving testosterone to humans has shown mixed results with one study showing that anabolic-androgenic steroids led to both positive and negative mood symptoms, with the latter including anger, hostility, and violent feelings.
• Multiple hormones affect aggression, with testosterone playing a significant role.
• Deficiencies in serotonin are linked to increased impulsivity.
• Giving oxytocin reduces activity in the amygdala (a brain region involved in emotional responses) and decreases aggression in men.

Socioeconomic Factors

• High rates of violence are found within impoverished communities in the United States.
• Being exposed to violence increases the likelihood of future aggressive behavior.
• Debate exists regarding the impact of economic inequality versus absolute poverty on aggressive behavior.

Environmental Factors

• Crowding, high temperature, and noise increase the risk for aggressive behavior.
• These environmental factors increase stress levels, which can negatively affect mood and behavior.
• Past experiences and current behavior can also influence how aggression is expressed.

Predictors of Violence

• History of childhood abuse is a predictor
• History of violent acts, criminal activity, or arrests are predictors.
• Alcohol intake is a predictor.
• Numerous substances of abuse are associated with aggression, including methamphetamines, amphetamines, bath salts, anabolic steroids, synthetic marijuana, PCP, and alpha PVP (flakka).

Common Ways Anger is Displayed

• Frowning
• Clenched fists
• Speaking in a low voice through clenched teeth
• Yelling
• Intense staring or avoiding eye contact
• Being easily offended
• Defensiveness
• Passive-aggressive behavior
• Difficulty controlling emotions
• Intense discomfort and tension
• Flushed face
• Anxious, tense, and angry facial expression

Defining Aggression

• Aggression can stem from various emotional states like anger, anxiety, guilt, frustration, or suspiciousness.
• It involves verbal and physical attacks intended to harm others and often reflects a desire for dominance and control.

Classifications of Aggressive Behaviors

• Mild: sarcasm
• Moderate: slamming doors
• Severe: threats of physical violence
• Extreme: physical acts of violence

Defining Characteristics of Aggression

• Pacing, restlessness
• Threatening body language
• Verbal or physical threats
• Loud voice, shouting, use of obscenities, argumentative
• Threats of homicide or suicide
• Increased agitation and overreaction to stimuli
• Panic anxiety, leading to misinterpretation of the environment
• Suspiciousness and defensive behavior
• Disproportionate anger
• Destruction of property
• Physical harm towards others

Types of Aggression

• Reactive: Fear-based and impulsive.
• Proactive: Predatory and calculated.

Intent

• Both proactive and reactive aggression involve intent to harm, but the motives differ.
• Intent to inflict harm or destruction is a key requirement for defining behavior as aggression.
• Accidents causing unintentional harm are not considered aggression.

Risk of Violence

• Individuals who become violent often feel helpless.
• Three Important Factors:
  • Past History of Violence: A major risk factor in treatment settings.
  • Patient Diagnosis: Assaultive behavior is linked to specific diagnoses, with substance abuse being a significant risk factor.
    • Violence prevalence:
      • 35% in individuals with substance abuse
      • 16% in those with schizophrenia or a major affective disorder
      • 43.6% in those with both a mental illness and substance abuse
  • Current Behavior

Successfully Managing and Predicting Violent Behavior

• Successfully managing violence relies on understanding its dynamics; threatening behavior often stems from feeling powerless, helpless, or humiliated.
• Aggression rarely occurs without warning.
• Prodromal Syndrome: Includes anxiety, tension, verbal abuse, profanity, and increasing hyperactivity; behaviors usually overlap.
• Behaviors:
  • Rigid posture
  • Clenched fists and jaws
  • Defiant affect
  • Rapid, raised voice
  • Arguing and demanding
  • Profanity and threatening language
  • Agitation and pacing
  • Pounding and slamming
• Importance of Observation: Most assaultive behavior is preceded by hyperactivity; these behaviors should be addressed immediately.
• Keen observation and knowledge are critical for predicting potential violence.
• Brøset Violence Checklist: A quick, simple tool to assess the risk of potential violence.
• De-escalation techniques should also be used.

Diagnosing and Setting Goals

• There isn't a specific nursing diagnosis for anger in NANDA International; maladaptive grieving can be used if anger is related to a loss.
  • Possible Nursing Diagnoses:
    • Ineffective coping
    • Risk for self-directed or other-directed violence
  • Outcome Criteria:
    • Goals should be set for the short and long term, with timelines decided on an individual basis.
    • Criteria for measuring outcomes include the patient:
• Recognizing when they are angry and seeking support
• Taking responsibility for their anger
• Showing internal control over their feelings
• Diffusing anger before losing control
• Using tension constructively
• Avoiding harm to self or others
• Using problem-solving instead of violence

Plan of Care

• A care plan includes outcome criteria, nursing interventions, and rationales for each diagnosis related to inappropriate anger expression.
• Cognitive Behavior Therapy (CBT): Is an evidence-based strategy for managing anger and reducing aggression; effective in reducing maladaptive aggression, especially in children and adolescents.
• Role of the Nurse: A general psychiatric nurse can use CBT principles in psychoeducation to prepare patients for longer-term CBT.

Evaluating Nursing Interventions

• Reassessment: Evaluation involves reassessing the patient to see if the nursing interventions have helped them meet their goals.
• Information to Gather: To determine success, gather information on whether the patient:
  • Recognizes when they are angry
  • Takes responsibility for their feelings and controls them
  • Seeks support when feeling angry
  • Channels anger into constructive activities
  • Avoids harming themselves or others
  • Solves problems adaptively without violence