Anger Management: Understanding and Managing Anger and Aggression

Anger is not always a negative expression. It is a normal human emotion that, when handled appropriately and expressed assertively, can provide an individual with a positive force to solve problems and make decisions concerning life situations. Anger becomes a problem when it is not expressed or whe...

Anger is not always a negative expression. It is a normal human emotion that, when handled appropriately and expressed assertively, can provide an individual with a positive force to solve problems and make decisions concerning life situations. Anger becomes a problem when it is not expressed or when it is expressed aggressively. Violence occurs when individuals lose control of their anger. The rate of violent crimes in the United States in 2020 was 398.5 per 100,000 inhabitants and aggravated assault accounted for around two-thirds of all violent crimes (Statistica, 2021). Although the rate of violent crimes (reported by the Federal Bureau of Investigation) has seen a downward trend since the 1990s, 2020 saw an increase in violent crimes, particularly in murder and nonnegligent manslaughter rates. Violent crimes are reported daily by the news media, and health-care workers see the results each day in the emergency departments of general hospitals. This chapter addresses the concepts of anger and aggression. Predisposing factors to the maladaptive expression of anger are discussed, and the nursing process as a vehicle for delivery of care to assist clients in the management of anger and aggression is described. Anger and Aggression, Defined CORE CONCEPT Anger Anger is "an emotional state that varies in intensity from mild irritation to intense fury and rage," according to Charles Spielberger, a clinical psychologist best known for developing the State/Trait Anxiety Inventory. Anger is accompanied by physiological and biological changes, such as increases in heart rate, blood pressure, and levels of the energy hormones adrenaline and noradrenaline (American Psychological Association \[APA\], 2022). Anger is a normal, healthy emotion that serves as a warning signal and alerts us to potential threat or trauma. It triggers energy that sets us up for a good fight or quick flight and can range from mild irritation to rage. Warren (1993) outlined some fundamental points about anger:   Anger is not a primary emotion, but it is typically experienced as an almost automatic inner response to hurt, frustration, or fear.   Anger is physiological arousal. It instills feelings of power and generates preparedness.   Anger and aggression are significantly different.   The expression of anger is learned.   The expression of anger can come under personal control. Anger is a very powerful emotion. When it is denied or buried, it can precipitate a number of physical problems such as migraine headaches, ulcers, colitis, and even coronary heart disease. When turned inward on oneself, anger can result in depression and low self-esteem. When it is expressed inappropriately, it commonly interferes with relationships. When suppressed, anger may turn into resentment, which often manifests in negative, passive-aggressive behavior. Anger creates a state of preparedness by arousing the sympathetic nervous system. The activation of this system results in increased heart rate and blood pressure, increased secretion of epinephrine (resulting in additional physiological arousal), and increased levels of serum glucose, among others. Anger prepares the body, physiologically, to fight. When anger is unresolved, this physiological arousal can be the predisposing factor to several health problems. Even if the situation that created the anger is removed by miles or years, it can be replayed through the memory, reactivating the sympathetic arousal when this occurs. Table 15--1 lists positive and negative functions of anger. CORE CONCEPT Aggression Aggression has many different definitions depending on the context in which it is described. When describing aggression as a behavioral response to anger, aggression has been defined as a behavior intended to threaten or injure the victim's security or self-esteem. It means "to go against," "to assault," or "to attack." It is a response that aims at inflicting pain or injury on objects or persons (Warren, 1993, pp. 119--120). Aggression may include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control (Kassinove, 2023). Aggression, in general, may range from a self-protective response to a destructive, violent act. TABLE 15--1  The Functions of Anger POSITIVE FUNCTIONS OR CONSTRUCTIVE USES NEGATIVE FUNCTIONS OR DESTRUCTIVE USES Anger energizes and mobilizes the body for self-defense. Without cognitive input, anger may result in impulsive behavior, disregarding possible negative consequences. Communicated assertively, anger can promote conflict resolution. Communicated passive-aggressively or aggressively, conflict escalates, and the problem that created the conflict goes unresolved. Anger arousal is a personal signal of threat or injustice against the self. The signal elicits coping responses to deal with the distress. Anger can lead to aggression when the coping response is displacement. Anger can be destructive if it is discharged against an object or person unrelated to the true target of the anger. Anger is constructive when it provides a feeling of control over a situation and the individual is able to assertively take charge of a situation. Anger can be destructive when the feeling of control is exaggerated and the individual uses the power to intimidate others. Anger is constructive when it is expressed assertively, serves to increase self-esteem, and leads to mutual understanding and forgiveness. Anger can be destructive when it masks honest feelings, weakens self-esteem, and leads to hostility and rage. The term anger often takes on a negative connotation because of its link with aggression. Aggression is one way individuals express anger. It is sometimes used to try to force someone into compliance with the aggressor's wishes, but at other times, the only objective seems to be the infliction of punishment and pain. In virtually all instances, aggression is a negative function or destructive use of anger. Predisposing Factors to Anger and Aggression A number of factors have been implicated in the way an individual expresses anger. Some theorists view aggression as purely biological, and some suggest that it results from individuals' interactions with their environments. It is likely a combination of both. Modeling Role modeling is one of the strongest forms of learning. Children model their behavior at a very early age after their primary caregivers, usually parents. How parents or 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. Much has been written about the abused child becoming physically abusive as an adult, which may be connected to a learned response. Role models are not always related to home life relationships, however. Evidence supports the role of television and video violence as a predisposing factor to later aggressive behavior (APA, 2013). Zhang and associates (2021) found that even brief exposure to violent video games increased aggressive cognition and behavior and that the effect was stronger in boys than in girls. Whether modeling occurs in the home, community, or popular media, its role in the development of aggression has been well supported. Operant Conditioning Operant conditioning occurs when a specific behavior is reinforced. Positive reinforcement is a response to a specific behavior that is pleasurable or offers a reward. Negative reinforcement is a response to a specific behavior that prevents an undesirable result from occurring. Anger responses can be learned through operant conditioning. For example, when a child wants something and has been told no by a parent, the child might have a temper tantrum. If the parent then gives the child an ice cream cone, the anger displayed during the temper tantrum has been positively reinforced (or rewarded). An example of learning by negative reinforcement follows: A mother asks the child to pick up their toys, and the child becomes angry and has a temper tantrum. If, when the temper tantrum begins, the mother thinks, "Oh, it's not worth all this!" and picks up the toys herself, the anger has been negatively reinforced (the child was rewarded by not having to pick up their toys). Neurophysiological Factors The neurophysiology of aggression is extremely complex and only partially understood despite years of research. Perry (2016) described the findings as such: "Any factors which increase the activity or reactivity of the brainstem (e.g., chronic traumatic stress, testosterone, dysregulated serotonin or norepinephrine systems) or decrease the moderating capacity of the limbic or cortical areas (e.g., neglect) will increase an individual's aggressivity, impulsivity, and capacity to display violence." Loss of function in the frontal cortex (and subsequently decreased moderating capacity) can also occur as a result of many pathological processes, including stroke, dementia, alcohol intoxication, and traumatic brain injuries, and has been associated with increased aggression. Tumors in the brain, particularly in the areas of the limbic system and the temporal lobes; trauma to the brain resulting in cerebral changes; and diseases such as encephalitis (or medications that may effect this syndrome) have all been implicated in the predisposition to aggression and violent behavior. Individuals may be genetically predisposed to aggression related to genetic variants that control levels of serotonin in the central and peripheral nervous systems. Consequently, administration of selective serotonin reuptake inhibitors (SSRIs) has been associated with increased frontal cortex activity and decreased aggression (Merritt, 2017; Pavlov et al., 2012). Biochemical Factors The effect of hormones, particularly testosterone, in aggression has been the focus of animal research, and although it has been associated with increased aggression in animals and correlation studies in humans, the effects of testosterone administration have yielded mixed results (Boland & Verduin, 2022). For example, in one controlled study where anabolic-androgenic steroids were given to normal subjects, the participants reported both positive and negative mood symptoms; the latter included anger, hostility, and violent feelings (Boland & Verduin, 2022). Although aggression is modulated by several hormonal systems, testosterone is identified as playing a key role, and deficits in serotonin have been associated with an increase in impulsivity (Vetulani, 2013). Oxytocin administration has been associated with decreasing activation in the amygdala and decreasing aggression in men (Merritt, 2017). Socioeconomic Factors High rates of violence exist within the subculture of poverty in the United States. Exposure to violence has been identified as having an effect on future tendencies toward aggression. An ongoing controversy exists as to whether economic inequality or absolute poverty is most responsible for aggressive and violent behavior within this subculture. That is, does violence occur because individuals perceive themselves as disadvantaged relative to other persons, or does violence occur because of the deprivation itself? These concepts are not easily understood and are still under investigation. Environmental Factors Three environmental factors that have been shown to increase risks for aggression are crowding, temperature, and noise (Archer, 2012). All three of these environmental factors increase stress, which has a multitude of effects on mood and behavior. Past experiences and current behavior also influence aggressive expression. The three most common predictors of violent behavior in this context are a history of childhood abuse, a history of violent acts with criminal activity or arrests, and alcohol intake (Boland & Verduin, 2022). Numerous other substances of abuse have been associated with aggression, including methamphetamines and amphetamines, bath salts, anabolic steroids, synthetic marijuana, PCP, and alpha PVP (also known as flakka). The Nursing Process in Anger Management CORE CONCEPT Anger Management The use of various techniques and strategies to control responses to anger-provoking situations. The goal of anger management is to reduce both the emotional feelings and the physiological arousal that anger engenders. Assessment Sometimes crises occur for hospitalized psychiatric patients when they become unable to manage personal responsibility for their behaviors in response to anger. Nurses must be aware of the risk factors and symptoms associated with anger and aggression to make an accurate assessment. In a meta-analysis of prevalence and risk factors for violence by psychiatric acute inpatients (Iozzino et al., 2015), the researchers found that close to 1 in 5 patients may commit an act of violence. The highest risk factors were male sex, a diagnosis of schizophrenia, substance use, and a history of violence. Assessing for violence potential is an important aspect of nursing care in efforts to prevent violence in psychiatric settings. Strategies to accomplish this are presented in the following section. Anger Anger is often manifested in the following ways:   Frowning facial expression   Clenched fists   Low-pitched verbalizations forced through clenched teeth   Yelling and shouting   Intense eye contact or avoidance of eye contact   Hypersensitivity, easily offended   Defensive response to criticism   Passive-aggressive behaviors   Lack of control or overcontrolled emotions   Intense discomfort; continuous state of tension   Flushed face   Anxious, tense, angry facial expression (affect) Anger is often described as a secondary emotion. For example, it may be a response to unresolved grief, depression, fear, anxiety, or unresolved post-traumatic stress. Anger is also one of the stages of the normal grief process and thus is an expected emotion. Because of the negative connotation of the word anger, some people will not acknowledge that they are feeling angry. These individuals need assistance to recognize their true feelings and understand that anger is a perfectly acceptable emotion; it is one's behavior in response to anger that may be unacceptable, such as when it results in aggression. Aggression Aggression can arise from a number of feeling states, including anger, anxiety, guilt, frustration, or suspiciousness. Kassinove (2023) stated that aggression may include verbal and physical attacks that intend harm to another and often reflect a desire for dominance and control. Aggressive behaviors can be classified as mild (e.g., sarcasm), moderate (e.g., slamming doors), severe (e.g., threats of physical violence against others), or extreme (e.g., physical acts of violence against others). Aggression may be associated with (but not limited to) the following defining characteristics:   Pacing, restlessness   Threatening body language   Verbal or physical threats   Loud voice, shouting, use of obscenities, argumentative   Threats of homicide or suicide   Increase in agitation, with overreaction to environmental stimuli   Panic anxiety, leading to misinterpretation of the environment   Suspiciousness and defensive posturing   Angry mood, often disproportionate to the situation   Destruction of property   Acts of physical harm toward another person Aggression may be differentiated as reactive versus proactive. Reactive aggression is defined as fear based and impulsive; proactive aggression is described as predatory and calculated. In both cases, there is intent to harm another, but the motives differ. Intent is a requisite in the definition of aggression. It refers to behavior that is intended to inflict harm or destruction. Accidents that lead to unintentional harm or destruction are not considered aggression. Assessing Risk Factors Prevention is a key issue in managing aggressive or violent behavior. The individual who becomes violent usually feels an underlying helplessness. The following three factors have been identified as important considerations in assessing for potential violence: 1.  Past history of violence 2.  Patient diagnosis 3.  Current behavior Past history of violence is widely recognized as a major risk factor for violence in a treatment setting. Assaultive behavior is also highly correlated with specific diagnoses. Substance abuse (alone or in combination with a mental illness) is the single most important risk factor for violence; the lifetime prevalence is 35% in individuals with substance abuse or dependence compared with 16% for those with schizophrenia or a major affective disorder and a notable 43.6% in those with a comorbid mental illness and substance abuse (Victoroff, 2017). Novitsky and associates (2009) stated: The successful management of violence is predicated on an understanding of the dynamics of violence. A patient's threatening behavior is commonly an overreaction to feelings of impotence, helplessness, and perceived or actual humiliation. Aggression rarely occurs suddenly and unexpectedly. (p. 50) Novitsky and associates (2009) described a prodromal syndrome characterized by anxiety and tension, verbal abuse and profanity, and increasing hyperactivity. These escalating behaviors usually do not occur in stages but most often overlap and sometimes occur simultaneously. Behaviors associated with this prodromal stage include rigid posture; clenched fists and jaws; grim, defiant affect; talking in a rapid, raised voice; arguing and demanding; using profanity and threatening verbalizations; agitation and pacing; and pounding and slamming. Most assaultive behavior is preceded by a period of increasing hyperactivity. Behaviors associated with the prodromal syndrome should be considered emergent and demand immediate attention. Keen observation skills and background knowledge for accurate assessment are critical factors in predicting the potential for violent behavior. The Brøset Violence Checklist is presented in Box 15--1. It is a quick, simple, and reliable checklist that can be used to assess the risk for potential violence. Validity testing has shown a 63% accuracy for prediction of violence at a score of 2 and above (Almvik et al., 2000). De-escalation techniques are also included. BOX 15--1 The Brøset Violence Checklist Score 1 point for each behavior observed. At a score of ≥2, begin de-escalation techniques. Behaviors Score Confusion   Irritability   Boisterousness   Physical threats   Verbal threats   Attacks on objects   TOTAL SCORE   DE-ESCALATION TECHNIQUES Calm voice Walk outdoors or fresh air Identify consequences Group participation Open hands and nonthreatening posture Relaxation techniques Allow phone call Express concern Offer food or drink Reduce stimulation and loud noise Helpful attitude Reduction in demands Decrease waiting times and request refusals Verbal redirection and limit setting Distract with a more positive activity (e.g., soft music or a quiet room) Time-out/quiet time/open seclusion Offer prn medication If de-escalation techniques fail: 1\. Suggest prn medications 2\. Time-out or unlocked seclusion, which can progress to locked seclusion Source: From Almvik, R., Woods, P., & Rasmussen, K. (2000). The Brøset violence checklist: Sensitivity, specificity, and interrater reliability. Journal of Interpersonal Violence, 15(12), 1284--1296, with permission. De-escalation techniques reprinted with permission from Barbara Barnes, Milwaukee County Behavioral Health Division. Diagnosis and Outcome Identification NANDA International does not include a separate nursing diagnosis for anger. The nursing diagnosis of maladaptive grieving may be used when anger is expressed inappropriately and the etiology is related to a loss. The following nursing diagnoses may be considered for patients demonstrating inappropriate expression of anger or aggression:   Ineffective coping   Risk for self-directed or other-directed violence Outcome Criteria Outcome criteria include short- and long-term goals. Timelines are individually determined. The following criteria may be used for measurement of outcomes in the care of the patient needing assistance with management of anger and aggression. The patient:   Recognizes when they are angry and seeks out staff/support person to talk about their feelings   Takes responsibility for own feelings of anger   Demonstrates the ability to exert internal control over feelings of anger   Demonstrates the ability to diffuse anger before losing control   Uses the tension generated by the anger in a constructive manner   Causes no harm to self or others   Uses steps of the problem-solving process rather than becoming violent as a means of seeking solutions Planning and Implementation In Table 15--2, a plan of care is presented for the patient who expresses anger inappropriately. Outcome criteria, appropriate nursing interventions, and rationales are included for each diagnosis. Cognitive behavior therapy (CBT) as a strategy for anger management and aggression reduction is an evidence-based treatment that, especially when incorporated in treatment for children and adolescents, has demonstrated effectiveness in reducing maladaptive aggression (Smeets et al., 2015; Sukhodolsky et al., 2016; Vacher et al., 2022). Although CBT is typically conducted by advanced practice nurses and other trained specialists, the generalist psychiatric nurse can incorporate principles of this modality in psychoeducation, which provides a foundation for referral to longer-term CBT. Table 15--2 \| CARE PLAN FOR THE INDIVIDUAL WHO EXPRESSES ANGER INAPPROPRIATELY NURSING DIAGNOSIS: INEFFECTIVE COPING RELATED TO: Negative role modeling and dysfunctional family system EVIDENCED BY: Yelling, name calling, hitting others, and temper tantrums as expressions of anger OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE Patient is able to recognize anger in self and take responsibility before losing control. 1.  Remain calm when dealing with an angry patient. 1.  Anger expressed by the nurse will most likely incite increased anger in patients.   2.  Set verbal limits on behavior. Clearly delineate the consequences of inappropriate expression of anger and always follow through. 2.  Consistency in enforcing the consequences is essential if positive outcomes are to be achieved. Inconsistency creates confusion and encourages testing of limits.   3.  Encourage the patient to keep a diary of angry thoughts and feelings, what triggered them, and how they were handled. 3.  This activity provides a more objective measure of the problem. Introducing the patient to some basic principles of cognitive reflection not only encourages problem-solving in the short term but lays the groundwork for referral to longer-term CBT if this is identified as desirable.   4.  Avoid touching the patient when they become angry. 4.  The patient may view touch as threatening and could become violent.   5.  Help the patient determine the real source of the anger. 5.  Often, anger is displaced onto a safer object or person. If resolution is to occur, the first step is to identify the source of the anger.   6.  Help the patient find alternative ways of releasing tension, such as physical outlets, and more appropriate ways of expressing anger, such as seeking out staff when feelings emerge. 6.  Patients will likely need assistance to problem solve more appropriate ways of behaving.   7.  Role model appropriate ways of expressing anger assertively, such as, "I dislike being called names. I get angry when I hear you saying those things about me." 7.  Role modeling is one of the strongest methods of learning. NURSING DIAGNOSIS: RISK FOR SELF-DIRECTED OR OTHER-DIRECTED VIOLENCE RISK FACTORS: Having been nurtured in an atmosphere of violence; history of violence; substance intoxication OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE Patient will not harm self or others. Patient verbalizes anger rather than hit others. 1.  Observe the patient for escalation of anger (called the prodromal syndrome): increased motor activity, pounding, slamming, tense posture, defiant affect, clenched teeth and fists, arguing, demanding, and challenging or threatening staff. 1.  Violence may be prevented if risks are identified in time.   2.  When these behaviors are observed, first ensure that sufficient staff are available to help with a potentially violent situation. Attempt to defuse the anger beginning with the least restrictive means. 2.  The initial consideration must be ensuring that adequate staff are present to assist in diffusing a potentially violent situation. Patient rights must be honored while preventing harm to patient and others.   3.  Techniques for dealing with aggression: 3.  Aggression control techniques promote safety and reduce risk of harm to patient and others:   a\. Talking down. Say, "John, you seem very angry. Let's sit down and talk about it." (Be attentive to safe physical distance from the patient and the nurse's ability to exit \[i.e., ensure that patient does not position self between a door and nurse\].) a\. Promotes a trusting relationship and may prevent patient's anxiety from escalating while attending to the safety needs of the nurse as well.   b\. Physical outlets. Suggest exercise, walking, or engaging in another activity that provides an acceptable outlet for energy. Offer to stay with the patient during this activity. b\. Provides effective way for patient to release tension associated with high levels of anger. Staying with the patient offers an opportunity to provide support and to assess the patient's perception of the activity's effectiveness.   c\. Medication. If agitation continues to escalate, offer patient choice of taking medication voluntarily. If they refuse, reassess the situation to determine whether harm to self or others is imminent. c\. Tranquilizing medication may calm patient and prevent violence from escalating.   d\. Call for assistance. Remove self and other patients from the immediate area. Call violence code, push panic button, call for assault team, and follow other measures established by the institution. Sufficient staff to indicate a show of strength may be enough to de-escalate the situation, and the patient may agree to take the medication. d\. Patient and staff safety are of primary concern. Many states' accrediting bodies (such as The Joint Commission) and facilities require that staff members working with hospitalized psychiatric patients be trained or certified in psychiatric emergency interventions to ensure that the strategies used are in the best interest of staff and patient safety.   e\. Seclusion or restraints. If the patient is not calmed by talking down or by medication, use of mechanical restraints, seclusion, or both may be necessary. Be sure to have sufficient staff available to assist and appropriately deal with an out-of-control patient. Follow protocol for restraints or seclusion established by the institution. Restraints should be used as a last resort, after all other interventions have been unsuccessful and patient is clearly at risk of harm to self or others. e\. Patients who do not have internal control over their behavior may require external controls, such as seclusion, mechanical restraints, or both in order to prevent harm to self or others. However, these restrictive measures should be used only as a last resort after all other measures have been attempted and have failed.   f\. Observation and documentation. Hospital policy typically dictates the requirements for observation of the patient in restraints. Basic safety principles include that the patient in restraints should be observed throughout the period of restraint. Every 15 minutes, the patient should be monitored to ensure that circulation to extremities is not compromised (check temperature, color, pulses). Assist the patient with needs related to nutrition, hydration, and elimination. Position the patient so that comfort is facilitated, breathing is unobstructed, and aspiration prevented. (Patients should not be restrained in the prone position.) Document all observations. f\. Patient safety and well-being are nursing priorities.   g\. Ongoing assessment. As agitation decreases, assess the patient's readiness for restraint removal or reduction. With assistance from other staff members, remove one restraint at a time, while assessing the patient's response. This process minimizes the risk of injury to patient and staff. g\. Gradual removal of the restraints allows for testing of the patient's self-control. Patient and staff safety are of primary concern.   h\. Debriefing. It is important, when a patient loses control, for staff to follow up with a discussion about the situation. This discussion should occur among staff and with the patient (when the patient has regained control). The staff should discuss factors that necessitated the crisis intervention, factors that contributed to the failure of less restrictive interventions, and staff's thoughts about the safety and effectiveness of the intervention. When the patient has regained control, a debriefing should occur in which the patient is encouraged to discuss thoughts about what contributed to the crisis situation and about staff interventions and to explore strategies to avert a crisis situation in the future. It is also important to discuss the situation with other patients who witnessed the episode so they understand and process what happened. Some patients may fear that they could be at risk for experiencing a crisis or that they might be in danger when someone else's behavior becomes aggressive. h\. Debriefing helps to diminish the emotional effect of the intervention. Mutual feedback is shared, and staff has an opportunity to process and learn from the event. Evaluation Evaluation consists of reassessment to determine whether 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 a patient exhibiting inappropriate expression of anger:   Is the patient able to recognize when they are angry now?   Can the patient take responsibility for these feelings and keep them in check without losing control?   Does the patient seek out staff or a support person to talk about feelings of anger when they occur?   Is the patient able to transfer tension generated by the anger into constructive activities?   Has harm to patient and others been avoided?   Is the patient able to solve problems adaptively without undue frustration and without becoming violent? Summary and Key Points   Anger, a normal human emotion, is not necessarily a negative response.   When used appropriately, anger can provide positive assistance with problem-solving and decision making in everyday life situations.   Violence occurs when individuals lose control of their anger.   Anger is viewed as an emotional response to one's perception of a situation.   When denied or buried, anger can precipitate several psychophysiological disorders.   When anger is turned inward on the self, it can result in depression.   When expressed inappropriately, anger commonly interferes with interpersonal relationships.   When anger is suppressed, it often turns to resentment.   Anger generates a physiological arousal comparable to the stress response discussed in Chapter 1, "The Concept of Stress Adaptation."   Aggression is one way in which individuals express anger.   Aggression is a behavior intended to threaten or injure the victim's security or self-esteem.   Aggression can be physical or verbal, but it is virtually always designed to punish.   Aggression is a negative function or destructive use of anger.   Various predisposing factors to the way individuals express anger have been implicated. Some theorists suggest that the etiology is purely biological, whereas others believe it depends on psychological and environmental factors.   Some possible predisposing factors include role modeling, operant conditioning, neurophysiological disorders (e.g., brain tumors, trauma, or diseases), biochemical factors (e.g., increased levels of androgens or other alterations in hormone levels and neurotransmitter involvement), socioeconomic factors (e.g., living in poverty), and environmental factors (e.g., physical crowding, uncomfortable temperature, use of alcohol or drugs).   Nurses must be aware of the symptoms associated with anger and aggression in order to make an accurate assessment.   Prevention is a key issue in the management of aggressive or violent behavior.   Elements identified as key risk factors in the potential for violence among acute psychiatric inpatients include (1) male gender, (2) substance use, (3) past history of violence, and (4) a diagnosis of schizophrenia.   Cognitive behavior therapy is an evidence-based treatment strategy for reducing maladaptive aggression, especially in the treatment of aggression in children and adolescents.