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ANGER MANAGEMENT
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 hot, fiery energy. Anger is an emotion characterized by
antagonism toward someone or something you feel has deliberately done you
wrong. Anger can be a good thing. It can give you a way to express negative feelings, for
example, or motivate you to find solutions to problems. But excessive anger can cause
problems. Warren (1990) outlines some
fundamental points about anger:

1. Anger is not a primary emotion,

but it is typically experienced as
an almost automatic inner response
to hurt, frustration, or fear.
2. Anger is physiological arousal.
It instills feelings of power and
generates preparedness.
3. Anger and aggression are
significantly different.
4. The expression of anger is learned.
5. The expression of anger can come under personal control.

DEFINITION :

Anger is an emotional state that varies in intensity from mild irritation to intense fury and
rage. It is accompanied by physiological and biological changes, such as increases in heart
rate, blood pressure, and levels of the hormones epinephrine and norepinephrine

(American Psychological Association, 2006a)

“A strong feeling that makes you want to hurt someone or be unpleasant because of
something unfair or unkind that has happened.”

( Cambridge English dictionary )

“Anyone can become angry. That is easy. But to be angry with the right person, to the right
degree, at the right time, for the right purpose and in the right way – that is not easy.”

( Aristotle (384-322 BC)

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 itself in negative, passive–
aggressive behaviour.
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The most Common Factors that make People Angry are:

 Grief - losing a loved one.

 Rudeness
 Tiredness
 Hunger
 Pain
 Withdrawal from drugs or some medications
 Some physical conditions (such as pre-menstrual syndrome)
 Physical illness
 Mental illness
 Alcohol, some drugs, alcohol abuse, drug abuse
 Injustice
 FUNCTIONS OF ANGER

Positive /constructive functions of anger

 Anger energizes and mobilizes the body for self-defense.
 Communicated assertively, anger can promote conflict resolution.
 Anger arousal is a personal signal of threat or injustice against the self. The signal
elicits coping responses to deal with the distress. 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 is constructive when it is expressed assertively, serves to increase self-esteem,
and leads to mutual understanding and forgiveness.

Negative destructive use of anger :

 Without cognitive input, anger may result in impulsive behavior, disregarding
possible negative consequences. Communicated passive–aggressively or
aggressively, conflict escalates, and the problem that created the conflict goes
unresolved.
 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 can be destructive when the feeling of control is exaggerated and the
individual uses the power to intimidate others.
 Anger can be destructive when it masks honest feelings, weakens self-esteem, and
leads to hostility and rage.
 TYPES OF ANGER
1. Behavioral Anger : This type of anger is comprised of aggressive and cruel
actions. It inclines mostly on the physical aspect. It usually implies an attack
towards the subject of the anger, usually a person. It is expressed through
troublemaking, physical attack and defiance.
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2. Verbal anger : This type of anger, on the other hand, merely uses words and not
actions. It is expressed mostly by openly speaking insulting words and hurtful
criticisms. Accusing somebody of a crime or of a wrong-doing is also an example
of verbal anger.
3. Passive anger : Passive anger is shown mostly through mockery, or through
avoiding a certain instance. People who are displaying this type of anger are not
showing their anger outright but are devising covert ways of expressing it. They
do not confront a person or a situation.
4. Self –inflicted anger : This type of anger is the one that is directed toward a
person’s own body. Sometimes, people showing this type of anger tend to starve
themselves or eat too much, for example. These are the people into the idea of
punishing their own self for something wrong they have done.
5. Chronic anger: People with chronic anger are just angry in general. They are
angry with their lives, with their selves, with the people around them and the
whole world in general. They do not necessarily have a definite reason why. Most
of the time, they are just angry for apparently no reason at all.
6. Judgemental anger : This type of anger would lead somebody to hurtfully shame
the people around him, like his family, friends and neighbours. He expresses his
anger by putting others down and belittling their abilities as a person.
7. Overwhelmed anger : This type of anger is seen on people that hate the situations
happening around them that directly affect their lives. They usually shout or lash
out at someone or something easily. They do so because that’s their way of
relieving the stress and the pain they are feeling.
8. Constructive anger : This type of anger is the type that makes people want to go
out and join groups and movements. And they usually do it because they wanted
to do something to correct a certain situation. They wanted to make a positive
change. And that is the main effect of this type of anger.
9. Volatile Anger : This type of anger is the one that easily comes and goes.
The magnitude of this anger varies too. It could build into a rage, or it could be a
mild, sudden anger. It could explode abruptly, or it could go unseen. It all depends
on the person controlling the anger. This type is expressed either by verbal or
physical assault.
10. Retaliatory anger : This type of anger is the most common one. Usually people
get angry because other people are angry at them. This anger depends mainly on
the other person. If your anger is due to a person lashing out at you, then you are
guilty of this type of anger.
11. Paranoid anger : This anger arises if a person feels, in an irrational way, that
they are intimidated by others. People with this type of anger feel and think that
other people wanted to take what is rightfully theirs. They are angry toward that
person because, for one, they are jealous.
12. Deliberate Anger : This type of anger is shown by people who would like to gain
control over a situation. They are mostly not angry at first. But they will be once
you have shown that you are against what they have planned and what they would
like to happen. They use anger to gain power over somebody or something.
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 AGGRESSION

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.

Aggression refers to behavior that is intended to harm another individual. Violence

is aggression that creates extreme physical harm. Emotional or impulsive aggression refers
to aggression that occurs with only a small amount of forethought or intent. Instrumental or
cognitive aggression is intentional and planned.

In psychology and other social and behavioral sciences, aggression refers to behavior that is
intended to cause harm or pain. Aggression can be either physical or verbal, and behavior is
classified as aggression even if it does not actually succeed in causing harm or pain. Behavior
that accidentally causes harm or pain is not aggression.
DEFINITION :

“Aggression is 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. Whether the damage is caused by words, fists, or
weapons, the behavior is virtually always designed to punish. It is frequently accompanied by
bitterness, meanness, and ridicule. An aggressive person is often vengeful .”

(Warren, 1990, p. 81).

“Aggression as behavior that is intended to harm another individual who does not wish to
be harmed .” (Baron & Richardson, 1994).

“Aggression is defined as behavior intended to harm another individual and can vary
according toculture, gender and individual differences .”

(Kassin, Fein, & Markus, 2008).

TYPES OF AGGRESSION :

 Hostile aggression

A type of aggression meant to hurt another person. Hostile aggression comes in three
varieties: physical aggression, verbal aggression, and relational aggression (Berk, 2007).
People who experience hostile aggression thrive on inflicting harm on their victims (both
mentally and physically). This form of aggression, unlike instrumental aggression, is often
aided by intent and anger.
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 Physical Aggression-harms others through physical injury- pushing, hitting, kicking,

or punching others or destroying another's property (Berk, 2007).
 Verbal Aggression-harms others through threats of physical aggression, name-calling,
or hostile teasing (Berk, 2007).
 Relational Aggression-damages another's peer relationships through social exclusion,
malicious gossip, or friendship manipulation (Berk, 2007).
 Instrumental Aggression

Instrumental aggression is the most common type of aggression in which children want an
object, privilege, or space and, in trying to get, push, shout at, or otherwise attack a person
who is in the way (Berk, 2007). Unlike hostile aggression, physical harm to others is not the
overall goal of instrumental aggression. Instead, it is a means to achieve a specific goal, toy,
or reward.

 Moyer Classification
Moyer (1968) presented an early and influential classification of seven
different forms of aggression, from a biological and evolutionary point of
view.

 Predatory aggression: Attack on prey by a predator.

 Inter-male aggression: Competition between males of the same species over access
to resources such as females, dominance, status, etc.
 Fear-induced aggression: Aggression associated with attempts to flee from a threat.
 Irritable aggression: Aggression induced by frustration and directed against an
available target.
 Territorial aggression: Defense of a fixed area against intruders, typically conflicts.
 Maternal aggression: A female's aggression to protect her offspring from a threat.
Paternal aggression also exists.
 Instrumental aggression: Aggression directed towards obtaining some goal,
considered to be a learned response to a situation.

 FIVE-PHASE AGGRESSION CYCLE

Phase Definition Signs, Symptoms, and Behaviours
Triggering An event or circumstances in the initiates the client’s response, which is often anger or
environment initiates the client’s hostility.
response, which is often anger or
Restlessness, anxiety, irritability, pacing, muscle
hostility.
tension, rapid breathing, perspiration, loud voice,
anger

Escalation Client’s responses represent Pale or flushed face, yelling, swearing, agitated,
escalating behaviors that indicate threatening, demanding, clenched fists, threatening
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movement toward a loss of control. gestures, hostility, loss of ability to solve the problem
or think clearly

Crisis During a period of emotional and Loss of emotional and physical control, throwing
physical crisis, the client loses objects, kicking, hitting, spitting, biting, scratching,
control. shrieking, screaming, inability to communicate clearly

Recovery Client regains physical and Lowering of voice; decreased muscle tension; clearer,
emotional control. more rational communication; physical relaxation

Post crisis Client attempts reconciliation with Remorse; apologies; crying; quiet, withdrawn behavior
others and returns to the level of
functioning before the aggressive
incident and its antecedents.

 PREDISPOSING FACTORS TO ANGER AND AGGRESSION

A number of factors have been implicated in the way individuals express 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.

1. Modelling : Role modelling 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 modelling 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. Role models are not always in the home, however. Evidence
supports the role of television violence as a predisposing factor to later aggressive
behavior (American Psychological Association, 2006b). The American Psychiatric
Association (2006) suggests that monitoring what children view and regulation of
violence in the media are necessary to prevent this type of violent modelling.
2. 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 desired 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 example, when a child
wants something and has been told “no” by a parent, he or she might have a temper
tantrum. If, when the temper tantrum begins, the parent lets the child have what is
wanted, the anger has been positively reinforced (or rewarded). An example of
learning by negative reinforcement follows: 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, it’s not worth all this!” and picks up the toys
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herself, the anger has been negatively reinforced (child was rewarded by not having to
pick up her toys).
3. Neurophysiological Disorders : Some research has implicated epilepsy of temporal
and frontal lobe origin in episodic aggression and violent behavior (Sadock & Sadock,
2007). Clients with episodic decontrol often respond to anticonvulsant medication.
Tumours 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. A study by Lee and
associates (1998) showed that destruction of the amygdaloidal body in patients with
intractable aggression resulted in a reduction in autonomic arousal levels and in the
number of aggressive outbursts.
4. Biochemical Factors : Violent behavior may be associated with hormonal
dysfunction caused by Cushing’s disease or hyperthyroidism (Tardif, 2003). Studies
have not supported a correlation between violence and increased levels of androgens
or alterations in hormone levels associated with hypoglycaemia or premenstrual
syndrome. Some research indicates that various neurotransmitters (e.g., epinephrine,
norepinephrine, dopamine, acetylcholine, and serotonin) may play a role in the
facilitation and inhibition of aggressive impulses (Sadock & Sadock, 2007).
5. Socioeconomic Factors : High rates of violence exist within the subculture of poverty
in the United States. This has been attributed to lack of resources, breakup of families,
alienation, discrimination, and frustration (Tardiff, 2003). An on-going controversy
exists as to whether economic inequality or absolute poverty is most responsible for
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.
6. Environmental Factors : Physical crowding may be related to violence through
increased contact and decreased defensible space (Tardif, 2003). A relationship
between heat and aggression also has been indicated (Anderson, 2001). Moderately
uncomfortable temperature appears to be associated with an increase in aggression,
while extremely hot temperatures seem 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 (Tardif, 2003).
 SOURCES OF ANGER /AGGRESSION
According to Loo, an experienced negotiator and an expert in conflict resolution, there
are two sources of anger: Insidious and outer source, earlier one stems from irrational
perceptions of reality, and low frustration point.

A) INTERNAL SOURCES: Psychologists have put forward four types of thinking that
lead to internal sources of anger:
• Emotional reasoning: Some people innocent and emotionally reason and often
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become irritated and apprehend these things as attacks on themselves .

• Low frustration tolerance: Experience of low tolerance to frustration is inevitable
in everyone life at some point. Assertion is stress-related anxiety tends to lower our
tolerance.
• Unreasonable expectations: In some occasion, people make demands unnecessarily
without knowing the exactness of the condition. Unable to have things go their way or
have others act a certain way, lowers the tolerance for frustration and causes people to
get frustrated and angry .
• People-rating: Reason to cause anger triggers derogatory labelling, dehumanizes
and makes it easier become angry at other people
B) EXTERNAL SOURCES: As for extrinsic sources, psychologists have come up with
hundreds of events which cause people to get angry and assembled the point as below:
• Verbal abuse one way of attacks against other people
• Confronting with cut and paste of another idea, opinion and down casting it
• People threaten other people’s basic needs family, life, work and another thing, etc.
• Due to environmental factors in their lives, their level of tolerance toward frustration
diminishes.
Both external and internal sources of play an important role in terms of anger issue
recognizing and thence resolving is vital for smooth continuation, though following
factors invariably tends to lower frustration tolerance level.
• Stress/anxiety
• Pain-physical and emotional
• Drugs/alcohol
• Recent irritations - “Having a bad day.”
 PHYSIOLOGY OF ANGER/ AGGRESSION
Amygdala, the two almond-shaped structures that are located inside the brain that is the
point where emotion is evoked are efficient in identifying and recognizing threat and
relays alarm signal to protect ourselves before the cortex (the intellectual, reasoning, and
judgment) . PSNS releases the neurotransmitter acetylcholine to prevent arousal of the
emotion of anger by neutralizing stress hormone so that body can relax and calm down.
People with dominating PSNS are under less risk of heart disease this concludes that
people with Type A personalities are higher in risk of heart disease duets their weaker
PSNS responses with less life time period in relaxation.

The first spark of anger activates the amygdala before you're even aware of
it.

The amygdala activates the hypothalamus

The hypothalamus signalling the pituitary gland by discharging corticotrophin

releasing hormone (CRH)
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The pituitary activates adrenal glands by releasing adrenocorticotrophic hormone

(ACTH)

The adrenal glands secrete stress hormones like cortisol , adrenaline and noradrenaline

Elevated cortisol causes neurons to accept too much calcium through

their membrane. A calcium overload can make cells fire too frequently
and die.
The hippocampus and prefrontal cortex (PFC) are particularly vulnerable
to cortisol and these negative effects.

 THEORIES OF ANGER /AGGRESSION :

a. PSYCHOANALYTICAL THEORIES: Sigmund Freud is well known as the father of
psychoanalysis. In his early theory, Freud asserts that human behaviors are motivated by
sexual and instinctive drives known as the libido, which is energy derived from the Eros, or
life instinct. Thus, the repression of such libidinal urges is displayed as aggression.
Later, Freud added the concept of Thanatos, or death force, to his Eros theory of
human behavior. Contrary to the libido energy emitted from the Eros, Thanatos
energy encourages destruction and death. In this conflict between Eros and
Thanatos, some of the negative energy of the Thanatos is directed toward others, to
prevent the self-destruction of the individual. Thus, Freud claimed that the
displacement of negative energy of the Thanatos onto others is the basis of
aggression.
Freud's psychoanalytic theory demonstrates that aggression is innate, inevitable,
common to all humans, leading to self or others destruction.
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According to Freud:
— Aggression may be due to impaired mother-child relationship (children of punitive
parents are more aggressive) Aggression is developed during the oral stage when
the pleasure of biting is added to that of sucking. Fixation on the oral stage of
psychosexual development may lead to sadistic personality. Aggression may be due
to impaired development of superego. Aggression may be due to defense
mechanisms:
 Projection
 Narcissism
 Repression
b. LORENZ THEORY- THE EVOLUTIONARY THEORY OF AGGRESSION:
Lorenz looked at instinctual aggressiveness as a product of evolution.
Aggressiveness is beneficial and allows for the survival, territory protection and
success of populations of aggressive species since the strongest animals would
eliminate weaker ones and over the course of evolution, the result would be a
stronger, healthier population.
c. HUMANISTIC THEORY( FRUSTRATION-AGGRESSION HYPOTHESIS):
Aggression is a drive (basic concept). It arises from deprivation of basic needs
(Abraham Maslow) . The drive theory attributes aggression to an impulse created by
an innate need. In this theory, frustration and aggression are linked in a cause and
effect relationship. Frustration is the cause of aggression and aggression is the result
of frustration.
d. SOCIAL LEARNING THEORY:
 Albert Bandura and his colleagues were able to demonstrate one of the ways in which
children learn aggression. Bandura's theory proposes that learning occurs through
observation and interaction with other people
 The experiment involved exposing children to two different adult models, an
aggressive model and a non-aggressive one. After witnessing the adult's behavior, the
children would then be placed in a room without the model and were observed to see
if they would imitate the behavior they had witnessed earlier. He predicted that
children who observed an adult acting aggressively would be likely to act
aggressively.
 Aggression is initially learned from social behavior and maintained by reward,
which encourages the further display of aggression. Aggressive responses are
acquired so they are evitable

 Models Of Aggression
a. Biological Basis of Aggression
i. Genetic factor
o Twin Studies: Concordance rates for monozygotic twins is higher
than dizygotic as regards aggressive behavior.
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o Pedigree Studies: Some study showed that persons with FH of

aggression are prone to violent behavior.
o Chromosomal influence: More researchers concentrated on XYY
syndrome (tall, below average IQ, more likely to engage in
criminal behavior).
o Inborn errors of metabolism: It is reported to be associated with
aggression, e.g. Lish Nyhan S, Phenyl ketonuria, etc…
ii. Anatomical Basis (Neural Substrates):
 Amygdala, temporal lobes and limbic system: Stimulation of the
amygdala results in augmented aggressive behavior, while lesions
of this area greatly reduce one's competitive drive and aggression.
 Hypothalamus: regulatory role. The hypothalamus causes
aggressive behavior when electrically stimulated, but also has
receptors that determine aggression levels through the
neurotransmitters serotonin and vasopressin.
 Frontal lobe dysfunctions alter neurochemistry, neurometabolism.
Impaired function of the prefrontal cortex leads to aggression as
aggressive individuals have reduced prefrontal activation. Lesions
in the frontal cortex are characterized by aggression, irritability and
short tempers. Hypo function of the frontal lobes (which helps
control impulsive behavior) has been found in studies on:

Clinical: Temporal lobe lesion: may be associated with explosive aggressive behavior.
Temporal lobotomy alleviates aggression. Birth trauma, head injury and intra-cerebral
infections affecting temporal lobe limbic system lead to aggression.

Experimental: Overstimulation of amygdala in temporal lobe leads to aggressive behavior.

Lesion or removal of temporal lobes or amygdala decrease aggression (Kluver Bucy
syndrome) the animal becomes hypersexual, apathetic, and over eating behavior. Sham-rage
reaction: loss of inhibition on amygdala. Pharmacological evidences: antiepileptic drugs may
be used in aggression.

iii. Biochemical factors of aggression:

 Testosterone has been shown to correlate with aggressive behavior in mice and in
some humans.
 Progesterone, LH, and Prolactin (in birds) increase aggression. Estrogen decreases
aggression.
 Thyroid hormones: increase aggression.
 Serotonin: Low serotonin could contribute to aggressive behavior.
 Alcohol disinhibits an individual. Over half of all acts of rape occur while the
aggressor is under the influence of alcohol.

 CHARACTERISTICS OF ANGER :
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A. Passive anger
Passive anger can be expressed in the following ways
Dispassion, such as giving someone the cold shoulder or a fake smile, looking unconcerned
or "sitting on the fence" while others sort things out, dampening feelings with substance
abuse, overreacting, oversleeping, not responding to another's anger, frigidity, indulging in
sexual practices that depress spontaneity and make objects of participants, giving inordinate
amounts of time to machines, objects or intellectual pursuits, talking of frustrations but
showing no feeling.

 Evasiveness, such as turning one's back in a crisis, avoiding conflict, not arguing back,
becoming phobic.
 Defeatism, such as setting yourself and others up for failure, choosing unreliable people
to depend on, being accident prone, underachieving, sexual impotence, expressing
frustration at insignificant things but ignoring serious ones.
 Obsessive behavior, such as needing to be inordinately clean and tidy, making a habit of
constantly checking things, over-dieting or overeating, demanding that all jobs be done
perfectly.
 Psychological manipulation, such as provoking people to aggression and then
patronizing them, provoking aggression but staying on the sidelines, emotional
blackmail, false tearfulness, feigning illness, sabotaging relationships, using sexual
provocation, using a third party to convey negative feelings, withholding money or
resources.
 Secretive behavior, such as stockpiling resentments that are expressed behind people's
backs, giving the silent treatment or under-the-breath mutterings, avoiding eye contact,
putting people down, gossiping, anonymous complaints, poison pen letters, stealing,
and conning.
 Self-blame, such as apologizing too often, being overly critical, inviting criticism.
B. Aggressive anger
The symptoms of aggressive anger are:

 Bullying, such as threatening people directly, persecuting, insulting, pushing or shoving,

using power to oppress, shouting, driving someone off the road, playing on
people's weaknesses.
 Destructiveness, such as destroying objects as in vandalism, harming animals, child
abuse, destroying a relationship, reckless driving, substance abuse.
 Grandiosity, such as showing off, expressing mistrust, not delegating, being a sore loser,
wanting center stage all the time, not listening, talking over people's heads, expecting kiss
and make-up sessions to solve problems.
 Hurtfulness, such as violence, including sexual abuse and rape, verbal abuse, biased
or vulgar jokes, breaking confidence, using foul language, ignoring people's feelings,
willfully discriminating, blaming, punishing people for unwarranted deeds, labeling
others.
 Risk-taking behavior, such as speaking too fast, walking too fast, driving too fast,
reckless spending.
 Selfishness, such as ignoring others' needs, not responding to requests for help, queue
jumping.
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 Threats, such as frightening people by saying how one could harm them, their
property or their prospects, finger pointing, fist shaking, wearing clothes or symbols
associated with violent behaviour, tailgating, excessively blowing a car horn, slamming
doors.
 Unjust blaming, such as accusing other people for one's own mistakes, blaming people
for your own feelings, making general accusations.
 Unpredictability, such as explosive rages over minor frustrations, attacking
indiscriminately, dispensing unjust punishment, inflicting harm on others for the sake of
it, illogical arguments.
 Vengeance, such as being over-punitive. This differs from retributive justice, as
vengeance is personal, and possibly unlimited in scale.
C. Assertive anger:

 Blame, such as after a particular individual commits an action that’s possibly frowned
upon, the particular person will resort to scolding. This is in fact, common in discipline
terms.
 Punishment, the angry person will give a temporary punishment to an individual like
further limiting a child’s will to do anything they want like playing video games, no
reading, etc, after they did something to cause trouble.
 Sternness, such as calling out a person on their behaviour, with their voices raised with
utter disapproval/disappointment.

 EFFECTS OF ANGER /AGGRESSION

a) Effects on brain
1. Elevated cortisol causes neurons to accept too much calcium through their membrane.
A calcium overload can make cells fire too frequently and die. The hippocampus and
prefrontal cortex (PFC) are particularly vulnerable to cortisol and these negative
effects.
2. PREFRONTAL CORTEX: Elevated cortisol causes a loss of neurons in the
prefrontal cortex (PCF). Suppressed activity in the PFC prevents you from using your
best judgment - it keeps you from making good decisions and planning for the future.
3. HIPPOCAMPUS : Elevated cortisol kills neurons in the hippocampus and disrupts
the creation of new ones. Suppressed activity in the hippocampus weakens short-term
memory. It also prevents you from forming new memories properly. (This is why you
might not remember what you want to say in an argument.)
4. Too much cortisol will decrease serotonin – that’s the hormone that makes you happy.
A decrease in serotonin can make you feel anger and pain more easily, as well as
increase aggressive behavior and lead to depression.

b) Effects on your body

 a churning feeling in your stomach
 tightness in your chest
 an increased and rapid heartbeat
 legs go weak
 tense muscles
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 you feel hot

 you have an urge to go to the toilet
 sweating, especially your palms
 a pounding head
 shaking or trembling
 dizziness
c) Effects on your mind
 feeling tense, nervous or unable to relax
 feeling guilty
 feeling resentful towards other people or situations
 you are easily irritated
 'red mist' comes down on you
 feeling humiliated

 Methods for reducing aggression

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1- Punishment : Physical punishment is itself aggressive, it actually models such behavior to

children and may engage greater aggressiveness, punishment often fails to reduce aggression
because it does not communicate what the aggressor should do, only what he should not do.
Sometimes it may be effective deterrent to overt aggression if it is non-physical and delivered
immediately after aggression.

2- Catharsis : The theory of catharsis predicts that venting one’s anger would serve to make
one less likely to engage in subsequent acts of aggression. Guided by this theory, many
educators encourage aggressive person to express aggression in another form as contact sport.

3- Defusing anger through apology : Apology plays an integral part to reduce aggressive
behavior but the first question is whether the person believes an apology is even necessary
and here a gender difference is seen, many men think that apology is not “manly“.

4- Modelling : Exposing children to non-aggressive models, to people who, when provoked,

express themselves in a restrained, rational, pleasant manner. Later, children will behave
peacefully and gently if put in a provoking situation.

5- Training in communication and problem solving skills:

People are not born knowing how to express anger non-violently, teaching people techniques
how to communicate anger in constructive ways, how to negotiate and compromise when
conflicts arise and how to be more sensitive to the needs and desires of others

6- Building Empathy : Empathy has shown significant effect in reducing levels of

aggression among school children while raising social/emotional competence and reducing
anger.

7- Aggression Replacement Training (ART) : cognitive behavioral intervention focused on

adolescents, a program that has three components: Social skills, Anger Control Training, and
Moral Reasoning.

 STEPS OF 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.

1. Stop.
As you sense your control slipping–STOP. If you are in the middle of a sentence–STOP–
don’t even finish your thought, except perhaps to say, “I’m getting mad!” If you are moving–
STOP moving. Practice a STOP gesture that can be used as a way to put a physical brake on
your emotions. A good STOP gesture is to hold your hands up in front of your face, fingers
straight up, palms out. Push the anger away from you, and at the same time say the word
STOP.

What if you are so angry at your child that you are ready to strike him and you cannot find
the restraint to use your STOP gesture? In that case, channel your physical reaction into a
16

burst of applause. When you feel yourself about to strike, clap your hands. Clap them hard
and fast, while you express your feelings of anger.

This anger management technique of acknowledging anger and stopping yourself can be used
for all problems. It can be effective with everything from minor irritations that bring
irrational anger to major problems that require a clear head to solve.

2. Give yourself space.

When you are angry, the LAST thing you need to do is stay engaged in the situation that is
making you mad–all that does is escalate your anger. It is critically important that at this
point you do NOT try to deal with the situation that is making you angry. You cannot solve a
problem in a fit of anger; it will likely just escalate the situation or create a new layer of
problems to deal with. You are going to step away from your child so that you can calm and
collect yourself and, very likely, allow your child to calm down a bit, too.

3. Breathe deeply.
Begin by controlling your internal, physical responses to anger. Likely your heart rate is
increased, your breathing is rapid, your face is flushed, or your voice is raised. The first step
to inner control is to breathe deeply.

Breathing deeply allows your body to fill with oxygen. This will stop the adrenaline rush that
floods your body when you are angry. This extra oxygen flow will relax your body, clam
your breathing, slow your heart rate, and allow your brain to resume rational thought.

Take a number of slow, even, deep breaths. Put your hand on your stomach and carry the air
down until you feel your stomach rise. Try counting or repeating a calming word or phrase,
such as “This too shall pass.”

4. Analyze.
Once you’ve calmed down, try to see what really happened. A good way to analyze what
happened is to imagine that it happened to someone else–your sister, your brother, or a friend.
Looking at the situation as an outsider might help you see the truth. You might more clearly
understand where your anger came from, or you may see that your reaction was way out of
proportion.

5. Define the problem.

After you have seen the situation more clearly, it is time to precisely define the problem in
exact words. See if you can come up with a description of the problem in one or two
sentences. Put it in clear, plain words that exactly state the real issue that sparked your anger.

6. Solve.
Once you’ve stated the problem, you can then consider options for solving it. You may want
to jot down several possible options on paper or talk about options with another adult.
There’s no reason for you to make decisions in a vacuum.

 NURSING MANAGEMENT OF ANGER

Nurses provide care for patients with many types of problems; people who enter the
health care system are often in great distress and exhibit many maladaptive coping
17

responses. Nurses who work in the setting such as emergency rooms, critical care
areas and trauma centre often care for people who respond to events with angry and
aggressive behaviour that can pose a significant risk to themselves, other patients and
health acre providers. Thus preventing and managing behaviour are important skills
for all nurses to have.

General Principles of Management

 The safety of patient, clinician , staff ,other patients and potential intended victims is
of most importance while looking after aggressive patients
 The doors should be open outwards and not be lockable from inside or capable of
being blocked from inside.
 while working with impulsively aggressive or violent patients in any setting one must
take care to reduce accessibility to patients of movable objects as well as jewellery
and other attire that might add to the risk of injury during an assault, including
neckties, necklaces, earrings, eyeglasses, lamps and pens.
 Adequate caregiver training and the availability of appropriate supervision are critical
safeguards in the treatment of potentially dangerous patients.
 The caregiver may choose to present a few key observations in a calm and firm but
respectful manner, putting space between self and patient; avoiding physical or
verbal threats, false promises and build rapport with client.
 For caregivers treating patients with a high risk for violence behaviour, training in
basic self defence techniques and physical restraint techniques are useful.

Drug Treatment in Aggressive and Violent Behaviours

Careful diagnosis has to be made to avoid overuse and misuse of medication. Medications are
used primarily for 2 purposes-

 To use sedating medication in an acute situation to calm the client so that client will
not harm self or others.
 To use medication to treat chronic aggressive behaviour.

Factors influencing choice of drug –availability of an IM injection, speed of onset and

previous history of response.

Acute agitation and aggression

Antipsychotic –often it is the sedating property of antipsychotic that produce the calming
effect for the client. Atypical antipsychotic are also commonly used. But only Ziprasidone is
available in intramuscular form.

Haloperidol-1 mg or 0.5 mg IM
Risperidone o.5mg-1mg- In dementia and schizophrenia.
Trazodone – 50-100mg . In older clients with sun downing syndrome and aggression.
18

Benzodiazepines- used due to the sedative effect and rapid action. Most commonly
lorazepam, oral or injection. Other sedating agents used include Valproate, chloral hydrate
and diphenhydramine.

Chronic aggression

When client continues to exhibit aggression more than several weeks’ choice of medication is
based on underlying condition. I.e., if related to schizophrenia-antipsychotic.

 Antipsychotic
 Anxiolytics- Buspirone
 Carbamazepine and valproate to treat bipolar associated aggressive behaviour.
 Antidepressants –trazodone in aggression associated with organic mental disorder.
 Antihypersensitive medication – Propanolol to treat aggression related to organic
brain syndrome.

NURSING PROCESS

Nursing Assessment

 A violence assessment tool can help the nurse.

 Establish a therapeutic alliance with the patient.
 Assess patient’s potential for violence.
 Develop a plan of care.
 Implement the plan of care.
 Prevent aggression and violence in the milieu.
 Following the assessment , if the patient is believed to be potentially violent, the nurse
should:
 Implement the appropriate clinical protocol to provide for the patient and staff safety
 Notify co-workers
 Obtain additional security if needed
 Assess the environment and make necessary changes.
 Notify the physician and assess the need for prn medications.

Nursing Interventions

Nursing interventions can be thought of existing in a continuum . They range from preventive
strategies such as self awareness, patient education and assertiveness training to anticipatory
strategies such as verbal and nonverbal communications, and the use of medications. If the
patient’s aggressive behaviour escalates despite these actions the nurse may need to
implement crisis management techniques and containment strategies such as seclusion or
restraints.

Self awareness

The most valuable resource of a nurse is the ability to assess one’s self to help others .to
ensure the most effective use of self , its important to know about personal stress that can
19

interfere in one’s ability to communicate with patients. Anxiety, angry, tiredness, apathy,
personal work problems etc... from the part of nurse can affect the patient. Negative countert
ransferance reactions may lead to non therapeutic responses on the part of the staff. On going
self awareness and supervision can assist the nurse in ensuring that patient needs rather than
personal needs are satisfied.

Patient education

Teaching patients about communication and the appropriate way to express anger can be one
of the most successful interventions in preventing aggressive behaviour.
Teaching patients that feelings are not right or wrong or good or bad can allow them to
explore feelings that may have been bottled up, ignored or repressed. The nurse can then
work with patients on ways to express their feelings and evaluate whether the responses they
select are adaptive or mal adaptive.

Patient education plan for appropriate expression of anger

Content Instructional activities Evaluation

Help the patient identify Focus on nonverbal
anger behaviour.
Role plays nonverbal
expression of anger.
Label the feeling using the
patients preferred words
Give permission for Describe situations in which
angry feelings. it is normal to feel angry.
Practice the expression of Role play fantasized
anger. situations in which anger is
an appropriate response
Apply the expression of -Help to identify a real
anger to real situation. situation that makes the
patient angry.
-Role plays a confrontation
with the object of the anger.
-Provide a positive feedback
for successful expression of
anger.
Identify alternative ways -List several ways to
to express anger express anger, with and
without confrontation.
-Role plays alternative
behaviours.
-Discuss situations in which
alternatives would be
appropriate
Confrontation with a -Provide support during
person who is a source of confrontation if needed.
Patient demonstrates an
angry body posture and
facial expression.
Patient describes a situation
to which anger would be an
appropriate response.
Patient participates in role
play and identifies
behaviours associated with
expression of anger.
Patient identifies a real
situation that results in
anger.
Patient is able to role play
expression of anger.
Patient participates in
identifying alternatives and
plans when each might be
useful.
Patient identifies the feeling
of anger and appropriately
20

anger. -Discuss experience after confronts the object of anger

confrontation takes place.

Assertiveness training

 Interpersonal frustration often escalates to aggressive behaviour because patients have

not mastered the assertive behaviours.
 Assertive behaviour is a basic interpersonal skill that includes the following –
 Communicating directly with another person.
 say no to unreasonable requests
 Being able to state complaints.
 Patients with few assertive skills can learn them by participating in structured groups
and programmes .In these settings patients can watch demonstrate specific skills and
then role play the skills themselves.
 Staff can provide feedback to patients on appropriateness and effectiveness on their
responses.
 Homework also can be given to these patients to help them generalise these skills
 Expressing appreciation as appropriate outside the group milieu.

Communication strategies
Nurses have to:

 present a calm appearance

 speak softly
 speak in a non proactive and non judgemental manner
 speak in a neutral and concrete way put space between yourself and patient
 show respect to the patient
 avoid intense direct eye contact
 Demonstrate control over the situation without assuming an overly authoritarian
stance.
 Facilitate the patient’s stance.
 Listen to the patient
 Avoid early interpretations
 Do not make promises that cannot keep.

Environmental strategies

 Inpatient units that provide many productive activities reduce the chance of
inappropriate patient behaviour and increase adaptive social and leisure functioning.
 Both the unit norms and the rewards associated with such activities may reduce the
amount of disorganised patient behaviour and the number of aggressive acts.
 Units which are overly structured with too much stimulation and little regard for the
privacy needs of the patients may increase aggressive behaviour.
 Aggressive behaviour is more effectively managed by allowing those at risk to spend
time in their rooms away from the hectic day room rather than encouraging them to
interact with others in a crowded milieu.
21

 The environment that may have been therapeutic in the days of extended hospital
stays may no longer be suitable for patients with who are hospitalised on short term,
acute inpatient units where the acuity of the patient is extremely high.
 Inpatient units should adapt the environment to best meet needs of the patient they
treat.

1. Room programme

 In an inpatient setting the use of structured programme is an effective tool for the
management of agitated patients.
 A room programme limits the amount of time patients are allowed in the unit milieu.
Egg. Patients initially are asked to be in the rooms for a certain length of time, or
conversely be allowed out of their rooms for a specific amount of time every hour.
The amount of time in the milieu may then be increased by increments of 15 min as
patients tolerate the environment.
 Another way of implementing a room program is to allow patients to come out of
their rooms during designated hours, such as when the unit is quite when the other
patients are off the unit. Such a structured programme allows patients time away from
situations that may increase agitation and provides away to regulate the amount of
stimulation patients receive. Its purpose is prevention of a crisis that could result in
more serious patient complications.

2. Cathartic activities

The use of cathartic activities may help the patients deal with their anger and agitation. These
can be of 2 types:

a). Physically cathartic activities – It is based on the assumption that some physical activity
can be useful in releasing aggression and can prevent more explosive or destructive forms of
aggression or violence .Some traditional nursing interventions, such as encouraging patients
to release tension through the use of exercise equipment or allowing patients to pace the hall
in the expectation that their tension will decrease. Because these strategies are not supported
by research and may increase patient’s agitation they are not recommended now.

b). Emotionally cathartic activities – these are evidence based. Having patients write their
feelings, do deep breathing or relaxation exercises, or talk about their emotions with a
supportive person can help the patient regain control and lower feelings of tension and
agitation.

Behavioral strategies
Nursing interventions include applying principles of behaviour management to aggressive
patient.

a) Limit setting
22

 Limit setting is a non punitive non manipulative act in which patient is told what
behaviour is acceptable and what is not acceptable , and the consequences of
behaviour unacceptably.
 By explaining the rational for the limit and communicating to the patient in a calm
and respectful manner, potentially aggressive behaviour can be avoided.
 If nurse communicates in an authoritarian, controlling or disrespectful way patients
respond in an angry, aggressive manner.
 The patient has the right to choose behaviour and understands its consequences.
Limits should be clarified before negative consequences be are applied.
 One a limit has been identified; the consequences must take place if the behaviour
occurs. Every staff member must be aware of the plan and carry out it consistently. If
staff do not do so, the patient is likely to manipulate staff by acting out and then point
out areas of inconsistent limit setting. Clear, firm and no punitive enforcement of
limits is the goal.
 When limit setting is implemented, the maladaptive behaviour will not immediately
decrease, in fact, briefly increase. This is consistent with behavioural principles and
testing behaviour.

b). Behavioral contracts

If the patient uses violence to win control and make personal gains, the nursing care must be
planned to eliminate the rewards patient receives while still allowing the patient to assume as
much as control, as possible.

Once the rewards are understood, nursing care must be planned that does not reinforce
aggressive and violent behaviour. Behavioural contracts with the patient can be helpful in this
regard. Eg. Head injured patients with low impulse control can be told that staff will take
them for a walk if they can refrain from using profanity for 4 hours.
To be effective contracts require detailed information about:

 unacceptable behaviours.
 acceptable behaviours.
 consequences for breaking the contact.

The nurse’s contribution to care.

Patients also should have input into the development of the contract to increase their sense of
self control.

c). Time out

 In an inpatient setting, the use of time out can be an effective tool for the management
of agitated patients. It is a strategy that can decrease the need for for seclusion and
restraint.
 Time out from reinforcement is a behavioural technique in which socially
inappropriate behaviours can be decreased by short term removal of the patient from
over stimulating and sometime reinforcing situations.
23

 Time out usually will be in a quiet area of the patients unit or the patient’s room. They
remain there until they become non aggressive for a couple of minutes. It may be
initiated by the patient or staff. Patient is allowed to be out of the time out area when
he is able to remain calm. Patient determines their own readiness to leave the time out
area.
 Time out is not considered to be seclusion.

d). Token economy

 In this intervention, identified interpersonal skills and self care behaviours are
rewarded with tokens that can be used by the patient to buy items or receive rewards
or privileges.
 Behaviours to be targeted are specific to each patient. guidelines has to be made for
desired
 behaviours required to receive the tokens, the number of tokens to be received for
each behaviour and the
 Length of time a desired behaviour must be exhibited to receive tokens.

e). Crisis Management

 Team Response
 Effective crisis management must be organised and should be directed by one clearly
identified crisis leader.
 Procedure for managing psychiatric emergencies.
 Identify crisis leader
 Assemble crisis team
 Notify security officers if necessary
 Remove all other patients from the area
 Obtain restraints if appropriate
 Device a plan to manage crisis and inform team
 Assign securing of patients limbs to crisis team members
 Explain necessity of intervention to patient and attempt to enlist cooperation
 Restrain patient when decided by the crisis leader
 Administer medication if ordered
 Maintain calm, consistent approach to patient
 Review crisis management interventions with crisis team
 Process events with other patients and staff as appropriate
 Process event with patient
 Gradually reintegrate patient into milieu.

f). Seclusion

Seclusion is the involuntary confining of a person alone in a room from which the person is
physically prevented from leaving (Brown, 2000). Degree of seclusion varies. They include
confining a patient in a room with a closed or unlocked door or placing a patient in a locked
room with a mattress but no linens and with limited opportunity for communication.
24

The rational for the use of seclusion is based on 3 therapeutic principles:

 Containment – using this principle patients are restricted to a place where they are
safe from harming themselves and other patients.
 Isolation – addresses the need for patients to distance themselves from relationships
that, because of illness are pathologically intense. Some patients, particularly those
with paranoia, distort the meaning of the interactions around them. Their distortions
create such psychic pain that seclusion may provide some relief and may be the only
place to feel safe from their “persecutors".
 The third principle is that seclusion provides a decrease in sensory input for patients
whose illness results in a heightened sensitivity to external stimulation. The quiet
atmosphere and monotony of a seclusion room may provide some relief from the
sensory overload.

g). Restraints

Indications – used when the client-

 is no longer exerting control over his/her own behaviour.

 to prevent harm to others and to patient
 to prevent serious disruption of treatment environment.

Physical restraints are any manual methods or physical or mechanical device attached to or
adjacent to the patient’s body that she/he cannot easily remove and that restricts freedom of
movement or normal access to one’s body, material or equipment (Brown, 2000)

Chemical restraints are medications used to restrict patient’s freedom of movement or for
emergency control of behaviour, but it is not a standard treatment for the patient’s medical or
psychiatric condition (Murphy, 2002).

Because seclusion and restraints represents restriction of patient freedom and can result in
harm to both the patient and the staff who implement them, they should be used only as an
emergency intervention to ensure the safety of the patient or others and only when other less
restrictive interventions has been ineffective. They are a violation of patient rights if used as a
means of coercion, discipline or convenience of staff (Brown, 2000).

Restraints should be applied efficiently and with care that not to injure a patient. Adequate
personnel must be assembled before the patient is approached. Each staff member should be
assigned responsibility for controlling specific body parts. Restraints should be available and
in working order. Padding of cuff restraints helps to prevent skin breakdown. For the same
the patient should be positioned in anatomical alignment.

Guidelines for use of restraints

1. Restraints must not be used to punish a patient or solely following the convenience of
staff or other patients.
2. Staff must take into consideration the medical/psychiatric status of patient.
25

3. Written policy must be followed.

4. In non-emergency situation physical restraints should be used very sparingly and only
after careful and comprehensive review, assessment and documentation provide
substantial evidence that no safer alternative or setting can be found to prevent their
use.
5. The least restrictive device should be used.
6. All mechanical restraints must be padded to decrease the chance of pressure damage
and abrasion to skin and underlying tissues; proper size and type must be used.
7. Both the patient and restraining device must be checked frequently and the restraining
device removed periodically. A restrained limb should be periodically exercised and,
if possible the patient should be ambulated at reasonable intervals. Attention to need
fro hydration, elimination, comfort, and social interaction must be assured.
8. Behaviour that precipitates a decision to restrain patient should first trigger
investigation and treatment aimed at understanding and eliminating the cause of the
behaviour.
9. Nursing staff should observe the patient every 15 min.
10. All the needs of the patient must be met with caution.
11. With four point restraint each limb should be released or restraint loosened every
15min.
12. Patient should be gradually decreased from seclusion or restraint.
m) Patient should not be made to feel guilty after being released from restraints of his
past behaviour.
13. Documentation is necessary.

Risks with restraints

Falls, strangulation, loss of muscle tone, pressure sores, decreased mobility, agitation,
reduced bone mass, stiffness, and frustration, loss of dignity, incontinence, and constipation.

Terminating the intervention

Patients should be removed from seclusion or restraints as soon as they meet criteria for
release. It is important to review with the patient the behaviour that precipitated the
intervention and the patient’s current capacity to control over his/her behaviour. Patients
should be told witch behaviours or impulses they need to exhibit and which intervention they
need to control before the intervention can be discontinued. Communication and careful
documentation are critical in making an accurate assessment of a patient’s level of control.

Debriefing

Debriefing is an important part of terminating the use of seclusion or restraints. Debriefing is

a therapeutic intervention that includes reviewing the facts related to an event and processing
the response to them. It provides the staff and patient with an opportunity to clarify the
rational for seclusion, offer mutual feedback, and identify alternative, methods of coping that
might help the patient avoid seclusion in the future.
26

PREVENTION OF AGGRESSION
Workplace guidelines

 Management commitment and employee involvement

 Work site analysis
 analyse incidents including the characteristics of assailants and victims, an account of
what happened before and during the incident, and the relevant details of the situation
and its outcome.
 identify jobs or locations with greatest risk of violence and processes procedures that
put employees at risk of assault including how often and when
 note high risk factors such as type of clients ,psychiatric conditions, patients
disoriented by drugs, physical risk factors of the building, isolated locations, areas
with previous security problems etc.
 evaluate the effectiveness of existing security measures
 Prevention and control
 Safety and health training

Staff development

 Staff education regarding

 The workplace violence prevention policy
 Risk factors that cause or contribute to assaults
 Early recognition of escalating behaviour or recognition of warning signs or situations
that may lead to assaults
 Ways of preventing or diffusing volatile situations or aggressive behaviour, managing
anger, and appropriately using medication or chemical restraints.
 Information on multicultural diversity to develop sensitivity to racial and ethnic issues
and differences.
 A standard response action plan to violent situations, including availability of
assistance, response to alarm systems, and communication procedures.
 How to deal with hostile persons other than clients such as relatives and visitors.
 Progressive behaviour control methods and procedures and safe methods of restraint
application
 Ways to protect oneself and fellow workers.
 Policies and procedures, recording and reporting.
 Policies and procedures for obtaining medical care, counselling, workers
compensation or legal assistance after a violent episode of injury.

Staff support
Nurses can be supported by allowing adequate time off from work to address their physical
and emotional needs. Discussing the event in a nonblaming manner is also helpful. Validation
from others that assaults occur despite clinical competence and appropriate interventions can
help the assaulted nurse in healing.

CONCLUSION
27

Anger is a normal human emotion that is crucial for individual’s growth. When handled
appropriately and expressed assertively, anger is a positive creative force that leads to
problem solving and productive change. When channeled inappropriately and expressed as
verbal aggression or physical aggression, anger is destructive and potentially life threatening
force.

Psychiatric nurses in particular, work with patients who have inadequate coping mechanisms
for dealing with stress. Patients admitted to an inpatient psychiatric unit are usually in crisis,
so their coping skills are even less effective. During these times of stress acts of physical
aggression or violence can occur. Also nurses spends more time in the inpatient unit than any
other disciplines, so they are more at risk of being victims of acts of violence by patients. For
these reasons, it is critical that psychiatric nurses be able to assess patients at risk for violence
and intervene effectively with patients before, during and after an aggressive episode.

REFERENCES :

1. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical

Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers;2009.
2. Moyer, KE. 1968. Kinds of aggression and their physiological basis. Communications
in Behavioral Biology 2A:65-87
3. Townsend M C Psychiatric mental health nursing- concepts of care. 8 th edn.
Philadelphia: F.A Dais company; 2009.
4. www.wikipedia.com
5. www.slideshare.com
6. www.scribd.com