Aggressive & Violent Behavior

(In terms of adults with mental illness)

Vicki Notes

By 2010 an estimated 25% increase in admissions of violent clients to specialty mental health
facilities will occur.

Aggressive behavior generally includes abusive language, violent threats of harm, physical
assault to self or others, & damage to property. Behavior may be understood in terms of
negative appraisals & attitudes toward self, others, the world & the future.

Aggression, hostility-related variables & violence

 Related variables to hostility are emotions, attitudes & behaviors that occur regularly &
are predictable in aggressive & violence-prone individuals.
 Emotions – such as anger, irritability & resentment  which can lead to BP & heart
disease.
 Attitudes – such as persistent negative views of others & the world, cynicism, mistrust,
suspiciousness & looking at everything in it’s worst light.
 These emotions & attitudes may result in hostile behavior a.k.a. expressive hostility –
such as facial expressions, body language, verbalizations, gestures, acts against self,
others or property.

Anger

 Is an emotion that occurs when an individual’s expectations are not met.

 It can be a positive emotion when it motivates some positive change.
 It loses it constructiveness when it is turned inward, is used ineffectively towards others
with little or no cause, bullies, harms or hurts self or others, or is expressed out of
control.

Impulsivity

 Is a way of interacting  acts performed with little or no regard for

the consequences (In MH nursing impulsivity can be viewed as being related to an
underlying disorder or pervasive personality trait).
 Impulse control disorders are characterized by three things:
o An inability to control an impulse viewed as harmful.
o A sense of increasing tension.
o A sense of excitement, gratification & tension release during the
act.
 Possible causes of impulsivity are – a life pattern of impulsive behavior, nervous system
abnormalities, anxiety, life crisis, & sexual & aggressive drives.
 Signs/symptoms of impulsivity may include – unpredictable behavior, threats towards
others, irresponsible acts, low frustration tolerance, poor problem solving skills,
disturbed interpersonal relationships, restlessness & general disregard for social rules &
customs.

Violence
  Is a form of aggression.
 Includes verbal or written threats (including sexual harassment), physical assault
(including sexual assault) and damage to property.
 Intent – is what differentiates accidental harm or injury from purposeful harm or injury.

Aggressive behaviors & violence occur in all clinical diagnostic categories  however certain
subgroups of psychiatric diagnosis have been linked with violent behavior such as:

o Antisocial personality disorder

o Paranoid schizophrenia
o Schizoaffective disorder
o Bipolar disorder
o Substance abuse disorder

Profiles related to aggressive behavior

Client arrest profiles – show that those hospitalized in public psychiatric facilities tend to have
higher arrest rates than the general public. Arrests for violent behavior were higher in antisocial
personality, paranoid schizophrenia & substance abuse disorder  and highest in
schizoaffectrive disorder.

Inpatient profiles – show that most incidents occur the 1st week of hospitalization & steadily
decline, are highest in males 26-35 y/o and females 36-45 y/o. Physical incidents occurred
more with men & suicide occurred more often with women. The most common diagnosis was
schizophrenia (highest for assault), substance abuse or major depression.

 Two types of antecedent events of escalating violence were linked with staff-client
interactions
o A. Where the patient is frustrated or angered do to,
for example, not being able to leave the ward/unit,
a dispute over medications or not having a request
granted. (Staff should explain all behavior or verbal
requests).
o B. Ignoring the patient – Here the patient may
become aggressive to gain staff attention.
 Client backgrounds – Rural vs. Urban – studies suggest a higher incidence of
aggressive behavior of patient’s from rural areas. Possibly due to abused substances
prior to admission & barriers to mental health care in rural areas.

Outpatient profiles

 30% of male & female psychiatric patients with a HX of violent behavior will become
violent again within a year of discharge  and may be related to medication
noncompliance  they feel good & stop taking their medications. This is why patient
teaching is so important!

Families with a mentally ill member

 Families with a violence-prone mentally ill member – report other family members as
being the object of an attack 56% - 65% of the time.
General Population vs. Seriously Mental Ill

 Findings support an increased risk of violence among mentally ill persons with a HX of
violent behavior, substance abuse & noncompliance with medications when compared
with the general population.

AGGRESSION – WHAT DETERMINES IT?

 First let’s define aggression – which is any behavior that expresses anger or its related
emotions.
 Now, to answer your question – aggressive is determine by several factors including
psychological, biological, sociocultural & environmental.

 The Psychological view (or theory) refers to the classic frustration-

aggression theory that states as people become more frustrated  the greater the
chance for aggressive behavior. An example might be – you searching & searching for
a major care plan paper that’s due that morning, which is lost in the mess that is your
house since you began nursing school, as you continue to search & continue NOT to
find the paper your frustration builds until you are yelling at your house plants &
throwing dirty laundry about in anger… a mild example… but you get the picture!

 The Temperament view (or theory) – refers to your personality disposition (which is
partly inherited). It is thought to influence three parts of the personality: negative
emotionality, positive emotionality & constraint.
o Negative emotionality – is most commonly discussed as a ‘difficult’
temperament  this is the shy, inhibited person who is withdrawn in novel or
new situations, has irregular biological functions, is slow to adapt, with an
intense & negative mood.
o Positive emotionality – refers to the easy person, who has regular biological
functions, positive & active with people, seeks out new situations, positive
adaptation, agreeableness & a mild & generally positive mood.
o Constraint – examples include – people high in constraint are conscientious,
cautions, reliable, responsible & hardworking while those low in constraint are
impulsive, careless & concerned with their own immediate wants.

 The Cognitive view (or theory) – refers to how a person thinks, or interprets situations
& events – and how they interpret or view the event determines whether or not they
become aggressive.
o A person uses their attitudes, beliefs & appraisals to explain or interpret events
that happen. (That appraisal you do in your head is referred to as self-talk,
private speech or automatic thoughts – they all refer to the same thing).
o If a person appraises an event or situation as aversive (unpleasant) & anger
inducing  then it is likely that they will react with anger.

 The Neurobiological view (or theory) – Research, through brain neuroimaging, has
found that neurobiological deficits or injuries in the limbic system or frontal or temporal
lobes of the brain are related to aggressive behavior.
  Aggressive behavior, personality changes & irritability have been seen incases of limbic
tumors & frontal lobe lesions. Rabies, encephalitis & some brain injuries are associated
with loss of impulse control.

Neurotransmitter Dysregulation

 Low Serotonin Syndrome – refers to, of course, conditions of low serotonin or low 5-
hydroxyindoleacetic acid (a.k.a. 5-HIAA) a little ol’ metabolite of serotonin in the CSF
(cerebrospinal fluid)  this is characterized by episodes of mood changes and/or
impulsive behavior.
 Studies have found that patients who attempted suicide had the lowest CSF levels of 5-
HIAA.
 MAO activity may also be linked to behavioral expression of aggression  MAO
metabolizes serotonin & thus contributes to decreased serotonin levels in the brain…
physiology is just too cool…

Substance Abuse

 Alcohol intoxication is often a contributor to violent behavior. Studies suggest that

alcohol abusers have a neurological defect in serotonin turnover  this deficit increase
the chance for violent behavior. This defect id thought to be inherited.

The Social learning view (or theory)

 Explains aggressive behavior as learned from exposure to aggressive models (i.e. in

the family, gangs, TV, movies, video games) or as the result of random positive
reinforcement or direct experience.

Environmental & situational determinants

 Dehospitalization& deinstitutionalization have resulted in thousands of MH

displacements.
 There is a great need for a supportive social network after discharge.
 Dehospitalization& unsupervised patients in the community may become involved in
antisocial acts & violence.

The Nursing Process

Assessment

 watching and listening for clues to behaviors allows the nurse to prevent angry and
hostile feelings from turning into something dangerous (i.e. the person acting with
violence)
 The following are cues to violent or dangerous behavior:
 Thinking and perception- A person having hallucinations or delusions that are
threatening to hurt them or commanding them to hurt someone else. (ex: women thinks
husband is trying to kill her)
 Motor activity- A person with increased psychomotor agitation can indicate a person
cannot tolerance others being close or a way to release building tension is not available.
(ex: a pacing person)
  Mood and Affect- Has their mood and affect become more intense? Angry tone of
voice that gets louder. Is there a noticeable change in the way they express
themselves?
 Physical state- Are they in a state where they cannot communicate a warning- such as
beginning seizures, delirium or brain lesions.
 Context- Does the person have a history of violent outbursts against themselves or
others (include criminal behavior and suicide).

Some studies say the single best predictor of violence is a history of violence  Ask that
question, "Do you feel like hurting yourself or anyone else?" (This does not suggest violence to
the person but gives them a route of expression by talking about it rather than acting out)

There should be concern about the following types of patients as well:

 Those who lack perspective regarding their anger

 Those who continually want to hurt specific others
 Those with a history of episodic aggression
 Those who do not verbally communicate their anger to others.
 Assault occurred more frequently with schizophrenia, mania or organic psychotic
conditions.

Some of the tools (scales or tests) used to measure aggressive behavior include the:

 Overt aggression scale (OAS) – this is used to document behaviors and interventions
during an aggressive episode. It helps to justify the use of medications and is a way to
compare other facilities to one another in terms of using seclusion, restraints and PRN
meds.
 The Minnesota Multiphasic Personality Inventory - measures general
psychopathology through a variety of tests.
 The Brief Anger Aggression Questionnaire- is a six-item measure (test) used for
quick assessment of irritability and tendency toward aggressive or violent behavior.

Nursing Diagnosis

 Risk for violence: self directed or directed at others. Will be the primarily relevant
diagnosis with aggressive and violent persons.

Patient Outcomes and Goals

 The ultimate goals are to improve the patient’s health outcomes and health status.

Discharge Planning

 Early discharge of violent or potentially violent persons is a growing and urgent concern
to all.
 Continuity of care involves:
 A seamless care delivery system after discharge. Here all care systems work from one
database to meet patient needs.
 Creating a through-computerized database on the patient. That can be quickly
assessed for inpatient and outpatient use.
 Collect outcome data- what interventions worked? Medication effects? Side effects?
  Recent research findings show that intensive case management programs are effective
in reducing patient’s dangerousness in the community.

Interventions
 Staff must maintain attitudes of caring, concern and nonauthoritarianism, while setting
appropriate limits to demonstrate social norms within the milieu. (This is essential to
prevent violent behavior, especially on inpatient units)
 Self-awareness by the nurse: The nurse should be awareness for herself, that in the fall
of aggressive or assaultive behavior a universal response is fear. Outcomes of the
nurse’s fear could lead to countertransference reaction due to angry feeling which
leads to limit setting, instead of talking through behavior. Anxiety reactions due to
helpless feeling leading to right from the situation. Or a therapeutic reaction where
the nurse explores thoughts, feelings and behaviors.

Three Intervention Strategies

 Include verbal, pharmacological (medications) and physical (seclusion and restraint).

Used separately or in combination.

Safety Guidelines when Interacting with Angry or Potentially Aggressive Patients:

 Stand just outside the patient’s personal space (slightly out of arms reach)
 Stand on the patients nondominate side (usually the side the wrist watch is worn)
 Keep the patient in visual range
 Make sure the door is accessible
 Don’t let the patient come between you and the door
 Retreat from the situation and call for help if the patient becomes violent.
 Avoid dealing unaided with a violent patient

Verbal Intervention

 It is most helpful with milder levels of aggression, although it works for all and can
prevent escalation of aggressive behavior.

 Attend to what the patient is saying with empathy and genuine concern

 Talk with the patient one on one.

There are 3 phases to verbal intervention to prevent the escalation of violence:

1. Make contact- appear calm and in control when approaching the patient. Speak in a
normal tone and nonjudgemental. Watch their verbal and nonverbal behavior. Tell them
what you see them doing behaviorally and how you think they feel. Then check your
understanding. Example: Sue, I see you pacing and hitting your leg with a magazine.
You seem angry. Are you angry?
2. Discovering the source of distress- use open-ended questions to elicit more meaningful
descriptions. Encourage the patient to describe and clarify the problematic feelings and
what triggers them (increases the patient self-awareness). Don’t ask why questions
(puts them on the defensive). Do not "parrot" this patient rather paraphrase.
 3. Focus on the patients competency and alternative problem solving: If possible talk with
the person how their ideas regarding a plan that would help them deal with the situation.

Limit Setting

 Is a process through which someone in authority determines temporary and artificial

ego boundaries for another person.
 The nurse must have a keen sense of detecting a patient’s desire for control and must
be able to set limits without being punitive. It is usually reassuring to patients to know
that they will not be allowed to be destructive to self, others or property,

 Compliment patients on whatever degree of control they can maintain. (saying,"Aren’t

you proud of yourself?) This focuses the patient on pride in his own behavior rather than
pleasing another person.

 Knowing limits gives the patient a framework within which to function more freely and
adequately, maintain self-esteem, learn new behaviors and gain new self-awareness.

The following are useful for setting limits:

1. Assess the need for limit setting.

2. Describe the patient’s unacceptable behavior and communicate expected behavior and
give alternatives. Acceptable substitute behaviors for example are walking with the
nurse, talking about feelings and thoughts, or participating in recreational therapy.
3. State the limit. Inform the patient exactly what the consequence or limit is.
4. Help the patient understand the reason for the limit. Explaining consequences gives the
patient a sense of responsibility for the outcomes or results of behavior.
5. Enforce the limit. When a patient tests a limit, they experience some anxiety and having
the stuff respond in a predictable manner ensures the safety and protection of the
patient and provides security and comfort.

Remember DISC:

D - describe patient behavior

I - indicate desired behavior

S - specify nurses’ actions

C – confronts with positive or negative consequences

Intervention with medication in managing aggression:

 May be needed to calm when the patient does not respond to verbal intervention.

 Medications may not be advisable if the assaultive patient is believed to be under the
influence of an unknown drug.

 Antipsychotics are the most commonly used for aggression in acute psychosis  the
sedative effect decreases the aggression (Haldol, Thorazine, Clozaril and Risperdal).

 Rapid tranquillization may be used.

  Haloperidol and diazepam (a benzodiazepine) are most commonly used PRN for
sedation and calmness. Works within 30 minutes  and provides a "calm settle" within
1 hour.

 Lithium is effective in decreasing aggression, irritability, manipulation, persecutory

delusions and hostile behaviors. Also decreases aggression and self-injurious behavior
in children  however it may increase aggression in patients with temporal lobe
epilepsy. (lithium is an antimanic)

 Antidepressants – have also been used to decrease aggression. (Elavil, Desyrel,

Prozac, and Zoloft)

 Sedative and anxiolytics such as benzodiazepines (Ativan), barbiturates, and chloral

hydrate decrease aggression by sedating  use short-term only. (Ativan and Benadryl)

 A nonbenzodiazepine anxiolytic is buspirone (Buspar) which does not sedate, relax

muscles or have anticonvulsant activity.

 Anticonvulsant, such as carbamazepine (Tegretol and Valproic Acid) is used, Side

effect: BONE MARROW DEPRESSION, aplastic anemia and hepatotoxicity.

 Beta blockers – such as propanolol (Inderal), pindolol (Visken) and Metoprolal

(Lopressor) are found to decrease aggression in both children and adults.

Seclusion & Restraint

 Should be used only when all other interventions fail.

 The purpose is to stop injurious actions, decreases difficult interpersonal interactions

and decrease sensory input to relieve sensory.

 Some experts believe that seclusion and restraint do not teach patients coping skills
that will help them- may also foster distrust.

 Greater use is being made of less restrictive forms of isolation such as quiet rooms
without using restraints or quiet rooms with the door open to decrease stimuli (but
isolation is minimal).

 The Supreme Court ruled in Youngberg vs. Romeo that a person could be deprived of
his liberty in terms of being restrained if it could be justified to protect him or her self or
others. It could be justified on professional clinical judgement.

According to Task Force of the American Psychiatric Association indications for use of
seclusion and restraint are:

A. To prevent harm to patient and others- if no others means are effective.

B. Prevent serious disruption of treatment program or damage to environment.
C. As part of an ongoing behavior treatment program.
D. As the patients request (for seclusion, used for violence, patient on the verge of
exploding).
E. Seclusion and restraint should be viewed as important as CPR in mental health.
***Be sure to read Box 31-2 on page 622, Guidelines for Seclusion and Restraint of Violent
Clients.

When the decision for use of seclusion and restraint is made, the staff:

 approached with 4 members behind the team leader

 approach in a calm, helpful and nonprovacative manner
 inform patient what is occurring and why
 if patient refuses to walk with or without help progress to

*Each team member holds a limb and transports patient to seclusion or to apply
restraints, (include wrist and ankle

cuffs, sheet restraints and camisoles {straight jackets}).

 if this occurs, all other interventions must be DOCUMENTED as having failed to help
the patient maintain control.
 Criteria for release from seclusion or restraints:

 decreased psychomotor agitation- decreased restlessness, lowered BP and pulse rate

 stabilization of moods- absence of physical threats, lowered anxiety level, consistency
of verbal and nonverbal behavior and feelings of trust in staff
 cognitive processes – signs of insight and ability to look at the incident in an objective
manner, increased ability to concentrate and improved reality testing

 Staff discussion occurs after the incident to discuss what happened, what would have
prevented it, the rationale for the seclusion/restraint and the reactions of the patient and
staff.

Behavior Therapy

 A behavior therapy program requires target behaviors be clearly stated.

 Terms such as assaultive or violent should not be used but rather use pushing, shoving,
hitting, pulling hair and throwing chairs.
 Limit setting and behavioral management techniques by use of behavioral contracts,
token economics or seclusionary time out.

 a behavioral contract or no-harm contract is a statement signed by the patient that

he/she will not harm themselves or others
 token economy-is probably the most commonly used behavioral management strategy-
desired behavior results in receipt of tokens while undesired behavior results in token
loss
 reinforcing patient positive social behaviors can proactively decrease hostile and
aggressive response on inpatient units and decrease aggressive episodes
 time-out- removes patients who are exhibiting socially in appropriate behavior from over
stimulating and reinforcing situations- effective with people who experience loss of as a
negative consequence, for example in a quiet room (some are locked, some are not)

Cognitive Therapy
  Is a brief, directive, collaborative form of psychotherapy that is useful in assisting
patients to confront their dysfunctional and irrational thinking; test the reality of their
thinking and behavior and learn to use more positive and assertive responses in
interactions with others.

 Guided discovery- is a technique that helps patients recognize the connection

between their thoughts, feelings and behaviors, identify, negative thinking and replace it
with more positive thinking and identify dysfunctional expectations and appraisals using
more reality based interpretations.
 Anger - management training- is where patients are taught anger cues and dynamics,
signals related to anger arousal, signs of impending loss of control and re-channeling
aggressive response in early stages. Patients are also taught the difference between
acceptable responses (anger, frustration and fear) from inappropriate and destructive
behavioral responses.

- Often responses of anger are deeply ingrained.

 Less anger is aroused if a person can define a situation as a problem that calls for a
solution rather that as a threat that calls for an attack.
 Problem-solving skills training- teaches patients to be aware of other’s points of view
and anticipate and understand the consequences of their own emotional and behavioral
responses.

Group and Family Therapy

 Has its advantages, in that patients can receive feedback form other group members.
 There is peer pressure for socially acceptable behavior.
 Family members can be educated about anger deceleration and problem solving
strategies.

Evaluation

 Was an escalation of violence prevented?

 Was safety maintained?
 Were institution guidelines followed?
 Did aggressive and violent behavior decrease?
 Did the patient or nurse learn new problem solving techniques?

Cultural Issues

 MH care facilities must employ case managers who are culturally similar to the patients
served.
 Subcultures such as hearing impaired or homosexual may require other cultural
considerations as well.

Legal Issues

 There are primarily four issues:

o Involuntary commitment to mental hospitals.
o Protection for potential victims of a patient’s aggressive behavior.
 o Maintenance of patient rights.
o Preservation of the rights of staff.
 Many states have started a requirement for the "least restrictive treatment
alternative"  and use outpatient treatment settings whenever possible.
 Preventive commitment – refers to allowing outpatient treatment and inpatient
treatment when needed  the statute that governs this is called "predicted
deterioration" standard.
 Conditional release – refers to the requirement of continued supervision of a person
following discharge from a hospital  if the patient violates the conditions of release,
immediate rehospitalization may result, or in some cases a court hearing. This release
tests the person’s ability to function in the community.
 Principals of Medical Ethics – states a physician shall safeguard patient’s confidence
within the constraints of the law  protective privilege ends where public peril begins.
 Voluntary patients may refuse any treatment & involuntary patient’s have a right to
refuse antipsychotic drugs unless found incompetent.
 And last but certainly not least – if a violent person makes clear threats to harm specific
people  MH care providers can be held responsible if potential victims are not
warned  and yes, you can face legal liability either way!

Reference:

Barabara Schoen Johnson (1997) Adaptation & Growth Psychiatric-Mental Health Nursing
4th ed