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.

• Related variables to hostility are emotions, attitudes & behaviors that occur regularly & are predictable in aggressive & violence-prone individuals.
• Emotions – such as anger, irritability & resentment à 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.

• 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.

• Is a way of interacting à 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:
• An inability to control an impulse viewed as harmful.
• A sense of increasing tension.
• 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.

• 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 à however certain subgroups of psychiatric diagnosis have been linked with violent behavior such as:

• Antisocial personality disorder
• Paranoid schizophrenia
• Schizoaffective disorder
• Bipolar disorder
• Substance abuse disorder

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 à and highest in schizoaffectrive disorder.

Inpatient profiles – show that most incidents occur the 1^st 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
• 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).
• 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.

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

• Families with a violence-prone mentally ill member – report other family members as being the object of an attack 56% - 65% of the time.

• 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.

• 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 à 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.
• Negative emotionality – is most commonly discussed as a ‘difficult’ temperament à 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.
• 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.
• 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.
• 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).
• If a person appraises an event or situation as aversive (unpleasant) & anger inducing à 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.

• 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) à 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 à MAO metabolizes serotonin & thus contributes to decreased serotonin levels in the brain… physiology is just too cool…

• Alcohol intoxication is often a contributor to violent behavior. Studies suggest that alcohol abusers have a neurological defect in serotonin turnover à this deficit increase the chance for violent behavior. This defect id thought to be inherited.

• 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.

• 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.

• 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 à 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)

• 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.

• 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.

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

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

• 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.

• Include verbal, pharmacological (medications) and physical (seclusion and restraint). Used separately or in combination.

• 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

• 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.

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.

• 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.

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.

D - describe patient behavior

I - indicate desired behavior

S - specify nurses’ actions

C – confronts with positive or negative consequences

• 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 è 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 è 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 è 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 è 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.

• 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.

1. To prevent harm to patient and others- if no others means are effective.
2. Prevent serious disruption of treatment program or damage to environment.
3. As part of an ongoing behavior treatment program.
4. As the patients request (for seclusion, used for violence, patient on the verge of exploding).
5. 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.

• 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

• 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.

• 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)

• 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.

• 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?

• 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.

• There are primarily four issues:
• Involuntary commitment to mental hospitals.
• Protection for potential victims of a patient’s aggressive behavior.
• Maintenance of patient rights.
• Preservation of the rights of staff.
• Many states have started a requirement for the "least restrictive treatment alternative" à and use outpatient treatment settings whenever possible.
• Preventive commitment – refers to allowing outpatient treatment and inpatient treatment when needed à 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 à 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 à 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 à MH care providers can be held responsible if potential victims are not warned à and yes, you can face legal liability either way!

Reference:

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

ADDITIONAL NOTES: