Causes of Aggression and Violence

1. Mental Health Conditions:

   • Hallucinations: Individuals may respond aggressively to commands or frightening perceptions experienced through auditory or visual hallucinations, acting in what they perceive as self-defense. For example, hearing voices that incite violence or misinterpreting healthcare staff as threatening figures.

   • Delusions: False beliefs, particularly persecutory delusions where individuals feel targeted or in danger, can trigger violent reactions as a perceived means of self-protection.

2. Involuntary Hospitalization: Being admitted to a mental health facility against one’s will can be a source of anger and potential aggression.

3. Forced Discharge: Patients experiencing institutional neurosis, who feel safer and more secure in a hospital setting, may react aggressively when compelled to leave and return to the community.

4. Coerced Procedures: Involuntary or forced medical procedures, such as Female Genital Mutilation (in contexts where this is relevant and forced), can be a major trigger for aggression and violence due to trauma and violation.

5. Sensory and Perceptual Disturbances: Experiencing delusions and hallucinations, especially auditory or visual types, can lead to agitated and potentially violent behavior as a reaction to distorted realities.

6. Epileptic States: The periods before (pre-ictal) or after (post-ictal) a seizure in epilepsy can sometimes be associated with confusion, agitation, and aggressive actions.

7. Inactivity and Boredom: Lack of stimulation and feeling idle, especially in a hospital ward setting, can contribute to frustration and increased irritability, potentially leading to aggression.

8. Repetitive Ward Routines: A monotonous and unchanging daily schedule on a ward can be a source of frustration and contribute to agitated behavior.

9. Unpleasant Environment: A ward environment that is perceived as unstimulating, unclean, or generally negative can heighten patient distress and increase the likelihood of aggression.

10. Provocation: Aggressive responses can be triggered by direct provocation from various sources including fellow patients, staff members, friends, or family.

11. Communication Deficits: Poor or absent communication between patients and staff can lead to misunderstandings, frustration, and escalate into aggressive behavior.

12. Non-Therapeutic Staff Interactions: Lack of empathy, neglect, or a poor nurse-patient relationship where staff are not providing therapeutic support can be a significant contributor to patient aggression.

13. Learned Behavior: Aggressive behavior can be acquired through observation and imitation of aggressive role models, such as friends or family members.

14. Genetic Predisposition: There may be a genetic component influencing a predisposition towards aggression in some individuals.

15. Hormonal Imbalances: Certain hormonal conditions, like Cushing’s disease (though hyperthyroidism was incorrectly mentioned in the original text, hormonal imbalances in general are relevant), can be associated with increased irritability and aggression.

16. Socioeconomic Factors: Individuals from impoverished families, lacking basic necessities, may experience heightened stress and frustration that can manifest as aggression.

17. Frustration: Feeling unable to achieve goals or resolve problems, leading to a sense of helplessness and anger, can be a major cause of aggression.

18. Impulsivity: A pre-existing pattern of impulsive behavior can increase the likelihood of aggressive reactions in various situations.

19. Medication Misinterpretation: If medication is administered against a patient’s will, they might misinterpret the intentions of family and caregivers, potentially leading to aggression towards them.

20. Substance Abuse: Alcohol and drug misuse significantly impair judgment and increase impulsivity, making aggressive and violent behavior more probable.

21. Stigma: Experiencing negative labeling and social stigma from the community or family can lead to feelings of anger, isolation, and reactive aggression as a response to societal rejection.

22. Lack of Support for Aftercare: Insufficient financial or logistical support for patients to attend follow-up appointments post-discharge, or neglect from family in ensuring continued care, can lead to relapse and potentially aggressive behavior.

23. Peer Influence: Association with peer groups where aggressive behavior is normalized or prevalent can reinforce and encourage aggressive tendencies.

Indicators of Violence and Aggression

• Restlessness and Agitation: Inability to remain still, pacing, general unease.

• Body Language: Tense posture, clenched fists, rigid movements, facial expressions of anger.

• Threats: Verbal or physical expressions of intent to harm oneself or others.

• Elevated Voice: Speaking loudly or shouting.

• Offensive Language: Using insults, swear words, or derogatory terms.

• Sleep Disturbance: Difficulty sleeping or changes in sleep patterns.

• Weapon-Seeking: Searching for or carrying objects that could be used to cause harm.

• Yelling: Loud vocalizations expressing anger or distress.

• Profanity: Use of obscene or offensive language.

• Argumentative Stance: Engaging in frequent disputes and disagreements.

• Harm Ideation: Expressing thoughts of harming or killing oneself or others.

• Panic Symptoms: Experiencing sudden episodes of intense fear and anxiety.

• Disordered Thinking: Exhibiting illogical or confused thought patterns.

• Suspiciousness: Displaying mistrust and paranoia towards others.

• Inappropriate Anger: Feeling angry in situations that do not typically warrant such emotion, or anger that is disproportionate to the situation.

• Unexplained Crying: Tearfulness without an apparent cause.

• Social Withdrawal: Isolating oneself and avoiding interaction with others.

• Temper Outbursts: Sudden and uncontrollable episodes of anger, potentially including physical actions.

• Provocative Behavior: Intentionally trying to irritate or annoy others.

• Negativistic Behavior: Resisting requests or doing the opposite of what is asked.

• Silence Due to Anger: Becoming withdrawn and non-communicative as a result of intense anger.

Management of Aggression and Violence

This is a Psychiatric Emergency.

Aims of Management:

1. Ensure the safety of the patient and others.

2. Provide treatment and ongoing monitoring for the patient.

Management Steps:

1. Admission and Safety Precautions:

   • Admit the patient to a secure, acute psychiatric ward.

   • Immediately remove any potentially harmful objects from the patient’s vicinity to create a safer environment.

   • Maintain a calm and composed demeanor when interacting with the patient to de-escalate the situation.

2. Comprehensive Assessment:

   • Conduct standard observations, including vital signs, and perform both general and specific psychiatric assessments.

   • Rule out or address any underlying physical illnesses that may be contributing to the aggression.

   • Thoroughly evaluate the patient’s current mental state.

   • Assess the immediate risk of violence and aggression, noting any indicators.

   • Investigate potential causes of the aggressive behavior. If identifiable, attempt to address or mitigate these factors.

3. Establish Therapeutic Alliance: Prioritize building a positive and trusting nurse-patient relationship as a foundation for effective intervention.

4. Procedure Transparency: If hospitalization is necessary, avoid sudden actions. Clearly explain all procedures to the patient beforehand, and reassure them regarding their safety and security within the environment.

5. Understanding Before Restraint: Before resorting to physical restraint or seclusion, healthcare professionals should strive to understand the underlying reasons for the patient’s aggression to address the root cause if possible.

6. Projecting Control: Communicate to the aggressive patient, both verbally and nonverbally, that you are in charge of the situation and capable of maintaining safety.

7. Welcoming Approach: Greet the patient upon arrival to the ward, addressing them by name to establish a personalized and respectful interaction.

8. Open Posture: Approach the patient with open hands and non-threatening body language to convey a sense of safety and approachability.

9. Verbal Engagement: Engage in conversation with the patient, actively listen to their responses, and adopt a firm yet kind and understanding tone.

10. Adequate Staffing: Ensure sufficient staff are present and readily available to assist if the patient’s aggression escalates, requiring physical intervention.

11. De-escalation Attempts: If the patient is physically restrained (e.g., chained – though this is generally not a recommended practice in modern psychiatric care), carefully remove restraints and closely observe the patient’s reaction to gauge their level of agitation.

12. Weapon Removal: Before approaching, ensure there are no weapons or dangerous items accessible to the patient. If present, calmly request the patient to place them on a table or floor.

13. Distraction Technique: Employ distraction tactics to divert the patient’s attention while other staff members discreetly position themselves to assist with restraint if needed.

14. Safe Restraint Procedures: During physical restraint, prioritize safety to prevent injury to both the patient and staff, and minimize damage to property.

15. Controlled Restraint Application: Approach the patient assertively and confidently. If resistance persists, swiftly and safely guide the patient to a bed or the floor for immobilization, ensuring proper technique.

16. Restraint Technique: When restraining, firmly but carefully hold joints and limbs to prevent fractures, dislocations, or other injuries.

17. Post-Restraint Assessment: After restraint, continuously monitor the patient’s level of aggression and violence. Engage in verbal de-escalation; ask the patient if they can commit to refraining from further aggressive behaviors.

18. Pharmacological Intervention: Administer sedative or tranquilizing medication, if available in injectable form, as prescribed (e.g., diazepam 10-20mg IM, as per medical order).

19. Seclusion (if necessary): If aggression persists despite initial interventions, place the patient in a side room (seclusion room). Clearly communicate the duration of seclusion to the patient.

20. Ongoing Monitoring and Sedation: Continue to observe the patient in seclusion for ongoing aggression or violence. If needed, repeat sedation as per medical orders and ongoing assessment.

21. Discharge Planning: Begin planning for the patient’s eventual release from seclusion and, ultimately, discharge from the hospital.

22. Behavioral Expectations: Gradually counsel the patient on avoiding aggression and violence in the future and strategies for managing or avoiding provoking situations.

23. Verbal Contract: Engage in a verbal contract with the patient, seeking their commitment to refrain from violence upon release into less restrictive settings.

24. Multidisciplinary Review: The clinical team should collaboratively discuss the patient’s prognosis, ongoing care needs, and future management strategies.

Management After Discharge (While at Home)

• Family Support: Encourage family members to provide ongoing emotional and practical support to the patient.

• Community Education: Educate the community about the harmful effects of stigmatizing individuals with mental health conditions.

• Family Education on Early Warning Signs: Educate relatives to recognize early indicators of escalating aggression and violence so they can intervene promptly.

• Emotional Regulation and Stress Management Skills: Teach the patient techniques for managing their emotions and coping with stress to reduce the likelihood of aggressive outbursts.

• Contingency Planning: Advise family members to seek immediate professional help and refer the patient back to healthcare services if aggressive or violent behavior re-emerges.

Nursing Care

• Non-Provocative Approach: Avoid touching the patient without explicit consent, especially when agitated, as this could be misinterpreted as threatening and escalate aggression.

• Behavioral Contract: Establish a verbal or written contract with the patient outlining expectations for non-violent behavior, fostering a sense of mutual understanding and responsibility.

• Anger Triggers Identification: Assist the patient in exploring and identifying the underlying causes and triggers of their anger to develop personalized coping strategies.

• Ignore Minor Provocations (Initially): If possible, initially disregard minor derogatory remarks made by the patient, avoiding escalation of conflict over trivial issues.

• Anger Diary: Encourage the patient to keep a record of their angry feelings, noting triggers, intensity, and how they were managed, to promote self-awareness and track progress.

• Continuous Observation: Maintain ongoing observation of the patient for signs of escalating anger and agitation to allow for timely intervention.

• Staff Availability: Ensure adequate staffing levels are maintained in anticipation of potential aggressive incidents to ensure safety and effective response.

• Emergency Response: If the patient becomes violent, immediately call for assistance, ensuring sufficient staff are present, and remove other patients from the immediate area to safeguard their well-being.

• Physical Restraint (If Necessary and as Last Resort):

  • Approach the patient from the front with open hands to signal non-threatening intent.

  • Address the patient by name when approaching to personalize the interaction and gain their attention.

  • Allow the patient to express their feelings verbally, actively listening to their concerns.

  • Prioritize safety during restraint: ensure neither patient nor staff are injured. Restraint should be implemented by trained staff, avoiding placing weight on the patient (e.g., sitting on them). Patients should not be involved in restraining other patients.

  • Avoid lifting the patient when transferring to a seclusion room; if possible, have the patient walk to the room with staff escort.

  • Seclude the patient for a specific, predetermined period. Clearly explain to the patient the reasons for seclusion and the goals of this intervention in managing their behavior.

  • Continuously monitor the patient in seclusion. If they calm down, consider gradual removal from seclusion. If agitation persists, continue seclusion along with prescribed treatments.

• Chemotherapy (Pharmacotherapy):

  • Administer prescribed medications to calm the patient. This may include tranquilizers such as chlorpromazine or haloperidol, and sedatives like diazepam (often administered intramuscularly in acute situations). Medication administration should always be as per medical prescription and protocol.

• Documentation: Thoroughly and accurately document all nursing care provided, including assessments, interventions, patient responses, and medication administration, for legal and continuity of care purposes.