aggression TOPIC RELATED TO, ANGER FORENSIC NURSING ,

AGGREION

1. Is aggression defined by behaviours that cause harm? For example: hitting, pushing versus verbal threats Is aggression defined by the outcome of behaviour? For example: Successful versus unsuccessful attempts to aggress Or does aggression reside in the intentions of the aggressor? For example: Harm cause by accident versus harm caused by intent

2. Derived  from  the word  aggress means   "unprovoked attack”(1610). Behavior that results in personal injury or destruction of property (Bandura, 1973) Behaviour between members of the same species intended to cause pain or harm( (Scherer et al, 1975) The intentional infliction of some form of harm on others (Baron & Byrne, 2000) Behaviour that involves threat or action that potentially or actually causes pain, withdrawal, or loss of resources.

3. VIOLENCE - extreme, unjustifiable aggression, usually violating social sanctions and causing destruction. It is used almost exclusively to describe human behaviour. Violence is physically or psychologically harmful human aggression that involves the threat or use of force. All violence is aggression, but many instances of aggression are not violent.

4. Instrumental aggression is rational and calculated Aggression is used by the individual in order to maximize personal gains

5. Emotional aggression is reactive and impulsive Aggression is driven by feelings (e.g., anger), often in the absence of a rational cost-benefit analysis

6. SANCTIONED VERSUS NONSANCTIONED AGGRESSION Every society classifies aggression into its own socially acceptable and unacceptable categories Socially sanctioned aggression, depending on culture, might include rough and tumble play, hunting, police or intelligence service actions, capital punishment, or war. Socially prohibited aggression in most cultures includes criminal assault, rape, homicide, parenticide, infanticide, child abuse, domestic violence, torture, civil disturbance, and terrorism. These distinctions are not absolute

7. HYPOAROUSAL- VERSUS HYPERAROUSAL-RELATED AGGRESSION Many individuals who exhibit psychopathic traits—including nonsanctioned aggression, lack of respect for the rights of others, cruelty, lack of remorse, and lack of empathy—have been found to have lower-than-usual resting heart rates and less autonomic reactivity. This has led to a classification distinguishing such hypoarousal -related aggression from the aggression seen in anxiety disorders, mania, or stimulant intoxication, which is called hyperarousal related.

8. Proactive versus Reactive Aggression The modern literature on human aggression usually applies a different typology. PROACTIVE AGGRESSION (instrumental ,planned, premeditated, cold-blooded, or predatory aggression) A ctor initiates the aggression against a target without immediate provocation. It is atypical in psychiatric emergencies. REACTIVE AGGRESSION (Hostile, affective, defensive, hot-blooded, or impulsive aggression ) in the sense that the actor is responding to a threat. This is characteristic of violence seen in psychiatric emergencies

9. EXPRESSION OF ANGER Directed Toward Others (Physical aggression verbal abuse Directed Inwards(Self Destruction) Well Controlled (Positive Expression)

10. EMOTIONAL PHYSICAL MENTAL SPIRITUAL Anger Negative Effect

11. Age- Violence peaks in the late teens and early 20s Sex - Males more than females in general populations; among people with mental disorders males and females don’t significantly differ in their base rates of aggression. Social class- three times as likely in lower socio economic class than in the higher. I.Q .- Inversely proportional to violence

12. History of substance abuse- Substance abuse tripled the rate of violence in the non patients in the community and increased the rate of violence by discharged patients by up to 5 times Education - Less education Employment- Lack of sustained employment Residential instability- Homeless mentally ill commit 35 times more crimes than domiciled mentally ill( Martell et al , 1995 ) Diagnosis - The higher the number of psychiatric diagnoses, the greater the rate of aggression.

13. During the roughly 5600 years of recorded history, there have been over 14,400 wars Humans are one of the few species that systematically kills members of its own kind In short, aggression is an important social problem. Studying the causes of aggression might suggest strategies for reducing aggression in society.

14. Freud (1930) argued that human aggressions stems from a ‘ Death Instinct ’: This destructive energy builds up inside us and eventually spills out in the form of violence against others or against the self Lorenz (1966) adapted Darwin’s theory of evolution and the principle of survival of the fittest: He argued that the ‘ Fighting Instinct ’ is inherent and necessary for survival Freud LORENZ

15. Limbic System Amygdala, Hippocampus Formation, Septum Hypothalamus Frontal Lobe

16. Two neuroanatomical networks, one primarily subcortical, the other primarily cortical, with both intersecting in the amygdala—appear to account for processing of human aggression in the brain. SUBCORTICAL CIRCUIT LOOP supports communication among the amygdala, the hypothalamus, the nucleus accumbens/septal region and the brainstem. The amygdala receives sensory input via the thalamus and the cortex and assesses whether this is an aggression-provocative stimulus. Connections with the brainstem, hypothalamus, and septal area integrate arousal, serotonergic status, autonomic status. The amygdalar signal for an aggressive response tendency is passed via the looping stria terminalis to the NAc and the VM hypothalamus

17. CORTICAL CIRCUIT LOOP The amygdala is simultaneously communicating with the cortex. Highly processed sensory information about potentially aggression-provocative stimuli travel from association regions such as the inferior parietal lobule to reach both the amygdala and the VMPFC. These regions assess the threat, opportunity, social significance. This assessment is crucial to developing a good motor plan adjusted via connections with the anterior cingulate gyrus and DLPFC. When the system is working well, a person makes rapid, appropriate, survival-critical evaluations of the circumstances, his or her brain juggling largely unconscious information with conscious awareness, and acts accordingly, for instance, by fighting or fleeing.

18. Virtually every amine neurotransmitter and many peptide and steroid hormones play a role in the cerebral mediation of aggression Still following questions are unanswered: Are ideal subtypes of aggression are mediated by different transmitters? What physiological processes—such as increased or decreased transmission, activation of pre- versus postsynaptic receptors, transporter function, or gene expression—account for observed correlations between levels of neurochemicals and behaviour? The answers to these questions are necessary for best guesses about likely treatments for subtypes of aggression and for rational drug discovery.

19. SEROTONIN : Low serotonergic function are more common in impulsive aggression. These findings have led to simplistic conclusion that serotonin is an aggression damper. Risperidone actually have more antagonist effect at 5-HT 2A than at D 2 receptors and useful in decreasing aggression. NOREPINEPHRINE AND EPINEPHRINE: PERIPHERAL AROUSAL FUNCTION : Helps to face a threat such as an anticipated fight via sympathetic nervous system activation, adaptive changes in cardiovascular status. The effects of NE on aggression may be mediated to some degree by its effect on corticotropin-releasing factor (CRF) and steroid hormone metabolism. α-2 agonists such as clonidine decreases aggression in hyperactive or autistic children.

20. DOPAMINE : Mesocorticolimbic arm of the DA system, is involved in regulation of aggression. DA activity appears to play an indirect, permissive role. One theory is that aggression is often intrinsically rewarding. In the absence of DA stimulation of reward centers, motivation for aggression is decreased. GABA: GABAergic transmission paradoxically increases aggression. Benzodiazepines—which positively affect GABA A reception—sometimes make humans angry and aggressive. Animal studies of this phenomenon show that low doses of benzodiazepines increase whereas higher doses decrease aggression.

21. TESTOSTERONE: Influence of testosterone on overt aggression depends both on fetal and pubertal brain exposure. Rough correlations are found between testosterone levels and aggression, high testosterone is probably more predictive of dominance seeking and dominance winning than of violence. Finally, testosterone hardly acts in isolation. We are just beginning to uncover neurochemical interactions that help to explain the role of this hormone in inappropriate aggression . CORTISOL : Chronically low salivary cortisol levels are associated with disruptive, aggressive behavior in boys. Decreased cortisol levels have also been reported in adolescent girls with conduct disorder. Yet not all findings are consistent with this low-cortisol–aggression association

22. Cognitive Neoassociation Theory Berkowitz (1993) has proposed that aversive events such as frustrations, provocations, loud noises, uncomfortable temperatures, and unpleasant odors produce negative affect. Negative affect automatically stimulates various thoughts, memories, expressive motor reactions, and physiological responses associated with both fight and flight tendencies The fight associations give rise to rudimentary feelings of anger, whereas the flight associations give rise to rudimentary feelings of fear Cognitive neoassociation theory not only subsumes the earlier frustration-aggression hypothesis (Dollard et al. 1939), but it also provides a causal mechanism for explaining why aversive events increase aggressive inclinations, i.e., via negative affect

23. Social Learning Theory According to social learning theories (Bandura  2001), people acquire aggressive responses the same way they acquire other complex forms of social behavior—either by direct experience or by observing others. It explains the acquisition of aggressive behaviors, via observational learning processes and provides a useful set of concepts for understanding and describing the beliefs and expectations that guide social behavior.

24. Social Interaction Theory Social interaction theory (Felson 1994) interprets aggressive behavior (or coercive actions) as social influence behaviour, i.e., an actor uses coercive actions to produce some change in the target's behaviour.   Coercive actions can be used by an actor to obtain something of value (e.g., information, money, goods, sex, services, safety) to bring about desired social and self identities (e.g., toughness, competence)  This theory provides an excellent way to understand recent findings that aggression is often the result of threats to high self-esteem

25. Excitation Transfer Theory This theory suggests that arousal from one situation can be transferred to another situation .  If two arousing events are separated by a short amount of time, arousal from the first event may be misattributed to the second event. If the second event is related to anger, then the additional arousal should make the person even angrier .

26. Frustration Does not always lead to some form of aggression Aggression does not always result from frustration.. However, it can elicit aggression when the cause of the frustration is viewed as illegitimate or unjustified. Provocation Physical or verbal provocation is one of the main causes of aggression. People tend to reciprocate with the same or slightly higher level of aggression that they receive from others. Condescension, the expression of arrogance is a strong predictor of aggression Heightened arousal Arousal in one situation can increase aggression in response to provocation, frustration, etc. in another, unrelated situation

27. Exposure to Media Violence May be a factor that contributes to high levels of violence in countries where it is viewed by many people This is supported by short-term laboratory experiments and longitudinal studies. It can prime aggressive thoughts and lead to a hostile expectation bias that others will behave aggressively, which causes individuals to act more aggressively Violent Pornography Can increase the likelihood that men will aggress against women Can desensitize people to victims of sexual violence

28. Narcissism The holding of an over-inflated view of one’s virtues or abilities. ‘Type A’ personality (drive to achieve, time urgency, competitiveness, and hostility) is associated with: higher aggression in competitive tasks (Carver & Glass, 1978) greater likelihood to engage in child abuse (Strube et al., 1984) greater conflict with peers in workplace (Baron, 1989). Hostile attributional bias: The tendency to attribute hostile intentions to others (Graham et al., 1992)

29. Situational Determinants of Aggression Alcohol Intoxication facilitates aggression by impairing cognitive processing, narrows attention Result is more extreme, less moderated behavior Aggressive response : often powerful and simple Inhibiting response : often weaker and more complex

30. There is no single answer (… sorry). Theories have been proposed at all levels of analysis: biology individual personality specific situations broader cultural norms and values

31. Aggression is likely to be the outcome of a complex process that involves multiple factors Biological process related to arousal and the experience of emotion. Individual differences in the interpretation of incoming information. Situational cues that exacerbate hostility or trigger an aggressive response. Norms and values about what is and is not appropriate.

32. Impulsive (rapid, thoughtless, aggressive acts) 2. Affective instability (affectively charged attacks with seemingly little provocation) 3. Anxiety/hyperarousal (overwhelming anxiety and frustration leading to aggressive outbursts)

33. I. The failure to resist and impulse, drive, or temptation, resulting in rapid, unplanned reactions to internal and external stimuli. A. Inability to delay reward where the individual is unable to modify his or her behaviour according to the context of the situation or to reflect on the consequences of the behaviour, thus impairing judgment. B. Underestimated sense of harm or lack of regard of the negative consequences. II. Impulsive aggressive disorder is defined as recurrent incidents of physical or verbal aggression that are out of proportion to the circumstances, occur at least twice a week for more than one month and lead to marked distress and impairment.

34. I. Emotional regulation is described as the ability to manage arousal or to modulate the intensity of emotional reactions. A. Emotional regulation develops biologically and dysregulation is common to several disorders: 1. Bipolar patterns 2. Developmental disorders like autism spectrum disorders.

35. II. Affective instability is emotional dysregulation expressed as exaggerated reactions to negative or frustrating stimuli, which may result in rage or aggression. A. In children and adolescents affective instability usually occurs rapidly and is highly reactive. III. Affective instability may be combined with impulsivity to result in risky and aggressive behaviour, but the two do not describe the same phenomenon; a person can be impulsive with or without the aggressive component. A. Pure impulsive aggression has no identifiable precedent, seemingly coming out of the blue. B. Affective aggression usually happens rapidly and may seem impulsive, but is differentiated by the preceding rush of affect, resulting in “hot tempered” aggression Both affective instability and impulsivity are related to poor attention, attention shifting, and verbal self-control.

36. I. Anxiety is an emotional response linked to a threatening stimulus, even in the absence of direct danger. II. Anxiety may be considered part of a normal response until it becomes excessive or difficult to tolerate, resulting in overstimulation. III. As coping tolerance is exceeded, the anxious hyperarousal may precipitate decompensation and disorganization, resulting in poorly directed aggression towards self or others, sleep disturbances, irritability, difficulty concentrating, hypervigilance.

37. PSYCHOSIS Schizophrenia, particularly paranoid schizophrenia patients, may be at risk, especially in the active phases of their illness to commit violent acts. General risk factors for violence in such patients include: Presence of hallucinations, delusions, or bizarre behaviors (paranoid patients with delusions may be at a higher risk to commit a violent act because of their ability to plan and their retention of some reality testing) Substance abuse Presence of neurological impairment Being male, poor, unskilled, uneducated, or unmarried

38. PERSONALITY DISORDERS Traits associated with aggression are ( Nestor , 2002): Impulsivity Low frustration tolerance Inability to tolerate criticism Tendency to have superficial relationships and to dehumanize others Failure to accept responsibility for one’s actions Cold, lack of empathy Lack of remorse

39. Dementia Impaired executive functioning Increased agitation Sometimes hallucinations and/or delusions Mania More likely to be assaultive without prior threat although often respond violently to any limit setting 26% of patients with mania attack someone within the first 24 hours of hospitalization Depression Despair, in rare cases could lead to striking out against other people Murder-suicide is suicidal within 1 week of a homicide; in couples it is highly associated with jealousy (Felthous et al, 1995) The individual can no longer endure a life without what is perceived to be a vital element (e.g., a spouse, family, job, health) but can’t bear the thought of the other persons carrying on without him, so he forces the others to joint him in death. Suicidal mother hence, should always be asked about her children.

40. DISSOCIATIVE DISORDER PTSD CEREBROVASCULAR DISEASE TRAUMATIC BRAIN INJURY EPILEPSY

41. Alcohol Cocaine Methamphetamine Anabolic Steroids Phencyclidine

42. Aggression is among the most common reasons for psychiatric referral of children and adolescents. 60 percent of referrals to outpatient child psychiatric clinics explicitly for evaluation and treatment of aggression. Disorders frequently associated with aggression are Mental Retardation (MR) Autistic Disorder Pervasive Developmental Disorder Attention-Deficit/Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder (ODD) Conduct Disorder (CD).

43. Non pharmacological Pharmacological

44. NON-PHARMACOLOGICAL

45. Medications are often used to manage agitated behavior These include : Antipsychotics (eg Risperidone, olanzapine, clozapine) Benzodiazepines (eg lorazepam) Mood stabilizers(eg lithium, valproate, and carbamazepine ) Antidepressants (eg SSRIs ) Anxiolytics Beta-adrenergic blockers, in particular propranolol.

46. Acute behavioural disturbance can occur in the context of psychiatric illness, physical illness, substance abuse, or personality disorders etc. Doctor’s primary goal in the emergency situation : violence risk assessment to keep the patient safe to arrive at rapid stabilization and disposition of the patient

47. STEP 1 : To de-escalate acute aggression : Assess the environment for potential dangers (eg, objects that can be thrown or used as a weapon). Take verbal threats seriously. Remain several feet away to avoid crowding the patient. Clear the area of other patients. Remain calm, maintain a confident and competent demeanor, and attempt to deescalate by engaging the patient in conversation. Avoid arguments between staff members in front of the patient. If restraints are necessary, have at least 4 people available

48. STEP 2: Offer oral treatment A regular antipsychotic(olanzapine, haloperidol) /lorazepam 1-2 mg. STEP 3: Consider IM treatment Lorazepam 1–2 mg/Promethazine 50 mg/Olanzapine 10 mg/Haloperidol 5 mg Repeat after 30–60 min if insufficient effect STEP 4: IV treatment Diazepam 10 mg over at least 5 minutes. Repeat after 5–10 minutes if insufficient effect (up to 3 times)

49. NONPHARMACOLOGICAL INTERVENTIONS: Comparatively less effective Combination of group-based cognitive skill training with a stepwise system of rewards for target behaviours may be useful . B. PHARMACOLOGICAL INTERVENTIONS: Atypical agents have been more effective than typical agents in reducing aggression. Clozapine is postulated to have a specific antiaggressive benefit But risks of clozapine to bone marrow may outweigh its possible superiority as an antiaggression treatment A provisional treatment recommendation is that risperidone may be a useful first choice. If it fails olanzapine or even clozapine may be used. It is unclear whether concomitant antidepressant or mood-stabilizing therapy will boost the antiaggressive benefit in schizoaffective patients

50. (A)Nonpharmacological Interventions: Transference-focused psychotherapy may be beneficial. (B)Pharmacological interventions Aggressive BPD patients with prominent affective disturbance may benefit from mood stabilizers( e.g. divalproex sodium ) Those with prominent idiosyncratic thoughts, especially paranoia, may do better with antipsychotics.

51. (A)Nonpharmacological Interventions: The benefits of nonpharmacological therapies depend on the level of cognitive decline. Unfortunately by the time aggression is a significant problem, most patients have lost the ability to follow the nonpharmacological methods. Structured activities, music therapy, and even aromatherapy have been reported to reduce agitation (B)Pharmacological Interventions: Atypical antipsychotic agents are the most prescribed medications. Low-dose risperidone and olanzapine are the best-supported choices

52. (A)Nonpharmacological Interventions: Higher-functioning patients may significantly benefit from CBT, supportive, or insight-oriented psychotherapy. Behavioral modification methods helpful for patients with poor cognitive outcomes . (B)Pharmacological Interventions: A useful provisional treatment recommendation is that for reactive/impulsive aggression or irritability after TBI propranolol in doses beginning at 10 mg twice a day is a reasonable first choice.

53. Nonpharmacological Interventions are less effective. Most commonly used drug is risperidone. Mood stabilizers such as Divalproex sodium, carbamazepine , Lithium etc may be useful. α- adrenergic agonist clonidine Stimulants

54. The link between brain activity and human aggression is a promising area of current and future research, both in terms of understanding those brain structures that are implicated in aggressive responding (e.g., Weber et al., 2006) and in terms of the effects of internal and external triggers on neural responses and how these relate to aggression (e.g., Bartholow et al., 2006). A related area of work that holds considerable promise for vastly improving our ability to predict who will be violent under what circumstances is behavioural genetics .

55. Researchers are beginning to discover variations in the regulation of neurochemicals linked to aggression and variations that ultimately have genetic causes and that can be targeted for pharmacological and behavioral interventions to reduce their influence on the expression of aggressive behaviour (e.g., See et al., 2008). A third promising research direction is apology and forgiveness (e.g., McCullough, 2008). Hopefully social psychologists will be at the forefront, conducting research on these and other important topics that ultimately have the potential to make the world a less violent, more peaceful place

56. MEASUREMENT OF ANGER EXPRESSION

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