interventions during the triggering and escalation
phases are key to preventing physically aggressive
behavior (discussed below).RELATED DISORDERS
The media gives a great deal of attention to people
with mental illness who commit aggressive acts. This
gives the general public the mistaken idea that most
people with mental illness are aggressive and should
be feared. In reality, clients with psychiatric disor-
ders are much more likely to hurt themselves than
other people.
Although most clients with psychiatric disorders
are not aggressive (Shepherd & Lavender, 1999),
clients with a variety of psychiatric diagnoses can ex-
hibit angry, hostile, and aggressive behavior. Clients
with paranoid delusions may believe others are out
to get them; believing they are protecting themselves,
they will retaliate with hostility or aggression. Some
clients have auditory hallucinations that command
them to hurt others. Aggressive behavior also is seen
in clients with dementia, delirium, head injuries, in-
toxication with alcohol or other drugs, and antisocial
and borderline personality disorders.
Fava and Rosenbaum (1999) reported that about
40% of clients with major depression have anger at-
tacks. These sudden, intense spells of anger typically
occur in situations in which the depressed person feels
emotionally trapped. Anger attacks involve verbal ex-
pressions of anger or rage but no physical aggression.
Clients described these anger attacks as uncharac-
teristic behavior that was inappropriate for the situ-
ation and was followed by remorse. The anger attacks
seen in some depressed clients may be related to irri-
table mood, overreaction to minor annoyances, and de-
creased coping abilities (Fava & Rosenbaum, 1999).
Intermittent explosive disorder is a rare psychi-
atric diagnosis characterized by discrete episodes of
aggressive impulses that result in serious assaults
or destruction of property. The aggressive behavior
the person displays is grossly disproportionate to any
provocation or precipitating factor. This diagnosis is
made only if the client has no other comorbid psychi-
atric disorders, as discussed above. The person de-
scribes a period of tension or arousal that the aggres-
sive outburst seems to relieve. Afterward, however,
the person is remorseful and embarrassed, and there
are no signs of aggressiveness between episodes (Burt
& Katzman, 2000). Intermittent explosive disorder de-
velops between late adolescence and the third decade
of life (American Psychiatric Association [APA], 2000).
Burt and Katzman noted that clients with intermit-
tent explosive disorder typically are large men with
dependent personality features who respond to feel-
ings of uselessness or ineffectiveness with violent
outbursts.194 Unit 3 CURRENTSOCIAL ANDEMOTIONALCONCERNS
confused with suppressing angry feelings, which can
lead to the problems described earlier.
Anger suppression is especially common in
women (Davila, 1999) who have been socialized to
maintain and enhance relationships with others and
to avoid the expression of so-called negative or unfem-
inine emotions such as anger. Manifestations of anger
suppression through somatic complaints and psycho-
logical problems are more common among women than
men. Davila suggests that women must recognize that
anger awareness and expression are necessary for
their growth and development.
Hostility and Aggression
Hostile and aggressive behavior can be sudden and
unexpected. Often, however, stages or phases can be
identified in aggressive incidents: a triggering phase,
an escalation phase, a crisis phase, a recovery phase,
and a postcrisis phase. These phases and their signs,
symptoms, and behaviors are discussed later in the
chapter.
As a client’s behavior escalates toward the crisis
phase, he or she loses the ability to perceive events
accurately, solve problems, express feelings appro-
priately, or control his or her behavior; behavior es-
calation may lead to physical aggression. Therefore,
Assertive communication