Acting outis an immature defense mechanism
by which the person deals with emotional conflicts or
stressors through actions rather than through reflec-
tion or feelings. The person engages in acting-out be-
havior, such as verbal or physical aggression, to feel
temporarily less helpless or powerless. Children and
adolescents often “act out” when they cannot handle
intense feelings or deal with emotional conflict ver-
bally. To understand acting-out behaviors, it is im-
portant to consider the situation and the person’s abil-
ity to deal with feelings and emotions.
ETIOLOGY
Neurobiologic Theories
Researchers have examined the role of neurotransmit-
ters in aggression in animals and humans, but they
have been unable to identify a single cause. Findings
reveal that serotonin plays a major inhibitory role in
aggressive behavior; therefore, low serotonin levels
may lead to increased aggressive behavior. This find-
ing may be related to the anger attacks seen in some
clients with depression. In addition, increased activity
of dopamine and norepinephrine in the brain is asso-
ciated with increased impulsively violent behavior
(Kavoussi et al., 1997). Further, structural damage to
the limbic system and the frontal and temporal lobes
of the brain may alter the person’s ability to modulate
aggression; this can lead to aggressive behavior.
Psychosocial Theories
Infants and toddlers express themselves loudly and
intensely, which is normal for these stages of growth
and development. Temper tantrums are a common re-
sponse from toddlers whose wishes are not granted.
As a child matures, he or she is expected to develop
impulse control(the ability to delay gratification)
and socially appropriate behavior. Positive relation-
ships with parents, teachers, and peers; success in
school; and the ability to be responsible for one’s self
foster development of these qualities. Children in dys-
functional families with poor parenting, inconsistent
responses to the child’s behavior, and lower socio-
economic status are at increased risk of failing to
develop socially appropriate behavior; this lack of
development can result in a person who is impulsive,
easily frustrated, and prone to aggressive behavior.
CULTURAL CONSIDERATIONS
What a culture considers acceptable strongly influ-
ences the expression of anger. The nurse must be
aware of cultural norms to provide culturally compe-
tent care. In the United States, women traditionally
were not permitted to express anger openly and di-
rectly, because doing so would not be “feminine” and
would challenge male authority. That cultural norm
has changed slowly in the past 25 years. Some cul-
tures, such as Asian and Native American, see ex-
pressing anger as rude or disrespectful and avoid it at
all costs. In these cultures, trying to help a client ex-
press anger verbally to an authority figure would be
unacceptable.
Spector (2001) conducted a literature review to
study whether or not racial bias influences clinicians’
perceptions of patient dangerousness in Britain and
the United States. She found that clinicians generally
perceived patients with black skin (regardless of eth-
nicity or place of birth) as being more dangerous; this
bias influenced treatment decisions (e.g., more com-
pulsory hospitalizations, increased use of restraint
and seclusion).
Two culture-bound syndromes involve aggressive
behavior. Bouffée delirante,a condition observed in
West Africa and Haiti, is characterized by a sudden
outburst of agitated and aggressive behavior, marked
confusion, and psychomotor excitement. These epi-
sodes may include visual and auditory hallucinations
and paranoid ideation that resemble brief psychotic
episodes (Mezzich et al., 2000). Amokis a dissociative
episode characterized by a period of brooding followed
by an outburst of violent, aggressive, or homicidal be-
havior directed at other people and objects. This be-
havior is precipitated by a perceived slight or insult
and is seen only in men. Originally reported from
Malaysia, similar behavior patterns are seen in Laos,
the Philippines, Papua New Guinea, Polynesia (ca-
fard), Puerto Rico (mal de pelea), and among the
Navajo (iich’aa) (Mezzich et al., 2000).TREATMENT
The treatment of aggressive clients often focuses on
treating the underlying or comorbid psychiatric di-
agnosis such as schizophrenia or bipolar disorder.
Successful treatment of comorbid disorders results in
successful treatment of aggressive behavior. Lithium
has been effective in treating aggressive clients with
bipolar disorder, conduct disorders (in children), and
mental retardation. Carbamazepine (Tegretol) and
valproate (Depakote) are used to treat aggression
associated with dementia, psychosis, and personality
disorders. Atypical antipsychotic agents such as cloza-
pine (Clozaril), risperidone (Risperdal), and olanza-
pine (Zyprexa) have been effective in treating aggres-
sive clients with dementia, brain injury, mental
retardation, and personality disorders. Benzodiaze-
pines can reduce irritability and agitation in older
adults with dementia, but they can result in the loss
of social inhibition for other aggressive clients,
thereby increasing rather than reducing their aggres-
sion (Fava, 1997).10 ANGER, HOSTILITY, ANDAGGRESSION 195