Onset and Clinical Course

ONSET AND CLINICAL COURSE

Anger

Although anger is normal, it often is perceived as a nega-tive feeling. Many people are not comfortable expressing anger directly. Nevertheless, anger can be a normal and healthy reaction when situations or circumstances are unfair or unjust, personal rights are not respected, or real-istic expectations are not met. If the person can express his or her anger assertively, problem-solving or conflict reso-lution is possible.

Anger becomes negative when the person denies it, suppresses it, or expresses it inappropriately. A person may deny or suppress (i.e., hold in) angry feelings if he or she is uncomfortable expressing anger. Possible consequences are physical problems such as migraine headaches, ulcers, or coronary artery disease and emotional problems such as depression and low self-esteem.

Anger that is expressed inappropriately can lead to hos-tility and aggression. The nurse can help clients express anger appropriately by serving as a model and by role-playing assertive communication techniques. Assertive communication uses “I” statements that express feelings and are specific to the situation, for example, “I feel angry when you interrupt me,” or “I am angry that you changed the work schedule without talking to me.” Statements such as these allow appropriate expression of anger and can lead to productive problem-solving discussions and reduced anger.

Some people try to express their angry feelings by engaging in aggressive but safe activities such as hitting a punching bag or yelling. Such activities, called catharsis, are supposed to provide a release for anger. However, catharsis can increase rather than alleviate angry feelings. Therefore, cathartic activities may be contraindicated for angry clients. Activities that are not aggressive, such as walking or talking with another person, are more likely to be effective in decreasing anger (Jacob & Pelham, 2005).

Shapiro (2005) reported that high hostility is associated with increased risk for coronary artery disease and hyper-tension. Hostility can lead to angry outbursts that are not effective for anger expression. Effective methods of anger expression, such as using assertive communication, to express anger should replace angry aggressive outbursts of temper such as yelling or throwing things. Controlling one’s temper or managing anger effectively should not be confused with suppressing angry feelings, which can lead to the problems described earlier.

Anger suppression is especially common in women, who have been socialized to maintain and enhance relationships with others and to avoid the expression of so-called nega-tive or unfeminine emotions such as anger. Women’s anger often results when people deny them power or resources, treat them unjustly, or behave irresponsibly toward them. School-age girls report experiences of disrespect, dismissal, and denial of the right to express anger (van-Daalen-Smith, 2008). The offenders are not strangers, but are usually their closest intimates. Manifestations of anger suppression through somatic complaints and psychological problems are more common among women than men. 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 unex-pected. Often, however, stages or phases can be identified in aggressive incidents: a triggering phase (incident or situation that initiates an aggressive response), an escala-tion phase, a crisis phase, a recovery phase, and a postcri-sis phase.

As a client’s behavior escalates toward the crisis phase, he or she loses the ability to perceive events accurately, solve problems, express feelings appropriately, or control his or her behavior; behavior escalation may lead to physi-cal aggression. Therefore, interventions during the trigger-ing and escalation phases are key to preventing physically aggressive behavior (discussion to follow).