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 real-ity, clients with psychiatric disorders are much more likely to hurt themselves than other people.
Although most clients with psychiatric disorders are not aggressive, clients with a variety of psychiatric diagnoses can exhibit angry, hostile, and aggressive behavior. Clients with paranoid delusions may believe others are out to get them; believing they are protecting themselves, they retali-ate with hostility or aggression. Some clients have auditory hallucinations that command them to hurt others. Aggres-sive behavior also is seen in clients with dementia, delir-ium, head injuries, intoxication with alcohol or other drugs, and antisocial and borderline personality disorders. Violent patients tend to be more symptomatic, have poorer functioning, and a marked lack of insight compared with nonviolent patients (Dolan & Davies, 2006).
Some clients with depression have anger attacks. These sudden intense spells of anger typically occur in situations in which the depressed person feels emotionally trapped. Anger attacks involve verbal expressions of anger or rage but no physical aggression. Clients describe these anger attacks as uncharacteristic behavior that is inappropriate for the situation and followed by remorse. The anger attacks seen in some depressed clients may be related to irritable mood, overreaction to minor annoyances, and decreased coping abilities (Akiskal, 2005).
Intermittent explosive disorder is a rare psychiatric 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 precipi-tating factor. This diagnosis is made only if the client has no other comorbid psychiatric disorders, as previously discussed. The person describes a period of tension or arousal that the aggressive outburst seems to relieve. Afterward, however, the person is remorseful and embar-rassed, and there are no signs of aggressiveness between episodes (Greenberg, 2005). Intermittent explosive dis-order develops between late adolescence and the third decade of life (American Psychiatric Association, 2000). Clients with intermittent explosive disorder typically are large men with dependent personality features who respond to feelings of uselessness or ineffectiveness with violent outbursts.
Acting out is an immature defense mechanism by which the person deals with emotional conflicts or stressors through actions rather than through reflection or feelings. The person engages in acting-out behavior, 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 verbally. To understand acting-out behaviors, it is important to consider the situation and the person’s ability to deal with feelings and emotions.