Abuse Violence

NCM 117 (LEC)
MALADAPTIVE PATTERNS OF BEHAVIOR

HANDOUT
I. ABUSE AND VIOLENCE
I. INTRODUCTION
Violent behavior is a product of anger and aggression. Violence can happen anywhere and
publicly and the scope and its prevalence are expanding along with the increasing list of
terminologies to describe specific types of aggression. From road rage, air rage, desk rage and
ward rage (– violent confrontation occurring in a hospital setting). Rage can be a manifestation of
a pent up anger wherein at a given time when an individual can no longer hold or suppress that
anger might burst uncontrollably.
What is more disturbing is the violence which, due to the fear of social stigma, could be hidden
from public eye for a long time but could have serious health consequences for the individual,
family, and society – that is domestic violence and abuse in an intimate relationship.
Abuse and Violence encompasses all forms of injury and battering from physical, psychological,
financial and sexual abuse. It could be Intrafamilial or Extrafamilial as pictured out in the above
paragraph.
ANGER – a normal human emotion, a strong, uncomfortable, emotional response to a real or

perceived provocation results when a person is frustrated, hurt or afraid. Although anger is
normal, it is often perceived as a negative feeling. Anger can become negative when the person
denies it, suppresses it, or expresses it inappropriately
HOSTILITY AND AGGRESSION – anger expressed through verbal and physical behavior like
attack, assault and violence
VIOLENCE - the use of destructive action or force so as to injure, abuse, damage, or destroy
another person THE DISTANCE BETWEEN ANGER AND VIOLENCE IS VERY SLIM
Prepared by Prof. Amelia Z. Manaois for PLM College of Nursing to be used as Instructional Material only for the Lecture in Maladaptive
Patterns of Behavior. Refrain from reproducing this material without the consent of the preparer and the PLM-CN
Intra-Familial Abuse and Violence – Domestic Violence
• Violence perpetrated within the context of intimate relationship, between a husband and
a wife, a girlfriend and boyfriend, or gay or lesbian partners. It could be violence between
parents and children, adult children and elderly parents, or in between siblings.
Extra-Familial Abuse and Violence – an act of abuse and violence by anyone to anyone other
than relative
II. FACTORS CONTRIBUTING TO ABUSE AND VIOLENCE
A. Socio-cultural Factor:
1. The experience of violence in the family of origin teaches that the use of physical
force is appropriate and acceptable
2. Abused children grow up to become another abuser or another adult victim
3. Women are placed below or lower or weaker than men.
4. Men are stronger gender, reinforcing identity that a man has the power over
women
5. Men viewed their family as their possession.
B. Psycho-social Factors:
1. Self-esteem of the abused and abuser
2. Substance induced violent behavior
C. Physical Factors:
1. Poverty
2. Congestion of home
III. PSYCHOLOGICAL PROFILE OF AN ABUSIVE FAMILY MEMBER

A. Has a very low self esteem
B. No guilt
a. Impulsive, irrational, explosive, immature
b. Has history of abuse
c. Machismo
C. Jekyll and Hyde Syndrome
a. Project feeling of guilt and emotional dependency on wife but reverses when in
privacy
D. Paranoid, suspicious, extremely jealous, possessive
E. Obsessive-compulsive behavior
F. Substance dependent (alcohol or drugs)
G. Highly dependent
IV. CYCLE OF VIOLENCE
A. Tension Building Phase

Initially characterized by irritability followed by threatening, nagging, and tapping.
This stage can still be pacified.
B. Explosion or Acute Phase

“Battering Phase” where the actual abuse takes place causing deprivation of
individual rights. It is characterized by: hitting, scratching, kicking or throwing of
objects when women are involved in violent conflict with men. Men are likely to
push, shove, slap, beat up and even use weapons (guns, knife) against their
wives/partners.
C. Calm, loving and respite phase

“Honeymoon” phase
PHASES OF AGGRESSION CYCLE
1. Triggering Phase – Muscular tension

Changes in voice quality,
Pacing, Non-compliance
Restlessness, irritability, Glaring
2. Escalation phase –
Movement towards loss of control
3. Crisis Phase –
Full blown “acting out”. Fighting, hitting, kicking, scratching, throwing things
4. Recovery Phase – Cooling down
5. Post Crisis –
Client attempts reconciliation with others. Crying and apologies are evident. Quiet
and withdrawn behavior.
V. FORMS OF ABUSE AND VIOLENCE
A. Psychological Form
• Verbal threat of intimidation
• Threat with guns, knives or any lethal weapon
• Degrading or insulting words
• Public humiliation
• Nagging
• Accusation of infidelity
• Unfulfilled promises
• Prolonged silence in the presence of a conflict
• Siding with relatives
• Forcing to bear children / Forcing to have abortion
B. Physical Form
• Slapping
• Hitting with a fist or using an object to hit
• Head banging
• Choking
C. Economic/Financial
• Withdrawal of financial support
• Control over conjugal financial resources
• Control over earnings of survivor’s earnings
• Using/selling household properties in place of vices
D. Sexual Abuse – are both physical and psychological form of abuse
• Demanding sex regardless of partner’s condition
• Forcing to perform sexual acts that are unacceptable to the partner
• Forcing to watch performance and materials
• Inappropriate sexual behavior: instigated by an abuser whose purpose is sexual
arousal of a victim through exhibitionism, peeping and explicit sexual talk,
masturbation, sadism, masochism and intercourse.
• The key factor is “Lack of Consent”
TYPES OF RAPE:
Anger Rape:
Distinguished by physical violence and cruelty to the survivor. The abuser believes he
is the victim of an unjust society and takes revenge on others by raping. He uses
extreme force and viciousness to debase the survivor.
Power Rape:
The intent of the rapist is not to injure the victim but to command and master another
person sexually. The rapist has an insecure self-image and feelings of incompetence
and inadequacy. The rape is the vehicle for expressing power, potency and might .
Sadistic Rape:
Involves brutality. The use of bondage and torture is not an expression of anger but
necessary for the rapist’s sexual excitement. The assault is eroticized and is sexually
stimulating
VI. PSYCHODYNAMICS
A. Biologic Theories
• The neurophysiologic theory proposes that the limbic system, prefrontal cortex,
amygdala and the neuro-transmitters are implicated in violent behavior. An increase
in Norepinephrine, dopamine and serotonin increases irritability, and may result in
various type of aggression
• Substance abuse is often implicated
B. The Instinctivist Theory

Suggests that people possess a natural fighting instinct to preserve self-hood (ID)
C. Interpersonal theories
• Aggression is seen as a basic drive within the personality if threatened.
• Violence is the result of an inability to control the impulsive expression of anger and
hostility
a. Rejection
b. Obsessive-compulsive, jealous, suspicious, paranoid or sadistic
D. Social Learning Theory

• It proposes that violence is a learned behavior rather than an instinctive one. Both the
abuser and the survivor learn their roles during childhood
WHY STAY????
Fear for safety of the children
Lack of support system
Religious / socio-cultural belief
Financial reasons
Lack of community support service
Indulging with the “Honeymoon” phase of the cycle
VII. NURSING PROCESS
A. ASSESSMENT
ABUSER / AGGRESSOR
• Comprehensive history (previous acts of violence, comorbid disorders, past

triggers) and present coping skills
• Willingness and ability to learn alternative and nonviolent ways of handling angry
feelings
• Recognize predictors or signs and symptoms of tendencies
• Early Warning Signs / Symptoms

• Fire starting
• Cruelty to animals
• Bed wetting
• Socially isolated, outcast or withdrawn
• Emotions and behavior are easily influenced by peers
• Victimized or treated badly by peers
• History of assault and battery
• Immediate Warning:
• Possession of weapon in an inappropriate place
• Destructive, threatening, violent gestures or loud statements
• Verbalized directly or implied violent and destructive behavior
• NO WARNING AT ALL!!! – stone silence
• VARIABLES LEADING TO PATIENT AGGRESSION

*Hospital Setting
• Transmission of nurse’s fear and anxiety to patient
• Excessive stimuli – overcrowding
• Excessive or unfair restrictions of rights and privileges
• Lack of resources for excessive energy
• Patient’s perception of lack of control of life and freedom
• Boredom – Lack of structured and unstructured activities
• Hallucinations
• Manipulative behavior
ABUSED / SURVIVOR
• Abused children maybe retarded in the areas of growth and development.
• Survivors of all ages may have any combinations of the following:
o Bruised or swollen eyes
o Petechia or hematoma
o Bald patches
o Burns or scars of past injuries on the skin, genitals and rectal areas
o Fractures or evidence of previous fractures, particularly of the arms and ribs
o Dislocated joints
o Intraabdominal injuries, especially to pregnant women
o Paresthesia or numbness
o Rape or Sexually abused:
o Irritated or swollen genitals or rectal tissues
o Presence of STD
o Some become pregnant
o Loss of social interaction outside family boundaries
o Loss of appetite/loss of weight
o Psychophysiologic Responses
o Anxiety (Recurrent nightmares: PTSD)
o Depression
B. NURSING DIAGNOSIS
PATIENT – VIOLENT AND AGGRESSIVE

1. Risk for other-directed violence
2. Risk for self-directed violence
3. Ineffective coping (overwhelmed or maladaptive)
4. Stress overload
5. Impaired impulse control
PATIENT – ABUSED (SURVIVOR)

1. Risk for suicide
2. Risk for infection
3. Rape trauma syndrome
4. Anxiety, Fear, Hopelessness, Powerlessness
5. Situational and Chronic Low-self esteem
6. Ineffective individual coping
7. Dysfunctional family process
8. Impaired parenting
9. Disabled family coping
10. Ineffective role performance
C. PLANNING / IMPLEMENTATION OF CARE
PATIENT – VIOLENT / AGGRESSIVE

1. Matter of Fact Attitude Therapy
2. Avoid invading personal space
3. Avoid arguing, Give clear instructions
4. Do not take chances in going alone with the patient
5. Use of Seclusion and Restraints, prn
6. Psychotherapies
7. Pharmacotherapies (Benzodiazepines and Antipsychotics)
PATIENT – ABUSED (SURVIVOR)

1. Primary Intervention
• Promote parent child bonding
• Increase awareness on abuse and violence through information dissemination
• Reducing stress and influence of risk factors
• Increasing coping skills and self-esteem
• Social support: Inform – referral of family at risk
• Inform forms of protection (Law)
R.A. 9262 – Violence Against Women and their Children
R.A. 7610 – Special Protection Against Child Abuse, Exploitation and
Discrimination
R.A. 7877 – Sexual Harassment
R.A. 8505 – Assistance and Protection for Rape Victim
2. Secondary Intervention
• Identify family stressors
• Identify clues of child and adult abuse
• Community involvement: Refer family to authorized institutions (DSWD)
• Crisis intervention
• Support and supervision
3. Tertiary
• Mental Health Setting Rehab of survivors:
Crisis Intervention: Grounding Technique (for clients with Flashbacks)
Counseling
Family therapy
Attitude therapy
Group therapy
Socialization
Pharmacotherapy
D. EVALUATION OF CARE
Evaluation of the care plan is essential for patients who are potentially angry and
aggressive and for patients who underwent a violent experience. A well-considered plan
has specific outcome criteria that will serve as a guide to future implementation or revision
of the plan of care if needed. Evaluation may reveal that the patient’s agitation has
improved or at least decreased to some extent.
Sample Desired Outcome for Aggressive / Violent Patient

Signs and Symptoms Nursing Diagnosis Outcomes
Body language (rigid posture, clenching of Risk for other- Identifies when angry, identifies
fists and jaw, hyperactivity, pacing), history directed violence alternatives to aggression,
of violence, history of family violence, refrains from verbal outbursts,
history of substance use avoids violating others’ personal
space, maintains self-control
Impulsivity, suicidal ideation (has plan, Risk for self- Expresses feelings, verbalizes
ability to carry it out), overt or covert directed violence suicidal ideas, refrains from
statements regarding killing self, feelings of suicide attempts, plans for the
worthlessness, hopelessness, helplessness future
Difficulty with simple tasks, inability to Ineffective coping Identifies ineffective and
function at previous level, poor problem effective coping, uses support
solving, poor cognitive functioning, system, uses new coping
verbalizations of inability to cope strategies, engages in personal
actions to manage stressors
effectively
Demonstrates feelings of anger, reports Stress overload Expresses feelings

feelings of pressure, tension, difficulty in constructively, reports feelings
functioning, of calmness and acceptance;
impatience; experiences negative impact physical symptoms of stress are
from stress; reports problems with decision reduced or absent; decision
making making is optimal
Considerations for Staff Safety (we do need to protect ourselves too)
There are six basic considerations for ensuring safety:

1. Avoid wearing dangling earrings, necklaces, and scarves in acute care environments.
2. Ensure that there is enough staff for backup. Only one person should talk to the patient,
but staff need to maintain an unobtrusive presence in case the situation escalates.
3. Always know the layout of the area.
4. Do not stand directly in front of the patient or in front of the doorway. The patient may
consider this position as confrontational.
5. Do not turn your back. Patient should always be visible and have enough distance for
observing behaviors
6. If a patient’s behavior begins to escalate, provide feedback: “You seem to be very upset.”
7. Avoid confrontation with the patient
Sample Desired Outcome for Family Violence

Signs and Symptoms Nursing Diagnosis Outcomes
History of abuse, history of violence, Risk for violence Family members remain free of
substance use harm
Bruises, cuts, broken bones, lacerations, Pain Timely treatment of injuries,

scars, burns, wounds in various phases of healing of physical injuries,
healing, vaginal-anal bruises, sores, absence of pain, protection from
discharge, peritoneal pain further injuries
Risk for infection
Restlessness, scanning, vigilance, Fear Absence of behavioral

uncertainty, isolation, fear, depression, manifestations of anxiety,
feelings of helplessness, decreased control reports a decrease in anxiety,
over environment, abuse reports feeling safe, expresses
Powerlessness expectations of a positive future,
sets goals
References:
• Margaret Jordan Halter, Varcaroli’s Foundations of Psychiatric-Mental Health Nursing,
8th edition, 2018
• Shiela L. Videbeck, Psychiatric Mental Health Nursing 5th edition 2011.

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NCM 117 (LEC)

MALADAPTIVE PATTERNS OF BEHAVIOR

I. ABUSE AND VIOLENCE

ANGER – a normal human emotion, a strong, uncomfortable, emotional response to a real or

II. FACTORS CONTRIBUTING TO ABUSE AND VIOLENCE

III. PSYCHOLOGICAL PROFILE OF AN ABUSIVE FAMILY MEMBER

IV. CYCLE OF VIOLENCE

A. Tension Building Phase

B. Explosion or Acute Phase

C. Calm, loving and respite phase

PHASES OF AGGRESSION CYCLE

1. Triggering Phase – Muscular tension

V. FORMS OF ABUSE AND VIOLENCE

B. The Instinctivist Theory

D. Social Learning Theory

VII. NURSING PROCESS

• Comprehensive history (previous acts of violence, comorbid disorders, past

• Recognize predictors or signs and symptoms of tendencies

• Early Warning Signs / Symptoms

• VARIABLES LEADING TO PATIENT AGGRESSION

PATIENT – VIOLENT AND AGGRESSIVE

PATIENT – ABUSED (SURVIVOR)

C. PLANNING / IMPLEMENTATION OF CARE

PATIENT – VIOLENT / AGGRESSIVE

PATIENT – ABUSED (SURVIVOR)

Sample Desired Outcome for Aggressive / Violent Patient

Demonstrates feelings of anger, reports Stress overload Expresses feelings

Considerations for Staff Safety (we do need to protect ourselves too)

There are six basic considerations for ensuring safety:

Sample Desired Outcome for Family Violence

Bruises, cuts, broken bones, lacerations, Pain Timely treatment of injuries,

Restlessness, scanning, vigilance, Fear Absence of behavioral

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