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A Two-Factor Model of Aggression

Steven J. Kingsbury, Michael T. Lambert & William Hendrickse

To cite this article: Steven J. Kingsbury, Michael T. Lambert & William Hendrickse (1997) A Two-
Factor Model of Aggression, Psychiatry, 60:3, 224-232, DOI: 10.1080/00332747.1997.11024800

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Published online: 28 Sep 2016.

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A Two-Factor Model of Aggression

Steven J. Kingsbury, Michael T. Lambert, and William Hendrickse
THIS article synthesizes theoretical material from psychology research into a
practical model for conceptualizing violence in psychiatric settings. Relevant
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research and theory are reviewed, focusing on two important behavioral mod-
els of aggressive behavior, hostile aggression and instrumental aggression. The
concepts of reinforcement, anticipated rewards, specific and nonspecific stimu-
lus-driven aggression, intermediary emotional states in aroused persons, and
the aggression stimulus threshold are developed into a bimodal model applica-
ble to the clinical management of violence. The model provides a broad frame-
work for categorizing, understanding, and addressing aggressive behavior in
clinical settings.

Violence is a major public health con- tors attempting to cover all instances of
cern in our country and is particularly rel- violence (Crain 1979a, Crain 1979b; Dubin
evant in the specialty of psychiatry, 1981; Eichelman 1988; Monopolis and
where understanding the causes of vio- Lion 1985; O'Shanick 1984; Rada 1981;
lence and the management of aggressive Slaby 1994). These approaches are valu-
behavior is critical. Although violence able, but they minimize organizing princi-
may not be more common in psychiatric ples and may create overly broad formulas
atients than the general population, ag- for developing interventions. These dis-
gresslOn IS a pro em m many psyc la rIc cusslons al 0 a ess e un er ymg 1-
settings where the risk of patient-on-staff mensions of different types of violent be-
assault is well documented (Hatti et al. haviors.
1982; Madden et al. 1976; Thackrey and We present a two-factor model of ag-
Bobbit 1990). gression developed from psychological
Practical suggestions for the pharmaco- theory and research. The model can help
logical and psychosocial management of clinicians categorize and understand the
violence and aggression exist, but there is determinants and potential management
surprisingly little discussion in the psy- strategies employed to control aggressive
chiatric literature of principles or theory. behaviors. Mental health clinicians, edu-
Strategies are categorized by diagnosis or cators, and researchers contending with
by listing multiple possible etiological fac- the problem of aggression need a frame-

Steven J. Kingsbury, MD, PhD. is a staff psychiatrist/psychologist at the Dallas Veterans Affairs Medi-
cal Center and Assistant Professor in the Departments of Psychiatry and Psychology at the University of
Texas Southwestern Medical Center at Dallas. TX.
Michael T. Lambert, MD. is Medical Director of the Mental Health Service at the Dallas Veterans Af-
fairs Medical Center and Assistant Professor in the Department of Psychiatry at the University of Texas
Southwestern Medical Center at Dallas. TX.
William Hendrickse, MD. is a staff psychiatrist at the Dallas Veterans Affairs Medical Center and Assis-
tant Professor in the Department of Psychiatry at the University of Texas Southwestern Medical Center at
Dallas. TX.
Address correspondence to: Steven J. Kingsbury. M.D .• Ph.D .• Dallas VAMC. U6A. 4500 South Lan-
caster Ave .• Dallas. TX 75216.

224 PSYCHIATRY, Vol. 60. Fall 1997

 AGGRESSION

work for discussion. This paradigm com- son ai, social, and biological components
pliments existing biological, psychologi- of aggression. Freud conceptualized ag-
cal, and sociological research of violence, gression and libido as the basic drive
without minimizing the importance of states (Freud 1920/1959, Stepansky 1977).
specific diagnoses or other psychiatric for- Hull emphasized operationalizing concepts
mulations that explain or intervene in ag- and systematic research of the compo-
gression. nents of aggressive drive (Dollard et al.
1939), leading to revisions of the drive for-
mulation (Berkowitz 1969) that stimu-
DEFINITIONS AND BACKGROUND lated the development of alternative mod-
els not based on drive theory (Bandura
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Most modern definitions of aggression 1973; Baron 1977; Buss 1961; Tedeschi et
contain several elements. First, aggres- al. 1974). The two behavioral psychology
sion is conceptualized as overtly destruc- paradigms we will develop into our bi-
tive behavior. Therefore, a thought or modal model evolved from the work of so-
dream with aggressive content would not cial psychologists.
be considered aggression. Second, the Models appeared from other traditions,
goal, intent, or purpose of the behavior is such as the ethological (Lorenz 1969), the
to cause injury or harm to another living sociological (Toch 1969), and the biologi-
being (Baron 1977; Berkowitz 1962; Dol- cal (Moyer 1981; Volavka 1995). Several
lard et al. 1939). Behavior that acciden- extensive reviews of aggression theory
tally causes harm is not considered ag- are available (Baron and Richardson 1994;
gression. Similarly, assertive behavior, Buss 1961; Felson and Tedeschi 1993;
such as presenting one's position, is not Huesmann 1994). Unfortunately, cross-
categorized as aggression (Bandura 1973). fertilization of thought between schools
Some definitions stipulate that aggres- has been sporadic, and each of the models
sion must be behavior that is not socially has developed its own classification
sanctioned, whereas other definitions in- system.
clude destruction of property, if the intent Although aggression models have been
is to affect the owner (Bandura 1973; Zill- applied to many problems, such as the ef- ;
-,----
I mann 1979). Using these defiiiitlo"ns, exe- fects of television violence (Geen 1976; ~"
I cuting a convicted murderer would not be Feshbach and Singer 1971), and racial '
aggression, but destroying a rival's impor- violence (Donnerstein and Donnerstein
tant papers would be. 1976), there has been little direct applica-
We use the definition of aggression as tion to clinical problems in psychiatry. We
"behavior directed toward the goal of har- start with an overview and synthesis of
ming or injuring another living being who concepts that we will develop into a prac-
is motivated to avoid such treatment" tical two-factor model intended for use in
(Baron 1977, p. 7). The term aggression is the clinical consideration of aggression.
commonly used in psychology studies,
whereas the term violence is frequently
used in the psychiatric literature. We will Two AGGRESSION MODELS FROM
use the terms synonomously here. Trau- SOCIAL PSYCHOLOGY
matization and victimization, which refer
to the sequellae of aggression, and sui- Aggression is typically discussed in two
cidal and self-destructive behaviors will forms, instrumental aggression and hos-
not be discussed in this article. tile aggression (Aronson 1992). These two
Aggression research and related theo- types of aggression are often studied in
retical work have evolved from an initial pure form (Baron and Richardson 1994),
focus on aggression as an innate drive but most discussions acknowledge that
state to more behaviorally oriented learn- many displays of aggression have ele-
ing models that recognize reinforcers and ments of both types. Any discussion of ag-
cues, as well as the contextual, interper- gression needs to account for both forms

PSYCHIATRY, Vol. 50, Fall 1997 225

 KINGSBURY ET AL.

as well as the interaction of the two forms jects, and Park et al. (1972) found that so-
of aggression. Zillmann (1979) described cial reinforcement of verbal aggression
instrumental aggression as incentive- subsequently generalized to greater phys-
motivated behavior and hostile aggres- ical aggression in the form of shocks ad-
sion as annoyance-motivated behavior. ministered. Social reinforcement of aggres-
sion occurs in mob and gang situations,
but it can also be operational in the milieu
Instrumental Aggression
of some psychiatric treatment settings.
Instrumental aggression is best under- A deficit in the ability to experience or
stood by the principles of operant con- anticipate remorse or the aversive out-
ditioning, where the probability of ag- comes that come as a consequence of
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gression is increased by prior history of .aggression increases the risk of instru-

subsequent reward or reinforcement (Hol- mental aggression (Guerra et al. 1994;
land and Skinner 1961; Reynolds 1968; Volavka 1995). This appears to be the case
Skinner 1969). Instrumental aggressive in aggressive individuals with antisocial
behavior is encouraged by the presence of personality disorder who have difficulty
stimuli that increase the expectation of a anticipating and experiencing negative
positive outcome from the behavior feelings of remorse or guilt (Hare 1970).
(Reynolds 1968). Aggression in organic brain syndromes
Instrumental aggression is harmful be- and inebriated individuals may in part be
havior driven by the expectation of rein- mediated by a similar deficit.
forcement at a time following the behav-
ior. Anticipated consequences or rewards
therefore control instrumental aggres- Hostile Aggression
sion. Instrumental aggression can be Unlike instrumental aggression, hostile
viewed as a means to an end. An impor- aggression has the specific goal of harm-
tant feature of instrumental behavior is ing another (Buss 1961). Hostile aggres-
that the actual removal of the apparent re- sion is usually associated with a state of
ward may not immediately eliminate the heightened arousal or excessive stimula-
behavior because it is the internalized as- tion that facilitates aggressive behavior.
soclatlon of oenavlOr·-ana: rewarQ-uure~-stlIfiwtthat increas~ the chance of hostile
leads to the aggression. aggressive behavior are associated with
There is a difference between Skinner's central nervous system arousal (Zillmann
model of operant conditioning (Skinner 1979), or an impaired ability to suppress
1969), in which behavior is understood to stimulated arousal and aggression (disin-
be a consequence of the probability and hibition). A variety of specific and non-
schedule of reinforcement, and Bandura's specific cues encourage hostile aggression
(1977) cognitive social learning theory. (Geen and Berkowitz 1966; Geen and
Skinner specifically eliminated cognitions, Stonner 1971). For example, Berkowitz
including expectations, as controlling stirn- and LePage (1967) demonstrated that the
uli from his model whereas Bandura's presence of a gun led to more aggression
approach gave this special emphasis. Ac- in study subjects than when the cue was
knowledging a role of conscious cognition not present. Hostile aggression is facili-
recognizes that the expected consequences tated by intermediary affective states
of the behavior can determine the behav- such as rage or frustration.
ior more than the consequences that aetu- Because of the cue- and arousal-based
ally follow the behavior (Bandura 1977). aspects of this form of aggression, respon-
The social context of reinforcement is dent conditioning is an important compo-
important in this component of aggres- nent of hostile aggression (Berkowitz
sion. Geen and Stonner (1971) found that 1969, 1988). Negative reinforcement, the
social reinforcement led to increased ad- goal of eliminating the annoyance, may
ministration of electrical shocks by sub- also contribute to hostile aggression, and

226 PSYCHIATRY, Vol. 60, Fall 1997

 AGGRESSION

inflicting pain may be positively reinforc- ior. The attack some battered women
ing (Bandura 1973; Eron 1994). Moyer make on abusive mates after years of en-
(1983) postulated aggression-modulating trapment (the "burning bed syndrome")
brain neural systems that fire in the pres- (Megargee 1966) exemplifies this, but for
ence of certain stimuli, resulting in hostile some individuals :relatively low levels of
feelings and aggressive behavior. Exam- stimulation may result in frustration and
ples of hostile aggression include un- aggression depending on how it is inter-
planned crimes of passion (such as assault preted (Zillmann 1988).
after an insult) and aggression in manic, Provocative insults or personal attacks
stimulant-intoxicated, or other psychotic act as powerful interpersonal cues that in-
patients, especially after perceived slights crease the chance of hostile aggression
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or insults. (Berkowitz 1989; Taylor 1967). Although

Because arousal at some level is ubiqui- this type of provocation could trigger hos-
tous yet stimulation-based aggression is tile aggression in many persons, certain
relatively rare even with provocation, a individuals are vulnerable to specific cues
threshold must exist at which the level of arising from their unique personal experi-
arousal facilitates aggression and de- ence, which would not facilitate aggres-
creases cognitive mediation (Berkowitz sion in most people.
1994). Conditions that lower the theoreti- Strenuous activity involved in acting
cal stimulus threshold, such as inebria- on instrumental aggression may increase
tion, delirium, or depression, could be as- arousal and further increase the risk of ag-
sociated with this form of stimulus driven gression through a cue-based mechanism.
aggression. This allows the model to inte- This illustrates one mechanism by which
grate both environmental and biological instrumental and hostile aggression may
variables that modulate the probability of interact synergistically. Similarly, aggres-
hostile aggression (Doob and Kirshen- sion mediated by anger may result in re-
baum 1973; Zillmann 1988). wards such as compliments about one's
Physiological arousal is an important toughness, again showing the interrelate-
component in the expression of hostile ag- dness of these two forms of aggression.
gression. Exercise (Zillmann et a!. 1972), To summarize, aggression ma be con-
e ,nOIse on- cep ua ze as e resu t 0 mstrumental
nerstein and Wilson 1976; Geen and Mc- and hostile factors or as an interaction of
Cown 1984), and sexual stimuli (Zillmann the two factors. Instrumental aggression
and Sapolsky 1977) increase general arous- is encouraged by expected reinforcements
al, facilitating hostile aggression under separate from inflicting harm. In hostile
the proPer conditions. Many psychiatric aggression, hyperarousal brought on by a
conditions bring a component of height- variety of stimuli leads to anger, fear, or
ened arousal associated with the disease frustration as mediating states that en-
process itself. courage the discharge of arousal through
Intermediary affective states such as aggressive behavior, especially when envi-
rage, fear, or extreme frustration are im- ronmental or interpersonal cues exist.
portant in hostile aggression. Anger Some aggressive individuals respond at
(rage) isthe most reliable elicitor of hostile low thresholds to a variety of nonspecific
aggression (Taylor 1967). Arousal also stimulatory mechanisms that they inter-
acts through fear when the individual pret as aggressive cues, whereas others
takes the fight option of the flight-or-fight have particular vulnerabilities to specific
response to perceived danger (Berkowitz types of stimuli.
1988; Monopolis and Lion 1985). Paranoid
individuals respond to arousal created by CLINICAL ApPLICATIONS
fear of a delusional threat. Extreme frus-
tration is another secondary affective Regardless of the various presentations
state associated with aggressive behav- of clinically significant aggressive behav-

PSYCHIATRY, Vol. 60, Fall 1997 227

 KINGSBURY ET AL.

ior, all violence involves elements of in- euphoria associated with patients being
strumental aggression, hostile aggres- medicated with benzodiazepines ordered
sion, or some combination of both. This "pm for agitation." The aggressive out-
provides a framework for thinking about bursts stop when the medication is changed
the determinants of violence, allowing the to a less pleasurable (rewarding) agent or is
task of understanding causes and inter- given in regularly scheduled doses (remov-
ventions to be rational and systematic. ing the contingent relationship of the be-
In psychiatric situations that may even- havior and the reinfocement).
tuate in aggression, the clinician should Persons with personality disorders of-
determine how violent behavior previous- ten fail to consider the negative effects of
ly led to some expected or real reinforce- aggression, focusing instead on the antici-
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ment. This is true whether the patient is pated rewards of instrumental aggressive
intoxicated, paranoid, antisocial, or af- behavior. An important component of sup-
fected by other transitory or enduring portive psychotherapy with such individ-
states. The clinician must also attend to uals is helping the patient to anticipate
factors that increase the patient's general the full range of consequences of behav-
arousal level, leading to the patient's ex- iors, hopefully to more appropriate choices.
periencing the situation as provoking or
frustrating, and be sensitive to cues that
might precipitate violent behavior. Clinical Vignette: Management of
Attention to the same two factors are Instrumental Aggression
necessary when treating aggressive indi- Mr. B is a 43-year-old white male with
viduals. Interventions may be grouped chronic, treatment refractory paranoid
into those interventions that decrease the schizophrenia and a long history of ag-
associated rewards for acting aggres- gressive and intimidating behavior. Hav-
sively and those that decrease the pa- ing spent years in and out of inpatient
tient's level of arousal, anger, and frustra- facilities, he was entered into an intensive
tion. As mentioned above, this does not case management program designed to
replace the need to systematically diag- both aid his transition back into the com-
nose the determin~ts of aggre~sion. How- munity and minimize hospitalization. He
ever, by keeping in mind these factors, the tenuou8ryaaapted to community livmg~~-·---~
clinician is able to group causes of vio- and frequently tried to return to the hospi-
lence as to whether reinfocement, arousal! tal. He found the inpatient unit to be ex-
anger, or both are operative. Further dis- tremely rewarding because of the attention
cussion will illustrate the value of this or- from nursing staff, food, and the social con-
ganizational schema. tact from staff and other patients.
During a visit with his social worker
case manager, Mr. B requested hospital-
Clinical Implications of ization. When the social worker tried to
Instrumental Aggression explore his reasons, he deliberately ap-
Managing instrumental aggression de- proached her and struck her in the face
pends on understanding the reinforcers and ribs. As she ran out of the room to get
that have been associated with aggressive help, Mr. B calmly remained behind in the
behavior, including consequences the per- examining room. When help came, Mr. B
petrator expects from the hostile act. Re- quietly held out his arms to receive an in-
moving reinforcement and changing the jection and willingly walked with multiple
expectation of rewards decrease the ex- escorts to an inpatient seclusion room. He
pression of instrumental aggression. did not require restraints and had no ag-
In clinical settings, instrumental fac- gressive episodes during this hospitaliza-
tors can play an important role in aggres- tion. He was calm throughout the episode,
sive behavior. For example, on inpatient and his admitting urine toxicology screen
units we see aggression reinforced by the was negative for any drugs of abuse.

228 PSYCHIATRY, Vol. 60, Fall 1997

 AGGRESSION

The social worker was unhurt but dis- crease arousal and the application of in-
turbed by what she perceived as her in- terventions that reduce arousal or which
ability to have predicted the attack. She raise the threshold of responding aggres-
stated that Mr. B had not seemed upset, sively to arousing stimuli. As mentioned
angry, or unusually animated. He seemed above, a number of acute and chronic psy-
to attack calmly and then stop, which she chiatric conditions are marked by ex-
felt was unlike her experience in emer- treme stimulation. Alcohol withdrawal,
gency settings. Later, the patient stated stimulant intoxication, mania, psychosis,
that he had not felt angry at the social and post traumatic stress disorder (PTSD)
worker. are frequently accompanied by arousal de-
This incident is usefully conceptualized rived from the illness itself. Some individ-
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using an instrumental aggression para- uals may have unique vulnerabilities to

digm in which the aggressive behavior certain stimuli based on previous learning
was emitted with the expected reward of experiences. For example, Vietnam com-
admission to the hospital. A history of bat veterans may be peculiarly suscepti-
past aggression and intimidation sug- ble to combat-related stimuli that further
gested that this was his method for seek- increase arousal. It follows that inter-
ing his goal of hospitalization. Aggression ventions that diminish this autonomic
against the social worker was a means to stimulation state would be useful in the
that end. management of hostile aggression. Benzo-
Subsequent management of Mr. B's ag- diazepines and antipsychotics are effec-
gression improved by appreciating what tive short-term antiaggressive medica-
Mr. B valued about hospitalization, un- tions that acutely decrease the arousal
derstanding the determinants of his ag- state (Dubin 1981; Eichelman 1988).
gression, and instituting similar reinforce- Environmental manipulation can de-
ments in the community setting. Staff crease the degree of arousal a patient ex-
realized that the goals of the case manage- periences. A quiet, calm environment
ment program were different from Mr. B's with adequate personal space and com-
goals. A functional analysis of the re- fortable appointments can help in decreas-
wards that the patient expected from the ing arousal. Interpersonal interactions
nrlU sa- can a so mo u a e arousa - IVen anger
lishing similar reinforcements in the out- responses, as demonstrated by the finding
patient setting. These alternate reinforce- that nurses with a more empathic style
ments included meal tickets, social activities, elicited less anger in impulsive patients
scheduled phone calls, and friendly visit- (Lancee et al. 1995). Including the pa-
ing by case management staff. tient's input and appreciating the patient's
Mr. B's history of intermittent rein- perspective are important interpersonal
forcement (admissions) for aggressive and maneuvers that can modulate arousal and
intimidating behavior suggested that sim- avoid intermediary affective states of
ply blocking admission could lead to an es- rage and frustration.
calation of aggressive behavior during the In addition to decreasing stimulation
extinction period. During this period the from internal and external sources, a
patient was not interviewed alone. Over number of strategies attempt to raise the
time, the reinforcing alternatives to hospi- theoretical threshold at which aggression
talization allowed the patient's care to ap- occurs. Antipsychotic and sedative medi-
propriately occur in the community. cations may have some minimal effect on
stimulus threshold in addition to their
calming effect, possibly acting through
Clinical Implications of dopaminergic and gamma aminobutyric
Hostile Aggression acid (GABA) systems (Eichelman 1988;
Management of hostile aggression re- Volovka 1995). Lithium, carbamazepine,
lies on an understanding of factors that in- clonidine, and propranolol are antiaggres-

PSYCHIATRY, Vol. 60, Fall 1997 229

L _ _ _ ___________ ~ ~ ______ ~_~ ____________ ~_~ _ _ _ _ _-

 ,~---------------------~~-----~----- -----------_._. -._--_._-----_.--

KINGSBURY ET AL.
sive agents that may affect the stimulus large right adrenal medulla tumor, a pheo-
threshold. The antiaggressive effect is not chromocytoma, was found and soon re-
immediate, as seen in medications that are sected.
decreasing stimulation acutely, but ap- The crescendo of arousal episodes and
pears gradually over a period of days or aggressive behavior dramatically ceased
weeks. after the surgery. The arousal from the
Psychosocial interventions such as ag- epinephrine released by the tumor had
gression management training, behavior clearly been facilitating aggression when
modification, and supportive psychother- coupled with the stimulation provided by
apy can be conceptualized as attempts to the intrusive component of the PTSD. The
raise the threshold at which stimulation patient's vulnerability to arousal"based
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based aggression is expressed (Moyer aggression was used in subsequent psy-

1969). chotherapy to help him recognize and
avoid situations that created hyperarrou-
sal. Medications that dampen sympa-
thetic tone, including the beta blocker pro-
Clinical Vignette: Management pranolol, were helpful in suppressing the
of Hostile Aggression arousal state that led to his aggressive
Mr. W, a divorced African American outbursts (Lambert 1992).
male, was 43 years old when he was admit-
ted for episodes of extreme agitation and
violence. He had a history of combat-
related PTSD and a history of attacking SUMMARY AND CONCLUSIONS
his first wife when extremely disturbed by
intrusive flashbacks. He admitted to a Aggression, and interventions intended
history of violence to others that he to manage aggression, may be organized
clearly related to periods of extreme using the concepts of instrumental and
arousal when his PTSD symptoms wors- hostile aggression. In many situations
ened and noted that the frequency of the both factors operate concurrently or even
episodes. had been .increasing over the last synergistically. Understanding reinforce-
yt:uCo .[Link] ug~n::;"".vu w UIS 11t:vt:r , I11t:11LIS WIU rt:wurulS,.' _..~
and he was always remorseful afterward. to specific and nonspecific stimuli, inter-
When aroused, he stated he felt as tense mediary emotional states in aroused per-
as he had in life-or-death combat situa- sons, and the concept of an aggression
tions in Vietnam. Certain provocations, stimulus threshold should be useful to cli-
such as references to Vietnam veterans as nicians who work with violent or aggres-
"baby killers," always acted as triggers for sive patients.
attacks w4en he was in a decompensated Past history is always a helpful pre-
state. He was aware of his vulnerability to dictor of future behaviors (Feshbach
arousal and felt that alcohol kept him 1994), but clinicians must frequently rap-
calm and less likely to act aggressively. idly assess and intervene with violent pa-
During the admission, periods of auto- tients with little or no background infor-
nomic hyperactivity were noted, with ele- mation available. This fact emphasizes
vated blood pressure and pulse. The epi- the need for clinicians to have a schema to
sodes were marked by extreme irritability guide their course of action. Inferences
and threatening behavior. He punched a may be made from an examination of the
hole through a wall on one such occasion patient's present mental state and obser-
and physically threatened staff on an- vation of current behaviors rather than on
other. After alcohol withdrawal was ruled past diagnoses or investigations that may
out, the continued episodes led to consid- not be available. This two-factor model
eration of medical problems that might provides a schema' by which clinicians
cause periods of autonomic arousal. A may develop strategies for intervening as

230 PSYCHIATRY, Vol. 60, Fall 1997

I
 AGGRESSION

well as for teaching about the causes and 1987). This model could improve commu-
the management of violence in the clinical nication between disciplines when dis-
setting. cussing the pragmatic application of ag-
In their training, the various mental gression theory to clinical situations,
health disciplines emphasize different providing clinicians, educators, and ad-
conceptual models regarding a number of ministrators a framework from which to
issues, including violence, and tend to discuss causes of violence and interven-
speak separate languages (Kingsbury tions to manage aggressive behaviors.

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