24 - Anger

Question 1

Lecture objectives

Answer 1

The student will be able to describe, list, define, recognize, identify, or perform the following:

• Different types of patients that frustrate clinicians and how to work with them
• Psychiatric diagnoses that relate to anger
• Short and long-term consequences of anger

Question 2

Describe the basic anger data we have

Answer 2

• About 33% of community-dwelling adults report experiencing anger nearly every day
• About 75% of community adults report feeling annoyed multiple times a week
• About 10% of community adults report that their anger leads to physical violence (yelling, complaining, verbally attacking, or withdrawing were much more common)
• However, textbooks and the scientific literature focus far more on depression and anxiety than anger

Question 3

Define anger

Answer 3

A negative, phenomenological feeling state that motivates desires for actions, usually against others, that aim to warn, intimidate, control, or attack, or gain retribution.

• It is associated with cognitive distortions and errors (the doctor is running behind because she thinks her time is more important than mine)
• It is typically associated with physiological changes and culturally-conditioned patterns of behavior

Question 4

Define hostility

Answer 4

Negative beliefs or attitudes about individuals or groups that predispose anger and aggression.

Question 5

Define aggression

Answer 5

Physical behavior enacted with the intent to harm. May occur out of anger, but also from modeling, group pressure, or social/environmental conditions (e.g. war) when anger is not present.

Question 6

What does the DSM-5 say about anger?

Answer 6

Oddly little attention to anger compared with other aversive emotional states. Irritability appears in the criteria for several disorders, but there are few diagnoses available for when anger is the central complaint

Question 7

Describe Oppositional Defiant Disorder in the DSM-5

Answer 7

Oppositional Defiant Disorder (Disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence)

• Pattern of negativistic, hostile, and defiant behavior lasting at least 6 months
• Criteria are a mixture of feelings (e.g. often touchy or easily annoyed by others) and behaviors (e.g. often deliberately annoys people)

Question 8

Describe Conduct Disorder in the DSM-5

Answer 8

Conduct Disorder (Disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence)

• Repeated pattern of violating the basic rights of others or violating age appropriate societal norms (e.g. serious physical aggression, destruction of property, theft)
• No mention of anger in criteria

Question 9

Describe Intermittent Explosive Disorder in the DSM-5

Answer 9

Intermittent Explosive Disorder (found in Impulse-Control Disorders Not Elsewhere Classified)

• Repeated seriously assaultive acts (e.g. striking someone or verbally threatening assault) or intentional destruction of property
• Degree of aggressiveness grossly disproportionate to triggering event

Question 10

Describe Amok in the DSM-5

Answer 10

Amok (culture-bound syndrome traditionally found in southeast Asia)

• Single episode of acute, unrestrained violence
• Individual does not remember the episode

Question 11

Describe new DSM-5 characterization of Disruptive Mood Dysregulation Disorder

Answer 11

New in DSM-5, Disruptive Mood Dysregulation Disorder

• Characterized by severe, recurrent temper outbursts occurring 3 or more times a week
• Between temper outbursts, mood for most of the day, nearly every day is angry or irritable
• Diagnosis should not be made for the first time before age 6 or after age 18; onset of criteria should occur by age 10
• Created specifically to decrease diagnosis of Bipolar Disorder in children

Question 12

Describe the association between anger and Major Depressive Disorder (MDD)

Answer 12

Not specifically listed as a symptom of Major Depressive Disorder (MDD), but

• One study (Judd et al, 2013) found >50% prevalence of irritability in MDD patients
• Presence of anger/irritability may predict more severe and chronic illness and more comorbidity

Question 13

Describe comorbidities seen in angry patients

Answer 13

Disorders of anger can exist independently, but are also frequently comorbid with

• Other emotional disorders
• In particular, frequently co-occurs with anxiety disorders
• Possibly related to frustration when efforts to manage the anxiety are thwarted or someone does something that increases anxiety
• Personality disorders
• Substance abuse

Question 14

Describe “Trait Anger” in the trait vs. state anger concept

Answer 14

A trait is a relatively stable part of an individual’s personality. Individuals high in trait anger become angry easily with relatively little provocation. May:

• Express anger outwardly
• Hold it in (rumination, revenge fantasies)
• Try productive ways to reduce the anger

Question 15

Describe the “State Anger” in the trait vs. state anger concept

Answer 15

A state is a transient reaction to a current stressor or situation. An individual low in trait anger may become angry based on a significant provocation or a combination of situational vulnerabilities (e.g. ill, exhausted, fearful about limited financial resources) and a small provocation

Question 16

Describe the learning theory and anger in terms of short term effects

Answer 16

In the short term, anger is often reinforced

• The targeted individual may comply with the demand or stop the offending behavior
• The self-righteous quality to anger can also be self-reinforcing, as when an individual feels good about having made the offending party understand how wrong they were

Question 17

Describe the learning theory and anger in terms of long term effects

Answer 17

Longer-term effects are more often aversive

• Shame and guilt
• Increased health risks
• Poor decision-making
• Avoidance and rejection by others

Question 18

What is the effect of learning theory and anger?

Answer 18

This can make it more difficult to extinguish aggressive behavior, because intermittently reinforced behavior is harder to extinguish

Question 19

Describe the physiology of anger

Answer 19

• Anger increases epinephrine and norepinephrine levels
• Cardiovascular, endocrine, and limbic changes all occur. When activation is chronic, this is damaging to the body
• Type A personality (anger is central construct) increases risk for heart disease and stroke

Question 20

Describe the factors that increase the likelihood of an angry person acting out

Answer 20

• Presence of PTSD or other history of having been victimized
• Living in a restricted setting (e.g. prison or locked ward)
• A history of violent behavior
• Individuals with significant developmental delays or brain injury

Question 21

What are some common causes of dangerously disruptive behavior in patients

Answer 21

• Psychosis (may be psychiatric in origin or resulting from a brain lesion)
• Sociopathy
• Disinhibition (e.g. from substances or neurological impairment)
• Severe Anxiety
• Personality Disorder

Schizophrenics are far more likely to be the victims of violence than to act out themselves

Question 22

Describe the reasons we avoid angry people and patients

Answer 22

A variety of behaviors and beliefs associated with anger can make treatment more difficult:

• Verbal attacks
• Lack of desire for treatment of the anger (belief that the anger is morally justified reduces motivation for change)
• Perception that the issue is someone else’s fault
• Threats of physical violence

Question 23

Describe the steps in interacting with angry patients

Answer 23

• First step is to provide careful listening and empathy
• Remain calm and engaged yourself
• Determine the reason for the anger and address it to the extent possible
• If the patient becomes disruptive…

Focus on problem behaviors without blaming or avoiding the patient

 - Set clear, firm expectations, then enforce them consistently
- Seek consultation sooner rather than later from a mental health professional

Question 24

What patients are more likely to act out?

Answer 24

Patients who are...
H = hungry  
A = angry
L = lonely
T = tired

Question 25

Describe violence in psychiatric patients

Answer 25

• Psychiatric patients are more likely to be victims of violence than perpetrators
  
  • -> 2.5 times the likelihood of being attacked or raped than overall population risk
• Individuals with psychosis do have a higher likelihood of perpetrating violence than the general population, including homicide
  
  • -> This elevated risk is strongly mediated by substance abuse
• Psychiatric patients are more likely to engage in agitated, disorganized violence than premeditated violent acts
  
  • -> Individuals engaging in premeditated violence generally do not have a mental disorder with the exception of Antisocial PD

Question 26

Describe the types of difficult patients who can make clinicians angry

Answer 26

Groves’ (1978) four types of extremely difficult patients

• Dependent clingers
• Entitled demanders
• Manipulative help-rejectors
• Self-destructive deniers

Question 27

Describe dependent clingers

Answer 27

• View self as needy and physician as inexhaustible source of help and support
• Dependent, unreasonably demanding
• Inspires a desire to avoid
• Requires firm, tactful limits

Question 28

Describe entitled demanders

Answer 28

• Also needy, but use intimidation and guilt rather than flattery to acquire care
• Controlling, demanding, may threaten litigation
• Physician becomes fearful and wants to retaliate
• Strategy is to accept anger, then re-channel the entitlement into ways to obtain the good medical care they deserve

Question 29

Describe manipulative help rejecters

Answer 29

• Also have enormous need for care; however, believe that nothing can help
• Typically no treatment is effective, but patient keeps returning
• Creates guilt, depression and self-doubt in the physician
• Manage by explicitly stating that treatment may not be curative, but that regular follow-ups will be needed to maintain whatever gains are possible
• Be consistent, firm, and set appropriate limits

Question 30

Describe self-destructive deniers

Answer 30

• Engage in behavior that is clearly and imminently destructive (e.g. continuing to drink heavily despite esophageal varices)
• Inspires malice in the clinician
• Recognize without shame or self-blame that the extreme form of this patient inspires a wish that they would die and get it over with
• Treat depression if possible; recognize one’s own limits and provide treatment as with other terminal illnesses

Question 31

Describe how you can manage anger

Answer 31

Relaxation techniques

• Deep breathing
• Soothing Imagery
• Increased Body Awareness

Exercise
- But not “getting it out” by punching, screaming, etc. (which actually increases anger)

Changing thoughts to be calm and rational rather than emphasizing the nature and severity of the offense

Angry thoughts quickly become irrational. Try to focus on logic and perspective.

Question 32

Describe how to plan to manage anger

Answer 32

• Make a plan to address problems
• Focus on positive communication that identifies your own needs rather than attacking others’ behavior
• Listen to the other person and try to understand his/her perspective
• Take a break, go for a walk, try to see the lighter side of the situation