Resolution, Not Conflict

The guide to problem-solving.

Madness! What Emotional Disorder Was Omitted from the DSM V?

What pervasive cognitive/emotional/behavioral disorder was left out of the new diagnostic manual for emotional disorders? Here's some hints: What emotion most frequently gets you in trouble? What behavior of others most quickly leads to your wanting to avoid them? Read More

Madness!

Susan,
This is a thoughtful and well written article. I am sure you are aware that the American Psychological Associaton has fought for the inclusion of anger as disease entity both in the DSM 4 and 5. It is the Group for the Advancement of Psychiatry that determines what is and what is not included in the DSM.

Unfortunately, anger is not a popular research topic and is rarely included in the training or internships available for any of the mental health disciplines.

Thank you George. I had not been aware...

Thank you George for this information. I had not been aware that APA has been battling the Psychiatry group in this issue.

My hunch is that the dearth of research on anger is related to its not being a diagnosable entity. Does research money flow more when a problem has been legitimized via the DSM?

Fortunately, research is happening on borderline disorders, which are essential anger disorders. Research on the role of the amygdala in excessive emotional reactivity looks especially promising.

In our offices we have treatments that bring down the settings on the amygdala. The results have been impressive, but we're not set up to do scientific studies. We just help individual clients.

Blog Post on Anger as a Mental Illness

The writer is correct that anger is not listed as a mental disorder in either DSM-IV or DSM-5. That's because it is not a disorder--it's a normal human emotion that some people may have trouble regulating, but everyone is capable of feeling from time to time. The DSM-5 has been attacked far and wide for allegedly "medicalizing" normal human emotions, and now it is being criticized for not doing so. I am surprised that Dr. Heitler does not seem to know that the DSM exists to help diagnose bonafide mental disorders based upon the latest science. Nevertheless, there are numerous disorders that may be characterized by inappropriate or uncontrollable anger, so the DSM does not ignore anger as a potentially destructive emotion. It just doesn't say that anger in and of itself is a mental disorder.

Anger, anxiety and depression can be normal, or excessive

I agree that anger in itself is not a mental disorder, just as anxiety only becomes a disorder when it is excessive. However excesssive anger, like generalized anxiety disorder IS a disorder.

As to the latest science, one aspect of relatively recent research has been in the role of the amygdala in anger disorders. In my practice we have specialized techniques for reducing amygdala hypersensitivity so people with excessive anger can live more normal and emotionally more healthy and happy lives.

So ... how is the

So ... how is the determination made what constitutes "excessive" anger? What cultural metrics are unconsciously included in that evaluation?

I'm a woman who also belongs to another cultural group whose reactions are regularly stigmatized and pathologized at a much more mild 'point of reaction' than more prominently situated and media-featured folks -- and also when those reactions appear in response to treatment much more egregious than some "regular" folks ever suffer.

Womens' displays of anger are punished much more frequently and severely than mens' (witness the treatment of Senator & Secretary Hillary Clinton for one of the most basic but also most illustrative examples) -- again when that anger is shown in response to much more egregious unfairness and disrespect than a man would ever suffer or ever be culturally expected to.

Unless those built-in-cultural biases are evaluated and adjusted for -- the "Implicit Bias" test and tools were developed by your alma mater, after all, Dr, Heitler -- I am extremely reluctant for either the culture or the mental health community (which any fair observer should be ready to admit carries its own pathologies inherent) to pathologize anger, especially without evaluating its causes and solution-based alternatives to its expressions.

Excessive anger would be like excessive alcohol use...

When a feeling or behavior, such as alcohol use or anger, interferes with functioning at home or at work, it becomes "excessive" and pathological.

When a feeling or behavior endangers personal health that also is a sign of excess. People with anger problems often develop physical problems such as IBS, headaches, etc. Excessive emotional intensity takes a toll on the body.

"When a feeling or behavior

"When a feeling or behavior endangers personal health that also is a sign of excess. People with anger problems often develop physical problems such as IBS, headaches, etc. Excessive emotional intensity takes a toll on the body."

Absolutely it does, and I have too many people -- too many of them women -- suffering in my family and extended family as a result of having suppressed that anger in order to be perceived as "reacting appropriately". I think it no accident whatsoever that the incidence not only of the illnesses to which you refer in addition to chronic ailments like high blood pressure, with yet more serious ramifications, occur disproportionately in populations punished for their reactions where people who look like them are not, and/or who suppress those reactions as a matter of course in fear of such punishment.

However, what your response & definitions do that remains unaddressed is punish the person experiencing the anger, if it is pathologized pursuant to those definitions, as opposed to address the injustices that contribute so greatly -- and documentably -- to its proliferation.

Is that the end result -- those peoples' receipt of blame, ostracism, punishment, and/or possible confinement/isolation as a result of their anger -- those professionally produced definitions are looking to produce?

As opposed to perhaps looking -- again, as a profession -- to the societal conditions & constructs that contribute to the production of that emotion?

There are studies that detail the proliferation of sociopaths at SPV and EVP levels of Fortune 100 and 500 corporations, which latter govern great swaths of American (and global) society. The modes of behavior rewarded as a result of such "leadership" trickle down and proliferate repeatedly, which I can't think can be argued against as a major factor contributing to the way these people are treated and their resultant angers. How in the face of that can the emotion itself be professionally and responsibly isolated and pathologized in a vacuum?

Suppressed anger....

One reason why the term "intermittent explosive..." does not suffice is exactly what you point out.

That is, just as people with generalized anxiety disorder do not necessarily show any of their inner feelings on the surface, many people with excessive anger suffer from their anger even though their intense inner feelings never get expressed with words or raised voices.

What is excessive Anger?

This is the problem - what is excessive anger? children are routinely diagnosed as having anger "disorders" solely on the basis of checklists compiled by school teachers. But what is excessive anger and what is a "disorder"? Are these terms not subjective? What one person perceives as an over-reaction may be a response to the last straw for the person suffering / suffering from anger.

What one person might perceive as an over the top reaction - another might see it as normal - especially if the person reacting is a child. So the perceiver's tolerance level is a factor in determining excessive anger (that is one reason why it is unfair that a child be judged on the basis of his / her teacher's tolerance level).

And the point that the person is "suffering" from something and it is the suffering which is manifests anger. There is a saying to the effect that 'a person is rarely angry for the reason he thinks he is angry'

I think that we are too quick to judge and that psychiatrists and psychologists are too quick to label

Strong emotion does not mean Excessive emotion

This is the problem - determining when an emotion is excessive or is not. A person might give a weak explanation for an "unacceptable" reaction (the more upset we are and or the greater the pain, the most inadequately we express our pain). Different things upset people and people can never really see things through another's eyes. Also people either don't know the real reason for their anger or they don't tell. In addition apparent small things can appear to hurt out of proportion. For instance a snub or a perceived snub from a loved one can be like a knife through the heart

If anger is a disease...

then people would not be responsible for their anger, legally speaking. That wouldn't help things at all. So maybe it's good that anger is still regarded as one of those behaviors we're responsible for.
I agree w everything you've said Susan, I'm just putting it in the legalistic context that we live in.

Excessive anger outbursts

Excessive anger outbursts usually have more to do with impulse control issues than actual anger. We all get angry but many of us can calm ourselves down before lashing out at others. Impulse control problems are a symptom of many mood,substance,and mental disorders. So excessive anger is usually a symptom of a disorder not the disorder itself.

anger uncontrolled

Yup! It's out-of-control anger that's a danger. Or there's the slow internal boiling that comes out at like a volcano--usually at the worst possible moment.

The world isn't going to get any better, what with the human overpopulation, diminishing resources and insane corporate greed. We're going extinct, taking nearly every species with us. The archbacteria will do all right. So we can only change our reaction to all this and not let our lack of control lead us to depression and/or crazy anger. Pent up anger--even justified--will destroy the angry person as well as everyone around. Focusing that anger on action will help dissipate it. I've found playing games a good outlet for pent-up anger (esp. hockey;), and also doing political work to resolve issues that need resolving--i.e., joining the fight against fracking, oil pipelines and oil tankers. Writing, painting, gardening, hiking, canoeing and music are also great things to lessen frustration and anger.

However, those with anger issues often don't do any of these things, so their innards suffer, as well as their health. They will take it out on others, thereby increasing all angst.

Jumping the gun

I think that we are jumping the gun by treating anger as being a wrong reaction. A reaction,which is involuntary, cannot be wrong - it might be socially unacceptable but it cannot be wrong. The anger is not the problem; the anger is merely a warning system. If a fire alarm went off would the fire alarm be the problem - if it was reacting to smoke which posed no danger?

There is a saying 'we are rarely angry for the reasons we think we are angry' A person, especially a child, who lashes out at the least provocation, is suffering - and the focus should be on investigating the underlying cause for the suffering.

Unfortunately, psychiatrists and psychologists tend to judge merely on behaviour and not on the underlying reasons therefor

We believe that socially acceptable behaviour must override natural and involuntary reactions. That is hardly fair.

As the eminent Australian Psychologist and Author, Dr. Dorothy Rowe said, "Psychiatrists judge on behaviours alone...Psychiatrists destroy lives"

I like your analogy

@Leo, The analogy of the fire alarm suggests, and I agree, that an alarm is helpful because it alerts people to a danger. The danger needs to be addressed.

At the same time, sometimes the fire alarm is set too sensitively so it keeps going off at mere light breezes or a bright light. These false alarms are unhealthy for fire departments and people alike. That's one form of "excessive" anger.

Here's where I need to stretch the analogy a bit. Ideally a fire alarm would have a way to indicate small fires versus five alarm blazes. "Excessive anger" is a reaction of five alarm blaze to smaller fires, resulting in excessive stress for the person in which the anger alarm goes off, and alienating the people that person wants and needs in his/her life because of the too-frequent and too-intense drama, and because of too much attacking behaviors.

You raise a second vital point too. If therapists label people with a term of excessive anger, that term needs to be helpful toward remediation, like if we label someone as having a broken bone or pneumonia. If instead the label is presented judgmentally, that would be problematic.

Now here's where it gets really dicey. For some people who have excessive anger, it is a significant relief to be told by a professional "You have excessive anger because your alarm system, your amygdala, is hyper-responsive. We can do a treatment together that will calm it down. Would you like to do this treatment?" When others, however, hear the same message, the message triggers their false-alarm response. They fly into emotional overload, and their response is either denial or attack instead of relief.

Thanks so much for your thought-provoking contributions.

diagnoses based on behaviours as opposed to reason behind the behaviours

It seems that what you are saying is that some people are more sensitive - and their reactions to anger (and probably all emotions) is stronger than usual. However, does that mean that they are flawed?
Obviously reactions which are considered too strong and or harmful to self and or others shouldn't have to be tolerated. But is the problem excessive anger? is it overload of intolerable stiumuli (what is going on in the person's life? If the person is being emotionally psychologically abused is he capable of expressing this) Is the problem intensity, sensitivity? Or does the problem lie in the way the person expresses anger (is this a learned behaviour?) Is the problem physical (intolerance to clothing material, noise, lights, food).
Unfortunately psychiatrists and psychologists do not investigate- they label on the basis of behaviours alone, eg. on the basis of checklists compiled by teachers - that is wrong.

You have excessive anger because your alarm system, your amygdala, is hyper-responsive.

Your statement:-

"You have excessive anger because your alarm system, your amygdala, is hyper-responsive".

is that explanation speculation or fact?

What biological checks are carried out to establish if the amygdala is hyper-responsive?

I understood that no biological bases have been found for "excessive anger" - except in cases of brain injury.

Research on "excessive anger" and the amygdala.

In my offices we are not set up with MRI's that could, I believe, actually test out the amygdala hyper-reactivity hypothesis. I sure would love if a neuropsychologist could and would devise such research. If any readers know of some, please post the link.

One of the therapists in my office suite however does utilize muscle kinesiology to get number assessments from the subconscience in response to the question "On a scale from 0 to 10, at what level is your amygdala set?" The responses of non bpd clients are generally 4, with occasional 3's or 5's Clients with bpd consistently rank themselves 8, 9 or 10 (usually 10).

The good news is that after treatment, the bpd individuals rank themselves the same as "normals," and report back that they have been feeling remarkably calmer and far less prone to quick emotional reactions. They are much happier and their relationships/marriage rapidly improves as well.

I am working now on a video that demos these techniques. Once it's done I'll post the youtube link with an article on my PT blog.

Thanks @Leo for your excellent questions.

Obviously MRI's cannot

Obviously MRI's cannot actually test out the amygdala hyper-reactivity hypothesis otherwise it wouldn't be a hypothesis.

The fact is that Psychiatrists who are unable or unwilling to carry out full and proper investigations suggest biological causes - knowing full well that there are no proven biological causes.

Psychiatrists (and Psychologists) might as well make a diagnosis on the possibility that the flying spaghetti monster poisoned the person's brain with his bad spaghetti

Obviously it is far easier to slap a "diagnosis" of a "disorder" on an innocent little child stigmatizing him / her for life - on the very spurious basis of a "biological" impairment -

Firstly it sounds very professional.
Secondly who is going to dispute a professional's learned conclusion?
Thirdly it will be accepted by those who want to blame illness as opposed to their lack of responsibility for their anger (their child's justifiable anger - possibly against the parents who are the cause and thus so grateful for a diagnosis exhonerating them)
Fourthly an abused child who is too frightened and confused to explain his anger is hardly going to be in a position to object to the "diagnosis"

instead of investigating if the child is being emotionally psychologically abused, instead of investigating if the child is intense, sensitive (the traits of giftedness), instead if the child is food, material, noise, light intolerant, etc., etc., etc. just slap on a "diagnosis" - made from a checklist filled in by parents and or schools (the abusers, the ignorant, the uninformed)

This is how the psychiatry and psychology systems operate. Hand out checklists (often to the abusers, i.e. the parents, the school teachers) and diagnose the child on the basis of his her behaviours, i.e. coping mechanisms.

This is the reality - I personally know of four wrong diagnoses (3 children and 1 adult) - wrong in that they allwere incorrect (all later corrected), wrong in that no symptoms indicated (it wasn't as if symptoms of another condition overlapped), wrong in that no actual assessments carried out (1 was on the basis of school checklist, one was on the basis of a telephone call by a school principal to a diagnostician - with whom the child wasn't even engaging - diagnosis found by accident 3 years later) wrong in that no treatment / strategies given and wrong in that they were harmful (children and adult (wrongly diagnosed with bi-polar and memory damaged by drug treatment) all later diagnosed as gifted).
The game is up - too many people know and the floodgates to Defamation charges will open up any one of these days

Oh and as for muscle kinesiology - please!!!!!!!!

Understanding Anger Disorders

Well done. This article makes an excellent point. I am actually not generally opposed to the DSM-5, there are a lot of good changes in it, but a lot of wimp-outs and areas of neglect, and this is possibly the greatest. There is a new diagnosis for kids of Disruptive Mood Dysregulation Disorder which, despite the alarmism about diagnosing tantrums as disorders, is pretty restrictive and doesn't really focus on the emotion of anger itself.
There is a great book which proposes a DSM diagnosis of Anger Regulation-Expression Disorder, complete with diagnostic criteria. The book is: Understanding Anger Disorders, by DiGiuseppe and Tafrate, published in 2007 by Oxford U. Press. 2007 was plenty of time to get this into the DSM-5... oh well.
Thank you, Dr. Heitler, for your continued persistent advocacy on this issue.

GREAT BOOK

Thank you so much Jim Foley for recommending this book. It just arrived, and it is EXCELLENT.

By the way, if you or anyone you know have been advocating for getting anger into our next diagnositic manual, I would be glad to help out.

You are so welcome Jim...

Thanks for mentioning this book, which I will purchase immediately.

By the way, the ICD diagnosis code does include anger (Irritibility and Anger) as a diagnostic label. The rest of the world, which more often uses this diagnostic manual than the DSM, does not seem to have the same blind spot as the authors of our DSM.

Crisis and "We are rarely angry for the reason we think we are angry"

According to the eminent Australian Psychologist and Author, Dr. Dorothy Rowe, anger is a vital emotion for dealing with crises situations. A person expressing extreme anger may be in a crisis and may not necessarily be able to understand and or explain what is going on - especially if that person is a child. There is a saying "we are rarely angry for the reasons we think we are angry". With regard to irritability, this is often an expression of depression - so I am not sure if the two should be lumped together as having similar origins or meanings

"Disorder" used to label simple "misbehaviour" :

The offensive and defamatory term of "Disorder" which is generally understood to mean, (in a derogatory way) "there is something wrong with that guy" should be replaced by a milder term.

Also the term is far too widely loosely used - especially for "misbehaviour" a term for behaviour not tolerated by another - when it is may be the "low tolerance" threshold might be the problem (especially where children, whose expressions of anger are simply justified frustration and or depression (an adult who cannot explain his anger is advised to ask himself "what am I afraid of?" and a person who cannot explain his sadness is advised to ask himself "what am I so angry about" . A child whose sadness and or fear is manifesting as anger and or irritablity cannot possibly explain and so gets labelled with an "Anger Disorder" How cruel and stupid.

Definition of "Disorder" by Eric Maisel, Ph.D.

"No-one really doubts the phenomena of birds and bees. But to call birds and bees miracles and to create a miracle-maker god who created them is a certain kind of fraudulent leap. No one really doubts the phenomena of sadness and worry. But to call them symptoms of mental disorders is exactly the same kind of fraudulent leap. We make gods and mental disorders in exactly the same fraudulent way, by illegitimately using real phenomena as “proof” of the existence of non-existing things.

Part of the joy and ease of this fraudulent creating is that you can define the non-existing thing any way you like. Who is to say if a god isn’t or isn’t friendly, spiteful, eternal, or taking a personal interest in you if there is no real thing involved? Who is to say if a mental disorder is the same or different from a brain disorder, the same or different for a Jungian, a Freudian, or a drug dispenser, the same or different from unwanted thoughts or behaviors, if there is no real thing involved? It ought to be the case that those making the claim for a non-existing thing should have to prove its existence but in real life the burden always falls on the whistle-blower. The perpetrators have it easy!

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See how easy the definers of non-existing mental disorder have it. First they define it one way, as they did in the DSM-4: “A mental disorder is a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”

Then, under pressure by skeptics as to the whether this definition made any sense whatsoever, they redefined non-existing mental disorders this new way in the recently released DSM-5:

"A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above."

The very idea that you can radically change the definition of something without anything in the real world changing and with no new increases in knowledge or understanding is remarkable, remarkable until you realize that the thing being defined does not exist. It is completely easy—effortless, really—to change the definition of something that does not exist to suit your current purposes. In fact, there is hardly any better proof of the non-existence of a non-existing thing than that you can define it one way today, another way tomorrow, and a third way on Sunday.

Certainly one could scrutinize the changes and make reasonable comments about the way that language has been employed to say absolutely nothing. A mental disorder is a psychological thing, or maybe it isn’t. A mental disorder is a biological thing, or maybe it isn’t. You can rail about your society unless you have a “dysfunction,” at which point your railing is a mental disorder. You can have a conflict with your politicians unless you have a “dysfunction,” at which point you are a mental deviant. One could go on with such observations but making such observations plays into the hands of the creators of non-existing things, who love it if you play their game. They can slip about with impunity, adding, qualifying, and shifting, while you waste your breath being reasonable and thoughtful.

The question is not, “What is the best definition of a mental disorder?” The question is not, “Is the DSM-5 definition of a mental disorder better than the DSM-IV definition of a mental disorder?” Those are absolutely not the right questions! The first and only question is, “Do mental disorders exist?” The phenomena certainly exist. The birds and bees exist; pain and suffering exist. But birds do not prove the existence of gods and pain does not prove the existence of mental disorders. Let us not play the game of debating the definitions of non-existent things. Let us move right on.

The phenomena itself confounds us and it would be lovely to create gods and mental disorders to explain them. But, being non-existent, gods and mental disorders explain nothing. Let us move on and do better.

**

Eric Maisel, Ph.D., is the author of more than 40 books including Making Your Creative Mark (New World Library, 2013) and Why Smart People Hurt (Conari Press, 2013). Widely regarded as America’s foremost creativity coach, Dr. Maisel founded natural psychology and leads workshops nationally and internationally. You can learn more about Dr. Maisel’s books, services, trainings, and workshops at http://www.ericmaisel.com. You can learn more about natural psychology at http://www.naturalpsychology.net. Dr. Maisel can be reached at ericmaisel@hotmail.com

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Susan Heitler, Ph.D., is the author of many books, including From Conflict to Resolution and The Power of Two. She is a graduate of Harvard University and New York University.

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