Resolution, Not Conflict

The guide to problem-solving.

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

How could this major cognitive/emotional/behavioral disorder have been left out?

Anger intensities can range from frustration or irritation to rage and madness.
Anger intensities can range from frustration or irritation to rage
(c) vladacanon www.fotosearch.com Stock Photography
What problem is one of the leading causes for divorce?  What parenting behavior creates life-long difficulties for children?  What mistaken habit often causes people to be fired at work?  What problematic emotional reaction even causes car accidents?  One answer to all of these questions? Anger.  Yes, getting mad.  Yet how many times is anger listed in the index of the DSM 5?  Zero.  That's madness!

I wrote about this dreadful gap in an earlier post about the fact that anger was omitted from our earlier diagnostic listing, the DSM IV.  Somehow I naively thought that anger would appear in this newest DSM version.  Wrong. Dead wrong.

This glaring omission of anger, that is, of getting mad, is especially odd given that madness is in fact one of the longest-standing words for mental illness.  How could madness, that is anger, not be listed as a contemporary diagnostic option?

The disruptive impacts of anger

What is the cause of most disrupted friendships?  Anger.

What is the cause of poor functioning as a spouse?  Poor handling of angry feelings.

What makes some work environments unpleasant?  Angry interchanges.

Madness in the business world spoils the bottom line.

(c) pressmaster www.fotosearch.com Stock Photography

How interested are you in continuing to interact with people who express their frustrations in angry voice tones?  I can’t speak for you, but for me, my interest plummets after even just one such interaction.  I don’t even wait for three strikes to decide that I will move the angry person to the outer peripheries of my friendship, family or work worlds.  

Recently for instance a business professional addressed me in a hostile demanding manner.  I withdrew from the situation asap.  I then wrote a polite email to the individual explaining that I was terminating my business association with him because I do not engage in business (or other) interactions when I am addressed in that manner.  The individual wrote back to me "I wasn't angry; I was just frustrated."  That lack of insight, of unwillingness to hear that what he subjectively experienced as frustration comes across to a receiver as anger, confirmed my determination to end the business relationship.  The man's anger, clearly a mental health issue, was having harmful impacts  on his ability to function at work, and most likely at home as well.  Yet according to the DSM V, there is no such thing as an anger problem.  

The above-described man did not necessarily have "intermittent explosive disorder," "conduct disorder," or "oppositional defiant disorder," the three anger-like potential DSM V labels.  Nor did he necessarily have a borderline personality disorder or a narcissistic or sociopathic disorder, the other potential labels for someone who gets mad too fast, too often, and too intensely.  Anyone watching however would have known immediately what the DSM V does not seem to know:  This man had an anger problem.

The frequency of anger as a key ingredient in much psychopathology

In addition to being a stand-alone disorder (analogous to generalized anxiety disorder), excessive anger plays a key role in many other disorders.

What is the underlying main problem in borderline personality disorder?  Excessive anger, excessive both in frequency and in intensity. 

Madness disrupts personal relationships.

(c) pzAxe www.fotosearch.com Stock Photography
What is a major underlying problem with narcissistic functioning?  If you disagree with someone who is narcissistic, he or she get angry.  If you try to discuss your emotional concerns with someone with narcissistic tendencies, he or she is likely to personalize, that is, assume you are blaming him or her for your feelings.  The upshot: the narcissistic individual will get mad. 

What is the burning undercurrent that feeds paranoid disorders? Anger.

What is a major emotional consequence of manic phases of bipolor disorder?  Quickness to anger.

So what’s the deal with this blind spot in the world of those who write the DSM?

I’m afraid I just don’t get it.  My hunch though is that, given that many people contribute to the project of creating the DSM diagnostic codes, the problem is a cultural rather than individual one.  Does our society recognize that anger is an inappropriate way to deal with differences?

We don’t condemn physical violence.  That is certainly an upgrade over parts of the world where differences continue to be handled via domination and physical attacks.  To our credit (and unlike in Islamic countries in the Middle East) we do consider domestic violence as well as public violence to be  criminal offences.

We have not progressed to the point though where we treat anger, at home especially, as an aberration.  Anxiety, yes.  Depression, yes.  But anger?  Oh, ‘everybody does it’ seems to be our American attitude.

Excessive anger, that is, too much "madness," should be considered a diagnosable disorder.

Angry feelings are normal, just like mild anxiety and sad moods are normal as opposed to more intense clinical anxiety or depression.  Frequently angry tones of voice, inappropriately harsh words, angry responses to non-threatening situations that could be handled cooperatively, and raging however are a definitive departure from healthy interactions.

Madness, that is, anger, ruins relationships.

(c) dobled www.fotosearch.com Stock Photography
Excessive anger however is obviously a form of psychopathology.  It is insufficient to dress this reality up in fancy euphemisms such as the DSM 5’s “Disruptive, Impulse-control, and Conduct Disorders” terminology.  The problem is ANGER. 

The term excessive emotional reactivity, a term now being used to hone in on the essential quality of borderline disorders, is a step in the right direction, though this term also is not listed in the DSM V index.  Excessive emotional reactivity, sometimes referred to as amygdala hyper-reactivity, is being studied now to explain and treat the excessive angry reactions of people with a borderline personality disorder.  Still, this label tip-toes around the raw reality.  Excessive anger should be listed as a clinically diagnosable problem.

Peace between nations begins with peace at home.  As the song  about Where have all the flowers gone? so poignantly asks, “When will we ever learn?  When will we ever learn?”

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Susan Heitler, PhD, is a Denver private practice psychologist and author of the book The Power of Two.  Dr Heitler's books and blogposts teach skills for more cooperative living as illustrated in the following humorous video from her online collaborative communication program, Power of Two Marriage. (Note: If the video is not visible, try refreshing the page).

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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