- Anger does not always have an obvious root. Sometimes we must look in unusual places to successfully address the matter.
- Hunger anger can reach problematic proportions if good eating habits are not sustained, leading to an arguments and discontent.
- Misophonia, extreme sensitivity to certain noises, may instill rage and anxiety in some. It is little recognized but affects up to 20% of people.
- Mindfulness approaches and dialectical behavioral therapy often prove to be sound interventions for these two issues.
Anger, a normal, healthy emotion that can become a runaway train, is a common theme in psychotherapy. Angry clients may bring to mind disgruntled folks like Adam Sandler in the movie Anger Management. Perhaps readers imagine specific diagnoses, like Cluster B Personality Disorders or Intermittent-Explosive Disorder. While the aforementioned are frequently culprits, anger is a diagnostically crosscutting symptom, and numerous other conditions can account for it.
There is a low frustration tolerance in ADHD and autism. Anger is also often present in mania and psychosis, and is very common in PTSD. Depressed people, especially males, can be irritable and angry instead of sad, and irritability is common in Generalized Anxiety Disorder.
However, you've surely met people who seem to struggle with anger for no apparent reason, or folks in the above populations whose anger is excessive for the diagnosis, but you can't put your finger on why. They're diagnostically puzzling, and the usual bag of anger management tricks isn't paying out. So, what's the deal?
As therapists, we tend to default to looking for some occurrence that sets the anger in motion or for maladaptive core schema. After physical evaluation to rule out medical conditions or substance-related causes, puzzled providers are invited to look for the devil in the finer details. Here are two sneaky devils that can keep stoking the flames of anger while keeping you guessing:
1. The hangry patient
Hangry: bad-tempered or irritable as a result of hunger (Oxford).
While not a clinical term, it describes a condition we can encounter as therapists. Ever since reading research by Bushman et al. (2014) several years ago about couples who tended to get contentious while having lower glucose levels, I've always asked about the eating habits of angry people.
A favorite example of "hanger" comes from the corporate world. In some careers, productivity is a shrine on whose altar employees sacrifice their well-being to appease the corporate gods or otherwise demanding employer. Mounting snappiness and irritability lead to a referral to the Employee Assistance Program. Here, it's discovered the employee, though thinking they have it together because their career is on course, they run before work every morning, and they happily return home each evening, is increasingly bleeding themselves during the workday. "I don't even get to eat lunch some days" passes their lips as if it's a badge signaling their dedication to the cause and thus their self-worth.
Though not the only item needing addressing, tackling their daytime food deprivation proved to be the most important in terms of reducing their touchiness. It's no secret that food intake, or the lack thereof, drastically affects mood. We need a certain amount of glucose to function optimally, especially in the "productive mode" of the workday. If glucose isn't being delivered on a plate, our bodies have a fancy, emergency backup mechanism to feed the need.
If glucose drops below a particular threshold, we release hormones that can increase glucose in the bloodstream. Two of these are the excitatory neurotransmitters/hormones adrenaline and cortisol, and both can inflame our temper. Also, Neuropeptide Y comes into play to signal hunger, which can also elevate aggression.
Since nutrition can have a huge bearing on mental health, therapists ideally ask about eating habits during all of their evaluations. With those presenting for anger management, simply asking if they have prolonged periods of not eating is a good starting point. If so, exploring if their anger correlates to days or times of day with decreased food intake, perhaps using a behavioral log, can be helpful.
Educating the patient on the deleterious effects of their nutritional neglect will help them see this anger management is well within their control, and correction is often a lesson in mindful eating.
Have you ever met someone who is not just irritated by a particular noise that many would find mildly annoying, like slurping or gum chewing, but becomes outright irate? They may even express hatred towards the noise-maker. Looking closer, they probably have a clenched jaw, balled-up fist, and are turning red as they remove themselves from the sound. There’s a good chance they’re misophonic.
Roughly translated, misophonia is "hate of sound." Those with misophonia have an ill disposition towards particular noises. Common triggers are certain high pitches, “deep” noise like growling mufflers, plastic crinkling, yawns, hearing food chewed, and the hum of fluorescent lights. Most are affected by a range of noises.
Though misophonia may be a new term to some, there is evidence it is experienced, to some degree, by up to 20 percent of the population (Wu et al., 2014). Growing awareness has led to it as a flourishing topic in mainstream media, including:
- "Misophonia: Scientists crack why eating sounds can make people angry" (BBC, 2017)
- "Misophonia: When Life's Noises Drive You Mad" (NPR, 2019)
- "Why Everything Is Getting Louder" (The Atlantic, 2019)
Researchers (e.g., Dozier et al., 2017; Naylor et al., 2020, etc.) note that misophonia is more closely related to mental health than we might think. While it tends to occur in people with super-sensitive hearing and those with tinnitus, it is also more common in people with OCD (Lewin, Storch & Murphy, 2015), ADHD, PTSD, and some personality disorders (Casiello-Robins, et al., 2020). Like many mental health conditions, it also tends to first surface around middle school age. For some, it is so severe that at first it may present as agoraphobia, given the person won't leave their home for fear of encountering the dreaded noise. Misophonia is so highly correlated to anger and anxiety that some (e.g., Dozier et al., 2017; Jager et al., 2020) are proposing it be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM).
While understanding misophonia is still in its infancy, researchers believe that disruption in areas like the anterior insular cortex, a part of the brain “critical for perception of interoceptive signals and emotional processing” (Kumar, 2017) and the limbic system (Palumbo et al., 2018) plays a role. On another note, there is also evidence that sufferers can exacerbate their misophonic anger by believing the noise-makers are intentionally being irritating (Palumbo et al., 2018).
Considering a possible 20 percent prevalence rate, it is not far-fetched that therapists may uncover misophonia if they ask about noise sensitivity being correlated to the anger. This may be especially true if any patients with the aforementioned correlated diagnoses report struggling with serious anger.
Unfortunately, there is no neurological, audiological, or psychological cure for misophonia. However, therapists are used to working with people on managing noxious symptoms for which there is yet no silver bullet.
A cursory look at the limited literature on treating misophonia (Cartriene, 2019; Jager et al., 2020) points to cognitive-behavioral interventions of distress tolerance as the most effective approach. If a patient has a proclivity for blaming the noise-maker as being intentionally irritating, it is important to work towards a realization that it is not a personal attack, which compounds the emotional distress. Dialectical Behavioral Therapy (DBT), with its focus on acceptance and distress tolerance, is well-suited to working with the anger and anxiety inherent to misophonia.
Bushman, B.J., DeWall, C.N., Pond, R.S., Hanus, M.D. (2014). Low glucose relates to greater aggression in married couples. Proceedings of the National Academy of Sciences, 111 (17) 6254-6257; DOI: 10.1073/pnas.1400619111
Cartreine, J. (2019, June 15). Misophonia: When sounds really do make you crazy. Harvard Health Blog. https://www.health.harvard.edu/blog/misophonia-sounds-really-make-crazy…
Cassiello-Robbins, C., Anand, D., McMahon, K., Brout, J., Kelley, L., & Rosenthal, M. Z. (2021). A Preliminary investigation of the association between misophonia and symptoms of psychopathology and personality disorders. Frontiers in Psychology, 11 : 519681. https://doi.org/10.3389/fpsyg.2020.519681
Dozier, T.H., Lopez, M., and Pearson, C. (2017). Proposed diagnostic criteria for misophonia: A multisensory aversive reflex disorder. Frontier in Psychology, 8 : 1975. doi: 10.3389/fpsyg.2017.01975
Jager I, de Koning P, Bost T, Denys D, & Vulink N (2020). Misophonia: Phenomenology, comorbidity and demographics in a large sample. PLOS ONE, 15(4): e0231390. https://doi.org/10.1371/journal.pone.0231390
Kumar, S., Tansley-Hancock, O., Sedley, W., Winston, J.S., Callaghan, M.F., Allen, M., Cope, T.E., Gander, P.E., Bamiou, D.E., & Griffiths, T.D. (2017). The brain basis for misophonia, Current Biology, 27(4), 527-533, https://doi.org/10.1016/j.cub.2016.12.048.
Lewin, A.B., Storch, E.A., Murphy, T.K., (2015). Like nails on a chalkboard: A misophonia overview. The OCD Newsletter. https://iocdf.org/expert-opinions/misophonia/
Oxford Languages (n.d.). Hangry. In Google Dictionary. Retrieved May 3, 2021, from https://languages.oup.com/google-dictionary-en/
Palumbo, D. B., Alsalman, O., De Ridder, D., Song, J. J., & Vanneste, S. (2018). Misophonia and potential underlying mechanisms: A perspective. Frontiers in Psychology, 9(953). https://doi.org/10.3389/fpsyg.2018.00953
Wu, M.S., Lewin, A.B., Murphy, T.K., Storch, E.A. Misophonia: Incidence, phenomenology, & clinical correlates in an undergraduate student example. Journal of Clinical Psychology 70(10). DOI:10.1002/jclp.22098