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Anger Disorder: What It Is and What We Can Do About It

Case studies in Intermittent Explosive Disorder and other aggressive states.

In this PT blog (Evil Deeds) I have been posting numerous examples of murderously violent behavior perpetrated by pathologically angry individuals, usually men, including the Columbine High School shootings, Virginia Tech, as well as some more recent savage massacres in Los Angeles, Germany, Florida and Alabama to mention but a few. (See previous post)

Last week, in North Carolina, Robert Stewart opened fire at a nursing home, killing seven very elderly residents and a nurse. Police speculated that the forty-five-year-old Stewart, who did not commit suicide and is currently in custody, targeted the facility because his estranged wife once worked there. And just today, a forty-two-year-old gunman with a high-powered rifle killed thirteen victims, critically wounded four, and took at least forty-one people hostage in Binghamton, New York before finally shooting himself. Curiously, despite the clearly raging epidemic of anger-fueled violence in America and abroad, the almost one-thousand pages of the American Psychiatric Association's official diagnostic manual, the DSM-IV-TR, contain only a handful of diagnoses capable of accurately addressing this disturbing and growing phenomenon. This is a serious omission, demanding immediate attention.

The most commonly used psychiatric diagnoses for aggressive, angry or violent behavior are Oppositional Defiant Disorder, Attention-Deficit/Hyperactivity Disorder and Conduct Disorder (in children and adolescents), Psychotic Disorder, Bipolar Disorder, Antisocial, Borderline, Paranoid and Narcissistic Personality Disorder, Adjustment Disorder with Disturbance of Conduct, and Intermittent Explosive Disorder. This latter diagnosis is an impulse control disorder characterized by repeated "failure to resist aggressive impulses that result in serious assaultive acts or destruction of property." Of all the DSM-IV-TR diagnoses, this one comes closest to accurately describing the escalating explosions of violence we are witnessing today. It is a classic anger disorder.

According to a recent study by sociologist Ronald Kessler at Harvard Medical School, this anger disorder is on the rise, and may be present in more than fifteen million Americans. And this is only the proverbial tip of the iceberg.

By definition, in Intermittent Explosive Disorder, "the degree of aggressiveness expressed during an episode is grossly out of proportion to any provocation or precipitating psychosocial stressor." This is precisely the case in so many of the mass shootings in recent years. But a difference is that some reportedly have no prior history of aggressive episodes. Typically the perpetrator, often described by friends, family and co-workers as passive, polite and quiet, is triggered by some insult, rejection or stressful event, running amok on a vengeful rampage to restore honor or repay the injury to his fragile ego. Some cynically and nihilistically seek recognition, attention, infamy. But, in any case, their violence is a gross overreaction, a devastating nuclear detonation of pent-up aggression, anger and rage. Why?

I believe we are seeing a similar pattern in most of the other diagnoses traditionally applied to such angry, aggressive, violent individuals. Oppositional and Conduct Disorder are manifestations of underlying rage. The depressed, irritable mood and often furious manic behavior of Bipolar Disorder have deep roots in unconscious anger and resentment, as do the hostility, temper tantrums, rage and aggressive acting out in Antisocial, Borderline and Narcissistic Personality Disorder. Indeed, I tend to consider all these diagnoses variations of anger disorder, and believe it is crucial to explicitly recognize them as such.

Anger disorders describe pathologically aggressive, violent or self-destructive behaviors symptomatic of and driven by an underlying and chronically repressed anger or rage. Anger disorders result primarily from the long-term mismanagement of anger, a process in which normal, existential anger grows insidiously over time into resentment, bitterness, hatred and destructive rage. Anger disorders may also be caused or exacerbated by neurological impairment and substance abuse, both of which can inhibit one's ability to resist aggressive, angry or violent impulses.

But, for the most part, anger disorders cannot be blamed on bad neurology, genes or biochemistry. They arise from a failure to recognize and consciously address anger as it arises, before it becomes pathological and dangerous, starting in childhood. Who is to blame for this failure? We are. To the extent our society condemns and denigrates the affect of anger as negative, worthless or evil, ignoring and denying its positive potentialities, we are partly responsible for the subsequent carnage. To the extent that mental health professionals continue to avoid confronting anger head on in our patients, choosing instead to try to drug, behaviorally modify or cognitively rationalize anger away, we clinicians too are compounding the problem.

How can we better deal with anger disorders and many other anger-related mental disorders? First we must acknowledge that some anger is a valid, necessary, appropriate and unavoidable human emotion.

It is not a question of whether we experience anger as much as how we deal with it. While it is true that our habitually-held irrational or unrealistic beliefs and expectations about life can cause us to feel unnecessarily frustrated and angry at times, as Albert Ellis illustrates in Rational Emotive Behavior Therapy (REBT), people will always have to reckon with their own anger. Anger is an existential given. An archetypal human emotion. Chronic repression or suppression of anger is counterproductive and, ultimately, futile and dangerous. This is why we as a culture need to encourage the acceptance of anger as a natural phenomenon, and teach children, adolescents and young adults how to manage and express it more constructively.

The same holds true, especially so, for patients suffering and inflicting suffering on those around them. The underlying anger must be consciously acknowledged, accepted, understood and its indestructibly dynamic energy redirected into some positive or creative activity.

While it may be driven deeper underground rendering it doubly dangerous, it won't just disappear or go away, no matter how much medication, meditation, intellectualization or cognitive restructuring is done. Our anger is here to stay. The only real question is what we do with it.

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