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«Anger: definition, health consequences, and treatment approaches. Martin P. Paulus, M.D.*†§ James Fiedler § Susan G. Leckband, R.Ph, BCPP§ Alby ...»

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Anger: definition, health consequences, and treatment approaches.

Martin P. Paulus, M.D.*†§

James Fiedler §

Susan G. Leckband, R.Ph, BCPP§

Alby Quinlan, RN, MSN §

†Department of Psychiatry

*Laboratory of Biological Dynamics and Theoretical Medicine

University of California San Diego

§ Veterans Affairs San Diego Health Care System

Correspondence should be sent to:

Martin P Paulus, M.D.

Department of Psychiatry,

UCSD, 9500 Gilman Drive La Jolla CA 92093-0603 Phone: (858) 822-1473 FAX: (858) 642-1429 Email: mpaulus@ucsd.edu


In this review, four main aspects of anger are discussed. First, the definition and measurement of anger is examined; second, the neurobiological basis for anger and its expression is outlined; third, health consequences are summarized; and fourth treatment approaches are outlined. Based upon this review, it is evident that anger is a very important emotion and is different from aggression, although many confuse one with the other. Anger, with or without aggression, has been shown to have devastating health consequences, but may be amenable to several treatment modalities, including medication approaches. Well-controlled prospective studies will be necessary to determine the best treatment approaches and their effects on health consequences in the future.

Anger definition Emotions play an organizing role in an individual’s experience of reality, sense of self, and orientation toward others (107). Anger is a complex emotion and occurs as a result of an interaction between one or more eliciting events, the individual’s pre-anger state, appraisals of the eliciting events, and available coping resources (33). In the broader sense, anger is composed of interrelated elements of cynical beliefs and attributions, angry emotional states, and aggressive or antagonistic behaviors (90). In a narrower sense, however, anger describes the affective experience, which can range from mild annoyance to fury and outrage, and can be differentiated from hostility, which refers to a person's tendency to view the world in a negative, cynical fashion, or aggression, which is used to describe destructive and violent behavior. This triad of anger, hostility, and aggression has been referred to as the “AHA” (anger, hostility, aggression) structure (137) and is also summarized as the “ABC” structure of trait anger, i.e.

“Angry Affect”, “Behavioral Aggression”, and “Cynical Cognition” (90).

Anger can be elicited by specific events, behaviors of others, and one’s own behavior, or a combination of external events and anger-related memories.

Anger can also be elicited by thoughts and feelings that are associated with memories or anticipation of anger. A pre-anger state is often critical for the expression of anger and consists of the immediate feeling preceding the anger situation. This pre-anger state frequently emerges when a person is in an aversive emotional or physical situation, his/her identity is challenged, or if expectations or desires are not met. The basis for the pre-anger state as well as the basis of an angry response is often entrenched in personal identity, frequently represents consequences of traumatic life history, and can be associated with both Axis I and Axis II disorders (118)

Factors affecting anger prevalence and presentation

The precise prevalence of anger related problems is unknown, however, in a large epidemiological study, about 15% of individuals reported extremely high hostility scores (119). Some investigators have shown that problems associated with anger do not seem to vary significantly with age (14) but are inversely related to education (125). Higher levels of trait anger have been reported in younger individuals, African Americans, and in males (125). A range of factors ranging from social to genetic has been found to significantly affect the prevalence of anger. There is a strong connection between observed aggressive parenting and subsequent aggressive parenting in the offspring generation, which seems to suggest that anger/aggression is passed on via parenting styles from one generation to the next (24). This finding is consistent with the observation that hostility aggregates in families (91). Both negative life events and lack of social support were associated with higher hostility scores (125).

Some have raised the issue of gender-specific expression of anger. Specifically, physical and verbal antagonism was found more frequently in men while more women reported passive consent (12). More recent evidence points to a specific genetic influence on anger prevalence, e.g. relative to the L allele presence of any U allele in the tryptophan hydroxylase gene was associated with a higher likelihood of outward expression of anger (87), which has been replicated in a different sample (121). Thus, the modulation of anger is multifactorial and involves gender-specific effects, genetic background, and family environment.

Among the most frequently reported anger situations is road rage. Anger expressions during road rage have been categorized into verbal or physical aggressive expression (34). In a recent survey, about 50% of driving individuals reported being shouted at, cursed at or had rude gestures directed at them in the past year. About 7% of respondents were threatened with damage to their vehicle or personal injury by others. Moreover, nearly a third of respondents admitted to shouting or cursing at someone (130). Relative to other common daily activities, anger was more likely to occur while driving (108). After controlling for gender, age, driving frequency, and annual miles driven, verbal expression, an angry/threatening driving subscale of road rage was significantly associated with hazardous driving behaviors including frequency of driving over the legal blood alcohol limit, receipt of tickets in the past year, and habitually exceeding the speed limit as well as being involved in a motor vehicle accident (MVA) (155). This is consistent with reports that in driving simulations, high anger drivers were twice as likely to become involved in a MVA while under a high stress situations (32).

Tools for the assessment of anger

There are many scales and assessment tools currently used in anger studies;

however, only three of the more widely used measures will be discussed here.

The most widely used anger scale, with extensive normative data and predictive

validity, is a paper-and-pencil measure devised by Spielberger and colleagues:

the State-Trait Anger Expression Inventory (STAXI) (47;137). The STAXI is a 44item scale that measures anger experience, expression, and control (92). The STAXI has several factors: State Anger (S-Anger); Trait Anger Temperament and Reaction; and Anger-In, Anger-Out, and Anger-Control. More recently, a “feeling like expressing anger” factor has been added to augment the original model (47).

The most frequently used distinction, Anger-Out versus Anger-In, refers to the tendency to focus angry expression outward on other people or objects versus directed inward towards oneself, respectively. Further analyses using this scale revealed seven additional forms of anger expression: Noisy Arguing, Verbal Assault, Physical Assault-People, Physical Assault-Objects, Reciprocal Communication, Time Out, and Direct Expression (35). Interestingly, the STAXI was not effective in accurately classifying subjects as high and low in self-report of aggressive behavior (152). Thus, measuring angry feelings may not appropriately predict aggressive behavior.

Alternatively, the Buss Durkee Hostility Inventory (BDHI)(18) has been used widely, and its reliability and factor structure have been validated repeatedly (11).

While the BDHI has better reliability than other anger scales and possesses some ability to predict the experience of anger, most of the BDHI subscales do not measure specific states or behavior (13).

Finally, the Cook and Medley Hostility (Ho)(25) scale has been widely used in studies with cardiac patients (see below) and shows good convergent and discriminant validity. This scale primarily assesses suspiciousness, resentment, frequent anger, and cynical distrust of others rather than overtly aggressive behavior or general emotional distress. Moreover, subjects with high scores high exhibited a particularly unhealthy psychosocial risk profile (134).

Psychiatric comorbidity and anger

Drugs and Alcohol: High trait anger individuals report more drug and alcohol use (143). In women, hostility was associated with increased tobacco smoking, caffeine use, and the number of alcoholic beverages consumed (19). Moreover, individuals who report low levels of trait anger may be more resistant to the potentiating effects of alcohol on aggression (109). In youth, elevated levels of anger and irritability have been shown to predispose to subsequent use of alcohol and drugs (144;147).

Axis I: Anger and aggression are prominent in psychiatric outpatients (113).

Relative to patients with anxiety disorders, depressed individuals had twice the prevalence of anger attacks, which was associated with more depressed symptoms (53). Others have found that increased levels of anger suppression have been associated with less improvement in depression (17). Anger problems have frequently been reported in individuals with PTSD (52). Higher prevalence of anger has also been reported for individuals with AttentionDeficit/Hyperactivity Disorder (116) Axis II and Personality: Cluster B personality disorders contribute most prominently to the presence of both anger and aggression in psychiatric populations (113). For example, subjects with high levels of narcissism reported greater verbally expressed anger and males high in narcissism were more likely to express anger physically (93). In addition, anger has been linked to various personality traits and coping styles. For example, a higher level of anger as measured by the Ho scale was associated with increased levels of neuroticism, attentional overload, and interpersonal alienation (21). In contrast, self-control skills were inversely related to hostility, anger, and aggression (58). High-angerarousal subjects were found to score lower on socialization, self-control, tolerance, psychological-mindedness, and flexibility (10). Moreover, in interpersonal conflict situations men with high levels of hostility responded with significant increases in self-reported anger and anxiety or overt hostile behavior and saw the disagreement-engendering behavior as more intentional (135).

High impulsivity has also been related to high expression of anger feelings (43).

Assertiveness and fear play an important role in the expression of anger. For example, individuals who express a high level of assertiveness expressed overt forms of more anger and aggression, whereas those with low level of assertiveness experienced more covert anger (38). Whereas fearful people expressed pessimistic risk estimates and risk-averse choices, angry people expressed optimistic risk estimates and risk-seeking choices (83). High Ho individuals report low covert self-esteem, avoid seeking or accepting social support, experience anger that is excessive and that occurs in a wide variety of situations, and suppress expression of anger, these individuals tend to drink more alcohol and drive a car more frequently after drinking and to have greater relative weight (60). Finally, very low ratings for spirituality was often associated with anger, pointlessness, selfishness, abandonment, and loneliness (54). In combination, although not a single personality factor predisposes to a high expression of anger, converging evidence suggests that neuroticism (a trait measure of fear), narcissism, impulsivity, low spiritualism is associated with higher levels of anger.

Neurobiology of anger:

The somatic marker hypothesis proposed by Damasio and colleagues (26) is a useful conceptual approach to understand the neurobiology of emotions in general, and anger specifically. The key idea is that “marker” signals, which are brain representations of “body states”, have critical influence on how individual respond to external stimuli. This influence takes place at multiple levels of operation, some of which occur overtly or consciously and some of which occur covertly or non-consciously. The marker signals arise as the result of bioregulatory processes, i.e. resolving the differences between information about the “body state” from the peripheral nervous system and the brain generated expectation of the current state. The markers are called somatic because they relate to body-state structure and regulation even when they do not arise in the body proper but rather in the brain's representation of the body (27). This view of multi-level bioregulatory processes underlying the modulation of anger and other emotions is consistent with some of the special, attentional features of emotional processing, i.e. the automaticity of fear and anger reactions, hyper-reactivity to minimal threat-cues, and the evidence that the physiological responses in anger may be independent of slower, language-based appraisal processes (78). Some investigators have posited that impulsive anger and aggression arise as a consequence of faulty emotion regulation (30). Particular emphasis has been placed on the prefrontal cortex, anterior cingulate, parietal cortex, and the amygdala as critical components of the circuitry that may be dysfunctional in people with anger-related problems (29).

In a recent review of the functional neuroimaging literature, the medial prefrontal cortex was found to have a general role in emotional processing. Whereas fear specifically engaged the amygdala, and sadness was associated with activity in the subcallosal cingulate. The emotional induction by visual stimuli activated the occipital cortex and the amygdala. In comparison, induction by emotional recall/imagery recruited the anterior cingulate and insula. Finally, emotional tasks with cognitive demand also involved the anterior cingulate and insula (112).

Thus, a circuitry comprising the amygdala, anterior cingulate, and insula may be the key structures for the assessment and expression of anger.

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