Anger

With the terms anger, rage and wrath, we indicate an altered psychic state, aroused by elements perceived as threats or provocations capable of removing the inhibitory brakes that normally dampen the choices of the subject involved. The angry person feels a deep aversion to something or someone and, in some cases, even to himself.

Anger involves physiological changes, such as increased heart rate and blood pressure, and increased levels of adrenaline and noradrenaline. Anger behavior is often characterized by some form of violence, verbal or even physical. The psychophysiological reaction of anger is presumably related to attack or flight behavior, and is therefore also correlated with the emotion of fear and the psychological phenomenon of stress.

Anger is a basic emotion, evolutionarily aimed at defending oneself for survival and with a fundamentally adaptive function. It can become dysfunctional or problematic when bouts of anger (also called fits of rage) compromise relationships or quality of life, or create suffering by prompting harmful actions towards oneself or others.

Although anger attacks are a widely observed problem in our lives, this appears to be little explored compared to anxiety and depression. The various manifestations of anger attacks extend from the family to the workplace, to relationships more generally, and to the clinical therapeutic setting. This has prompted many researchers to develop anger assessment tools, especially self-report questionnaires as interest in this emotion grows and to make emotional regulation interventions aimed at containing anger outbursts more specific.

Anger has been defined in many ways based on the different aspects emphasized. There is a broad consensus in commonly viewing feelings of anger as “wrong” and accompanied by actions intended to counteract or remedy such bouts of anger.

In general, anger has been characterized in terms of psychophysiological patterns and facial activation. Although it may be considered to have some beneficial effects, such as a role in mobilizing psychological resources, stimulating behavior, and protecting self-esteem, it is typically considered to have negative emotional valence with potentially harmful consequences.

The outbursts of anger, when poorly regulated, constitute to psycho-physical distress. The term hostility is more specifically reserved to define recurrent anger attacks or a general propensity to anger. It is considered the result of an attitudinal bias or a cognitive pattern of strong disapproval of others or similar to a personality trait.

The regulation of anger outbursts

In recent years, psychological interventions to improve the regulation of anger outbursts, commonly known as anger management programs, have been designed and have been developed to treat a wide range of mental and physical health problems.

The rationale for treatment is based on research that has demonstrated an association between anger and, for example, cardiovascular disorders, personality disorders, substance abuse, and organic brain disorders.

Anger is also commonly identified as the most significant antecedent of aggression and attack. Thus, one of the main reasons for treating anger attacks is to reduce the risk of engaging in violent or aggressive behavior.

The effectiveness of treatments

A number of meta-analyses on the effectiveness of anger management treatments (DiGiuseppe & Tafrate,2003) have demonstrated sufficiently positive results to produce reliable clinical changes.

Despite this, there are groups of patients with anger problems that appear to be quite difficult to treat. For example, there is limited evidence supporting anger management treatments for violent offenders, perhaps because in this case there may be associated problems such as substance abuse, personality disorders, family difficulties, or psychopathological disorders that interfere with progress in treatment.

A recent article analyzed the ways in which psychological trauma influences the frequency of anger attacks, the corresponding treatment, and the strategies implemented especially in those who experience a problematic type of anger related to traumatic histories.

There is evidence showing an association between trauma symptoms and dysregulated anger, but there are no anger management treatments directly targeting traumatic experiences.

Cognitive behavioral therapy for anger

Cognitive-behavioral methods for anger management include treatment modules or sessions. They involve researching and identifying the nature of the problem, trigger events, and contextual stressors, as well as changing dysfunctional patterns and cognitive causal inferences.

Intervention may then involve increasing skills such as improving coping responses, controlling physiological activation, preventing escalation of the anger attack, and reinforcing commitment to change.

More recent interventions instead consider deficits related to social information processing as an important element on which to direct treatment of anger outbursts, particularly in relation to the aggressor’s ability to assume the victim’s perspective.

This includes, for example, examining how the person responds to perceived provocations, both at the time of the event (judgments about who was responsible or guilty) and afterward (e.g., ruminations about legal disputes that intensify the emotional experience).

An important part of the intervention concerns events that serve as triggers for anger attacks, which may be misinterpreted as threatening and malicious, and in this sense, displays of dysregulated anger may be counterproductive.

Trauma and anger outbursts

The concept of trauma can be described as an emotional shock that results from particular events that lead those who are traumatized to feel anesthetized, frightened, vulnerable, and isolated.

Post-traumatic stress disorder (PTSD) is a psychiatric diagnosis involving psychological distress, triggered by exposure to the traumatic event, in which the individual perceives a threat to his or her own or others’ safety or physical integrity and in which he or she experiences fear, helplessness, or terror (APA, 1994).

The disorder is characterized by intrusive memories about the traumatic experience in the form of “flashbacks” or nightmares, avoidance of the stimuli that trigger such memories, emotional anesthesia, and hyper-arousal symptoms such as impulsivity, insomnia, irritability, and bouts of anger.

Although research has historically identified fear as the emotion that characterizes the disorder, significant attention has been given in recent years to anger as the key emotion associated with hyper-arousal.

PTSD and anger

Anger has been shown to be strongly associated with the severity of PTSD. In fact, a meta-analysis of 39 studies of adults exposed to trauma conducted by Orth and Weiland (2006) concluded that anger and hostility were associated with PTSD.

This analysis also reported that, on average, the strength of the association between bouts of anger and PTSD increases primarily in the first few months after exposure to the traumatic event, before slowly declining over time.

One group of people for whom anger dysregulation appears to be particularly problematic are those who have experienced what is termed “complex PTSD,” or extreme stress disorder not otherwise specified (APA, 1994).

The term complex PTSD is commonly used for those who have experienced early, prolonged, and repeated exposure to trauma, characterized, for example, by experiences such as torture, sexual abuse, domestic violence, chronic exposure to confrontation and conflict, and severe social deprivation.

A number of studies have shown that rates of aggression and violence are elevated in those who have experienced PTSD and report a history of childhood sexual abuse, leading Dyer and associates (2009) to observe that one of the most “clinically urgent” aspects of complex PTSD is problematic anger and the high levels of aggression and self-harm associated with it.

The relationship between trauma and anger

There are numerous studies that attempt to explain the association between traumatic experience and anger attacks. For some authors there would exist a theory of anger regulation for which, during exposure to stress, anger would activate attack or survival behaviors, suppression of feelings of helplessness and probably allow the individual to gain a sense of control over the situation.

Traumatized individuals might develop a propensity to perceive situations as threatening, and the perception of threat would activate a biologically predisposed survival mode that includes fear and flight reactions or bouts of anger and aggression. They would then be more or less able to regulate bouts of anger and are consequently more likely to experience this form of problematic anger and act aggressively.

Other researchers suggest that fear is essentially a prospective emotion, growing during the event and activated with respect to potential future harm, whereas other emotions such as anger and guilt may be considered retrospective emotions, growing largely after posttraumatic assessments of the event and its consequences.

This hypothesis is supported by studies showing that anger outbursts gradually increase after the traumatic event, while fear tends to decrease.

In the literature there are some authors who rely on theories based on appraisal to understand how the evaluation of the meaning of the experience determines the consequent emotion. The nuclear relational theme of anger primarily analyzed would be “the blaming or blaming of others.”

Applying this hypothesis to the experience of trauma, it has been suggested that problematic anger is most likely to occur when another person is held responsible for the traumatic event.

Work on self-blame

However, research suggests that anger management programs should also consider assessments of “self-blame or self-blame” as particularly relevant for those with symptoms of post-traumatic disorder.

Finally, for many of those who have been traumatized, it is possible that angry outbursts and bouts of rage are actually associated with pathological overcontrol (inhibition of expression) of anger and, as such, treatment should address the accumulation of frustration and perceptions of injustice (related to both the traumatic event and daily “annoyances”) in such a way as to develop appropriate emotional expressive skills.

Self-perception

Dyer and associates (2009) identified in studies of complex trauma that “alterations in self-perception” would be a significant correlate of anger, aggression, avoidance, and hyper-arousal.

The term “alterations in self-perception” is used to refer to feelings of shame, ineffectiveness, guilt, responsibility, isolation, and a sense of being permanently damaged, leading Dyer and colleagues to conclude that “posttraumatic shame” could play a significant role in both anger outbursts and aggression in traumatized individuals.

Thus, the more global negative evaluations of the self following trauma increase, the more this contributes to anger dysregulation. This offers an evolutionary explanation for how historical events (such as abuse or neglect) can, at least for some people, lead to the development of stable personality traits as well as high levels of anger expression or a reduced threshold for anger expression.

Problematic anger (high levels of trait anger, anger expression, and low levels of anger control) has been associated with long-term, rather than acute, effects of trauma, reflected in difficulties sometimes related to an inadequate sense of self and personal identity (Day et al., 2008).

References

  1. American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders 4th ed. [DSM-IV]. Washington: APA.
  2. Day, A., Howells, K., Mohr, P., Schall, E., and Gerace, A. (2008). The development of CBT programmes for anger: The role of interventions to promote perspective-taking skills. Behavioural and Cognitive Psychotherapy, 36, 299-312. Deffenbacher
  3. DiGiuseppe, R., and Iafrate, R. (2003). Anger treatment for adults: a meta-analytic review. Clinical Psychology: Science and Practice, I 0, 70-84
  4. Dyer, K. F. W., Dorahy, M., Hamilton, G., Corry, M., Shannon, M., MacSherry, A., McRobert, G., Elder, R., and McElhill, B. (2009). Anger, aggression, and self-harm in PTSD and Complex PTSD. Journal a/Clinical Psychology, 65, 1099-1114.
  5. Orth, U., and Wieland, E (2006). Anger, hostility, and Posttraumatic Stress Disorder in trauma-exposed adults: A meta-analysis. Journal of Consulting and Clinical Psychology, 74, 698-706.
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