Anger

Introduction

• Anger is a strong emotional state of irritation or hostility that arises in response to perceived threats, unfairness, or frustration.

• It is a normal adaptive response — helping defend against danger — but becomes maladaptive when frequent, intense, or uncontrollable.

• Uncontrolled anger is associated with:

  • Aggression and violence.

  • Relationship problems.

  • Workplace difficulties.

  • Increased risk of hypertension, heart disease, depression, and substance abuse.

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Physiology of Anger

• Controlled by the limbic system (especially the amygdala) and regulated by the prefrontal cortex.

• Involves activation of the sympathetic nervous system:

  • ↑ Adrenaline, cortisol.

  • ↑ Heart rate, blood pressure, respiration.

  • “Fight-or-flight” response.

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Causes of Anger

1. Psychological / Social Triggers

• Stress at work or home.

• Perceived injustice, unfair treatment.

• Relationship conflicts.

• Trauma or abuse history.

• Poor coping mechanisms.

2. Mental Health Disorders

• Intermittent explosive disorder (IED).

• Borderline personality disorder.

• Bipolar disorder (manic episodes).

• Conduct disorder, oppositional defiant disorder (in children/adolescents).

• Depression, PTSD, anxiety disorders.

3. Medical / Neurological Conditions

• Dementia.

• Traumatic brain injury.

• Stroke.

• Epilepsy (especially temporal lobe).

• Hormonal imbalance (thyroid dysfunction, low testosterone).

4. Substance-Related

• Alcohol intoxication.

• Stimulants (cocaine, amphetamines).

• Withdrawal states (alcohol, benzodiazepines, nicotine).

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Clinical Features

• Emotional: irritability, hostility, rage.

• Cognitive: distorted thinking, blaming, catastrophizing.

• Physical: increased heart rate, sweating, muscle tension, clenched fists/jaw.

• Behavioral: shouting, aggression, violence, withdrawal.

Uncontrolled anger may result in:

• Verbal or physical aggression.

• Relationship breakdown.

• Legal issues.

• Self-harm or suicidal behavior.

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Diagnostic Approach

1. History

• Frequency, triggers, severity of anger.

• Consequences (violence, job loss, strained relationships).

• Past psychiatric illness, trauma history.

• Substance use.

2. Assessment Tools

• State-Trait Anger Expression Inventory (STAXI).

• Buss–Perry Aggression Questionnaire.

• Clinical interviews (DSM-5 criteria if anger linked to IED, BPD, etc.).

3. Examination & Investigations

• Rule out medical causes:

  • Neurological exam.

  • Thyroid function tests.

  • Neuroimaging if head trauma, seizures.

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Management and Treatment

Management involves psychological therapy, lifestyle modification, and medication if anger is part of a psychiatric or medical condition.

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A. Psychological / Behavioral Interventions

1. Cognitive Behavioral Therapy (CBT)

   • Identifies triggers and modifies thought patterns.

   • Teaches relaxation, coping, problem-solving skills.

2. Anger Management Programs

   • Group or individual therapy.

   • Role-playing, relaxation, assertiveness training.

3. Mindfulness and Relaxation Techniques

   • Meditation, deep breathing, yoga.

   • Progressive muscle relaxation.

4. Communication Skills Training

   • Assertiveness training to express needs without aggression.

5. Stress Management

   • Time management, healthy coping strategies.

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B. Lifestyle Measures

• Regular exercise (aerobic activity reduces stress hormones).

• Adequate sleep.

• Avoid caffeine, stimulants, and alcohol.

• Balanced diet.

• Strong social support networks.

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C. Pharmacological Treatment

No drug treats “anger” directly, but medications are useful if anger is linked to psychiatric or neurological conditions.

1. Antidepressants (for depression/anxiety/PTSD with anger)

   • SSRIs:

     • Sertraline 50 mg orally daily (range 50–200 mg).

     • Fluoxetine 20 mg orally daily.

   • SNRIs: Venlafaxine XR 75–150 mg daily.

2. Mood Stabilizers (for bipolar disorder, IED)

   • Valproate 500–1000 mg/day orally in divided doses.

   • Lithium carbonate 600–1200 mg/day orally (maintain serum 0.6–1.2 mmol/L).

   • Carbamazepine 200–400 mg orally twice daily.

3. Antipsychotics (for aggression in psychosis, dementia, severe IED)

   • Risperidone 0.5–2 mg orally daily.

   • Olanzapine 5–10 mg orally daily.

4. Anxiolytics (short-term use for acute agitation)

   • Lorazepam 1–2 mg orally/IM as needed.
     * Avoid long-term benzodiazepines due to dependence risk.

5. Beta-blockers (reduce physical symptoms of anger/anxiety)

   • Propranolol 20–40 mg orally three times daily.

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D. Emergency Management of Acute Aggression

• Ensure safety of patient and others.

• De-escalation techniques: calm communication, non-threatening posture.

• If severe agitation:

  • Lorazepam 2 mg IM OR

  • Haloperidol 5 mg IM ± benzodiazepine.

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Complications

• Relationship breakdown, domestic violence.

• Occupational and financial difficulties.

• Substance abuse.

• Legal issues, imprisonment.

• Physical health risks: hypertension, stroke, coronary heart disease.

• Suicide or self-harm.

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Prognosis

• With therapy, prognosis is very good.

• CBT and anger management are highly effective.

• Medication helps when anger is part of psychiatric illness.

• Prognosis is poor if left untreated — risk of violence, social isolation, and chronic disease increases.

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Patient Education

• Anger is normal but must be controlled and expressed constructively.

• Recognize early warning signs (clenched fists, fast heartbeat).

• Take time-outs when feeling overwhelmed.

• Use relaxation techniques and exercise regularly.

• Avoid alcohol and recreational drugs.

• Seek help if anger leads to aggression, violence, or relationship problems.

• Emergency help is essential if thoughts of harming self or others occur.