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Anger Attacks in Patients with Depression

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Anger Attacks in Patients with Depression Anger Attacks in Patients With Depression Anger Attacks in Patients With Depression Maurizio Fava, M.D., and Jerrold F. Rosenbaum, M.D. Anger attacks are sudden intense spells of anger that resemble panic attacks but lack the predomi- nant affects of fear and anxiety associated with panic attacks. They typically occur in situations in © Copyrightwhich an individual feels2000 emotionally Physicians trapped and experiences Postgraduate outbursts of anger that Press, are later de- Inc. scribed by the patient as being uncharacteristic and inappropriate to the situation at hand. Anger at- tacks consist of both behavioral and autonomic features, and various criteria and an Anger Attacks Questionnaire have been designed to identify the presence of these attacks. The prevalence of anger attacks in depressed patients is approximately 30% to 40%, and the attacks have disappeared in 53% to 71% of depressed patients treated with fluoxetine, sertraline, or imipramine. This article discusses the development of the concept of anger attacks, the presence of anger attacks in depression and other psychiatric disorders, and the current treatment of anger attacks. (J Clin Psychiatry 1999;60[suppl 15]:21–24) nger attacks are sudden intenseOne spells personal of anger copythat maythe bedevelopment printed of the concept of anger attacks, the pres- Aresemble panic attacks but lack the predominant af- ence of anger attacks in depression and other psychiatric fects of fear and anxiety associated with panic attacks. An- disorders, and the current treatment of anger attacks. ger attacks typically occur in situations in which an indi- In 1990, we5 reported on a series of patients who expe- vidual feels emotionally trapped and experiences outbursts rienced sudden outbursts of anger resembling panic attacks. of anger. Dysregulated anger is a state in which the behav- These anger attacks were described by the patients as un- ior must be provoked in order to be observed. Thus, an an- characteristic behavior that was inappropriate for the situ- ger attack is a combination of predisposition—or some en- ation at hand and was followed by remorse. The outbursts during state of vulnerability—and provocation. It is of angry behavior were accompanied by physical features possible that dysregulated anger is a response to the fight/ of autonomic activation that included sweating, trembling, flight reaction expressed cognitively and behaviorally as tachycardia, and hot flashes. Since the anger attacks im- anger and fight instead of fear and flight.1 On the other proved with antidepressant treatment, they were postulated hand, anger and irritability may be part of a depressive to be variants of major depression. A self-rating Anger At- symptomatology.2 Irritable mood is a core symptom of ma- tacks Questionnaire was subsequently designed as an jor depressive disorder in children and adolescents but is ad hoc instrument for assessing the presence of anger and emphasized less as a symptom of depression in adults. Nev- was administered to patients already participating in clini- ertheless, Snaith and Taylor3 report that 37% of depressed cal trials. Surprisingly, anger attacks—as defined by the inpatients had moderate-to-severe outwardly directed irri- questionnaire—were significantly more common among tability, and findings from the Epidemiologic Catchment depressed outpatients than in healthy volunteers with no Area surveys indicate that depression is related to violent known psychiatric history.6 behavior in samples taken from the community.4 Moreover, a substantial number of depressed adult patients seek medi- ANGER ATTACKS AND DEPRESSION cal treatment because of irritability and/or anger that causes distress and conflict in their lives. This article will discuss The prevalence of anger attacks in patients with major depression has been assessed at 44% (56/127) in one sample,7 39% (64/164) in a later sample,8 and 38% (36/94) in patients with atypical major depression, 28% (21/74) in From the Outpatient Psychiatry Division, Clinical patients with dysthymia, and 0% (0/38) in screened normal Psychopharmacology Unit, Massachusetts General Hospital, 9 and Harvard Medical School, Boston. controls. Given the presence of mood reactivity in atypi- Presented at the closed symposium “Phenomenology and cal major depression, the prevalence of anger attacks is Treatment of Aggression Across Psychiatric Illnesses,” held similar whether patients have typical or atypical major de- August 31, 1998, Chicago, Illinois, and sponsored by an unrestricted educational grant from Abbott Laboratories. pression. On the basis of these findings, the prevalence of Reprint requests to: Jerrold F. Rosenbaum, M.D., anger attacks in depressed populations is approximately Depression Clinical and Research Program, WACC 815, 10 Massachusetts General Hospital, 15 Parkman St., Boston, MA 30% to 40%. While no significant differences in rates of 02114. lifetime comorbid anxiety, eating, and substance use disor- J Clin Psychiatry 1999;60 (suppl 15 ) 21 Fava and Rosenbaum Figure 1. Frequency of Autonomic Arousal Symptoms and Figure 2. Scores of Depressed Patients With and Without Behavioral Outbursts During Anger Attacks (N = 56)a Anger Attacks on Symptom Questionnairea Tachycardia SQ Anxiety p = .01 Hot Flashes Patients With Anger Attacks Chest Tightness or Pressure SQ Depression Patients Without Limb Numbness or Tingling Anger Attacks Scale Lightheadedness or Dizziness SQ Somatization p = .006 Shortness of Breath Sweating SQ Hostility p = .0001 Shaking or Trembling 02040 ©Fear, Copyright Panic, or Anxiety 2000 Physicians Postgraduate Press, Inc. Mean Scores on Scales Feeling Out of Control aData adapted from reference 7. Feeling Like Attacking Others Attacking Physically/Verbally Throwing or Destroying Objects Anger Attacks as Uncharacteristic to attack others. While 63% of the patients with anger at- Guilt or Regret After Anger Attacks tacks reported physical or verbal attacks directed at others, 0 20406080100 only 30% actually threw objects or destroyed property. Af- % With Symptoms ter the attacks, guilt or regret was almost universal (93%) a Data adapted from reference 7. (Figure 1).7 On the Symptom Questionnaire that measures global psychological distress, depressed patients with an- One personal copy mayger beattacks printed scored higher on the anxiety, somatization, and ders were found between depressed patients with and with- hostility scales than depressed patients without anger at- out anger attacks, 8% of depressed patients with anger at- tacks. No significant difference was noted on the depres- tacks met criteria for current comorbid panic disorder com- sion scale of the Symptom Questionnaire between patients pared with 3% of depressed patients without anger attacks, with and without anger attacks, a finding that corresponded with a trend toward a statistically significant difference.11 with Hamilton Depression Rating Scale (HAM-D) scores (Figure 2).7 High scores on the anxiety scale may be a re- Criteria and Measurement of Anger Attacks flection of the autonomic symptoms experienced or a pos- The criteria adopted to define anger attacks6 include sible link between dysregulated anger and anxiety. (1) irritability during the previous 6 months, (2) overreac- Irritability and anger in depressed patients is sometimes tion to minor annoyances with anger, (3) occurrence of viewed as evidence for a personality disorder, and the 1 or more anger attacks during the previous month, and self-rated Personality Diagnostic Questionnaire-Revised (4) inappropriate anger and rage directed at others during (PDQ-R) was used to assess comorbid personality disor- an anger attack. Additional criteria—modeled in part from ders in depressed patients with and without anger attacks. the DSM-IV criteria for panic attack—include the occur- Depressed patients with anger attacks were more likely to rence of at least 4 of the following autonomic and/or be- meet criteria for histrionic, narcissistic, borderline, and an- havioral features in at least 1 of the attacks: heart palpita- tisocial personality disorders than depressed patients with- tions, flushing, chest tightness or pressure, paresthesias, out anger attacks.7 In another sample of 333 depressed light-headedness or dizziness, excessive sweating, short- outpatients (148 men, 185 women, mean ± SD age = ness of breath, shaking or trembling, intense fear or anxi- 40.0 ± 10.4 years), the clinician-rated SCID-II (Structured ety, feeling out of control, feeling like attacking others, Clinical Interview for Personality Disorders), the SCID, physically and/or verbally attacking others, and throwing and the Anger Attacks Questionnaire were used for evalu- or destroying objects. In 79 consecutive patients (25 men, ation, and depressed patients with anger attacks were sig- 54 women) with major depression diagnosed by the Struc- nificantly more likely to meet criteria for dependent, tured Clinical Interview for DSM-III-R (SCID) and as- avoidant, narcissistic, borderline, and antisocial personal- sessed with the Anger Attacks Questionnaire, 34 patients ity disorder than depressed patients without anger attacks.10 (13 men, 21 women) reported having anger attacks accord- ing to the criteria.6 In a sample of 127 depressed outpa- Serotonergic Function and Anger Attacks tients, 56 (44%) reported a mean ± SD of 7.4 ± 13.0 anger Derangements in serotonergic function have been re- attacks per month when assessed with the Anger Attacks ported in both depression and aggressive behavior.12,13
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