A Comprehensive Treatment Program for Anger Disorders

1. A Comprehensive Treatment Program for Anger Disorders Raymond DiGiuseppe, Ph.D., D.Sc., ABPPSt. John's UniversityandThe Albert Ellis Institute Villanova University

2. Seneca On Anger We are here to encounter the most outrageous, brutal, dangerous, and intractable of all passions; the most loathsome and unmannerly; nay, the most ridiculous too; and the subduing of this monster will do a great deal toward the establishment of human peace (Seneca, On Anger, 40-50 AD) Villanova University

3. Seneca On Anger “My purpose is to picture the cruelty of anger which not only vents its fury on a man here and there but renders in pieces whole nations.” (Seneca, On Anger 40-50 AD) Villanova University

4. LOS ANGELES (October 26, 2010) — According to a new study by the Josephson Institute of Ethics on High School Students I hit a person because I was angry at least once within the past 12 months. Type of School Boys Girls Overall Public Schools 57% 48% 53% Religious Private schools 57% 38% 47% Non religious private schools 44% 35% 40% All Schools combined 56% 47% 52% Villanova University

5. Anger on the Web March 16, 2013 An online Google™ search at the time this manual goes to print for the terms “anger management produced more than 80 Million hits “anger management treatment” produced more than 28,100,000 hits and “children” produced links to more than 28,100,000 pages devoted to this topic. A search for the terms “anger” and “adolescents” in Google™ resulted in more than 1,720,000 pages. Villanova University

6. Anger and “children” produced links to more than 28,100,000 pages devoted to this topic. A search for the terms “anger” and “adolescents” in Google™ resulted in more than 1,720,000 pages. Villanova University

7. Problems Studying Clinical Anger • We know much less about anger as a clinical problem than we know about other emotional disorders: • We have less literature to inform us. • People question anger’s status as a basic human emotion. Clinicians often see it as secondary to depression and anxiety. • Definitional confusion exists among anger and related terms. • We have questions about how is anger learned. Villanova University

8. Can anger be dysfunctional? • No diagnostic categories exist for anger problems in DSM IV, 5. • We have little treatment outcome research to guide practice. • Confusion exists about the elements of the anger experience. What elements make up anger? • How should treatment proceed? Villanova University

9. Less Literature to Inform Us A much larger literature exits about depression and anxiety compared with anger for: • Diagnosis • Assessment • Treatment Villanova University

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12. G. Stanley Hall, 1899 “The psychological literature contains no comprehensive memoir on this very important and interesting subject. Most textbooks treat it either very briefly or not at all, or enumerate it with fear, love, etc., as one of the feelings, sentiments or emotions which are discussed collectively. Where it is especially studied, it is either in an abstract, speculative way, as in ethical works, or descriptively as in books on expression or anthropology or with reference to its place in some scheme or tabulation of the feelings, …or its expressions are treated in the way of literary characterizations as in novels, poetry, epics, etc., or finally its morbid and perhaps hospital forms are described in treatises on insanity.” Villanova University

13. This state of affairs is true for other emotions also. • Disgust • Envy • Jealousy Since Freud we have limited the study of dysfunctional emotions to depression & Anxiety Villanova University

14. Is Anger a Secondary Emotion or a BasicEmotion? Villanova University

15. The majority of theorists and researchers in the Psychology of emotions consider anger one of the basic emotions. These include: Arnold, Darwin, Ekman, Friesen and Ellsworth, Gray, Izard, James, McDougall, Oatley and Johnson Laird, Panksepp, Plutchik, Tomkins. Watson. Frijda, Mowrer, and Weiner and Graham do not. Villanova University

16. Thus, most scientists studying emotions disagree with commonly held position of clinicians that anger is a secondary emotion. Villanova University

17. Anger is Not Well Defined • Rothenberg (1971) noted more than 38 years ago said that, • “...almost invariably, anger has not been considered an independent topic worthy of investigation ... [which] has not only deprived anger of its rightful importance in the understanding of human behavior, but has also led to a morass of confused definitions, misconceptions, and simplistic theories.” (p. 86) Villanova University

18. Definitions • Anger: an internal, mental, subjective feeling state with associated cognitions and physiological arousal patterns. • Aggression: overt behavior enacted with the intent to do harm or injury to a person or object. • Hostility: A personality trait evidenced by cross-situational patterns of anger with verbal or behavioral aggression. An attitude of resentment, suspiciousness, and bitterness (Buss & Perry, 1992), and the desire to get revenge (Mikulincer, 1998). Villanova University

19. Irritability: increased sensitivity to environmental stimulation that causes physiological arousal and tension without cognitive mediation, that results in a lowered threshold to anger. AFFECTIVE AROUSAL without COGNITION There is a lack of agreement on irritability items. • Hate: long-lasting predisposition to dwell on the transgressions committed by a person held in general disdain and condemned for their transgressions or traits. COGNITION without AFFECTIVE AROUSAL Villanova University

20. Most tests of anger do not agree on what constructs or components of anger and aggression to measures. How WORD files of tests Villanova University

21. How is Anger Learned? • Theorists frequently comment that animals & people learn anger through classical and operant conditioning. • Pavlov listed anger as one of the responses that could be learned by classical conditioning. • Literature searches of classical conditioning terms uncovered only three references about anger. • Two were with fish. One acknowledged extensive research leading to the null hypothesis. Villanova University

22. How is Anger Learned? • People easily learn to fear an angry face or voice. • No evidence has emerged that people learn to feel angry through classical conditioning. • Anger seems to be an approach, not an escape emotion. • Experiential avoidance does not seem to be a mechanism of disturbance or treatment. Villanova University

23. How is Anger Learned? Anger produces neural activity in theleft frontal lobe with approach emotions, such as joy. It does not activate activity in the right frontal lobe as do other negative emotions which produce an escape gradient. Treatment should be based on reinforcement models of anger and aggression Villanova University

24. Is Anger A Clinical Problem? • As many clients seek mental health services for anger as do for depression and anxiety (Posternak & Zimmerman, 2002). • Clinicians claim they see as many angry clients as anxious clients (Lochman, DiGiuseppe, & Fuller, 2005). • Anger can be as dysfunctional as any emotional excess. Villanova University

25. Can Anger Be Dysfunctional? “Certain wise men have claimed that anger is temporary madness. For it is equally devoid of self-control, forgetful of decency, unmindful of ties, persistent and diligent in whatever it begins, closed to reason and counsel, excited by trifle causes, unfit to discern the right and true -the very counterpart of a ruin that is shattered in pieces where it overwhelms. But you have only to behold the aspect of those possessed by anger to know that they are insane. Seneca On Anger - 50 AD (Basore, 1958, p. 107).” Villanova University

26. Dysfunctional Anger - Brevis Furor “Whereof it is that anger is called Brevis Furor, a short madness, because it differs not from madness but in time. Saving that herein it is far worse, in that he who is possessed with madness is necessarily, willy, nilly, subject to that fury: but this passion is entered into wittingly and willingly. Madness is the evil of punishment, but anger is the evil of sin also; madness as it were thrusts reason from its imperial throne, but anger abuseth reason by forcing it with all violence to be a slave to passion. For Anger is a disease of the mind. From “A Treatise of Anger” by John Downame, 1608, cited in Hunter and Macalpine, 1963, p. 55).” Villanova University

27. Anger In Classical Philosophy • Anger was always considered a major part of human suffering since the classic Greek & Roman philosophers. • Anger ceased to be considered a clinical problem at the beginning of the 20th Century. Villanova University

28. Rabbi Moshe Chaim LuzzattoMesilas Yesharim (The Path of the Just) • Rabbi Moshe Chaim Luzzatto (1707 - 1746, 26 Iyar 5506), also known by the Hebrew acronym RaMHaL, was a prominent Italian Jewish rabbi, kabbalist, and philosopher. Born in Padua, he received classical Jewish and Italian educations, showing a predilection for literature at a very early age. He attended the University of Padua and with his vast knowledge in religious lore, the arts, and science, he quickly became the dominant figure in that group. Villanova University

29. "V'hasair Kaas Meeleebecha"  ("And you shall remove anger from your heart" from the verse in Ecclesiastes Chapter 11) • Whoever has a brain in his head needs to run from this evil attribute [of anger] as he [would] run from a fire. For [the person] is clearly aware that due to this evil attribute [of anger], in the future, on The Day of Judgment, he will definitely emerge [with a verdict of] guilty. [The person should be aware that he would emerge guilty on The Day of Judgment due to his attribute of anger, for it] is known that one who has a majority of demerits, falls in the category of [those who are] evil. Villanova University

30. Early 20th Century Kraeplin, and then Freud, made anger part of depression. They were referring to bipolar disorder and mania does have a strong anger component. Since Kraeplin & Freud, clinicians have seen anger as part of depression. Is this what they intended? Freud recognized the thought patterns of narcissistic entitlement which arose anger. Villanova University

31. Anger and Depression • Anger and depression are part of the social dominance system (Stevens & Price, 1996 Evolutionary Psychiatry). • Anger is the expression of dominance. • Depression is the expression of submission. • Thus, they are opposite ends of the dominance/submission social display system. Villanova University

32. Anger and Depression • For people who experience both anger and depression, we suspect a sequential relationship. • They get depressed about their anger episodes, or when they realize they cannot intimidate others into compliance. Villanova University

33. Anger in the DSM-IV-TR • No anger disorders exist in the DSM-IV. • ICD-10 has an Explosive Personality Disorder. • Many depressive (mood) disorders and anxiety disorders exist. • Intermittent Explosive Disorder is the most used diagnosis for anger problems. It does not define angry clients. Villanova University

34. Should we have an anger disorder diagnosis? Or at least a taxonomy of angry and aggressive clients? Villanova University

35. How Clinicians Diagnosis Anger Clients • We asked clinicians to diagnosis case studies of angry and anxious clients (Lochman, DiGiuseppe, & Fuller, 2006). • For the anger cases, the most common Axis I diagnosis was Intermittent Explosive Disorder. • Next most common is Organic Brain Syndrome. • Clinicians had low agreement for diagnosis of the anger cases. Villanova University

36. Diagnosing Anger • 80% used an Axis II diagnosis when allowed 2 diagnoses. • Clinicians over-pathologized anger clients. • Clinicians saw the diagnosis of an anger disorder as unrelated to the development of a treatment plan. Villanova University

37. Wakefield's & DSM’s Definition of a Disorder is that it involves a response both harmful and dysfunctional. Can anger be a harmful dysfunction? Villanova University

38. Anger has been dysfunctional in: • War - aggressors more frequently lose. • Terrorism – most often fails to reach political goals. • Torture – most often fails to get information. • Rape – often fails to gain satisfaction. • Murder – almost always regretted by offender. • Road Rage – causes unsafe and dangerous behaviors. • Illness – associated with many forms of illness. Villanova University

39. Anger is harmful in that: Anger harms interpersonal relationships. Anger impedes sexual functioning. Effects on marital relations. Negatively effects goal attainment. Anger leads to medication noncompliance. Anger is the component of Expressed Emotion that leads to relapse of serious mental illness. Anger increases involvement in the Criminal Justice System. Anger interferes with judgment. Anger slow the healing of wounds. Villanova University

40. Opposition to an Anger Disorder An anger disorder will hold people less culpable for antisocial/aggressive behavior. DSM has too many disorders already. What if other fields of medicine adopted this. Anger is covered by other diagnoses. Is this true? Anger can be functional. – So, are all emotions. Villanova University

41. Anger In Psychiatric Outpatients(McDermut, Fuller, DiGiuseppe, Zimmerman, & Chelminski, 2009) • Complete Structured Interviews to all outpatients • Axis I – SCID; Axis II – SIDP-IV; N = 1774 • Best anger item is Borderline Symptom 8. This has ten questions that ask: • Anger intensity, frequency, duration, Anger expression, type of triggers, Rated on scale of 0 to 3, Score of 2 or 3 indicated one has the symptom. Villanova University

42. Do most anger patients meet criteria for In Borderline PD • Since this symptom is part of the BPD module, does BPD account for anger in psychiatric outpatients? • NO. Villanova University

43. If the comorbidity of anger symptoms with any others disorder is very high, we do not need a new anger disorder to explain anger problems. Villanova University

44. Overlap of Anger and PD Diagnoses • Highest Kappa is anger symptoms and BPD = .33 • Kappa between anger symptoms and other PDs ranged from .01 to .13. • These are low and suggest that anger symptoms do not overlap much with Personality Disorders other than BPD. Villanova University

45. Mean Personality Disorder Traits By Level of Anger Borderline Depressive Mean No. of Traits Obsessive Avoidant Self-Defeat Antisocial Negativistic Narcissistic Paranoid Dependent Schizotypal Histrionic Schizoid Villanova University Level of Anger

46. Anger is often considered to be an impulse disorder, like IED, or part of mania. • Do these disorders account for those with anger symptoms? • No. The Kappa coefficients of these Dx and anger is les than .1 • Do anxiety and mood or depressive disorders account for anger symptoms? • NO – These relationship are small about .2. • Anger is more comorbid with anxiety than depression. Villanova University

47. Anger and Emotional Disorders • The most common comorbid Anxiety Disorders are those with possible anger symptoms such as GAD or PTSD. • It is Social Phobia. Villanova University

48. Diagnostic Criteria for Anger-Aggression/Expression Disorder Either (1) or (2) 1. Significant angry affect as indicated by frequent, intense, or enduring anger episodes that have persisted for at least six-months. Two more of the following characteristics are present during or immediately following anger experiences: a) Physical activation (e.g., increased heart rate, rapid breathing, muscle tension, stomach related symptoms, headaches) b) Rumination that interferes with concentration, task performance, problem-solving, or decision-making. c) Cognitive distortions (e.g., biased attributions regarding the intentions of others; inflexible demanding view of others unwanted behaviors, code of conduct, or typical inconveniences; low tolerance for discordant events; condemnation or global rating of others who engage in perceived transgressions). d) Ineffective communication . e) Brooding or withdrawal. f) Subjective distress (e.g., awareness of negative consequences associated with anger episodes, anger experiences perceived as negative, additional negative feelings such as guilt, shame, or regret follow anger episodes) Villanova University

49. Diagnostic Criteria for Anger-Aggression/Expression Disorder 2. A marked pattern of aggressive/expressive behaviors associated with anger episodes. Expressive patterns are out of proportion to the triggering event. However, anger experiences need not be frequent, of high intensity, or of long duration. At least one of the following expressive patterns is consistently related to anger experiences: a) Direct Aggression/Expression • Aversive verbalizations (e.g., yelling, screaming, arguing nosily, criticizing, using sarcasm, insulting) • Physical aggression toward people (e.g., pushing, shoving, hitting, kicking, throwing objects) • Destruction of property • Provocative bodily expression (negative gesticulation, menacing or threatening movements, physical obstruction of others) Villanova University

50. Diagnostic Criteria for Anger-Aggression/Expression Disorder b) Indirect Aggression/Expression • Intentionally failing to meet obligations or live up to others’ expectations • Covertly sabotaging (e.g., secretly destroying property, interfering with task completion, creating problems for others) • Disrupting or negatively influencing others’ social network (e.g., spreading rumors, gossiping; defamation, excluding others from important activities). B. There is evidence of regular damage to social or vocational relationships due to the anger episodes or expressive patterns. C. The angry or expressive symptoms are not better accounted for by another mental disorder (e.g., Substance Use disorder, Bipolar Disorder, Schizophrenia, or a personality disorder) or medical condition. Villanova University