Anger Management: Exploring Impulsive Aggression and Anger Disorders

Our language has many idiomatic expressions that describe a person with anger management issues, perhaps because impulsive anger is something we frequently witness or experience. Loses his cool. Has a quick temper. Has a short fuse. Blows his top. Busts a gasket. Has a temper tantrum. Has a cow. Foams at the mouth. Sees red. Goes ballistic. Goes through the roof. Bristles with rage. Flames with anger. Bites your head off. Most of us know someone volatile who seems to fly off the handle at the drop of a hat.

Anger Disorders vs. Just Plain Angry

We all experience anger, but not all of us experience it as intense fury. Many people experience anger as a byproduct of the stressors of daily life, grief over past losses or frustrations over health issues. They may have occasional angry outbursts that help them blow off steam, but fall within a normal emotional framework and don’t stem from any underlying mental health disorder — they may just be feeling angry. Some key factors that distinguish a person with an anger disorder from a person who is just plain angry include the issue of control, as well as the intensity of the anger and whether it is persistent or prolonged. People who have trouble controlling their temper and frequently experience intense bursts of rage may suffer from some type of anger disorder. It can be difficult to identify an anger disorder or to distinguish it from other behavior disorders. Anger is complex because it can be expressed in different ways. Some of the different ways anger may be felt or expressed include chronic anger, passive anger, overwhelmed anger, self-directed anger, judgmental anger, volatile anger and impulsive aggression. “Anger can be expressed outwardly, looking like a person being argumentative, being physically aggressive or attacking another person’s character,” says Frank Sanchez, PhD, LMFT, program director of the Young Adult Program at Promises. “Anger can also be turned inward, usually because the person is afraid of what their anger will do to someone else. An internal expression of anger could involve self-harm, such as cutting or burning themselves, putting themselves down silently or sabotaging things like work or relationships.”

A Person With ‘Anger Issues’ May Suffer From an Impulse-Control Disorder

If there is someone in your life that you tip-toe around for fear they might fly into a rage, spewing verbal vitriol and slamming doors or breaking the furniture, it is possible they suffer from an impulse-control disorder. Characterized by sudden, uncontrollable bursts of anger that are usually disproportionate to the situation, these outbursts often point to impulsive aggression, which is categorized among “Disruptive, Impulse-Control and Conduct Disorders” in the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition — the book that psychiatrists use to diagnose emotional, behavioral and mental health disorders. It is estimated that nearly 16 million Americans suffer from impulsive aggression, a condition known in psychiatry as intermittent explosive disorder (IED). This disorder, sometimes referred to as an anger-management disorder, can appear in childhood. A study from Harvard Medical School determined that nearly one in 12 Americans aged 13 to 17, or 6 million adolescents and teens, are affected by IED. IED often co-occurs with mood, anxiety and substance use disorders. In the Harvard study of adolescents with IED, nearly 64% of the study participants who reported lifelong fits of uncontrollable anger also met the criteria for having another disorder such as ADHD, depression, post-traumatic stress disorder (PTSD), bipolar disorder, conduct disorder or personality disorder, among others.

Signs, Symptoms and Diagnosis of Impulsive Aggression or IED

The physical symptoms of IED can look like symptoms of other disorders, so diagnosis can be challenging. A complication is a co-occurring disorder or health issue with mirroring or overlapping symptoms. Some studies have found that people who have suffered a traumatic brain injury are at higher risk for having anger-management problems. That said, signs of IED include angry outbursts, verbal aggression and even physical aggressiveness, where the person with IED attacks people or things. Problems with road rage can be a sign of IED. The diagnostic criteria for IED underwent a shift in 2013 when the DSM was updated to the fifth edition. Previous editions specified that for a diagnosis of IED, a person had to display physical aggression. According to the updated DSM-5, a diagnosis of IED can be reached if the person has only verbal outbursts or nondestructive physical aggression — the key is that the outbursts must be unpremeditated or impulsive in nature. Additional criteria are that the outbursts cause impairment, distress or negative consequences for the individual with IED. For a person who suffers from IED, angry outbursts may be preceded by internal symptoms like racing thoughts, extreme irritability, tension, tingling or tremors, headaches or pressure in the head, tightness in the chest, mood changes or energy changes. This is not to say that the IED sufferer can always recognize these symptoms or control an impending outburst. The outbursts often occur, or erupt, in response to a trigger that may only be perceived by the person with IED. Others can be caught off guard, not perceiving any external provocation, which makes the outbursts unexpected and shocking — as if they come out of nowhere.

Anger Management Therapy: Learning to Cool Your Jets

When anger is chronic and outbursts frequent, getting in the way of relationships at home and at work, anger management treatment is usually warranted. Issues with anger are often the underlying cause of substance abuse, so treatment can be tailored to address both problems simultaneously — providing the individual with tools and therapies that help keep emotions under control and also for overcoming addiction and avoiding relapse. Therapy, rather than medication, is usually the preferred approach for treating anger problems, unless there is a co-occurring disorder that would benefit from medication. Anger management therapies can help people with IED and other anger conditions recognize the early signs of an impending outburst so they can prevent themselves from reaching the explosion phase. Cognitive behavioral therapy is used in anger management to help people learn to recognize triggers and change the way they think about and react to things so they don’t respond with anger. Other tools and strategies used are improving communication skills to express anger more productively, gaining new problem-solving skills to prevent frustration, learning to avoid problematic situations and using relaxation techniques to stay calm and diminish anger surges. “When a person chooses to get help for anger issues, they learn different ways to respond to anger and how to identify when the anger has been triggered,” says Sanchez.  “They also learn how to stop themselves when they notice a trigger and to respond in an appropriate manner. They learn to change the thoughts and feelings associated with the trigger so they can have a more rational response to incidents.” Sanchez notes that once people undergo anger management training, they are better equipped to respond to situations appropriately, can overcome their tendency toward impulsive outbursts and can live a life free of regret. Sources: Research shows parallels between addiction and aggression. Compulsive addiction-like aggressive behavior in mice. SA Golden, et al. Biological Psychiatry, April 2017. Uncontrollable Anger Prevalent Among Youth. Intermittent Explosive Disorder affects up to 6 million U.S. adolescents. Ronald Kessler, PhD, et al. Harvard News and Archives of General Psychiatry, July 2012. Highlights of Changes from DSM-IV-TR to DSM-5 by American Psychiatric Publishing, July 2013. Managing Anger. SAMHSA News, Volume 22, Number 3, Summer Issue 2014. Impulsive Aggressive Behavior. Candice Hughes. Livestrong, 2015. Oppositional Defiant Disorder Symptoms. Steve Bressert, PhD. Psych Central, 2017.

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