“Anger
Attacks”:
Possible
and Major
Maurizio
Fava,
M.D.,
Keith
Variants
Depressive
Anderson,
Disorders
M.D.,
and Jerrold
strative
The authors report a series of illustrative cases in which patients presented with sudden “spells” of anger with physical features that resembled panic attacks but lacked the affects of fear and anxiety. These spells or “attacks” of anger were experienced as uncharacteristic and were inappropriate to the situations in which they occurred. Since treatment of these attacks with antidepressants produced in each case marked im-
provements
in behavior,
some hypotheses (Am J Psychiatry
the
as to the 1990;
authors
also
nature of these 147:867-870)
and
hen a nonpsychotic isodes of anger
%,v
grossly
out of proportion
stressons,
a personality
derline)
is typically
psychiatric
adult are
that
describes of short
treatments
of
marked
first
organic
considered.
disturbances,
however,
( )
Numerous
may
epand
or
bor-
other
be associated
hypotheses
ogy Unit,
Massachusetts
General
pital, Ottawa, Ont., Canada. Clinical Psychopharmacology tal, 15 Parkman St., ACC81S, Copyright © 1990 American
Am
J
Psychiatry
received
Aug.
the Clinical Hospital, and
1 and
Dec.
20,
PsychopharmacolOttawa Civic Hos-
Address reprint requests to Dr. Fava, Unit, Massachusetts General HospiBoston, MA 02114. Psychiatric Association.
1 47: 7, July
1990
in
attacks
in
as to the
treatment
which
patients
in
each
behavior, nature
case
we
pre-
that were exinappropriate Since specific produced
formulate
of these
episodes
some and
offer
recommendations.
REPORTS
1 Mr.
A, a 45-year-old
.
white
man,
was an attorney
who lived with his wife and referred by his therapist because and thought “in a fragmented problems to stressful life events
three children. He had been he lost his temper frequently way.” Mr. A attributed his over the previous 10 months.
He had
a long
with
lost
his mother
his wife
He denied
and
after
children,
feelings
and
had
of depression
illness, been
and
had
problems
distressed
sleep
at work.
or appetite
dis-
and diminished energy and concentration. He had been in therapy for a couple of years and had found that very helpful, since it had allowed him to deal with the loss of his mother and to turbance
with a tendency to anger 1 : affective disorders, hypochondniasis, schizophrenic disorders, paranoid disorders, and psychoactive substance intoxication or withdrawal. Adult “temper tantrums” have been reported among mentally retarded individuals (2) and in subjects with head trauma, minimal brain dysfunction, epilepsy, brain tumor, infections, cerebral vascular disease, other neurological disease, and endocrine and metabolic disorders (3). When these discrete episodes of loss of control oven aggressive impulses result in assaultive acts or destruction of property, the best diagnostic fit from DSM-III-R may be intermittent explosive disorder. The existence of a discrete disorder is controversial; these behaviors are often viewed as symptomatic of a personality disorder. Six years ago, one of us (K.A.) noted in a patient sudden “spells” of anger with physical features that resembled panic attacks but lacked the affects of fear and anxiety. Since then, we have observed a number of similar cases: we now report some of the most demon-
Received Aug. 2, 1988; revisions 1989; accepted Jan. 25, 1990. From
cases
these
changes
CASE
psychosocial
(e.g.,
illustrative
M.D.
formulate episodes.
repeated duration
to precipitating disorder
F. Rosenbaum,
sented with spells on “attacks” of anger penienced as uncharacteristic and were to the situations in which they occurred.
Case
“ VT
of Panic
but
her.
mourn
tient had his temper
reported
However,
had
yell;
fuse,”
explosive
things
few months,
during enraged and
that
in therapy
patient seizures,
the state
“anger
his heart
quickly, During
rate accelerated, and
his
he would
alien to him and was concerned that he would as a result. He denied having suffered from simin the past. About 12 years earlier he had been for
a short
unremarkable;
time
his
and
At the time for
very
attacks.”
about an hour He felt that these epi-
of arousal.
had no history of or drug or alcohol
alcoholism,
the pa-
which he would lose and yelling at others.
felt out of control
temper
he noticed
from
sodes were lose his job ilar episodes
teria
in
would flush while he felt out of control, after the initial surge, it would take him
to recover
was
interest
for the previous
a “short
an
these attacks face
of
been having episodes in a flash, becoming
He described and
lack
his
because
of
mania, abuse.
hypomania, His past
mother
father
had
had
of his evaluation,
depressive
disorder
a probable
a history
Mr. not
marital
problems.
head medical diagnosis
The injury, history of
of paranoia.
A met
otherwise
DSM-III-R specified;
not appear to have a personality disorder. In addition, a very high hostility score (score of 15; maximum=23)
cri-
he did
he had on
the Kellner Symptom Questionnaire (4), a self-rating scale of distress that contains subscales of anxiety, depression, somatization, and hostility and whose mean±SD hostility subscale score in normal control subjects is 3.7±3.5. Treatment was immediately initiated with desipramine, 10 mg h.s., which was later gradually increased to 200 mg h.s.
867
“ANGER
ATFACKS”
Mr. A was seen on average once every month for pharmacotherapy, and he continued to see his referring psychotherapist once every week. Within 3 weeks, he reported no more feelings of loss of control and cessation of outbursts. It was much harder to get him angry. His hostility score on the Keliner Symptom Questionnaire (4) was 0 two months after his initial evaluation, continued to be 0 two months later, and was 2 after five months of desipramine treatment. The symptoms of temper outbursts and anger did not recur during desipramine treatment. Case 2. Ms. B, a 31-year-old married white woman with no children, was a financial consultant. She had been referred by her family doctor because of chronic depression and burnout. She had been away from work for 3 weeks because of increasing anger in tense negotiations on the job. She felt that she was overreacting, usually in anger. Ms. B and her husband had been fighting a lot, which she attributed to her burnout at work. She reported that in situations “where you cannot do anything about it, like in a bureaucracy,” she would feel a tightness in her chest, her head would get “fuzzy,” she would feel almost dizzy, would feel hot and experience palpitations, would then feel like crying, and would explode in an anger attack. At the time of her evaluation, she denied feeling anxious or panicky and denied any sleep disturbance. She described her appetite as “exuberant,” saying that she had gained 30 pounds in the previous 2 years. She appeared to be mildly depressed without neurovegetative signs and did not meet criteria for personality disorder. The patient’s early childhood was described as “not a good time-I was always left out.” She did well in school until high school; while in high school, she “drank a lot and stayed out.” Ms. B did not have any history of head trauma or seizures. She had an older sister who had been treated for anxiety. She also had a maternal grandmother described as “a nasty old woman who beat her kids.” The patient was started on clomipramine treatment, SO mg h.s., at the time of the evaluation and was seen in follow-up on average once every month by the psychiatrist. Within a few days, she felt much better and in more control and returned to work within 1 week. Since the patient experienced anongasmia, the dose was reduced to 30 mg h.s., and she continued to do well for about 3 months until she decided to stop the medication. Four days later, she had an intense fight with her husband that she described as an anger attack; 2 days later, she had a dispute at work and decided to restart the medication. During the following 14 months of treatment, she did very well and was promoted twice at work. Seventeen months later, while away on a business trip, she called her husband to report that she again was erupting with inappropriate anger. She then recognized that the prescription she had picked up before leaving home looked different from earlier ones. At a pharmacy, she was told that the pills she had been taking for a week were an anti-inflammatory medication
appropriate in 2 days.
made
by the
medication At 2-year
manufacturer
was follow-up,
dispensed,
of clomipramine.
and Ms.
she continued
The
B felt better
to do well
with
clomipramine. Case 3. Ms. C, a 30-year-old single white woman and a registered nurse, had been referred by her psychotherapist, who had seen her for about 1 year. About 28 months before assessment she had become very depressed, and her depression had continued, accompanied by neurovegetative signs and occasional suicidal thoughts, for about 20 months. For this
868
reason,
she
entered
and
continued
psychotherapy.
Her
psychotherapy she
and
had been
her
very helpful
psychotherapist
felt
for her depression,
that
she
needed
but
pharmaco-
logical treatment of her anxiety and anger attacks. During the evaluation, Ms. C reported that she had nervous
been
and
anxious
extremely
situations, ity figures, situation,
since
she
was
a child.
shy and had tended
She
to be afraid
had
been
always
of numerous
such as any social gathering, dealing with authorcrowds, and driving. Especially in this kind of she would have anger attacks; during these epi-
sodes she would hyperventilate, the palms of her hands would begin to sweat, her face would get red, she would become angry and enraged, she would feel like attacking people, and she would want to escape and would feel as if she
was
going
tion.
Because
avoid
those
to lose
of these
control
if she
anger
situations
remained
attacks,
in
which
in that
the patient she
situa-
had begun
might
to
experience
the
attacks. She had been in therapy while she was in high school because of shyness. She had a history of phobia of escalators and elevators. She denied any history of suicide attempts, mania or hypomania, head ical history was unremarkable. of episodic rage, On evaluation, Ms. C appetite, concentration, helpless and hopeless. She histories
of a personality
injury,
or seizures. Her past Her father and brother
without physical violence. reported no difficulty with sleep, and energy. She occasionally felt lacked depressed mood or features
disorder.
In the
3 weeks
before
tion, she had experienced four anger attacks. score on the Kellner Symptom Questionnaire Immediately
after
her
mcdhad
evaluation
was
the
evalua-
Her hostility (4) was 16.
completed,
Ms.
C
started
treatment with clonazepam, 0.5 mg b.i.d., and desipramine, 10 mg h.s.; the latter was gradually increased to 150 mg h.s. There was some improvement in her symptoms in
the
first
few
days
of
the
treatment
in her symptoms
and
marked
improvement
with
ipramine hostility
in addition to the clonazepam. score on the symptom questionnaire
a consistent,
150 mg of des-
At
that point, her dropped to 6.
She reported
no anger attacks for about a month, felt more and was less irritable and “snappy”; she also mentioned that coffee used to have an “enraging” effect on her, but that effect had disappeared. Throughout hen pharmacological treatment, the patient continued to see her inin control,
dividual
psychotherapist.
Her
remission
was
sustained,
and
months later her hostility score was still 6; she continued take desipramine, 200 mg h.s., and clonazepam, 0.5
3
to mg
b.i.d.
Case 4. Mr. D, a 33-year-old by his family doctor because
married white man referred of “bad temper tantrums,” re-
ported that he would get “mad very fast,” especially with his children. His behavior was causing a great deal of marital difficulty. He had a history of quitting many jobs because he would fly into a rage over trivial issues. He had no history of panic
attacks.
He
reported
that
his
childhood
was
“not
great”
because of his mother’s drinking. He did fairly well socially in high school but failed the tenth grade. Since high school, he had had few friends, and “although I wanted to work, I couldn’t seem to hold a job because I would get peed off.” At the time of his referral he was working as a clerk. His mother had been an outgoing, high-strung woman who “abused alcohol and diazepam” to control her nerves. At the time of his evaluation, Mr. D said that he wanted treatment because he was depressed about his work record and he children.
did not like He denied
himself panic
for the way he dealt attacks but did admit
attacks. When these attacks started his heart pounded, he felt lightheaded,
Am
J
Psychiatry
with his to anger
he felt hot and flushed, his hands shook, and
147:7,
July
1990
FAVA,
he perspired. This would culminate in a “rush” of anger and a feeling of being out of control. He denied sleep or appetite disturbance or alcohol injury, or seizures. He
abuse did not
or a history of mania, head appear to have a personality
disorder on interview. neurovegetative signs.
He was
mildly
As soon
as the
evaluation
was
depressed
completed,
recurrence antidepressant symptoms. that anger
but without treatment
was
started with clomipramine, 35 mg h.s.; within a few days Mr. D reported marked improvement, and his wife reported that he was “much easier to live with.” He was initially seen once
every
2 weeks
and
then
once
every
month
during
course of the treatment. He continued to do well for about months. At that time, he failed to renew his prescription was close to payday and he could not afford the medication), and
3 days
“blowup”
after
with
stopping
the
medication,
he
had
the
2 (it
his
first
his children in 2 months. He restarted did well for a month. On a later occasion,
the
medication and he again stopped the medication and 2 days later had a fistfight with a man whom the patient felt was driving too fast near the area where the patient’s children were playing. After restarting treatment, he did very well and had no anger attacks for the next 4 months.
iety
The common feature of these cases is the presence of anger attacks characterized by ego-dystonic episodes of anger that were of short duration and grossly out of proportion to precipitating psychosocial stressons. These episodes were associated with a sudden surge of autonomic arousal including such symptoms as tachycardia, sweating, flushing, and a feeling of being out of control. Although the physical symptoms resemble those of a panic attack, none of the patients described anxious, panicky, or fearful emotions. The intensity of the anger is underscored by the Kellnen Symptom Q uestionnaire (4) hostility scale measures: the two patients administered the questionnaire had a mean pnetreatment scone of 15.5, the mean scone of normal controt subjects is 3.7±3.5. From a psychodynamic point of view, anger or aggression can be seen either as a response to frustration of libidinal wishes (5) or as a separate instinctual entity (6). In both cases anger is, in general, incorporated in the development of the character structure and tends to present as a problem when the patient’s defenses begin to fail in channeling or controlling it. One could postulate that the patients that we describe were all experiencing frustration at some level in their lives on that their instinctual aggressive drives were more intense and/or their defense mechanisms were ineffective. Anger attacks may become a response to feeling helpless or powerless, particularly in individuals with what is simply described as emotional immaturity, on to feeling threatened in some way. A purely psychodynamic explanation of these attacks does not take into account various factors such as the influence of mood on the cognitive appraisal of events as irritating, frustrating, or threatening, the fact that the anger attacks nesponded very well to thymoleptics, that discontinuation of the drug in some of these cases was followed by
sive,
July
1990
attacks, and that nechallenge with was also followed by remission of We would also like to highlight the attacks occurred in our patients in the
hypochondniasis,
Selected may
We
147:7,
of
disorders,
cases
Psychiatry
ROSENBAUM
personality
disorders,
schizophrenic disorders, paranoid disorders, and psychoactive substance intoxication and withdrawal. These conditions as currently defined did not chanacterize our patients, except one, who had a depressive disorder not otherwise specified that was associated with his anger attacks. Although our patients did not have a history of head injury on seizures, we cannot exclude the possibility of a subictal disorder, a clinical diagnosis typically lacking definitive EEG or other evidence.
J
AND
the the fact absence of diagnosable personality disorders; in fact, all patients underwent a comprehensive clinical assessment that included a differential diagnosis for axis II disorders according to DSM-III-R. Fava (1) reviewed the array of psychiatric distunbances most associated with a tendency to anger: affective disorders (particularly bipolar disorders), anx-
DISCUSSION
Am
ANDERSON,
find
be
for quite
two
a single
different,
explanations
common
for
although anger
feeling
these
of panic
not
mutually
exclu-
attacks.
1. Anger attacks may be Deffenbacher et al. (7) have iety is associated with anger of anger; the prodromal arousal during anger attacks attack symptoms. Although subjective
symptom,
heterogeneous.
a variant of panic attacks. observed that general anxin subjects with high levels symptoms of autonomic are similar to some panic our patients denied the
or
anxiety,
one
patient,
who
had a history of simple phobias, developed marked avoidance of settings associated with these attacks, had found caffeine provocative, and had an immediate response to the combination of a benzodiazepine and tnicyclic,
a response
somewhat
similar
to that
a
expected
in panic disorder patients. All of our patients responded to treatments that are considered by clinicians to be effective for panic disorder. For example, in countries where clomipramine is available, it is deemed an excellent antipanic therapy and is frequently observed to be effective at doses lower than those typically necessary for patients with major depression, and often early in treatment (8). That a panic attack may be considered a “false alarm” response, a spontaneous activation of the “fight-flight” reaction usually reserved for life threat, also contributes to this hypothesis. One might expect that fight-flight activation would be, on occasion, cognitively and behaviorally expressed not as fear and flight but as anger and fight. These cases might illustrate this missing link to the fight-flight paradigm. Indeed, the cognitive concomitants of a panic attack do vary, and some sufferers are reported to experience little or no fear or anxiety (9) with their panic attack. 2.
Anger
attacks
may
be an
atypical
depressive disorders. Akiskal et at. (10) the occurrence of irritable-angry-explosive the setting of cyclothymic disorders.
presentation
of
have
described mood in Depressed pa-
869
“ANGER
A1TACKS”
tients are observed to display more hostility than normat control groups (11), and hostility in depressed patients diminishes with recovery after treatment with a tnicyclic (12). There is some evidence of a common biological mechanism, involving senotonengic transmission, for affective disorders and aggression disondens (13). One of our patients also had a depressive disorder, and all patients responded to treatment with tnicyclics, which are commonly used in the treatment of depression. Although Mattes (14), in a review of pharmacological treatments of temper outbursts, noted that carbamazepine, propranolol, and lithium may reduce aggressiveness in patients with temper outbursts and that there was less evidence of beneficial effects on rage outbursts from other drugs, all our patients responded dramatically to tnicyclic antidepressants. We chose to use clomipramine, desipramine, and clonazepam in the treatment of these anger attacks since they are commonly used in the treatment of panic disorder and we thought that anger attacks resembled panic attacks in many respects. In some cases, the presence of comorbid depressive symptoms also played a role in the choice of an antidepressant. In cases 2 and 4, the patients experienced a recurrence of their anger attacks 4 and 3 days, respectively, after discontinuing the antidepressant. Abrupt relapses may appear inconsistent with postulated mechanisms of action of antidepnessants in depression but are consistent with clinical observation of some patients, particularly with panic disorder, who experience a brisk rebound of symptoms in response to decreased intensity of phanmacothenapy. This phenomenon may argue for the primacy of acute and direct effects of these agents, rather than delayed effects involving changes in receptor sensitivity. In conclusion, we report four illustrative cases of patients with anger attacks, which are characterized by short-lived outbursts of anger that are perceived to be excessive and grossly out of proportion to any precipitating psychosocial stressons. In most cases these episodes of anger attacks are associated with tachycardia, sweating, flushing, and a feeling of being out of controt. We have observed that patients with anger attacks respond very well to treatment with tnicyclic antidepressants, and such response may suggest the possibility that anger attacks are variants of panic disorder on depression. The fact that most of our patients reported feelings of helplessness and frustration may be con-
870
sidered further links with both depressive and panic disorders. Finally, recognizing and treating patients with anger attacks may be an important clinical task. Williams et at. (15) and Rosenman (16) have reviewed the consequences of anger for the development of candiovascular disease and support the idea that anger and hostility are the critical components of type A behavior that account for the increased risk of cononary artery disease. Our observations and hypotheses suffer all the limitations of a retrospective case series. However, we believe this to be a fairly prevalent clinical syndrome that is likely to be secondary to either anxiety or depression.
REFERENCES 1.
Fava
GA:
Irritable
mood
and
physical
illness.
Stress
Med
1987;
3:293-299
2.
Zetlin
AG,
Turner
JL:
Transition
from
adolescence
to
hood: perspectives of mentally retarded individuals families. Am J Ment Defic 1985; 89:570-579 3.
Elliott
trol
FA:
Neurological
syndrome).
factors
in violent
Bull Am Acad
adult-
and
their
behavior
(the
dyscon-
Law
1976;
4:297-
Psychiatry
315 4.
Kellner
R: A symptom
J Clin
questionnaire.
Psychiatry
1987;
48 :268-273 S.
Fenichel
0:
A critique
for the death
instinct.
Imago
1935;
21:
458-466
6. Freud
S: The ego and the id (1923),
Works, 7.
standard
DeffenbacherJL, correlates
Rosenbaum
10.
Akiskal amental
in Complete
London,
Behav
Hogarth
Res
IE, Whitsett
women.
iF: Limited
1987;
19.
PM, Brandon
treatment.
DG, Troyer
of agoraphobic 459 ics
vol
Demm
and
8. Johnston
9.
ed,
Arch
AD: High Ther
symptom
Psychiatry
panic
Psychosomat-
MK, Scott-Strauss A: Cyclothymic temperPsychiatr Clin North Am 1979; 2:527-554 R, Munari F, et al: Losses, hostility and de-
J
melancholia.
13. Van Praag Threat
Nerv
Ment
HM: Affective for a common
Behav
1986;
Dis
disorders biological
1986;
and
recovery
174:414-418
and aggression disorders: mechanism. Suicide Life
16:103-132
14. Mattes JA: Psychopharmacology of temper outbursts-a view. J Nerv Ment Dis 1986; 174:464-470 15. Williams RB, Barefoot JC, Shekelle RB: The health
16.
45:453-
28:407-412
HS, Khani disorders.
evidence
treatment
1988;
attacks.
anger:
24:481-489
SF: Clomipramine Gen
1961
general
1986;
I 1. Fava GA, Kellner pression. J Nerv Ment Dis 1982; 170:474-478 12. Fava GA, Kellner R, Lisansky J, et al: Hostility from
Psychological Press,
re-
consequences of hostility, in Anger and Hostility in Cardiovascular and Behavioral Disorders. Edited by Chesney MA, Rosenman RH. Washington, DC, Hemisphere Publishing Corp, 1985 Rosenman RH: Health consequences of anger and implications for treatment. Ibid
Am
J
Psychiatry
147:7,
July
1990
Attacks”:
Possible
and Major
Maurizio
Fava,
M.D.,
Keith
Variants
Depressive
Anderson,
Disorders
M.D.,
and Jerrold
strative
The authors report a series of illustrative cases in which patients presented with sudden “spells” of anger with physical features that resembled panic attacks but lacked the affects of fear and anxiety. These spells or “attacks” of anger were experienced as uncharacteristic and were inappropriate to the situations in which they occurred. Since treatment of these attacks with antidepressants produced in each case marked im-
provements
in behavior,
some hypotheses (Am J Psychiatry
the
as to the 1990;
authors
also
nature of these 147:867-870)
and
hen a nonpsychotic isodes of anger
%,v
grossly
out of proportion
stressons,
a personality
derline)
is typically
psychiatric
adult are
that
describes of short
treatments
of
marked
first
organic
considered.
disturbances,
however,
( )
Numerous
may
epand
or
bor-
other
be associated
hypotheses
ogy Unit,
Massachusetts
General
pital, Ottawa, Ont., Canada. Clinical Psychopharmacology tal, 15 Parkman St., ACC81S, Copyright © 1990 American
Am
J
Psychiatry
received
Aug.
the Clinical Hospital, and
1 and
Dec.
20,
PsychopharmacolOttawa Civic Hos-
Address reprint requests to Dr. Fava, Unit, Massachusetts General HospiBoston, MA 02114. Psychiatric Association.
1 47: 7, July
1990
in
attacks
in
as to the
treatment
which
patients
in
each
behavior, nature
case
we
pre-
that were exinappropriate Since specific produced
formulate
of these
episodes
some and
offer
recommendations.
REPORTS
1 Mr.
A, a 45-year-old
.
white
man,
was an attorney
who lived with his wife and referred by his therapist because and thought “in a fragmented problems to stressful life events
three children. He had been he lost his temper frequently way.” Mr. A attributed his over the previous 10 months.
He had
a long
with
lost
his mother
his wife
He denied
and
after
children,
feelings
and
had
of depression
illness, been
and
had
problems
distressed
sleep
at work.
or appetite
dis-
and diminished energy and concentration. He had been in therapy for a couple of years and had found that very helpful, since it had allowed him to deal with the loss of his mother and to turbance
with a tendency to anger 1 : affective disorders, hypochondniasis, schizophrenic disorders, paranoid disorders, and psychoactive substance intoxication or withdrawal. Adult “temper tantrums” have been reported among mentally retarded individuals (2) and in subjects with head trauma, minimal brain dysfunction, epilepsy, brain tumor, infections, cerebral vascular disease, other neurological disease, and endocrine and metabolic disorders (3). When these discrete episodes of loss of control oven aggressive impulses result in assaultive acts or destruction of property, the best diagnostic fit from DSM-III-R may be intermittent explosive disorder. The existence of a discrete disorder is controversial; these behaviors are often viewed as symptomatic of a personality disorder. Six years ago, one of us (K.A.) noted in a patient sudden “spells” of anger with physical features that resembled panic attacks but lacked the affects of fear and anxiety. Since then, we have observed a number of similar cases: we now report some of the most demon-
Received Aug. 2, 1988; revisions 1989; accepted Jan. 25, 1990. From
cases
these
changes
CASE
psychosocial
(e.g.,
illustrative
M.D.
formulate episodes.
repeated duration
to precipitating disorder
F. Rosenbaum,
sented with spells on “attacks” of anger penienced as uncharacteristic and were to the situations in which they occurred.
Case
“ VT
of Panic
but
her.
mourn
tient had his temper
reported
However,
had
yell;
fuse,”
explosive
things
few months,
during enraged and
that
in therapy
patient seizures,
the state
“anger
his heart
quickly, During
rate accelerated, and
his
he would
alien to him and was concerned that he would as a result. He denied having suffered from simin the past. About 12 years earlier he had been for
a short
unremarkable;
time
his
and
At the time for
very
attacks.”
about an hour He felt that these epi-
of arousal.
had no history of or drug or alcohol
alcoholism,
the pa-
which he would lose and yelling at others.
felt out of control
temper
he noticed
from
sodes were lose his job ilar episodes
teria
in
would flush while he felt out of control, after the initial surge, it would take him
to recover
was
interest
for the previous
a “short
an
these attacks face
of
been having episodes in a flash, becoming
He described and
lack
his
because
of
mania, abuse.
hypomania, His past
mother
father
had
had
of his evaluation,
depressive
disorder
a probable
a history
Mr. not
marital
problems.
head medical diagnosis
The injury, history of
of paranoia.
A met
otherwise
DSM-III-R specified;
not appear to have a personality disorder. In addition, a very high hostility score (score of 15; maximum=23)
cri-
he did
he had on
the Kellner Symptom Questionnaire (4), a self-rating scale of distress that contains subscales of anxiety, depression, somatization, and hostility and whose mean±SD hostility subscale score in normal control subjects is 3.7±3.5. Treatment was immediately initiated with desipramine, 10 mg h.s., which was later gradually increased to 200 mg h.s.
867
“ANGER
ATFACKS”
Mr. A was seen on average once every month for pharmacotherapy, and he continued to see his referring psychotherapist once every week. Within 3 weeks, he reported no more feelings of loss of control and cessation of outbursts. It was much harder to get him angry. His hostility score on the Keliner Symptom Questionnaire (4) was 0 two months after his initial evaluation, continued to be 0 two months later, and was 2 after five months of desipramine treatment. The symptoms of temper outbursts and anger did not recur during desipramine treatment. Case 2. Ms. B, a 31-year-old married white woman with no children, was a financial consultant. She had been referred by her family doctor because of chronic depression and burnout. She had been away from work for 3 weeks because of increasing anger in tense negotiations on the job. She felt that she was overreacting, usually in anger. Ms. B and her husband had been fighting a lot, which she attributed to her burnout at work. She reported that in situations “where you cannot do anything about it, like in a bureaucracy,” she would feel a tightness in her chest, her head would get “fuzzy,” she would feel almost dizzy, would feel hot and experience palpitations, would then feel like crying, and would explode in an anger attack. At the time of her evaluation, she denied feeling anxious or panicky and denied any sleep disturbance. She described her appetite as “exuberant,” saying that she had gained 30 pounds in the previous 2 years. She appeared to be mildly depressed without neurovegetative signs and did not meet criteria for personality disorder. The patient’s early childhood was described as “not a good time-I was always left out.” She did well in school until high school; while in high school, she “drank a lot and stayed out.” Ms. B did not have any history of head trauma or seizures. She had an older sister who had been treated for anxiety. She also had a maternal grandmother described as “a nasty old woman who beat her kids.” The patient was started on clomipramine treatment, SO mg h.s., at the time of the evaluation and was seen in follow-up on average once every month by the psychiatrist. Within a few days, she felt much better and in more control and returned to work within 1 week. Since the patient experienced anongasmia, the dose was reduced to 30 mg h.s., and she continued to do well for about 3 months until she decided to stop the medication. Four days later, she had an intense fight with her husband that she described as an anger attack; 2 days later, she had a dispute at work and decided to restart the medication. During the following 14 months of treatment, she did very well and was promoted twice at work. Seventeen months later, while away on a business trip, she called her husband to report that she again was erupting with inappropriate anger. She then recognized that the prescription she had picked up before leaving home looked different from earlier ones. At a pharmacy, she was told that the pills she had been taking for a week were an anti-inflammatory medication
appropriate in 2 days.
made
by the
medication At 2-year
manufacturer
was follow-up,
dispensed,
of clomipramine.
and Ms.
she continued
The
B felt better
to do well
with
clomipramine. Case 3. Ms. C, a 30-year-old single white woman and a registered nurse, had been referred by her psychotherapist, who had seen her for about 1 year. About 28 months before assessment she had become very depressed, and her depression had continued, accompanied by neurovegetative signs and occasional suicidal thoughts, for about 20 months. For this
868
reason,
she
entered
and
continued
psychotherapy.
Her
psychotherapy she
and
had been
her
very helpful
psychotherapist
felt
for her depression,
that
she
needed
but
pharmaco-
logical treatment of her anxiety and anger attacks. During the evaluation, Ms. C reported that she had nervous
been
and
anxious
extremely
situations, ity figures, situation,
since
she
was
a child.
shy and had tended
She
to be afraid
had
been
always
of numerous
such as any social gathering, dealing with authorcrowds, and driving. Especially in this kind of she would have anger attacks; during these epi-
sodes she would hyperventilate, the palms of her hands would begin to sweat, her face would get red, she would become angry and enraged, she would feel like attacking people, and she would want to escape and would feel as if she
was
going
tion.
Because
avoid
those
to lose
of these
control
if she
anger
situations
remained
attacks,
in
which
in that
the patient she
situa-
had begun
might
to
experience
the
attacks. She had been in therapy while she was in high school because of shyness. She had a history of phobia of escalators and elevators. She denied any history of suicide attempts, mania or hypomania, head ical history was unremarkable. of episodic rage, On evaluation, Ms. C appetite, concentration, helpless and hopeless. She histories
of a personality
injury,
or seizures. Her past Her father and brother
without physical violence. reported no difficulty with sleep, and energy. She occasionally felt lacked depressed mood or features
disorder.
In the
3 weeks
before
tion, she had experienced four anger attacks. score on the Kellner Symptom Questionnaire Immediately
after
her
mcdhad
evaluation
was
the
evalua-
Her hostility (4) was 16.
completed,
Ms.
C
started
treatment with clonazepam, 0.5 mg b.i.d., and desipramine, 10 mg h.s.; the latter was gradually increased to 150 mg h.s. There was some improvement in her symptoms in
the
first
few
days
of
the
treatment
in her symptoms
and
marked
improvement
with
ipramine hostility
in addition to the clonazepam. score on the symptom questionnaire
a consistent,
150 mg of des-
At
that point, her dropped to 6.
She reported
no anger attacks for about a month, felt more and was less irritable and “snappy”; she also mentioned that coffee used to have an “enraging” effect on her, but that effect had disappeared. Throughout hen pharmacological treatment, the patient continued to see her inin control,
dividual
psychotherapist.
Her
remission
was
sustained,
and
months later her hostility score was still 6; she continued take desipramine, 200 mg h.s., and clonazepam, 0.5
3
to mg
b.i.d.
Case 4. Mr. D, a 33-year-old by his family doctor because
married white man referred of “bad temper tantrums,” re-
ported that he would get “mad very fast,” especially with his children. His behavior was causing a great deal of marital difficulty. He had a history of quitting many jobs because he would fly into a rage over trivial issues. He had no history of panic
attacks.
He
reported
that
his
childhood
was
“not
great”
because of his mother’s drinking. He did fairly well socially in high school but failed the tenth grade. Since high school, he had had few friends, and “although I wanted to work, I couldn’t seem to hold a job because I would get peed off.” At the time of his referral he was working as a clerk. His mother had been an outgoing, high-strung woman who “abused alcohol and diazepam” to control her nerves. At the time of his evaluation, Mr. D said that he wanted treatment because he was depressed about his work record and he children.
did not like He denied
himself panic
for the way he dealt attacks but did admit
attacks. When these attacks started his heart pounded, he felt lightheaded,
Am
J
Psychiatry
with his to anger
he felt hot and flushed, his hands shook, and
147:7,
July
1990
FAVA,
he perspired. This would culminate in a “rush” of anger and a feeling of being out of control. He denied sleep or appetite disturbance or alcohol injury, or seizures. He
abuse did not
or a history of mania, head appear to have a personality
disorder on interview. neurovegetative signs.
He was
mildly
As soon
as the
evaluation
was
depressed
completed,
recurrence antidepressant symptoms. that anger
but without treatment
was
started with clomipramine, 35 mg h.s.; within a few days Mr. D reported marked improvement, and his wife reported that he was “much easier to live with.” He was initially seen once
every
2 weeks
and
then
once
every
month
during
course of the treatment. He continued to do well for about months. At that time, he failed to renew his prescription was close to payday and he could not afford the medication), and
3 days
“blowup”
after
with
stopping
the
medication,
he
had
the
2 (it
his
first
his children in 2 months. He restarted did well for a month. On a later occasion,
the
medication and he again stopped the medication and 2 days later had a fistfight with a man whom the patient felt was driving too fast near the area where the patient’s children were playing. After restarting treatment, he did very well and had no anger attacks for the next 4 months.
iety
The common feature of these cases is the presence of anger attacks characterized by ego-dystonic episodes of anger that were of short duration and grossly out of proportion to precipitating psychosocial stressons. These episodes were associated with a sudden surge of autonomic arousal including such symptoms as tachycardia, sweating, flushing, and a feeling of being out of control. Although the physical symptoms resemble those of a panic attack, none of the patients described anxious, panicky, or fearful emotions. The intensity of the anger is underscored by the Kellnen Symptom Q uestionnaire (4) hostility scale measures: the two patients administered the questionnaire had a mean pnetreatment scone of 15.5, the mean scone of normal controt subjects is 3.7±3.5. From a psychodynamic point of view, anger or aggression can be seen either as a response to frustration of libidinal wishes (5) or as a separate instinctual entity (6). In both cases anger is, in general, incorporated in the development of the character structure and tends to present as a problem when the patient’s defenses begin to fail in channeling or controlling it. One could postulate that the patients that we describe were all experiencing frustration at some level in their lives on that their instinctual aggressive drives were more intense and/or their defense mechanisms were ineffective. Anger attacks may become a response to feeling helpless or powerless, particularly in individuals with what is simply described as emotional immaturity, on to feeling threatened in some way. A purely psychodynamic explanation of these attacks does not take into account various factors such as the influence of mood on the cognitive appraisal of events as irritating, frustrating, or threatening, the fact that the anger attacks nesponded very well to thymoleptics, that discontinuation of the drug in some of these cases was followed by
sive,
July
1990
attacks, and that nechallenge with was also followed by remission of We would also like to highlight the attacks occurred in our patients in the
hypochondniasis,
Selected may
We
147:7,
of
disorders,
cases
Psychiatry
ROSENBAUM
personality
disorders,
schizophrenic disorders, paranoid disorders, and psychoactive substance intoxication and withdrawal. These conditions as currently defined did not chanacterize our patients, except one, who had a depressive disorder not otherwise specified that was associated with his anger attacks. Although our patients did not have a history of head injury on seizures, we cannot exclude the possibility of a subictal disorder, a clinical diagnosis typically lacking definitive EEG or other evidence.
J
AND
the the fact absence of diagnosable personality disorders; in fact, all patients underwent a comprehensive clinical assessment that included a differential diagnosis for axis II disorders according to DSM-III-R. Fava (1) reviewed the array of psychiatric distunbances most associated with a tendency to anger: affective disorders (particularly bipolar disorders), anx-
DISCUSSION
Am
ANDERSON,
find
be
for quite
two
a single
different,
explanations
common
for
although anger
feeling
these
of panic
not
mutually
exclu-
attacks.
1. Anger attacks may be Deffenbacher et al. (7) have iety is associated with anger of anger; the prodromal arousal during anger attacks attack symptoms. Although subjective
symptom,
heterogeneous.
a variant of panic attacks. observed that general anxin subjects with high levels symptoms of autonomic are similar to some panic our patients denied the
or
anxiety,
one
patient,
who
had a history of simple phobias, developed marked avoidance of settings associated with these attacks, had found caffeine provocative, and had an immediate response to the combination of a benzodiazepine and tnicyclic,
a response
somewhat
similar
to that
a
expected
in panic disorder patients. All of our patients responded to treatments that are considered by clinicians to be effective for panic disorder. For example, in countries where clomipramine is available, it is deemed an excellent antipanic therapy and is frequently observed to be effective at doses lower than those typically necessary for patients with major depression, and often early in treatment (8). That a panic attack may be considered a “false alarm” response, a spontaneous activation of the “fight-flight” reaction usually reserved for life threat, also contributes to this hypothesis. One might expect that fight-flight activation would be, on occasion, cognitively and behaviorally expressed not as fear and flight but as anger and fight. These cases might illustrate this missing link to the fight-flight paradigm. Indeed, the cognitive concomitants of a panic attack do vary, and some sufferers are reported to experience little or no fear or anxiety (9) with their panic attack. 2.
Anger
attacks
may
be an
atypical
depressive disorders. Akiskal et at. (10) the occurrence of irritable-angry-explosive the setting of cyclothymic disorders.
presentation
of
have
described mood in Depressed pa-
869
“ANGER
A1TACKS”
tients are observed to display more hostility than normat control groups (11), and hostility in depressed patients diminishes with recovery after treatment with a tnicyclic (12). There is some evidence of a common biological mechanism, involving senotonengic transmission, for affective disorders and aggression disondens (13). One of our patients also had a depressive disorder, and all patients responded to treatment with tnicyclics, which are commonly used in the treatment of depression. Although Mattes (14), in a review of pharmacological treatments of temper outbursts, noted that carbamazepine, propranolol, and lithium may reduce aggressiveness in patients with temper outbursts and that there was less evidence of beneficial effects on rage outbursts from other drugs, all our patients responded dramatically to tnicyclic antidepressants. We chose to use clomipramine, desipramine, and clonazepam in the treatment of these anger attacks since they are commonly used in the treatment of panic disorder and we thought that anger attacks resembled panic attacks in many respects. In some cases, the presence of comorbid depressive symptoms also played a role in the choice of an antidepressant. In cases 2 and 4, the patients experienced a recurrence of their anger attacks 4 and 3 days, respectively, after discontinuing the antidepressant. Abrupt relapses may appear inconsistent with postulated mechanisms of action of antidepnessants in depression but are consistent with clinical observation of some patients, particularly with panic disorder, who experience a brisk rebound of symptoms in response to decreased intensity of phanmacothenapy. This phenomenon may argue for the primacy of acute and direct effects of these agents, rather than delayed effects involving changes in receptor sensitivity. In conclusion, we report four illustrative cases of patients with anger attacks, which are characterized by short-lived outbursts of anger that are perceived to be excessive and grossly out of proportion to any precipitating psychosocial stressons. In most cases these episodes of anger attacks are associated with tachycardia, sweating, flushing, and a feeling of being out of controt. We have observed that patients with anger attacks respond very well to treatment with tnicyclic antidepressants, and such response may suggest the possibility that anger attacks are variants of panic disorder on depression. The fact that most of our patients reported feelings of helplessness and frustration may be con-
870
sidered further links with both depressive and panic disorders. Finally, recognizing and treating patients with anger attacks may be an important clinical task. Williams et at. (15) and Rosenman (16) have reviewed the consequences of anger for the development of candiovascular disease and support the idea that anger and hostility are the critical components of type A behavior that account for the increased risk of cononary artery disease. Our observations and hypotheses suffer all the limitations of a retrospective case series. However, we believe this to be a fairly prevalent clinical syndrome that is likely to be secondary to either anxiety or depression.
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1990
