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Anger in psychological disorders: Prevalence, presentation, etiology and prognostic implications

Ephrem Fernandez and Sheri L. Johnson

ABSTRACT: Anger is present as a key criterion in five diagnoses within DSM-5: Intermittent Explosive Disorder, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Borderline Personality Disorder and Bipolar Disorder. This review amasses scientific literature demonstrating that within each of these disorders, anger is a central clinical feature that is highly prevalent and predictive of important outcomes. For each disorder, we also discuss the phenomenology and etiology of anger. Although models of anger have been quite distinct across these disorders, few empirical studies have truly tested whether anger stems from different etiological factors across these different conditions. We end with a discussion of transdiagnostic research that draws from cognitive psychology, affective science, and the neuroscience of anger, and that also fits with integrative approaches to treatment.

Keywords: Anger, DSM-5, Intermittent Explosive Disorder, Oppositional Defiant Disorder, Borderline Personality Disorder, Bipolar Disorder

Fernandez, E. & Johnson, S. (2016). Anger in psychological disorders: Prevalence, presentation, etiology and prognostic implications. Clinical Psychology Review 46, 124-135

The Angry Personality: A Representation on Six Dimensions of Anger Expression

Ephrem Fernandez

Introduction: As in my chapter with Kerns (Vol. 1 of this handbook) I draw from affect science and phenomenology in conceptualizing emotion. I situate emotion within a triad of feeling-related phenomena, with mood and temperament as the other two close relatives of emotion. This means that anger, like any feeling, not only has quality and quantity but also has form. Qualitatively, it is unpleasant yet categorically different from other discrete emotions such as sadness and fear. Quantitatively, it varies on a continuum of intensity or arousal from low levels called annoyance to high levels called rage. Additionally, anger can assume the form of an emotion, a mood, or a temperament, depending on whether it is phasic, tonic, or cyclic. It is the temperament form of anger that is the focus of this chapter. Specifically, boundaries between anger and related concepts are explored, past measures of dispositional anger are surveyed, and a new set of dimensions is presented for a more comprehensive assessment of the 'angry person'.

Fernandez, E. The Angry Personality: A Representation on Six Dimensions of Anger Expression. In Boyle, G., Matthews, G., Saklofske, D. (Eds). The Sage Handbook of Personality Theory and Assessment, 402-419

Toward an Integrative Psychotherapy for Maladaptive Anger

Ephrem Fernandez

ABSTRACT: This chapter adopts the psychoevolutionary position that anger, like any emotion, is part of a repertoire for handling various adaptational demands. However, it is explained that anger can become maladaptive in terms of the current conceptualization of what constitutes a psychological disorder. In such instances, the treatment options range from philosophico religious approaches to standalone techniques. Shadowing recent trends in psychotherapy, a case is made for the integration of techniques to regulate anger. As shown, these are sequentially ordered according to phases for prevention, intervention, and postvention of anger. This parallels the course of anger from its onset, through its progression, to its resolution. As illustrated, the prevention phase is primarily behavioral, the intervention phase centers around cognitive strategies, and the postvention phase invokes affective therapies. The resulting cognitive behavioral affective therapy (CBAT) is programmatic in the additional sense that there is a built in contingency with which techniques are used. CBAT is more expansive in scope than CBT and in step with the current renaissance of affect as a topic of study within psychology and other disciplines. Preliminary empirical data are reported on the outcome of this program. The large effect sizes obtained are supportive of the absolute and relative efficacy of CBAT in regulating anger. Further research is encouraged for the implementation and evaluation of this integrative program in diverse populations.

Potegal, M. et al. (eds.), Toward an Integrative Psychotherapy for Maladaptive Anger. International Handbook of Anger, 499-513. doi 10.1007/978-0-387-89676-2_28.

Cognitive-Behavioral Therapy in the Treatment of Anger: A Meta-Analysis

Richard Beck and Ephrem Fernandez

ABSTRACT: Anger has come to be recognized as a significant social problem worthy of clinical attention and systematic research. In the last two decades, cognitive-behavioral therapy (CBT) has emerged as the most common approach to anger management. The overall efficacy of this treatment has not been ascertained, and therefore, it was decided to conduct a meta-analysis of this literature. Based on 50 studies incorporating 1,640 subjects, it was found that CBT produced a grand mean weighted effect size of .70, indicating that the average CBT recipient was better off than 76% of untreated subjects in terms of anger reduction. This effect was statistically significant, robust, and relatively homogeneous across studies. These findings represent a quantitative integration of 20 years of research into a coherent picture of the efficacy of CBT for anger management. The results also serve as an impetus for continued research on the treatment of anger.

Keywords: Anger, Cognitive-Behavioral Therapy, Meta-Analysis

Beck, R. & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: A meta-analysis. Cognitive Therapy and Research, 22, (1), 63-74

Measures of Anger and Hostility in Adults

Ephrem Fernandez, Andrew Day, and Gregory J. Boyle

Anger lags behind anxiety and depression in terms of volume of published research. Yet, anger is widely observed to be a problem in everyday life, its manifestation extending from the family to the workplace, and clinical settings. This has spurred many scholars to develop tools for the assessment of anger. By far, most of these tools take the form of self-report questionnaires. Some of these have been in use for more than half a century while there are also signs of a proliferation of new instruments that coincide with the increased interest in anger as a feature of everyday life and a target of self-regulation and intervention. Before delving into the individual measures, a phenomenological sketch of anger and related phenomena would be appropriate. First of all, anger has been defined in many ways with different aspects being emphasized. However, there is general consensus that it is a feeling tied to appraised wrongdoing and coupled with action tendencies to counter or redress the wrongdoing (Smedslund, 1993; Wranik & Scherer, 2010). More broadly, anger has been characterized in terms of patterns of psycho-physiological and facial activation. Although anger may be deemed to have some beneficial effects, as in its role of mobilizing psychological resources, energizing behavior, and protecting self-esteem (Taylor & Novaco, 2005), it is typically regarded as a negatively valenced emotion with potentially harmful consequences (Fernandez, 2013). As Howells (2004) has suggested, 'the argument that angry emotions, when poorly regulated, understood and expressed, make a major contribution to human distress is a compelling one' (p. 195). Though sometimes used interchangeably with anger, the term hostility is more specifically reserved for frequently recurring anger or anger proneness (Ramirez & Andreu, 2006); hostility is quite likely rooted in an attitudinal bias or a cognitive schema of strong disapproval toward others (Brodsky, 2011). By virtue of this dispositional quality, it is akin to trait anger (Smith, 1994). Aggression, which is outside the scope of this review is defined in social psychology as behavior that is intended to harm, hurt, or damage physically or psychologically (for a review of measures of aggression, please refer to Suris et al., 2004). Finally, violence is a subtype of physical aggression in which the intended harm/hurt/damage actually materializes.

From Ephrem Fernandez, Andrew Day and Gregory J. Boyle, Measures of Anger and Hostility in Adults. In: Gregory J. Boyle, Donald H. Saklofske and Gerald Matthews, editors, Measures of Personality and Social Psychological Constructs. Oxford: Academic Press, 2014, pp. 74-100.