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http://s.wsj.guy-quiz-10-03.htmlHEALTH JOURNAL MARCH 9, 2010
When Anger Is An Illness 'Intermittent Explosive Disorder,' Or Just a Temper Tantrum?
Erin Wigger for The Wall Street Journal
Scream at the boss? Snap at a colleague? Throw your cell phone into your @#$%%&* computer monitor? If so, you may find yourself headed to anger-management classes, which have become an all-purpose antidote for fit-throwing celebrities, chair-throwing coaches, vandals, road ragers, delinquent teens, disruptive airline passengers, and obstreperous employees.
Demand for such programs is coming from courts seeking alternatives to jail sentences and companies hoping to avoid lawsuits and office blowups. Aware that high-pressure jobs can make for hot tempers, some professions offer pre-emptive anger management. A few state bar associations now require "civility" training for lawyers renewing their licenses. And as of last year, hospitals must have programs for "disruptive" physicians as a condition of accreditation.
Programs run the gamut from $300-an-hour private therapists to one-day intensive seminars, weekly group sessions or online courses with no human interaction. Many advertise that they satisfy court requirements—even if all they offer is six CDs and a certificate of completion.
It's not clear if the programs work, as few studies have analyzed their effectiveness. There are no licensing requirements for anger-management trainers—anyone can open a business. And since participants don't usually sign up voluntarily, trainers say it's possible to complete a program without actually changing one's behavior.
Part of the problem is that professionals can't agree whether a pattern of angry outbursts signals a mental illness or simply a behavior issue. As a result, people who need psychiatric help may instead get shunted into a short-term anger-management course. Employers and courts may not adequately evaluate people before sending them for anger interventions, nor provide sufficient follow-up.
There have been some notable failures—the Columbine shooters, for example, attended anger-management classes before their 1999 killing spree. Amy Bishop, the University of Alabama biologist who allegedly killed three colleagues and wounded three more last month, had been advised by prosecutors to take anger-management classes after an earlier incident in 2002. Her lawyer says he doesn't know if she did.
Psychiatrists generally recommend a psychiatric exam for people with severe anger problems, because anger can often accompany depression, anxiety, bipolar disorder or obsessive-compulsive disorder.
The closest thing to a formal diagnosis for anger alone is Intermittent Explosive Disorder, defined as episodes of aggression against people or property out of proportion to any provocation. In 2006, studies at Harvard University and the University of Chicago estimated that one in 20 Americans (mostly men) may fit the criteria for IED. Some respond well to antidepressants, particularly serotonin reuptake inhibitors (SSRIs). Brain scans of people with IED found that when they were shown pictures of angry faces, their amygdalae, the primitive, emotional part of the brain, lit up with activity, but not the frontal cortex, which normally exercises impulse control.
"These people are hot heads, and the people around them are walking on egg shells. They don't know when they are going to blow up next," says University of Chicago psychiatrist Emil Coccaro, a leading IED researcher.
IED, recognized as a psychiatric illness since 1980, may be combined with a new disorder, termed Temper Dysregulation Disorder, in the next edition of the official Diagnostic and Statistical Manual, the DSM-V, because both are believed to begin in adolescence.
Psychologists believe that individual talk therapy is the most effective for anger problems. "Anger doesn't occur by itself. It's nested and embedded with a lot of other emotions—sadness, grief, shame," says Raymond Novaco, a University of California, Irvine, psychologist who widely credited with coining the term "anger management" in the 1970s and developed several widely used measurement scales. "Angry people want to talk, given the opportunity," he says.
Professional anger-management trainers say that in most cases anger isn't an illness but a normal human emotion that causes problems when it flares too hot, too often. They believe people can learn to manage their anger with practical skills.
Health columnist Melinda Beck discusses increasing anger in today's society and the rising demand for anger management services. She talks with Simon Constable about new diagnoses and treatments.
"I don't want everybody who calls up for anger management to be assumed to have a mental illness," says Ian Shaffer, chief medical officer for MHN, a subsidiary of Health Net Inc., which runs employee-assistance programs for companies, including anger management. MHN's anger-management program takes the form of conference calls. After an individual evaluation, employees whose jobs are on the line because of anger issues are told to call an 800 number for a 90-minute group discussion with a facilitator twice a week for six sessions. All participants are anonymous. MHN says one in-house study found that three-fourths of the employees whose jobs were in jeopardy were in good standing after completing the program.
How can they tell if the employees aren't working at the computer or filing their nails during the sessions? "We can't—but we can tell if you're participating or progressing," says Dr. Shaffer, a psychiatrist. "People can sandbag you—bright people know what to say to make it sound like they are progressing," he says. "But at the end of the day, we go back and ask your supervisor if you're better."
Most anger-management programs stress "emotional intelligence"—the idea that understanding why you are frustrated or annoyed or upset, and finding a calm, constructive means to get your way, is far more effective than losing your temper.
George Anderson, founder of Anderson & Anderson, a Brentwood, Calif., firm, says some people who get angry in the workplace are perfectionists who expect perfection from others, while some are subconsciously masking feelings of vulnerability. His firm offers dozens of customized anger-management programs for different professions. Among these: a $5,400 intensive on-site intervention for furious physicians who've lost hospital privileges due to patient or staff complaints.
Mr. Anderson tells of watching one surgeon ream out someone via cell phone while performing open-heart surgery. He says he helped the doctor realize he'd be more effective with a different approach.
"I'm not always successful," Mr. Anderson says. "I usually say, look, you're paying a lot of money for this… What would you be wiling to change? You've tried passive aggressive and it turns people off. Let's try assertive communication—you see if it works."
Tips to Help Keep A Temper in CheckMost anger-management programs use techniques borrowed from cognitive-behavioral therapy to help people deal with anger. Here are some strategies to help keep negative emotions in check.
• Reframe the situation. Instead of seeing every inconvenience or frustration as a personal affront, imagine a benign explanation.
• Find a constructive solution to the issue at hand. "Ask yourself: what do I need to be okay right now?," suggests Rich Pfeiffer, a psychologist and board president of the National Anger Management Association, a group of about 300 practitioners. "That shifts the focus from how the other person needs to be punished to how I need to respond in a healthy way."
• Keep an "anger log" to monitor what makes you angry. Learn to identify and avoid your triggers.
• Be aware that anger tends to rise in increments. Learn to evaluate yours from 1 (frustration) to 10 (rage). If you can catch yourself at 3 or 4, you can think more rationally about the situation.
• If you feel a blowup coming on, give yourself a time-out before acting on it. "Wait 15 minutes before you say something, or an hour before you send an email. Keep your options open," says Pauline Wallin, a psychologist in Camp Hill, Pa., and author of "Taming Your Inner Brat." "If it's not going to be important in an hour, then let it go. It's not worth getting angry about."
• Get a health checkup. Medical problems such as diabetes, chronic pain, low testosterone and low estrogen, can make people very irritable. Anger, either repressed or unleashed, can cause medical problems too. Some 30,000 heart attacks each year are triggered by momentary anger, according to a 2004 Harvard study.
• Be aware of how you talk to yourself. "If you keep saying how awful this is and making yourself feel alike a victim, you will get more angry," says Dr. Wallin.
• Don't ruminate on past affronts or injustices.
• Recognize patterns. "So often, people will say, 'I'm just like my father—my father got angry'," says Dr. Pfeiffer. "You don't have to go back into their childhoods and deal with that. You just have to work on how to respond effectively now."
• Calculate what your anger is costing you. Many people with anger problems think anger gives them an edge, and establishes superiority. "Instead, you just look like an idiot," says Leon Ingram, founder of Chicago-based angermgmt.com.
• Don't use alcohol to "calm" yourself. Alcohol lowers your inhibitions so you are more likely to do or say something you'll regret later.
• Get physical, without fists. When your primitive brain senses a threat, it sets off the "fight or flight" cascade of hormones. Opt for flight instead of fight and burn off the extra adrenaline and cortisol with exercise. Even a brisk walk will help calm you down.
• The ultimate lesson: Pay more attention to the important things in life and recognize that most frustrations, inconveniences and indignities are trivial and temporary.
