Consider anger in society and psychiatry

“Fear is the path to the dark side. Fear leads to anger. Anger leads to hate. Hate leads to suffering.”

—Yoda, from “Star Wars”

Grabbing the political headlines recently was the race in Montana for its lone House of Representatives seat. The Republican candidate, Greg Gianforte, was charged with assaulting a reporter on the eve of the election, apparently body-slamming him to the floor. His anger was heard on the audio tapes.

Yoda might think that Gianforte was fearful of the reporter’s persistent questions on healthcare—so important to our own work and patients—and that his answers would cost him the election. He won, nevertheless, and it is not clear whether his anger and consequent aggression helped or hindered the results of the voting.

Certainly, this was not the first such example since the recent presidential campaign was in full gear. At some of the rallies, anger at opponents spilled out one way or another, leaving some of us to wonder if something in the country is changing as far as the prevalence and expression of this emotion.

Anger as a normal emotion

It seems self-evident that we see the precursors of anger in infants. Their strident cries convey needs that need to be fulfilled. If parents respond to these needs appropriately, most children gradually learn to express their needs in other personally effective and socially appropriate ways.

As we age, societal authority figures like teachers, bosses, religious leaders and presidents are not only responsible for fulfilling some of the needs of others, but model how anger should be handled. The psychologist Abraham Maslow developed the commonly accepted hierarchy of needs pyramid, going up from physical, to safety, to belongingness and esteem needs, arriving at the top of the pyramid at self-actualization. 

Healthy anger is proportional and responsive to a real and persistent need. It can be a powerful component of human survival and adaptation. Normal anger can be sublimated into socially acceptable outlets such as sports and political blogging.

On occasion, normal anger can be expressed too intensely. That calls for an apology and better control in the future.

Clinical anger

There is no such diagnosis as an “anger disorder” that would be like a depressive or anxiety disorder in DSM-5. Probably the closest is intermittent explosive disorder, characterized by the periodic eruption of anger and rage which are quite disproportionate to the circumstances. Nevertheless, as a symptom, it can be a major manifestation of many other disorders, including oppositional defiant, mood dysregulation, bipolar and attention deficit disorders. Freud thought that depression could be caused by anger turned inward, but that is now a controversial theory.

Anger is common is substance use disorder, either directly or from withdrawal effects. It is also common in personality disorders, such as borderline and narcissistic. Some medical disorders need to be considered as the cause at times, including being in a delirious or demented state.

Treatment of the anger needs to be appropriate to the underlying condition. Modalities include anger management therapy, behavioral modification, cognitive behavioral therapy and medication like beta blockers.

Anger in leadership

Those in administrative and leadership positions often have a higher than average degree of narcissism. When that narcissism is threatened by criticism, the reaction can be one of anger turned toward the conveyor of the criticism. Therefore, how a leader responds to criticism, especially constructive criticism, is an essential challenge and test of leadership.

With encouragement of followers, whether in gangs or politics, leaders can normalize anger extremism. That can be turn into a form of social psychopathology, perhaps.

Anger in psychiatric settings

Whenever anger is regularly expressed in ways that seem inappropriate to the circumstances, it is a sign that something is amiss. In patients, it calls for accurate diagnostic understanding and appropriate treatment. If not, aggression and violence may ensue.

With staff, it can also be an expression of our own mental disorders. This possibility needs to be sensitively considered, not stigmatized, and not punished until all avenues to get help have been explored.

If anger is widespread among staff, it can be a sign that the system is not working well and/or professional needs are not being met. Often, that can be seen in the cynicism that is a common component of clinician suffering and burn-out. It behooves leadership to involve the staff and clinicians in solving these systemic problems. The same holds true with board responsibility for the leaders. If not, most everybody, including patients, will suffer.