24 - Anger Flashcards Preview

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Flashcards in 24 - Anger Deck (32):
1

Lecture objectives

The student will be able to describe, list, define, recognize, identify, or perform the following:
- Different types of patients that frustrate clinicians and how to work with them
- Psychiatric diagnoses that relate to anger
- Short and long-term consequences of anger

2

Describe the basic anger data we have

- About 33% of community-dwelling adults report experiencing anger nearly every day
- About 75% of community adults report feeling annoyed multiple times a week
- About 10% of community adults report that their anger leads to physical violence (yelling, complaining, verbally attacking, or withdrawing were much more common)
- However, textbooks and the scientific literature focus far more on depression and anxiety than anger

3

Define anger

A negative, phenomenological feeling state that motivates desires for actions, usually against others, that aim to warn, intimidate, control, or attack, or gain retribution.
- It is associated with cognitive distortions and errors (the doctor is running behind because she thinks her time is more important than mine)
- It is typically associated with physiological changes and culturally-conditioned patterns of behavior

4

Define hostility

Negative beliefs or attitudes about individuals or groups that predispose anger and aggression.

5

Define aggression

Physical behavior enacted with the intent to harm. May occur out of anger, but also from modeling, group pressure, or social/environmental conditions (e.g. war) when anger is not present.

6

What does the DSM-5 say about anger?

Oddly little attention to anger compared with other aversive emotional states. Irritability appears in the criteria for several disorders, but there are few diagnoses available for when anger is the central complaint

7

Describe Oppositional Defiant Disorder in the DSM-5

Oppositional Defiant Disorder (Disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence)
- Pattern of negativistic, hostile, and defiant behavior lasting at least 6 months
- Criteria are a mixture of feelings (e.g. often touchy or easily annoyed by others) and behaviors (e.g. often deliberately annoys people)

8

Describe Conduct Disorder in the DSM-5

Conduct Disorder (Disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence)
- Repeated pattern of violating the basic rights of others or violating age appropriate societal norms (e.g. serious physical aggression, destruction of property, theft)
- No mention of anger in criteria

9

Describe Intermittent Explosive Disorder in the DSM-5

Intermittent Explosive Disorder (found in Impulse-Control Disorders Not Elsewhere Classified)
- Repeated seriously assaultive acts (e.g. striking someone or verbally threatening assault) or intentional destruction of property
- Degree of aggressiveness grossly disproportionate to triggering event

10

Describe Amok in the DSM-5

Amok (culture-bound syndrome traditionally found in southeast Asia)
- Single episode of acute, unrestrained violence
- Individual does not remember the episode

11

Describe new DSM-5 characterization of Disruptive Mood Dysregulation Disorder

New in DSM-5, Disruptive Mood Dysregulation Disorder
- Characterized by severe, recurrent temper outbursts occurring 3 or more times a week
- Between temper outbursts, mood for most of the day, nearly every day is angry or irritable
- Diagnosis should not be made for the first time before age 6 or after age 18; onset of criteria should occur by age 10
- Created specifically to decrease diagnosis of Bipolar Disorder in children

12

Describe the association between anger and Major Depressive Disorder (MDD)

Not specifically listed as a symptom of Major Depressive Disorder (MDD), but
- One study (Judd et al, 2013) found >50% prevalence of irritability in MDD patients
- Presence of anger/irritability may predict more severe and chronic illness and more comorbidity

13

Describe comorbidities seen in angry patients

Disorders of anger can exist independently, but are also frequently comorbid with
- Other emotional disorders
- In particular, frequently co-occurs with anxiety disorders
- Possibly related to frustration when efforts to manage the anxiety are thwarted or someone does something that increases anxiety
- Personality disorders
- Substance abuse

14

Describe "Trait Anger" in the trait vs. state anger concept

A trait is a relatively stable part of an individual’s personality. Individuals high in trait anger become angry easily with relatively little provocation. May:
- Express anger outwardly
- Hold it in (rumination, revenge fantasies)
- Try productive ways to reduce the anger

15

Describe the "State Anger" in the trait vs. state anger concept

A state is a transient reaction to a current stressor or situation. An individual low in trait anger may become angry based on a significant provocation or a combination of situational vulnerabilities (e.g. ill, exhausted, fearful about limited financial resources) and a small provocation

16

Describe the learning theory and anger in terms of short term effects

In the short term, anger is often reinforced
- The targeted individual may comply with the demand or stop the offending behavior
- The self-righteous quality to anger can also be self-reinforcing, as when an individual feels good about having made the offending party understand how wrong they were

17

Describe the learning theory and anger in terms of long term effects

Longer-term effects are more often aversive
- Shame and guilt
- Increased health risks
- Poor decision-making
- Avoidance and rejection by others

18

What is the effect of learning theory and anger?

This can make it more difficult to extinguish aggressive behavior, because intermittently reinforced behavior is harder to extinguish

19

Describe the physiology of anger

- Anger increases epinephrine and norepinephrine levels
- Cardiovascular, endocrine, and limbic changes all occur. When activation is chronic, this is damaging to the body
- Type A personality (anger is central construct) increases risk for heart disease and stroke

20

Describe the factors that increase the likelihood of an angry person acting out

- Presence of PTSD or other history of having been victimized
- Living in a restricted setting (e.g. prison or locked ward)
- A history of violent behavior
- Individuals with significant developmental delays or brain injury

21

What are some common causes of dangerously disruptive behavior in patients

- Psychosis (may be psychiatric in origin or resulting from a brain lesion)
- Sociopathy
- Disinhibition (e.g. from substances or neurological impairment)
- Severe Anxiety
- Personality Disorder

Schizophrenics are far more likely to be the victims of violence than to act out themselves

22

Describe the reasons we avoid angry people and patients

A variety of behaviors and beliefs associated with anger can make treatment more difficult:
- Verbal attacks
- Lack of desire for treatment of the anger (belief that the anger is morally justified reduces motivation for change)
- Perception that the issue is someone else’s fault
- Threats of physical violence

23

Describe the steps in interacting with angry patients

- First step is to provide careful listening and empathy
- Remain calm and engaged yourself
- Determine the reason for the anger and address it to the extent possible
- If the patient becomes disruptive...

Focus on problem behaviors without blaming or avoiding the patient
- Set clear, firm expectations, then enforce them consistently
- Seek consultation sooner rather than later from a mental health professional



24

What patients are more likely to act out?

Patients who are...
H = hungry
A = angry
L = lonely
T = tired

25

Describe violence in psychiatric patients

- Psychiatric patients are more likely to be victims of violence than perpetrators
--> 2.5 times the likelihood of being attacked or raped than overall population risk
- Individuals with psychosis do have a higher likelihood of perpetrating violence than the general population, including homicide
--> This elevated risk is strongly mediated by substance abuse
- Psychiatric patients are more likely to engage in agitated, disorganized violence than premeditated violent acts
--> Individuals engaging in premeditated violence generally do not have a mental disorder with the exception of Antisocial PD

26

Describe the types of difficult patients who can make clinicians angry

Groves’ (1978) four types of extremely difficult patients
- Dependent clingers
- Entitled demanders
- Manipulative help-rejectors
- Self-destructive deniers

27

Describe dependent clingers

- View self as needy and physician as inexhaustible source of help and support
- Dependent, unreasonably demanding
- Inspires a desire to avoid
- Requires firm, tactful limits

28

Describe entitled demanders

- Also needy, but use intimidation and guilt rather than flattery to acquire care
- Controlling, demanding, may threaten litigation
- Physician becomes fearful and wants to retaliate
- Strategy is to accept anger, then re-channel the entitlement into ways to obtain the good medical care they deserve

29

Describe manipulative help rejecters

- Also have enormous need for care; however, believe that nothing can help
- Typically no treatment is effective, but patient keeps returning
- Creates guilt, depression and self-doubt in the physician
- Manage by explicitly stating that treatment may not be curative, but that regular follow-ups will be needed to maintain whatever gains are possible
- Be consistent, firm, and set appropriate limits

30

Describe self-destructive deniers

- Engage in behavior that is clearly and imminently destructive (e.g. continuing to drink heavily despite esophageal varices)
- Inspires malice in the clinician
- Recognize without shame or self-blame that the extreme form of this patient inspires a wish that they would die and get it over with
- Treat depression if possible; recognize one’s own limits and provide treatment as with other terminal illnesses

31

Describe how you can manage anger

Relaxation techniques
- Deep breathing
- Soothing Imagery
- Increased Body Awareness

Exercise
- But not “getting it out” by punching, screaming, etc. (which actually increases anger)

Changing thoughts to be calm and rational rather than emphasizing the nature and severity of the offense

Angry thoughts quickly become irrational. Try to focus on logic and perspective.

32

Describe how to plan to manage anger

- Make a plan to address problems
- Focus on positive communication that identifies your own needs rather than attacking others’ behavior
- Listen to the other person and try to understand his/her perspective
- Take a break, go for a walk, try to see the lighter side of the situation