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Practice-based outcomes of dialectical behaviour therapy (DBT) targeting anger and violence, with male forensic patients: a pragmatic and non-contemporaneous comparison.

OBJECTIVE: To examine the effectiveness of an eighteen-month treatment based on dialectical behaviour therapy (DBT) targeting anger and violence, on a group of male forensic patients. METHOD: Eight male forensic patients in a high security hospital who met the criteria for borderline personality disorder measured by the Personality Assessment Inventory underwent 18 months of treatment. They completed three psychometric tests at pre-, mid- and post-treatment and at a six-month follow up. A comparison group (TAU) of nine patients, assessed as having similar personality disorders, received the usual treatment available in the hospital but excluding DBT. They completed the same tests at the same time intervals corresponding to the pre-, mid- and post-testing of the DBT group. In both groups, all instances behaviours related to anger and violence were monitored for three six-month periods, prior to, during and post-treatment. RESULTS: Overall, patients in the DBT group made greater gains than patients in the TAU group in reducing the seriousness of violence-related incidents, and in self report measures of hostility, cognitive anger, disposition to anger, outward expression of anger and anger experience. CONCLUSION: The results suggest a potential for DBT to impact positively and lastingly on violent behaviour and components of anger in male forensic patients when compared with standard treatment. The power of the current study to detect group differences was reduced by small ns, large confidence intervals, and a non-contemporaneous comparison group. Cost-effective strategies are proposed to take forward research on DBT with this population.

Adult↗

Anger and its association to distress and social/occupational functioning in symptomatic disaster relief workers responding to the September 11, 2001, World Trade Center disaster.

Empirical evidence suggests that anger plays a significant role in posttraumatic stress disorder (PTSD) and may impede recovery from traumatic events. The purpose of this study was to assess the role of anger and its relationship to distress and social/occupational functioning in disaster relief workers (DRWs) who had PTSD symptoms who were deployed to the World Trade Center after September 11, 2001. Six hundred twenty-six utility workers (96% male) completed measures of anger, distress, PTSD severity, and social/occupational functioning. Results indicated that anger was significantly higher in DRWs who had PTSD symptoms than in those who did not, and statistically significant associations were found among anger, distress, PTSD severity, and social/occupational functioning in workers who had PTSD symptoms. Careful assessment of anger in DRWs exposed to traumatic events is warranted as well as longitudinal studies to further understand the relationship between anger and PTSD.

Adult↗

Maternal appraisal styles, family risk status and anger biases of children.

The present study investigated the relationship between maternal appraisal styles, family risk status, and anger biases in children. Participants included 90 mothers and their children between 3-6 years of age. Eighty families were followed up 1 year later. Maternal appraisal styles were assessed via a naturalistic story-reading method, and Time 1 and Time 2 emotion biases included teacher ratings of anger and aggression, peer ratings of anger, as well as classroom and playground observations of anger. While discussing ambiguous stories with their children, mothers with higher scores on the family risk index utilized more hostile appraisals and fewer prosocial appraisals in their explanations. A higher proportion of hostile-to-prosocial appraisals was also related to higher-risk family status. Prosocial appraisals by mothers were inversely correlated with children's anger biases at school. When the appraisal balance in mothers' talk favored hostile appraisals, children tended to show higher levels of anger biases evidenced at school. Finally, a hostile balance of maternal appraisals was found to predict change in children's anger biases in the school with different effects in high- and low-risk families.

Aggression↗

Hostility, anger, and marital adjustment: concurrent and prospective associations with psychosocial vulnerability.

Hostility may contribute to risk for disease through psychosocial vulnerability, including the erosion of the quality of close relationships. This study examined hostility, anger, concurrent ratings of the relationship, and change in marital adjustment over 18 months in 122 married couples. Wives' and husbands' hostility and anger were related to concurrent ratings of marital adjustment and conflict. In prospective analyses, wives' but not husbands' hostility and anger were related to change in marital adjustment. In hierarchical regression and SEM models wives' anger was a unique predictor of both wives' and husbands' change in marital adjustment. The association between wives' anger and change in husbands' marital satisfaction was mediated by husbands' ratings of conflict in the marriage. These results support the role of hostility and anger in the development of psychosocial vulnerability, but also suggest an asymmetry in the effects of wives' and husbands' trait anger and hostility on marital adjustment.

Adult↗

Relationship of expressed anger to forearm muscle vascular resistance.

The relationship of style of anger expression to physiological reactivity was examined in 45 nonmedicated subjects during their performance of three tasks with contrasting response demands. The primary physiological focus was on forearm muscle vascular resistance (FMVR) with forearm muscle blood flow (FMBF), digital pulse volume (DPV), digital vascular resistance (DVR), heart rate (HR), diastolic blood pressure (DBP), systolic blood pressure (SBP), and electrodermal frequency (EF) monitored. Family Expressed Anger, i.e. the overtness of anger expression in the subject's family of origin, was related to FMVR such that the more anger was expressed in the family of origin, the greater the vasoconstriction during Mental Arithmetic and the less the vasoconstriction during Anger Imagery. Self Expressed Anger, i.e. the degree to which others were aware when the subject was feeling angry, was related to SBP and DBP during Vigilance with a lesser degree of anger expression going with greater blood pressure increases. The meaning of these findings in relation to task appraisal and task demand is discussed.

Adult↗

The scope and significance of anger in the experience of chronic pain.

This paper is divided into 3 sections. The first provides the conceptual framework by introducing definitions of anger and related constructs and highlighting pertinent aspects of the concept of pain. The second section examines the evidence for anger as a feature of chronic pain. The available research indicates that chronic pain patients experience anger but this may be underestimated because of denial. In fact, anger stands out as one of the most salient emotional correlates of pain, even though past research has been largely confined to the study of depression and anxiety. the third section explores the significance of anger in chronic pain, in terms of its compounding effects on pain, depression and psychosocial functioning, as well as its consequences for physical health and health habits. The impact of anger among chronic pain patients for treatment outcome is discussed. Finally, the information from these sections is integrated into a model depicting the antecedents and consequences of anger as specifically associated with the chronic pain experience.

Affective Symptoms↗

Clinicians' diagnosis of a case with anger problems.

Psychiatrists and psychologists responded to case vignettes to assess the prevalence, severity, and diagnostic confidence clinicians had concerning treating anger disordered clients compared with clients with generalized anxiety disorder. Five hundred and forty-two clinicians (a response rate of 30%) assessed one of two matched case histories by mail. One described generalized anxiety disorder (GAD) and the other a case of anger disorder (AD). Cases were identical except for thoughts and affect relevant to the disorders. Both male and female versions were used. More than 95% of the participants viewed the cases they received as pathological. The disorders were rated as equally common. The clinicians reported treating equal numbers of patients with similar anger or anxiety symptoms in the past year. Although the case histories were alike in length and detail, AD participants rated their case as less complete and had lower confidence in their diagnoses. The diagnostic consensus was high for GAD clinicians, but low for AD. Forty-three percent of participants selected an Axis II diagnosis for AD, compared with 3% for GAD. Clinicians appeared to encounter patients with chronic anger about as frequently as they see GAD, but they displayed diagnostic confusion and bias toward personality disorder diagnoses when presented with the anger symptoms. The findings support the development of a diagnostic category for primary anger. The wide dispersion of diagnoses for anger underscores the need for focused differential assessment.

Anger↗

Aggression, and some related psychological constructs (anger, hostility, and impulsivity); some comments from a research project.

The purpose of the present study was: first, to offer a few theoretical considerations on the concept of human aggression and its main types; and second, to analyse the relationship between those types of aggression and other related psychological constructs, such as anger, hostility, and impulsivity, summarizing the main empirical results of our research in progress. In order to assess their eventual correlations, several self-report techniques were compared: (a) AQ, used to measure several kinds of aggression, anger, and hostility; (b) CAMA, a questionnaire already used in a variety of cultures, for measuring attitudes toward interpersonal aggression in different instrumental and hostile situations; (c) ASQ, an instrument for measuring experienced anger and its expression in assertive or aggressive ways; and (d) BIS, used to prove three impulsiveness sub-traits: motor, attentional, and non-planning impulsiveness. The different definitions of aggression may be grouped according to whether the primary goal is distress or harm, focusing primarily on the objective infliction of harm, or on the subjective intention of harming. Most classifications in the literature show two kinds of aggression, even if different names are used: Hostile Aggression (among other names it is also known as 'reactive, impulsive, or affective') is an act primarily oriented to hurt another individual; and Instrumental Aggression (also known as 'proactive, premeditated, or predative') is a means or tool for solving problems or for obtaining a variety of objectives. As predicted, there was a positive correlation between experience and expression of anger. Anger involved physiological arousal and prepared for aggression. Anger and impulsiveness were also positively correlated with hostile aggression, but not with instrumental aggression. In the case of impulsiveness, non-planning impulsiveness was positively correlated with some situations related to hostile aggression, such as emotional agitation or lack of communication, but not with instrumental one. Finally, hostility positively correlated with anger and different kinds of aggression, but not its degree of justification. In sum, aggression can be reflected in the different personality constructs, measured by self-reports.

Aggression↗

Impaired recognition of facial expressions of anger in Parkinson's disease patients acutely withdrawn from dopamine replacement therapy.

We have previously reported that acute dopaminergic blockade in healthy volunteers results in a transient disruption of the recognition of facial expressions of anger, whilst leaving intact the recognition of other facial expressions (including fear and disgust) and facial identity processing. Parkinson's disease (PD) is characterised by cell loss in dopaminergic neuronal populations, and hence we predicted that PD would be associated with impaired anger recognition. We reasoned that treatment with dopamine replacement therapy (DRT) could mask any deficit present in PD, and therefore studied facial expression recognition in a group of PD patients transiently withdrawn from DRT. Seventeen PD patients were compared to 21 age- and IQ-matched controls on the Ekman 60 task, which required the forced-choice labelling of 10 exemplars of each of six facial expressions (anger, disgust, fear, sadness, happiness, surprise). In line with our predictions, PD patients showed a selective impairment in the recognition of facial expressions of anger. This deficit was not related to the PD patients' performance on the Benton unfamiliar-face matching task, which was normal, nor was the deficit related to overall disease severity, or to depression symptoms. However, as predicted by simulation theories, impaired anger recognition in PD was related to reduced levels of the anger-linked temperament trait, exploratory excitability. The results extend our previous findings of a role for dopamine in the processing of facial expressions of anger, and demonstrate the power of adopting a phylogenetic, comparative perspective on emotions.

Aged↗

Are aggressive people aggressive drivers? A study of the relationship between self-reported general aggressiveness, driver anger and aggressive driving.

In this study the relationships among self-reported general aggressiveness, impulsiveness, driver anger, and aggressive responses to anger-provoking situations on the road were studied. The British version of a driver anger scale (UK DAS), aggression questionnaire (AQ), and an impulsiveness questionnaire (I7) together with background questions (gender, age, annual mileage) were administered to a sample of 270 British drivers. Variation in strength of correlations between anger and aggressive reactions in the 21 UK DAS items showed that the relationship between driver anger and aggression depends in part on the characteristics of the situation. In addition, three path models for describing the relationships among the measures were constructed separately for women and men. The models suggested that the effects of verbal aggressiveness on self-reported driver aggression were mediated by driver anger whereas physical aggressiveness was directly related to aggressive behaviour. Age was negatively related to both driver anger and aggression among men whereas annual mileage was negatively related to aggression among women. The models constructed indicate that aggressive driver behaviour is a complex phenomenon with a range of psychological causes.

Adult↗

Internalized anger, self-control, and mastery experience in inpatient anorexic adolescents.

OBJECTIVES: To evaluate the implications of internalized anger, self-control and experience of mastery for adolescent girls with severe anorexia nervosa (AN). METHODS: Internalized and externalized anger, internal and external control, mastery, use of methods for self-control, and severity of anorexic symptoms were measured by self-report questionnaires in inpatient anorexic teenagers (N=26), inpatient female adolescent psychiatric patients (N=24), and a normal female comparison group (N=29). RESULTS: Internalized anger was significantly higher in both the anorexic and general psychiatric patients as compared to normal controls, but this difference was significant only for the anorexic patients. Anorexic and general psychiatric patients experienced significantly less mastery than normal controls, but again this difference was significant only in the anorexic group. Within the anorexic group, severity of symptoms correlated significantly with internalized anger, low mastery, and external locus of control, and negative significant correlations among control measures and anger were found. Total length of hospitalization correlated positively with internalized anger only for the anorexics. CONCLUSION: The findings support the notion that internalized anger and defective experience of self-control are important factors in the psychopathology of adolescent anorexic inpatient females The results may have implications for the clinical management of patients with severe AN.

Adolescent↗

Anger and personality in eating disorders.

OBJECTIVE: This study was designed to examine how anger, temperament and character profiles differ across subtypes of eating disorders (EDs) in comparison to healthy controls and to analyze the relationship between anger expression, eating attitudes and personality dimensions. METHOD: One hundred and thirty-five outpatients (50 of whom suffered from anorexia nervosa restrictor type [AN-R], 40 from anorexia nervosa binge/purging [AN-BP] and 45 from bulimia nervosa [BN]) and 50 control subjects were recruited and administered State-Trait Anger Expression Inventory (STAXI), Temperament and Character Inventory (TCI) and Eating Disorder Inventory II (EDI-II). RESULTS: STAXI showed greater levels of anger in patients with BN than in those with AN. TCI showed different personality profiles, in accordance with previous studies. Correlations were found between the management of anger feelings and psychological and personality traits typical of patients with EDs. CONCLUSIONS: Clinically, impulsivity seems to be the psychopathologic element most strongly correlated to anger. Moreover, it appears clear that anger is better managed by individuals with greater character strength.

Adolescent↗

Ethnic differences in circumstances of abuse and symptoms of depression and anger among sexually abused black and Latino boys.

OBJECTIVE: The present study was designed to examine the extent to which ethnic differences in the circumstances of abuse would be related to psychological outcomes and whether the relationship of ethnicity to psychological outcomes would be independent of ethnic differences in the circumstances of abuse. METHOD: Ethnic difference in the circumstances of the abuse, depression, and anger, as measured by the Children's Depression Inventory and the State-Trait Anger Expression Inventory, were assessed in 60 Black and Latino sexually abused males aged 13 to 18 years. Factors related to levels of depression and anger in these two groups were also identified. RESULTS: Latino males were more likely to have been sexually abused by an extended family member, experienced more genital fondling and were exposed to more sexually abusive behaviors. Blacks were more likely to be abused by an immediate family member. Black males had higher anger scores than Latino males, but, there were no ethnic differences in depression scores. Both ethnicity and the relationship to the perpetrator were significantly related to scores on the State-Trait Anger Expression Inventory, however, ethnicity was also significantly related to anger scores irrespective of the relationship to the perpetrator. CONCLUSIONS: Ethnic differences in the circumstances of abuse were related to psychological outcome and the relationship of ethnicity to anger scores was independent of ethnic differences in the circumstances of abuse.

Adolescent↗

The prevalence and clinical correlates of anger attacks during depressive episodes in bipolar disorder.

BACKGROUND: Anger attacks, characterized by sudden episodes of intense anger with autonomic arousal, have been described in patients with major depressive disorder (MDD). This study compared the prevalence and clinical significance of anger attacks in unipolar versus bipolar depression. METHODS: Using the questionnaire of Fava et al. [Psychopharmacol. Bull. 27(3) (1991) 275-279], we assessed rates of anger attacks among outpatients with MDD (n=50) or bipolar disorder (BPD) (n=29) who were currently in a pure depressive episode. RESULTS: Anger attacks were significantly more common among bipolar (62%) than unipolar (26%) depressed individuals. In a multiple logistic regression, the presence of anger attacks emerged as a significant predictor of bipolarity. LIMITATIONS: This preliminary finding should be confirmed in a larger sample. CONCLUSIONS: These results suggest that anger attacks may be a common feature of bipolar depression.

Adult↗

The relationship between anger-coping styles and lifestyle behaviors in teenagers.

PURPOSE: To investigate the relationship between anger-coping styles (anger expression and anger suppression) and lifestyle behaviors (physical activity and consumption of alcohol, cigarettes, and caffeine) in adolescents. METHODS: A sample of 411 adolescents (198 males: 101 white, 97 black; 213 females: 101 white, 112 black) aged 13-20 years (mean age 15.6 years) completed the Anger Expression Scale and brief self-report questionnaires assessing physical activity (weekly amount, comparison with peers) and consumption of alcohol (frequency and amount over the past 2 weeks), cigarettes (amount over past 2 weeks), and caffeine (from coffee and soda over past week). RESULTS: Correlational and Chi-square analyses showed teenagers high in anger suppression reported consuming alcohol more frequently, spending fewer hours per week in aerobic activity, and being less physically active than their peers. Teenagers high in anger expression reported consuming more caffeinated soda and coffee. CONCLUSIONS: Results suggest that excessive anger suppression or expression may be associated with an imprudent lifestyle relatively early in life.

Adaptation, Psychological↗

Anger and combat-related posttraumatic stress disorder.

We examined whether combat-related PTSD was differentially associated with particular dimensions of anger on two multi-index, psychometric instruments and whether the proportion of variation in PTSD scores explained by anger was significantly greater than that by demographic and exposure variables. We also examined the reliability and validity of a subset of Mississippi Scale items as an anger measure. Participants were 143 Vietnam combat veterans. Anger accounted for over 40% of the variance in Mississippi PTSD scores (minus the anger items) above that associated with age, education, and combat exposure. Veterans with structured-interview-diagnosed PTSD were significantly differentiated from those without PTSD on all anger indices. The results point to anger treatment as a high priority for combat-related PTSD.

Anger↗

Anger regulation deficits in combat-related posttraumatic stress disorder.

We describe a typology of regulatory deficits associated with anger in combat-related posttraumatic stress disorder (PTSD). Cognitive, arousal, and behavioral domain deficits in anger regulation were observed clinically in PTSD patients with high levels of anger who were participating in a multi-year trial of a structured anger treatment. We also describe a category of patients whose anger type we have termed "ball of rage." These patients exhibit regulatory deficits in all three domains of anger regulation. We offer a conceptual framework to advance the understanding of anger associated with PTSD and to guide its effective treatment.

Adaptation, Psychological↗

Anger as a predictor of aggression among incarcerated adolescents.

This study examined the validity of trait anger as a predictor of aggressive behavior among juvenile offenders. Two standard self-report anger scales were administered to 65 recently incarcerated male adolescents. These youths were followed prospectively for physical and verbal aggression during 3 months of subsequent incarceration. Anger scores were not correlated with participant history of violent offending or staff ratings of anger. However, anger scores from both instruments were predictive of subsequent physical and verbal aggression. For example, the Trait Anger scale successfully classified 66% of juvenile offenders into high and low aggressive groups; receiver operating characteristic analysis obtained an effect size of .72. These results support the predictive validity of self-reported anger in identifying juvenile offenders at risk for institutional aggression.

Adolescent↗