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Anger management and temper control: critical components of posttraumatic stress disorder and substance abuse treatment.

Recent studies have shown associations among combat experience, PTSD, anger and hostility, and involvement in violence. Clinical observations of veterans enrolled in the Substance Use/Posttraumatic Stress Disorder Team (SUPT) program at the San Francisco Veterans Affairs Medical Center revealed relatively high levels of anger and aggressive behavior, including physical assaults and property damage. In response to this anger and aggressive behavior, an anger management treatment was added to the SUPT program's treatment of substance abuse and PTSD. Anger management consisted of a 12-week cognitive-behavioral group treatment. Session topics included identifying the physical, emotional, and situational cues to anger, developing individualized anger-control plans, recognizing and altering destructive self-talk, utilizing time-out, practicing conflict resolution techniques, and using the group to discuss and evaluate high-risk anger situations. Special attention was given to self-monitoring anger-escalating behavior (using an anger meter) and avoiding negative consequences. This article describes the components of the anger management treatment. A clinical vignette is also presented to illustrate the benefits of anger management treatment.

Anger↗

Assessing anger expression in children and adolescents.

Anger expression styles are associated with psychological and physical well-being among adults. Little is known about the role of anger expression in children's functioning. This lack of knowledge has resulted, in part, from a lack of validated tools for anger expression measurement. The Pediatric Anger Expression Scale-3rd edition (PAES-III; Jacobs, Phelps, & Rohrs, 1989; Jacobs & Kronaizl, 1991) has been proposed as a reliable and valid assessment instrument of anger expression styles. The PAES-III includes three scales that measure anger turned inward, anger expressed outwardly, and anger controlled cognitively or behaviorally. We evaluated the psychometric properties of this instrument when it is administered verbally to children with juvenile rheumatoid arthritis, children with juvenile diabetes mellitus, and healthy children. Internal consistency was adequate for anger-in and anger-out, but marginal for anger-control. Concurrent validity was supported for the total sample. A principal components analysis suggested a four-factor model of anger expression. Overall, the PAES-III was found to have psychometric limitations. Use of a modified PAES-III may facilitate pediatric behavioral medicine research addressing risk factors for maladjustment among children with chronic illnesses.

Adaptation, Psychological↗

Genetic and environmental influences on anger expression, John Henryism, and stressful life events: the Georgia Cardiovascular Twin Study.

OBJECTIVE: To examine the genetic and/or environmental origin of variation and covariation of perceived stressful life events and two stress-related coping styles, anger expression and John Henryism. METHODS: Data were available from 306 European American (EA) and 213 African American (AA) twin pairs, including monozygotic and dizygotic of same as well as opposite sex (mean age, 14.8 +/- 3.1 years; range, 10.0-25.9 years). Anger expression, John Henryism, and life events were measured with the Anger Expression Scale (subscales: Anger-in, Anger-out, and Anger-control), the John Henryism Active Coping Scale, and the Adolescent Resources Challenges Scale, respectively. RESULTS: Model fitting showed no ethnic or sex differences for any of the scales. All traits showed at least some degree of familial resemblance, best explained by shared environment for Anger-in (18%), heritability for Anger-control (34%), John Henryism (34%), and life events (47%), and a combination of heritability (14% and 15%) and shared environment (10% and 20%) for Anger-out and overall anger expression, respectively. The remaining part of the variation for all traits was explained by environmental influences that are unique to the individual. Anger expression and life events were correlated (r = 0.28), and bivariate genetic modeling showed that 61% of this correlation was mediated by common genetic factors. CONCLUSIONS: Individual differences in coping styles and life events in youth can be explained by moderate genetic and substantial environmental influences, of which most are idiosyncratic to the individual. The association between anger expression and life events is largely the result of common genes.

Adaptation, Psychological↗

An investigation of the anger levels of residents: medical compared with surgical disciplines.

OBJECTIVE: To evaluate medical and surgical residents' anger levels with regard to the department in which they worked, seniority, sex, satisfaction with their work environment, and the number of nightshifts worked per month. The specific situations and persons at whom residents reacted with anger were also investigated. METHODS: 116 randomly selected residents staffed in a university hospital (62 medical and 54 surgical residents) were enrolled. The trait anger and anger expression scale was used to find out the personal anger levels of each participant. The participants also clarified the persons and situations that made them angry at work. RESULTS: Trait anger levels were greater in the surgical residents in their first two years when compared with levels of their senior colleagues (p = 0.033). Mean trait anger levels were greater in the residents who were not satisfied with their department (p = 0.004). Anger levels were not found to be related to the number of shifts per month. Male residents had higher levels of anger than female colleagues (p = 0.019). CONCLUSION: Residents in clinical sciences seem to have the potential to benefit from a screening process in terms of anger and its subcomponents by means of a tool such as the trait anger and anger expression scale during their residency.

Adult↗

Anger attacks: correlates and significance of an underrecognized symptom.

BACKGROUND: Anger attacks over provocations described as trivial by the individual are an underrecognized symptom associated with aggressive acts. They are usually followed by guilt and regret. Anger attacks among mothers are an important problem because they are often directed at the woman's spouse and/or children. This study examines the prevalence and correlates of anger attacks in a psychiatric clinic for women who are either pregnant or up to 18 months postpartum. METHOD: Fifty consecutive consenting patients were assessed at initial presentation with the Structured Clinical Interview for DSM-IV Axis I Disorders, a modified Anger Attacks Questionnaire, self-reports of psychiatric symptoms and psychosocial variables, and clinician ratings. RESULTS: Thirty (60%) of 50 patients reported anger attacks. Of those with anger attacks, 76.7% worried about them, and 73.3% had tried to prevent them. Compared with women without anger attacks, those with anger attacks were significantly more likely to report higher state and trait anger (p < .001), have a diagnosis of unipolar depression (p < .01), report more aggression directed at immediate family, and avoid their children. Both groups displayed little angry affect in the interview, thus appearing similar at assessment. CONCLUSION: Anger attacks in response to children and spouse were common in this group of women and were associated with subjective distress. Because those with and without anger attacks appear similar at interview, inquiring about the presence of anger attacks is important to ensure that they become a focus of treatment.

Adult↗

Systems conceptualization and treatment of anger.

Clinicians, researchers, and patients tend to view anger as attributable to immediate circumstances and current thoughts. In contrast, systems-oriented thinking approaches anger as a contextual and dynamic phenomenon. Personal dispositional systems of anger (cognitive, physiological, and behavioral) are embedded in an interdependent network of interpersonal and environmental systems. Anger coevolves with and is in equilibrium with these systems. The more adaptive and embedded it is within a system, the greater will be its inertia or resistance to change. The automaticity of anger further challenges its regulation, as does its transfer across domains. Other troublesome systems phenomena associated with anger and aggression are escalation and threshold effects. Anger arousal, as a deviation from homeostasis, is inhibited and counteracted by various negative feedback loops that are properties of internal, interpersonal, and environmental systems. Treatment augments anger-regulatory mechanisms. Interventions aimed at anger reduction should consider the systems in which anger is embedded and the adaptive functions anger serves within those systems. These and other systems concepts are explicated and are illustrated with material from two clinical cases.

Adaptation, Psychological↗

Anger expression, gender, and ambulatory blood pressure in mild, unmedicated adults with hypertension.

The suppression of anger has been associated with the development of hypertension. This study evaluated the association between anger management style (anger-in and anger-out) and ambulatory blood pressure (ABP) in patients with repeated clinic diastolic blood pressures (DBPs) between 90-105 mmHg, unmedicated and with no known coronary artery disease. A total of 128 men (46.0 years) and 66 women (46.6 years) participated. Fourteen percent of men and 35% of women were classified as having "white coat" hypertension (daytime DBP < 85 mmHg). Mean awake and sleep DBP and systolic blood pressure (SBP) were evaluated in a repeated measures analysis of variance (ANOVA). Anger-in and anger-out scores were categorized into low, medium, and high t-scores (< 50, 50-59, > or = 60). Results indicated that in women, increasing anger-in is associated with greater SBPs while awake and sleeping, whereas no effect was found for DBP, nor any effect in men. No significant association was found between gender, anger-out, and ABP. The clinical diagnostic status of white coat hypertension was not differentially associated with anger-in or anger-out in men and women. In conclusion, in a sample of mild unmedicated adults with hypertension, suppression of anger is associated with greater ambulatory SBP in women, but not in men.

Adult↗

Anger management style, opioid analgesic use, and chronic pain severity: a test of the opioid-deficit hypothesis.

Anger management style is related to both acute and chronic pain. Recent research suggests that individuals who predominantly express anger (anger-out) may report heightened chronic pain severity due in part to endogenous opioid antinociceptive dysfunction. If exogenous opioids serve to remediate opioid deficits, we predicted that regular use of opioid analgesics by chronic pain patients would alter these relationships such that anger-out would be related to chronic pain severity only among opioid-free patients. For 136 chronic pain patients, anger management style, depression, anxiety, pain severity, and use of opioid and antidepressant medication was assessed. Results of hierarchical multiple regressions to predict chronic pain severity showed: (a) a significant Anger-out x Opioid use interaction such that high Anger-out was associated with high pain severity only among patients not taking opioids; (b) controlling for depressed affect and anxiety did not affect this association; (c) the Anger-out x Antidepressant use interaction was nonsignificant; (d) Anger-in did not interact with use of any medication to affect pain severity. Results are consistent with an opioid-deficit hypothesis and suggest that regular use of opioid medications by patients high in anger expression may compensate for an endogenous opioid deficit, and mitigate the effects of elevated anger expression on chronic pain intensity.

Adaptation, Psychological↗

Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments.

To determine the effects of anger on coronary artery vasoconstriction, 12 patients with symptomatic myocardial ischemia were studied during cardiac catheterization. During catheterization, the patients were asked to recall a recent event that had produced anger. One narrowed and 2 non-narrowed arterial segments were selected using predetermined criteria. Patients also completed various self-report measurements upon entering the catheterization laboratory before any procedures, after completion of the clinical angiogram and after the anger recall stressor. There was a significant increase in subject reports of anger (F[1,6] = 21.94, p < 0.01) and arousal (F [2,6] = 5.49, p < 0.05) during the anger stressor. There were no significant changes in heart rate, systolic or diastolic blood pressure, or heart rate x systolic blood pressure product during the anger stressor. A total of 27 arterial segments (9 narrowed and 18 non-narrowed) were selected and analyzed using quantitative angiographic techniques. Repeated-measures analysis of variance (baseline vs anger stressor) found no significant group differences with regard to changes in arterial diameter between conditions or among segments. Reported anger was significantly correlated with a decrease in both mean (r = -0.76, p < 0.05) and minimal (r = -0.82, p < 0.05) diameter changes in narrowed arteries. Vasoconstriction only occurred with high levels of anger. There were no significant correlations between anger report and diameter change in non-narrowed arteries. Thus, anger may produce coronary vasoconstriction in previously narrowed coronary arteries.

Adaptation, Psychological↗

Self-reported anger in black high school adolescents.

The purpose of this study was to explore the recognition and expression of anger in black high school adolescents. A total of 56 teens, aged 14-19 years, responded to questions about their recognition of anger, how and to whom they express anger, and to whom they refrain from expressing anger. They also stated their opinions about acceptable and unacceptable expressions of anger and its relationship to depression or suicide. Data were analyzed using frequency tabulations for all questions on the survey instrument. Specific variables of age, grade in school, gender, and family composition were analyzed by one-sample chi 2 tests (alpha set at 0.05). The study demonstrated 1) all the teens surveyed could recognize when they were angry; 2) most teens expressed anger to their friends, to their siblings, and to their mothers; 3) younger teens (ages 14-15 years) when compared to older teens (ages 18-19 years), identified mother as the one who made them angry; 4) females were more likely to feel like crying when angry; 5) females were more likely to feel like being silent when angry; 6) students from one- and two-parent homes did not differ in their expression of anger. Implications of this study include the recognition that anger is a natural, human emotion. Adolescents need to observe adults who can effectively manage behavior associated with anger. Problem solving skills, stress management techniques, and role play situations can be utilized as effective tools in the recognition and expression of anger in acceptable ways and in attempts at the prevention of dysfunctional anger.

Adolescent↗

Anger expression, age, and blood pressure in modernizing Samoan adults.

OBJECTIVE: Relationships among anger expression, age, and blood pressure (BP) were studied in a cross-sectional sample of 593 American and Western Samoan adult men and women, 25 to 55 years of age. Prior studies indicated that anger coping is an important psychosocial domain in modernizing Samoans. METHODS: Anger expression was assessed using a modified 24-item version of the State-Trait Anxiety Inventory composed of anger-in, anger-out, and anger-control, along with 4 Samoan culture-specific anger items. Age and sex stratified analyses were performed. Body-mass adjusted BP was regressed on the anger expression subscales and age. RESULTS: In women < or = 40 years of age, anger-out was significantly (p < 0.01) and negatively related to adjusted diastolic BP. Young women from American and Western Samoa who outwardly expressed anger least frequently had higher adjusted diastolic BP. CONCLUSION: The significant influence of anger expression on BP in young modernizing Samoan women may be because: a) increased stress from the interaction of traditional gender role-related domestic demands and more opportunities for individual socioeconomic activities; and b) the culturally normative pattern of suppressed emotional expression.

Adult↗

Anger expression and ambulatory blood pressure: a comparison of state and trait measures.

OBJECTIVES: The goals of this study were (1) to compare trait and state measures of anger expression, (2) to examine associations between situational variables and anger expression, and (3) to examine relationships between trait and state anger expression and ambulatory blood pressure. METHODS: One hundred college students completed state and trait versions,of the Spielberger (1) anger expression scale. State measures were completed in response to specific anger-provoking situations as they occurred over a 7-day period. Ambulatory blood pressure was recorded on one of these days. RESULTS: Moderate correlations were observed between trait and state anger expression. Significant associations were found between a number of situational variables and state anger expression scales. Neither trait nor state anger expressions scales were related to blood pressure levels. CONCLUSIONS: These results indicate that trait and state measures of anger expression are not equivalent and that situational factors play an important role in anger expression. Situational variability may be an important factor in determining the health consequences of anger expression.

Adaptation, Psychological↗

Anger expression and risk of stroke and coronary heart disease among male health professionals.

OBJECTIVE: Anger expression is a dimension of anger that may be strongly related to coronary heart disease and stroke. To date few cohort studies have evaluated the role of anger coping style in the development of cardiovascular disease. This study prospectively examined the effects of anger expression on incidence of cardiovascular disease. METHODS: Participants were male health professionals (N = 23,522), aged 50 to 85 years old and without previous cardiovascular disease, who responded to a mailed questionnaire incorporating the Spielberger Anger-Out Expression Scale in 1996. The cohort was followed for 2 years (1996-1998). RESULTS: Men with moderate levels of anger expression had a reduced risk of nonfatal myocardial infarction compared with those with lower levels of expression (relative risk: 0.56; 95% confidence interval: 0.32-0.97), controlling for coronary risk factors, health behaviors, use of psychotropic medication, employment status, and social integration. Anger expression was also inversely associated with risk of stroke. The multivariate relative risk of stroke was 0.42 (95% confidence interval: 0.20-0.88), comparing men with higher anger-out scores to men with lower scores. A protective dose-response relationship was observed between anger-out score and risk of stroke (p for multivariate trend test: 0.04). CONCLUSIONS: Among this cohort of older men with high socioeconomic status and relatively low level of anger expression on average, moderate anger expression seemed to be protective against cardiovascular disease over a limited follow-up period.

Adaptation, Psychological↗

Children's responses to different forms of expression of anger between adults.

Anger is not a homogeneous stimulus, but can vary on a variety of dimensions and domains. This study examined children's responses to anger as a function of: (a) the mode of expression of anger (nonverbal, verbal, verbal-physical), and (b) whether or not anger between others was resolved. Children were presented with videotaped segments of angry and friendly interactions and asked questions concerning their responses. All angry interactions, including non-verbal anger, were perceived as negative events and elicited negative emotions. Unresolved anger was perceived as a far more negative event than resolved anger and induced greater feelings of anger and distress in children. Verbal-physical anger was perceived as the most negative form of expression of anger. Boys reported more angry feelings in response to anger than girls. Distress responding was greater in children from homes in which there was interparent physical aggression and in children with behavior problems. Finally, the utility of this methodology is supported by relatively high test-retest reliability and limited evidence of context effects.

Adaptation, Psychological↗

Psychophysiological responses to anger provocation among Asian Indian and White men.

To examine cultural differences in response to anger provocation, affective, cognitive, behavioral, and cardiovascular responses to social confrontation, role plays were measured in 20 Indian male immigrants in the United States and 40 White men. Participants engaged in 2 interactions with a nonacquiescent male confederate and were instructed to suppress or express their anger in counterbalanced order. Following each role play, participants state anger, and resentful and reflective cognitions pertaining to anger were assessed. Participants' videotaped behavioral responses were assessed for problem-solving skills and negative and positive verbal and nonverbal behaviors. Blood pressure and heart rate (HR) responses were recorded throughout the session. Results revealed that Indian participants used more introspective strategies comprising of repression and rational coping self-statements to anger provocation than their White counterparts. White participants experienced significantly higher HR responses and showed more awareness of physiological sensation compared to the Indian participants, but only when asked to exhibit their anger. Indian participants had a faster diastolic blood pressure (DBP) recovery when allowed to engage in anger inhibition (which is a culturally determined mode of functioning) compared to when they had to exhibit anger before inhibiting it. White men showed a heightened cardiac response to anger expression, something not seen among Indian men. Indian men, in contrast, exhibited delayed DBP recovery from anger expression and increased introspective cognitive strategies when asked to engage in anger exhibition, a behavior not congruent with their culture of origin.

Adolescent↗

Anger expression and lipid concentrations.

We used 2 different strategies to examine the relation between anger expression and lipid concentrations in 116 middle-aged men. Using the common analytic method used in the literature, the group crossing approach, we examined whether Anger-In. Anger-Out, and their interaction were related to lipids. Regression analyses revealed that Anger-In and Anger-Out were marginally related to total cholesterol. These associations disappeared after controlling for hostility, anger, and anxiety. Using a new intraindividual difference approach, we determined individuals' relative dominance of Anger-In and Anger-Out and examined linear and quadratic associations with lipids. Regression analyses revealed the quadratic was related to both total cholesterol and low-density lipoprotein-cholesterol (LDL-c), indicating that individuals who almost always express their anger or almost never express their anger had both elevated total cholesterol and LDL-c. The curvilinear association with total cholesterol persisted even after controlling for hostility, anger, and anxiety.

Journal Article↗

Development of a Russian State-Trait Anger Expression Inventory.

We examined the possible universality of Spielberger's (1988) model of anger by validating a Russian State-Trait Anger Expression Inventory (STAXI). In Eckhardt, Kassinove, Tsytsarev, and Sukhodolsky (1995), support was found for all STAXI factors except anger-in, using students from St. Petersburg State University. In the present study, 346 students from Russian high schools and the Pavlov Medical School served as subjects. Using new items, we found strong support for the factor structure hypothesized by Spielberger. All scales showed good to excellent alphas, and there was substantial similarity of the current means with results from the earlier study. The Russian samples, however, showed a lower level of state anger. The data support the possibility that state anger consists of two subscales, a simple experience and an experience combined with an action tendency. Trait anger occurs as a general temperament or as a reaction to specific triggers. It is positively related to anger-out and negatively related to anger control. Future studies can use this instrument to evaluate the stability of anger in Russian speaking populations, and to assess anger experiences and expression in response to specific triggers.

Adolescent↗

The Clinical Anger Scale: preliminary reliability and validity.

This article reports preliminary evidence for the development and validation of the Clinical Anger Scale (CAS), an objective self-report instrument designed to measure the syndrome of clinical anger. Factor analysis of the CAS confirmed a unidimensional item structure; reliability analyses also demonstrated adequate internal consistency and test-retest stability for the CAS; other results indicated that the CAS was unrelated to social desirability influences. Additional findings indicated that clinical anger was associated positively with several anger-related concepts (e.g., trait anger, state anger, anger-in, anger-out, anger-control) and that the CAS was related in predictable ways to people's psychopathological symptoms, personality traits, and early family environments. Implications for future research and therapeutic assessment with the Clinical Anger Scale are discussed.

Acting Out↗