- Top of page
Aims: The present study explores anger attacks in depressive and anxiety disorders for their prevalence and some of the clinical and psychosocial correlates.
Methods: The sample comprised of patients with ICD-10-diagnosed depressive and anxiety disorders (n = 328). All the subjects were given a demographic and clinical profile sheet, the Irritability Depression Anxiety Scale, World Health Organization Quality of Life – BREF Version and the Anger Attack Questionnaire. Using the Anger Attack Questionnaire they were divided into two groups – with anger attacks (n = 170) and without anger attacks (n = 158) – in order to study the differential profile of the two groups.
Results: Anger attacks were associated with more anxiety and irritability, and poorer quality of life. Frequency of anger attacks had a positive correlation with depression, irritability and aggression, and a negative correlation with education, income, and quality of life. Panic attacks, somatic anxiety and psychological domain of quality of life predicted the categorization of subjects into those with and without anger attacks.
Conclusion: Anger attacks are common among depressive and anxiety disorder cases and have a negative impact on quality of life. Status of anger attacks as either linked to anxiety and/or depression, or as an independent syndrome needs further study.
THE CURRENT CONCEPT of anger attacks (AA) was introduced by Fava et al.1 They reported a series of cases that presented with sudden episodes of anger accompanied by physiological features resembling panic attacks in the background of depressive- or anxiety-related psychopathology. These attacks occurred spontaneously or in response to a provocation, and were experienced by the subjects as uncharacteristic of themselves and inappropriate to the situation. The patients tended to have a profound feeling of guilt after having these attacks. AA were described in patients with either depressive or anxious disorders, who were free of personality disorders/traits. Based on the good response to antidepressant medications, the authors initially hypothesized that the AA were a possible variant of panic or depressive disorders.2–11 However, later they proposed that AA might exist as a distinct syndrome,3 and if left untreated, might lead to secondary anxiety or depression.
The subsequent research tended to move towards a consensus that AA were a variant of major depression. This was based on the consideration of the historical correlation between hostility, irritability and depression and the good response of AA to antidepressant medication. However, except for the similarity of response to antidepressant treatment, the depressive subgroups with and without AA appeared to be distinct in terms of clinical correlates, personality features and biological characteristics.2–15 Studies have shown that patients with anger attacks are significantly more depressed, anxious and hopeless compared to the patients without anger attacks.6 Fava et al.3 reported that depressed patients with AA have higher scores on the anxiety, somatization, state and trait hostility and global psychological distress scales than depressed patients without AA. On the self-rated Personality Disorder Questionnaire–Revised, depressed patients with AA were more likely to meet criteria for cluster B (histrionic, narcissistic, borderline, and antisocial) personality disorders in comparison to depressed patients without AA.10 In terms of biological correlates it has been shown that serum levels of homocysteine correlate positively with length of current major depressive episode and Hamilton Depression Rating Scale scores in patients with AA but not in those without AA.12
In the next phase, the studies investigated AA in non-depressive disorders, reporting the prevalence from 31% in eating disorders, especially in women with bulimia nervosa9 to 33% in panic and other anxiety disorders,15 to 60% in pregnant/post-partum women who were significantly more likely to suffer from unipolar depression, but with a reasonable percentage of those who could not be fitted into any psychiatric diagnosis.14
Thus, the research so far shows that although more AA are associated with depression, AA are not confined to depressive disorders alone, and are frequently associated with anxiety disorders too. Hence, AA could have similar psychological and neurobiological underpinnings to panic attacks, and could either be a part of depressive symptomatology or a distinct syndrome.
Considering the previous unidirectional approach to link AA with depression alone, we aimed to study AA in anxiety and depressive disorders for their prevalence and the impact in terms of quality of life and aggressive behavior towards family members and others.
- Top of page
The departmental ethics committee approved the study. Patients were informed about the nature and purpose of the study and written informed consent was obtained before recruitment into the study. Subjects were recruited from the outpatient clinic of the Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh over a period of 3 months and were assessed only once.
The inclusion criteria were: aged 20–60 years, either sex, and ICD-1016 diagnoses of depressive disorders F32, F33, F34 (excluding depression with psychotic symptoms), and neurotic, stress-related and somatoform disorders (F40). The exclusion criteria were: organic brain syndrome, psychotic disorder, and comorbid substance abuse (excluding tobacco).
The following instruments were given to all the subjects.
Clinical profile sheet
A specifically designed tool, the clinical profile sheet was used to record the clinical details across the following three components: (i) general variables of duration of illness, duration of treatment, type of pharmacological treatment (antidepressant alone, combinations and none), past history of illnesses, family history of psychiatric disorders; (ii) number and frequency of aggressive acts in the last month (threatening to leave, refusal to talk, sulking, yelling, stamping out or slamming the door, breaking and throwing objects – not at a person, throwing objects at a person, threatening to physically hurt, trying to physically hurt), and direction of aggressive acts (towards spouse, parents, children, other relatives, friends, colleagues, others); and (iii) assessment for presence or absence of panic attacks; if present, the psychological, autonomic and somatic symptoms of anxiety were rated on a four-point Likert scale as absent, mild, moderate or severe.
Anger Attack Questionnaire1
As a self-rated instrument designed to assess the presence or absence of ‘anger attacks’ the Anger Attack Questionniare was used to divide the study group into those with and without AA. For qualifying for the diagnosis of AA, subjects should have had at least one AA in the last month comprising of a minimum of four out of 13 autonomic, behavioral and psychic symptoms. The first item in the instrument enquires about the frequency of AA and the remaining items look into the presence/absence of 13 autonomic and behavioral symptoms. The first item has four possible responses and other items have a ‘Yes’ or ‘No’ response. This is the most commonly used scale for studying AA.2–4 This questionnaire was translated into the Hindi language using the standard protocol of translation and back-translation.
Irritability, Depression and Anxiety scale17
The Irritability, Depression and Anxiety (IDA) scale is a self-rated scale for assessment of irritability in clinical situations and it was used to assess irritability. The scale also included measures of depression and anxiety considering the significant correlations between these moods. The scale consists of 18 items – five items each for depression and anxiety, and eight items for irritability. Of the eight items for irritability, four relate to outwardly directed irritability and four relate to inwardly directed irritability. Each item is followed by four possible responses. The correlations between depression, anxiety, and irritability subscales with other scales of the respective type are all highly significant and satisfy the requirements for concurrent validity.17 This scale was translated into Hindi, adapting the standard protocol of translation and back-translation.
World Health Organization Quality of Life – BREF18
The World Health Organization Quality of Life – BREF is a self-administered multilingual instrument available in the Hindi language. It assesses a subjective evaluation of the respondent's health and living conditions. Four domains of quality of life (QOL) are measured – physical health, psychological health, social relationships, and environment. The scale has 26 items scored from 1 to 5 with a total score range of 26–130. Its psychometric properties are comparable to those of the full version (WHOQOL-100) and it shows good discriminant validity, concurrent validity, internal consistency, and test–retest reliability.18,19 It was used to assess the subjects' quality of life.
Consecutive outpatients attending the clinic for the first time were recruited as per the specified criteria. Either of the two authors (N.P., S.G.), who were qualified psychiatrists, assessed them in one sitting and filled out the clinical profile sheet and the Anger Attack Questionnaire. The IDA and the World Health Organization Quality of Life – BREF were either self-administered by the subjects or, for the subjects who could not read or write Hindi, the investigators read out the statements for the subjects to rate them. The average time taken was 45–60 min; more when the subject could not read or write Hindi.
Irrespective of the diagnostic category, the sample was divided into two groups according to the presence or absence of AA as per the Anger Attack Questionnaire.1 The groups were compared on demographic, clinical and psychological variables using appropriate non-parametric tests, such as the χ2-test, the Mann–Whitney U-test and parametric tests like the unpaired t-test. Correlation analysis was carried out using Pearson's coefficient, Spearman's ‘rho’ and coefficient of point biserial to assess the correlations between the frequency of AA and various demographic, clinical and psychological variables in the AA group. For all statistical analyses, P < 0.05 was considered to be statistically significant, and multiple comparisons were adjusted for by Bonferroni's correction. The adjusted P-value was considered significant at 0.0026. Finally, an attempt was made to determine the predictors for the presence and frequency of AA by using binominal and logistic regression analysis.
- Top of page
Of the 328 subjects, 170 fulfilled the criteria for AA, giving a prevalence rating of 51.8%. Across various diagnostic categories, the prevalence of AA ranged from the lowest of 35.3% in dissociative disorders to the highest of 73.3% in adjustment disorders. Among those with comorbid anxiety and depressive disorders, the prevalence of AA was 69% (Table 1).
Table 1. Prevalence of ‘anger attacks’ across various diagnostic categories (n = 328)
|Diagnostic categories||n||Anger attacks prevalence (%)|
|Comorbid anxiety & depressive disorders†||16||68.7%|
|First episode depression||129||51.9%|
|Obsessive compulsive disorder||28||50.0%|
|Other anxiety disorders‡||16||43.7%|
|Overall prevalence of anger attacks||51.8%|
Based on the presence/absence of AA, the sample was divided into two groups –‘with AA’ and ‘without AA’– that were compared on sociodemographic variables. Both groups were comparable on various clinical parameters, including duration of treatment and personal and family history of psychiatric illnesses. Both groups had a predominance of diagnosis of depressive disorders, with an additional nearly 1/10 suffering from comorbid anxiety and depressive disorders (Table 2).
Table 2. Comparison of sociodemographic and clinical characteristics of subjects with anger attacks and without anger attacks
|Variable||With anger attacks (n = 170) f (%)||Without anger attacks (n = 158) f (%)||χ2 value d.f. = 1|
|Age (years)†||33.11 (10.28)||34.29 (10.87)||1.005¶|
|Sex|| || || |
| Male||83 (48.8)||87 (55.1)|| |
| Female||87 (51.2)||71 (44.9)||1.277|
|Marital status|| || || |
| Never married||30 (17.6)||39 (24.7)|| |
| Married||140 (82.4)||119 (75.3)||2.441|
|Occupation|| || || |
| Employed||66 (38.8)||73 (46.2)|| |
| Unemployed||27 (15.9)||33(20.9)||5.336‡|
| Housewife||77 (45.3)||52 (32.9)|| |
|Education|| || || |
| <Matriculation||83 (48.8)||70 (44.3)|| |
| >Matriculation||87 (51.2)||88 (55.7)||0.672|
|Income in Indian rupees†||2067.62 (2577.7)||1952.62 (1586.26)||1.386§|
|Religion|| || || |
| Hindu||115 (67.6)||118 (62.0)|| |
| Others||55 (32.4)||40 (28.0)||1.971|
|Family type|| || || |
| Nuclear||114 (67.1)||101 (63.9)|| |
| Others||56 (32.9)||57 (36.1)||0.356|
|Locality|| || || |
| Urban||115 (67.6)||98 (62.0)|| |
| Rural||55 (32.4)||60 (28.0)||1.137|
|Diagnosis|| || || |
| Depressive disorders||101 (59.4)||90 (57.0)|| |
| Anxiety disorders||57 (33.5)||64 (40.5)||4.606‡|
| Comorbid D + A||12 (7.1)||04 (02.5)|| |
|Duration of illness† (months)||26.14 (37.24)||31.50 (54.78)||−0.451¶|
|Duration of treatment† (months)||4.38 (14.19)||4.42 (26.82)||−0.222¶|
|Antidepressant treatment|| || || |
| SSRI||118 (69.4)||107 (67.70)|| |
| Others||52 (30.6)||51 (32.3)||0.109|
|Non-antidepressant treatment|| || || |
| Benzodiazepines||54 (31.76)||32 (20.25)||6.69|
| Mood Stabilizers||02 (1.2)||05 (3.16)|| |
| Antipsychotics||01 (0.6)||01 (0.63)|| |
| No||113 (66.5)||128 (75.9)|| |
|Comorbidity physical|| || || |
| Present||16 (9.4)||17 (10.8)||0.164|
| Absent||154 (90.6)||141 (89.2)|| |
|Past psychiatric disorder|| || || |
| Present||15 (8.8)||16 (10.1)||0.162|
| Absent||155 (91.2)||142 (89.9)|| |
|Family history|| || || |
| Present||9 (5.3)||13 (8.2)||1.126|
| Absent||161 (94.7)||145 (91.8)|| |
When compared for the distribution of panic attacks and components of panic symptoms, the group with AA had significantly more comorbid panic attacks and the psychological, autonomic and somatic symptoms of anxiety (P < 0.001) (Table 3).
Table 3. Comparison of distribution of panic attacks, and other/related anxiety variables between groups with anger attacks and without anger attacks
|Variables||With anger attacks (n = 170) f (%)||Without anger attacks (n = 158) f (%)||χ2 values# d.f. = 3||Unadjusted P-value|
|Panic attacks|| || || || |
| Present||99 (58.2)||53 (33.5)||20.07*†||0.000|
| Absent||71 (41.8)||105 (66.5)|| || |
|Psychic Anxiety|| || || || |
| Absent||16 (9.4)||39 (24.7)||22.46*||0.000|
| Mild||22 (12.9)||34 (21.5)|| || |
| Moderate||100 (58.8)||68 (43.0)|| || |
| Severe||32 (18.8)||17 (10.8)|| || |
|Autonomic Anxiety|| || || || |
| Absent||17 (10.0)||42 (26.6)||20.45*||0.000|
| Mild||24 (14.1)||31 (19.6)|| || |
| Moderate||83 (48.8)||58 (36.7)|| || |
| Severe||46 (27.1)||27 (17.1)|| || |
|Somatic Anxiety|| || || || |
| Absent||17 (10.0)||41 (25.9)||24.10*||0.000|
| Mild||21 (12.4)||34 (21.5)|| || |
| Moderate||92 (54.1)||61 (38.6)|| || |
| Severe||40 (23.5)||22 (13.9)|| || |
On comparison for aggressive acts and their direction, the group with AA exhibited significantly more aggressive acts across various settings (types of aggressive acts and behaviors, and direction against both within and outside the family; the frequency being maximal towards spouse and children) (P < 0.001) (Table 4).
Table 4. Comparison of distribution of direction and acts of aggression in subjects with anger attacks and without anger attacks
|Variables (Aggressive acts in the last month)||With anger attacks (n = 170) f (%)||Without anger attacks (n = 158) f (%)||χ2 values d.f. = 1||Unadjusted P-value|
|Direction|| || || || |
| Spouse|| || || || |
| Present||101 (59.4)||11 (7.0)||100.18*||0.000|
| Absent||69 (40.6)||147 (93.0)|| || |
| Parents|| || || || |
| Present||37 (21.8)||3 (1.9)||30.18*||0.000|
| Absent||133 (78.2)||155 (98.1)|| || |
| Children|| || || || |
| Present||111(65.3)||14 (8.9)||110.52*||0.000|
| Absent||59 (34.7)||144 (91.1)|| || |
| Other relatives|| || || || |
| Present||38 (22.4)||4 (2.5)||28.81*||0.001|
| Absent||132 (77.6)||154 (97.5)|| || |
| Friends|| || || || |
| Present||15 (8.8)||1 (0.6)||11.84*||0.001|
| Absent||155 (91.2)||157 (99.4)|| || |
| Colleagues|| || || || |
| Present||19 (11.2)||2 (1.3)||13.42*||0.000|
| Absent||151 (88.8)||156 (98.7)|| || |
| Others|| || || || |
| Present||20 (11.8)||1 (0.6)||16.93*||0.000|
| Absent||150 (88.2)||157 (99.4)|| || |
|Acts|| || || || |
| Threatening to leave|| || || || |
| Present||56 (32.9)||2 (1.3)||56.44*||0.000|
| Absent||114 (67.1)||156 (98.7)|| || |
| Refusal to talk|| || || || |
| Present||80 (47.1)||10 (6.3)||68.23*||0.000|
| Absent||90 (52.9)||148 (93.7)|| || |
| Yelling|| || || || |
| Present||155 (91.2)||19 (12.0)||205.98*||0.000|
| Absent||15 (8.8)||139 (88.0)|| || |
| Slamming|| || || || |
| Present||27 (15.9)||2 (1.3)||21.70*||0.000|
| Absent||143 (84.1)||156 (98.7)|| || |
| Breaking & throwing objects|| || || || |
| Present||41 (24.1)||3 (1.9)||34.80*||0.000|
| Absent||129 (75.9)||155(98.1)|| || |
| Throwing objects at a person|| || || || |
| Present||21 (12.4)||2 (1.3)||15.43*||0.000|
| Absent||149 (87.6)||156 (98.7)|| || |
| Threatening to hurt|| || || || |
| Present||99 (58.2)||10 (6.3)||99.43*||0.000|
| Absent||71 (41.8)||148 (93.7)|| || |
| Trying to hurt|| || || || |
| Present||79 (46.5)||6 (3.8)||77.67*||0.000|
| Absent||91 (53.5)||152 (9.2)|| || |
On IDA scale parameters, both groups were comparable for the severity of depression; however, the group with AA had greater severity of anxiety (P < 0.05) and irritability (both inward and outward) (P < 0.001). On QOL parameters, the group with AA reported significantly poorer global QOL (P < 0.001) and, except social relationships, on all QOL domains (P < 0.05 to <0.001) (Table 5).
Table 5. Comparison of the scores of Irritability, Depression and Anxiety and World Health Organization Quality of Life – BREF scales in subjects with anger attacks and without anger attacks
|Variables||With anger attacks (n = 170) Mean (SD)||Without anger attacks (n = 158) Mean (SD)||t-value d.f. = 326|
|Irritability, depression and anxiety scale|| || || |
| Depression||7.88 (3.60)||7.17 (3.09)||1.9 NS|
| Anxiety||7.37 (2.88)||6.60 (2.91)||2.38*|
| Irritability – outwards||6.17 (3.09)||3.77 (2.41)||7.78***|
| Irritability – inwards||6.00 (3.32)||4.35 (3.43)||4.29***|
|WHOQOL – BREF|| || || |
| Physical health||19.10 (5.09)||20.67 (5.98)||2.55*|
| Psychological health||15.49 (4.27)||17.20 (5.47)||3.176**|
| Social relationship||9.34 (3.06)||9.89 (3.42)||1.556 NS|
| Environmental health||5.21 (2.06)||5.66 (2.06)||1.982*|
| General well-being||23.81 (6.43)||25.80 (5.78)||2.93**|
| Total score||73.14 (16.79)||79.24 (17.25)||3.24***|
Correlation analysis showed that the key variable of ‘frequency of AA per month’ had significant positive (P < 0.05) correlation with depression and irritability-outwards scores; significant negative correlation with education, income, total QOL score, and QOL domains of physical, psychological and environmental health (P < 0.05 to <0.001). Frequency of anger attacks also had significant positive correlation with all the acts and directions of aggression (P < 0.001) (Table 6).
Table 6. Correlation between anger attack frequency and sociodemographic, clinical and psychological characteristics in patients with anger attacks (n = 170)
|Variables||Anger attacks frequency (per month) Spearman's ‘rho’|
|Duration of illness (months)||0.158*|
|Duration of treatment (months)||−0.004|
|Comorbidity physical illness||−0.039†|
|History of psychiatric disorder||0.079†|
|Family history of psychiatric disorder||0.060†|
|IDA – Depression||0.194*|
|IDA – Anxiety||0.119|
|IDA – Irritability – inward||0.109|
|IDA – Irritability – outward||0.192*|
|WHOQOL – Physical health||−0.232**|
|WHOQOL – Psychological health||−0.167*|
|WHOQOL – Social relationship||−0.016|
|WHOQOL – Environmental health||−0.202**|
|WHOQOL – General wellbeing||−0.120|
|WHOQOL – Total Score||−0.214**|
To delineate variables that could predict categorization of patients into those with AA and without AA, independent variables that were significantly different in terms of odds ratio across the two groups were taken up. In stepwise forward binomial logistic regression, only three independent variables, i.e. panic attacks (P = 0.01), somatic anxiety (P = 0.007) and the psychological domain of QOL (0.003), predicted the categorization of subjects into those with and without AA.
Independent variables, which correlated significantly with frequency of anger attacks in the group with AA, were taken up for multiple linear regression (stepwise forward). Only two variables – education and physical QOL – together predicted 9.2% of the variance; the remaining variance remained unexplained.
- Top of page
Anger, irritability and aggression are usually studied as an extension of symptom profile in the context of psychiatric illnesses, including psychotic and affective disorders; the related phenomenon of AA has been studied mainly in relation to depressive disorders.
The present research studied ‘anger attacks’ across various psychiatric disorders. The AA were considered to be present when a subject had at least one AA in a month with at least four psychological, behavioral and autonomic symptoms of anxiety. This was done in line with the previous studies and the ICD-1016 diagnostic guidelines for panic disorder.
The strength of this study lay in it being prospective, with a consecutive sample of depressive and other neurotic disorders, and a relatively non-biased subjective reporting.
A prevalence of 51.8% in our study is concordant with the previous reports of a high prevalence of AA in depressive disorders (30–40%),4 panic disorders and non-panic anxiety disorders (32% and 29%, respectively)15 and post-partum/pregnant women (60%).20 However, none of these previous studies covered so large a sample and such diverse psychiatric disorders as in our study. Our finding that almost two-thirds of the patients with AA had comorbid anxiety and depressive disorders emphasizes the need to question the patients presenting with depressive and anxiety disorders about the presence of this common entity.
The socioclinical profile of patients with AA in our study was similar to that reported in the previous research.4 In our study the patients with depressive and anxiety disorders had a similar prevalence of AA. Even though it is contrary to the finding of a previous study,15 this finding is important as it hints not only towards the possibility of a more common occurrence, but also a probable independent existence of AA – unlike the conventional understanding of AA being a component/sub-syndrome of depression.
Furthermore, a significantly higher frequency of panic attacks (not panic disorders) in our AA group tends to support the hypothesis of a close association of anger and anxiety in the ‘fight–flight’ reaction occurring due to autonomic arousal.2 Also, a significantly higher frequency of psychic, autonomic and somatic symptoms of anxiety in the AA group may be a reflection of the construct of the AA questionnaire.
On the IDA scale, a significantly higher score on anxiety and irritability measures (both inward and outward) in our patients with AA further points towards the correlations between anger, irritability and anxiety. Both our groups, with and without AA, were comparable on severity of depression scores. These findings are similar to those of the previous studies with depressed patients,3,11 but are in contrast to other studies on anxiety, depressive, and eating disorders that showed higher depression scores in patients with AA.7,9,15
Despite a comparable severity of depression, in our study a higher score of depression correlated positively with frequency of AA. AA were not seen in all patients with depression, which could be due to the possibility that while various independent factors (e.g. personality variables) modulate the manifestation of anger and anxiety, it is the presence of depression that tends to fuel them. Hence, in persons predisposed to manifesting irritability and anger, development of a depressive illness leads to the more frequent manifestation of AA. It is a well-recognized observation in clinical practice that irritability, panic attacks, and dissociative symptoms occur frequently during a depressive episode.
Higher frequency of aggressive behavior and high severity of irritability with a positive correlation with frequency of AA can be understood as reflecting the construct validity of the AA questionnaire.
Previous studies6,15,20 have reported that current/history of depression, severity of depression and use of antidepressants significantly predicted AA. However, none of the depression-related variables predicted occurrence of AA in the present study. Also, despite studying a significant number of depression- and anxiety-related variables, nearly 92% of the variance in relation to the frequency of AA remained unexplained. This further attests to the need to understand AA beyond the boundaries of the current conceptual framework of the phenomenology and nosology of depressive and anxiety disorders.
Our subjects with AA suffered from a lower QOL in all aspects (except social relations) and a significant negative correlation of most of the QOL parameters with frequency of AA, indicating that the patients with AA suffer from high dissatisfaction and distress. Significantly higher aggressive behavior (both in terms of direction and type of acts) in patients with AA and its positive correlation with frequency of AA provide additional evidence of the impact of AA on the person's surroundings. Also, correlation analysis showed that the longer the depressive/anxiety illness is left untreated, the higher the possible frequency of occurrence of AA. Hence, it appears that patients with AA tend to suffer from a high degree of morbidity and distress, and are probably in greater need of therapeutic intervention.
Frequency of AA correlating negatively with educational and income status in our study may indicate that less cognitive maturity, limited repertoire of coping strategies to deal with anger, and greater stresses may have a bi-directional cause-and-effect correlation with lower education and socioeconomic status.
Conceptually, AA are supposed to be similar to panic attacks, and can be taken to exist on the other end of the anxiety–anger dimensional spectrum (as per the concept of flight–fight response). Additionally, our study shows that manifestations of AA correlated positively with ‘outward irritability’ and ‘depression’, which indicates that underlying depression (rather than anxiety) fuels the manifestation of AA. It may be pertinent to remind ourselves of one of the psychodynamic theories postulated for depression, i.e. depression occurring due to anger turned inwards;21 which makes one hypothesize that people with depression are more likely to experience/manifest ‘anger/irritability’ than ‘anxiety’. Hence, these may be the possible reasons for the apparently contradictory findings of a lower prevalence of AA in ‘anxiety disorders’ in our sample, and the high prevalence in those with ‘comorbid anxiety and depressive disorders’.
High prevalence of AA in our study suggests that it would be beneficial to consider AA as a distinct entity. As AA have a high frequency/prevalence in depressive and mixed anxiety–depressive disorders, the simple presence of AA (without overt manifestation of depressive features) should alert the clinician to the possibility of an underlying depressive illness. Our findings suggest that AA tend to be associated with distress, dysfunction and lower QOL, hence, simple recognition of this entity can help the clinician in being able to provide ‘anger management’ techniques/courses for the patient, thereby ensuring symptomatic treatment, and improved QOL with reduced distress and dysfunction. Furthermore, AA as an indicator of underlying depressive and/or anxiety states, may respond to pharmacological treatment, such as selective serotonin reuptake inhibitor, thereby alleviating distress, dysfunction and improving QOL. Hence, there may be merit in treating AA as a distinct category. However, further studies addressing response to treatment would be required to validate its distinctiveness.
Our study was limited by: being exploratory in nature; being clinic-based; not having a large representative sample for various other psychiatric disorders; not being able to utilize other measures/instruments for attempting to validate AA as a distinct entity (e.g. testing of underlying personality constructs); and not evaluating the biological correlates and the effect of antidepressant treatment on AA (either in the form of increase or decrease in AA).
Within these limitations, the results of our study support the following generalizations. AA is a highly prevalent condition, especially in depressive, anxiety and related disorders. AA appears to have a close association with panic attacks/anxiety symptoms, and is associated with a high degree of negative impact on behavior and QOL of an individual. Thus, as a phenomena, AA tend to cut across various psychiatric disorders. Hence, on lines similar to those for panic disorder, AA too may be conceptualized as a distinct syndrome (i.e. ‘anger disorder’). However, to establish this conceptual framework firmly there is a need to study AA comprehensively across various psychiatric illnesses as also the normal/healthy population, so as to address the issues related to their frequency and validity. This, in turn, will have implications for its treatment, outcome, and the nosological status.