Tricky ten minutes - I need help with my anger
Dr Elizabeth England, GPSI in mental health, offers advice on managing patients with anger problems
More than one in 10 people (12%) say that they have trouble controlling their own anger. However, fewer than one in seven (13%) of those people have sought help for their anger problems and 58% wouldn’t know where to seek help if they needed help with an anger problem.1 Anger is a normal, healthy emotion that involves a strong uncomfortable and emotional response to a perceived provocation and helps us to react to situations in which we feel threatened.2
People often think of anger and aggression as the same thing, but researchers estimate that people get aggressive just 10% of the times that they get angry. Anger is an emotional state and aggression is just one of the ways that people behave when they are angry. Alcohol can make some people act more aggressively and drug use can similarly lower inhibitions.
Establishing a diagnosis
Although anger is often associated with significant dysfunction, ‘anger disorders’ are not currently recognised by the American Psychiatric Association Diagnostic and Statistical Manual IV.3 Establishing a diagnosis of ‘anger requiring management’ needs the clinician to explore a number of factors. Patients do not often present concerned about anger issues themselves. People with problem anger often fail to recognise it as a problem, or if they do, they are reluctant to seek treatment because they feel ashamed.
The following are signs that may indicate that an individual needs anger management help:
- trouble with the authorities or the law
- frequently feeling that they have to hold in their anger
- numerous arguments with people around them, especially partners, parents, children or colleagues
- finding themselves involved in fights
- hitting their partner or children
- threatening violence to people or property
- outbursts where they break things
- losing their temper when driving and becoming reckless
- thinking that perhaps they do need help – anyone who actively seeks help because they feel anger is causing problems should receive it.
Causes of poorly controlled anger
Certain brain injuries, neurological problems or intellectual disabilities, severe mental health problems such as bipolar disorder or schizophrenia, mood swings from blood sugar levels and medications can all contribute to poorly controlled or uncontrollable anger. Anger that is caused not by perception and response but by medical conditions requires different techniques and guidance. The majority of patients, however, do not have any formal physical or psychiatric problems.
Assuming no underlying treatable cause for anger can be found, options include self-management, bibliotherapy (see bibliography, right), NHS support such as anger management courses, counselling, CBT and voluntary and third sector organisations such as British Association of Anger Management (BAAM), who also offer courses on anger management.
This is an option that can be taken independently or with support from a GP. The first and most important thing is recognising anger triggers – instances or events that cause us to feel angry.
Once an individual has recognised the triggers, they have four choices – to release the anger in an uncontrolled way (often through physical violence), suppress the anger and internalise it (which can lead to self-harm), vent the anger (physically letting go by punching a pillow, for example) or deal with the anger in a more mindful way:4
- Mindful immediate ways of dealing with anger include:
– removing themselves from the situation
– talking themselves down – imagining what their calmest friend would say
– visualisation – imagining themselves in a relaxing scene
– doing something that distracts and occupies the mind, such as reading a magazine, doing a crossword, listening to soothing music
– going for a walk, a run or engaging in a non-contact sport.
- Other self-help strategies include:5
– avoiding drugs and alcohol
– getting creative – writing, making music, dancing or painting can release tension and help reduce feelings of anger
– discussing feelings with friends.
Cognitive behavioural therapy
You could initially try a brief CBT-based approach with the patient. You can advise them that when they are ready and feeling calm, they should list and identify the situations that make them angry, noting down exactly what in these triggers makes them angry. You could then direct the patient to consider their interpretation of the situation with the following questions:6
• What evidence is there to show that their interpretation of the situation is accurate?
• Is there another equally believable interpretation of what is happening?
• What action can the patient take to have some control of the situation?
• If the patient’s best friend were in this situation, what advice would the patient give them?
• Has their friend been in the situation but not become angry? Why not?
• What are the costs and risks of getting angry?
Medication and anger
This is a controversial area and medication has a limited role in anger management, particularly in primary care. If the patient experiences concomitant anxiety or depression, it would be appropriate to give an SSRI, following the guidelines for an individual without anger management issues.
For individuals still having problems, you could suggest an anger management programme. These may be run by the NHS or private companies. A typical programme may involve one-to-one counselling and working in a small group. In some cases, programmes may last a couple of months and most include CBT as well as counselling.
What about if someone is concerned about someone else’s anger?
It can be very difficult if someone presents concerned about someone experiencing problems with anger, especially if this results in them being violent. A GP’s role initially should be establishing whether there are any potential safeguarding issues - are any of the individual involved from vulnerable groups such as children, older adults or people with intellectual disability for example. If so then your duty of care would involve alerting the appropriate authorities of the situation.
You can advise them to contact one of the support organisations listed below.
If the person with anger control issues has a mental health problem, this is likely to make supporting them more difficult and you need to ensure that you get support from appropriative sources such as the individual’s CMHT.
Dr Elizabeth England is a GPSI in mental health in Edgbaston and clinical lecturer in primary care clinical sciences at the University of Birmingham
1 Boiling Point: Problem Anger and What We Can Do About It. Mental Health Foundation, 2008. mentalhealth.org.uk
2 Oatley K, Johnson-Laird PN. Towards a cognitive theory of emotions. Cognition and Emotion 1987;1:29–50.
3 Diagnostic and statistical manual of mental disorders American Psychiatric Association, 2000, 4th edition.
4 Shapiro SL et al (2006). Mechanisms of mindfulness. J Clin Psychol 62:373–86.
5 How To Deal With Anger. Mind, 2009. mind.org.uk. Accessed 1.4.2013
6 Beck R, and Fernandez E. (1998) Cognitive-behavioral therapy in the treatment of anger: a meta-analysis. Cognitive Therapy and Research 22, 63; Feb: 74.
• Overcoming Anger and Irritability: A Self-help Guide Using Cognitive Behavioural Techniques. Davies W. Constable & Robinson Basic Books, 2008.
• Anger Management for Dummies. Bloxham G. John Wiley & Sons, 2010.