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13 Articles in Volume 18, Issue #3
Anger Expression & Chronic Pain
Ask the Expert: Should reliance on gabapentin/pregabalin be limited?
Chronic Pain in Children
Considering Comorbidities When Selecting Medications for Chronic Pain Management (Part 1)
Dousing the Physician Burnout Epidemic: An AMA Perspective
Harnessing the Power of Words
Inside ASRA with David Provenzano, MD
Management of Intrathecal Therapies by Interprofessional Teams
Nurse Burnout in Pediatric Pain Management: A Model and Pilot Intervention
Physician Burnout: An Oldtimer’s View
Reporting Metrics, Media Coverage...Letters from the Minds of Peers and Patients
The Case for Slow-Release Anesthetics
The Impact of Pain Practice

Anger Expression & Chronic Pain

When patients present with severe anger, physicians must be vigilant in enveloping these additional clinical needs into the treatment plan.

Where there is pain, there is often an unpleasant effect, which may include anger.1 Anger refers to an emotional experience that may be a current mood state or a general predisposition toward feeling angry. As a trait, anger is more common in aggression and studied in health-outcomes research.2 Anger is a natural emotion that helps individuals feel more in control. Relative to other negative emotions, such as fear, sadness, guilt, and shame, anger is the most prominent emotion in chronic pain patients.3 It is related to how we think about an event, person, or situation.

When Anger Takes its Toll

It is important to remember that anger does not occur in a vacuum, but has far-reaching effects on occupational, recreational, social, interpersonal, and self-care functions.4There are several signs of uncontrolled anger, including: having a short temper/being inpatient; sleep problems; eating problems; restlessness/agitation; hitting/slamming; having a desire to harm someone; verbal outbursts; a feeling of losing control; poor concentration; and obsessing about an event, person, or situation. Uncontrolled anger may negatively affect physical health, including by increasing pain. For example, anger has been linked to inflammation, particularly with blood levels of c-reactive protein and interleukin-6.5 Anger may function as a predisposing factor, but may also be a precipitating, exacerbating, or perpetuating factor in pain.4

There are many challenges that individuals living with chronic pain face, including diagnostic ambiguity, treatment failure, and battles with insurance carriers, employers, and the legal system. Pain and suffering are diverse and may take the form of anger, which, if left unaddressed, may be drawn out into disruptive, impulse-control, and conduct disorders.6

When Anger Leads to Disruptive, Impulse-Control, and Conduct Disorders

Disruptive, impulse-control, and conduct disorders include conditions involving problems in the self-control of emotions and behaviors.7 While other disorders in the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) may also involve problems in emotional and/or behavioral regulation, the conditions in the disruptive, impulse-control, and conduct disorders chapter are unique in that they are manifested in behaviors that violate the rights of others.7 These behaviors have the potential to bring an individual into significant conflict with societal norms or authority figures. The underlying causes of losses in the self-control of emotions (such as anger) and behaviors (such as aggression) can vary greatly across the disorders.

The disruptive, impulse-control, and conduct disorders include diagnoses, such as oppositional defiant disorder, intermittent explosive disorder, conduct disorder, pyromania (fire setting), kleptomania, and antisocial personality disorder.7 These conditions represent a major public health concern because they greatly increase the risk of incarceration, injury, depression, substance abuse, and death by homicide or suicide.8

These disorders tend to have first onset in childhood or adolescence. The prevalence of oppositional defiant disorder ranges from 1% to 11%.9 The one-year prevalence data for intermittent explosive disorder in the United States is about 4% to 7%,10 while conduct disorder prevalence ranges from 2% to 10%.11 The lifetime prevalence of pyromania has been reported as 1% in a population sample,12 while the prevalence of kleptomania in the general population ranges from approximately 0.3% to 0.6%.13 Approximately 5% to 15% of the US population, is disabled by impulse control disorders.14

DSM-5 Anger-Related Diagnoses

The APA chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5.7 It brings together disorders that were previously included in other chapters focusing on adolescence and impulse-control in the DSM-IV.7 Several changes have been made to the specific diagnoses. The symptoms of oppositional defiant disorder are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness.7 The primary change in intermittent explosive disorder is that the types of aggressive outbursts now include: physical aggression, verbal aggression, and nondestructive/noninjurious aggression.7 Criteria for conduct disorder, pyromania, and kleptomania are largely unchanged from the previous edition, DSM-IV. Antisocial personality disorder is also present in the new chapter, in addition to the chapter on personality disorders.

Anger & Pain

Anger in relation to pain has only been studied recently and scientific evidence has been slow to accumulate.4 This lack of focus on the subject may be due in part to anger not being a diagnostic category in psychiatric classification.15 Approximately 70% of chronic pain patients have reported feeling angry at themselves and at healthcare professionals,16 but this may be an underestimation. Among individuals with chronic pain, high levels of anger are often associated with greater muscle tension, pain severity, and pain behaviors.17

In a sample of chronic pain patients undergoing an extensive psychiatric evaluation, about 10% met criteria for intermittent explosive disorder.18 Research has shown that intermittent explosive disorder is associated with arthritis, back/neck pain, headaches, and other chronic pain conditions.2 Previous findings have shown that individuals with migraines or tension headaches have higher anger levels and poorer anger control.19 Researchers have also suggested that anger management style behavior is a particularly important predictor of treatment outcomes in male chronic back pain patients.20

In related pain and anger studies, results indicated that patients who scored high on hostility had significantly higher ratings of chest pain.21-24 Earlier research also found that anger was an important predictor of pain in patients suffering from spinal cord injuries.22 And, in cancer pain, researchers have demonstrated that the level of anger was significantly higher in patients having pain versus no pain, and those experiencing pain had higher intensity and longer duration.23-24

Are Providers at Risk for Patient-Perpetuated Violence?

There is evidence to suggest that frontline providers may be at risk for patient-perpetuated violence. The US Bureau of Labor Statistics reported that more workplace assaults and violent acts occur in healthcare and social service industries than in any other setting.25 In one decade (1980s), about 30 physicians in the country were the victims of work-related homicides.26 One study found that 63% of physicians queried indicated that they had experienced abuse or violence during the previous year, and 11% reported verbal abuse daily.27 The most common reasons given for the violence were drug-seeking behaviors and confrontations over drug use, long waits in physician offices, dissatisfaction or displeasure with care or outcomes, relationship with religion, or the physician’s refusal to endorse a report of disability.28-30 The risk factors most consistently associated with these types of violence include past antisocial conduct, previous episodes of violence, history of opioid abuse, and poor impulse control.31

Assessment of Risk for Violence

The first step in a clinical examination to assess violent behavior is to establish how many of these risk factors may be present.32 There are also clues that physicians may look for that suggest imminent violent behavior in patients, including being demanding; irritability; flared nostrils; boisterousness; clenched fists; loud talking; yelling; threats; abusive or profane language; restless or repetitive movement; pacing; gesticulating; and attacks on objects. If any of these are noted, then the physician and his/her staff should initiate measures to ensure their safety rather than allow the situation to escalate.32 Providers may also use self-report instruments to measure anger, such as the Profile of Mood States, the Clinical Anger Scale, the Subjective Anger Scale, the Multidimensional Anger Inventory, and the State-Trait Anger Expression Inventory-2.33

Physicians are advised to create space between themselves and the angry patient, and engage in other behaviors that may calm the situation.32 It is best not argue with or provoke a patient. It may be helpful to communicate in a calm, supportive manner, and to not talk down to the patient. In addition, healthcare practitioners should avoid showing fear and not touch the patient. Providers may help by determining what the patient is angry about and try to rectify the situation. Calling 911 for assistance is a valid last resort.

Overall, pain physicians should expect to face patients who have severe anger and be prepared to deal with these situations.32 Screening for patients who suffer from pain and anger is recommended so that, if needed, a referral to a mental health professional for additional assessment may be made.

Is there Treatment for Anger?

The Therapeutic Alliance

Anger that is unmanaged may complicate pain management efforts by disrupting relationships with healthcare providers and may interfere with medical or surgical procedures for chronic pain.34 This connection underlines the importance of the therapeutic relationship. The therapeutic alliance is a common psychotherapeutic factor identified by Grencavage and Norcross.35 Therapeutic relationship factors are characteristics of the provider and the patient that facilitate change and are present regardless of the type of intervention. Past research has shown that the therapeutic relationship accounted for 30% of treatment outcome.36,37 Research on the statistical power of the therapeutic relationship now reflects more than 1,000 findings.

There are also many therapeutic strategies available to help deal with anger. A predominant model of the etiology of chronic pain hypothesizes that feelings of intense anger that are repressed or unexpressed are likely to manifest as pain.38 One of the most common types of psychotherapy available to treat anger is cognitive behavioral therapy (CBT).39,40 The purpose of CBT for anger is to help a person recognize the self-defeating negative thoughts that lie behind anger flares. Patients learn to cope better with difficult life situations, positively resolve conflicts in relationships, deal with grief more effectively, mentally handle emotional stress, and overcome chronic pain. Other CBT therapies may include anger management protocols, such as dialectical behavioral therapy. Patients learn how to deal with their particular issues using conscious, goal-centered strategies.

Clinical Strategies

The first strategy should always be to help the patient develop self-awareness. They should learn how to identify environmental and internal/external triggers, be aware of how their body reacts to anger, and how they usually behave when they are angry. They also should learn how to identify underlying feelings (eg, fear, guilt, grief, confusion, shame, loss) and thoughts.

The second strategy is to modify their response to anger. Patients may be taught how to use relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation. They also may benefit from understanding how to change the way they think using cognitive restructuring. Positive behavior changes may include problem-solving, seeking an outlet (eg, exercise, hobby, talking to someone), distraction (eg, going to the movies with a friend), and/or pursuing healthier alternatives when feeling pain, such as watching a comedy.

The third strategy involves helping the patient to learn the difference between passive, passive-aggressive, aggressive, and assertive communication, and to provide ways to improve messaging. Patients should learn how to express angry feelings in an assertive manner, which is the healthiest way while still respecting the rights of others. To do this, they have to understand how to make clear their needs and how to get them met without hurting others. They ultimately understand that being assertive does not mean being pushy or demanding, but rather being respectful of themselves and others without anger.

It is also possible to treat anger symptoms with medication. Antidepressants are commonly prescribed because they have a calming effect, but these medications do not specifically target anger.40 The purpose of medications is to complement the psychotherapeutic process, not to replace or complicate it. There are also a number of herbs and supplements that have shown some promise in improving mood and support anger management therapy, including valerian and chamomile.40

Conclusion

Healthcare providers working with chronic pain patients who express anger in the clinical setting should aim to screen their patients for disruptive, impulse-control, and conduct disorders. When necessary, referral to a mental health professional may be incorporated into the overall treatment plan.

The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs or any other governmental agency.

Last updated on: April 12, 2019
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