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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.
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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

Last updated on: May 2, 2018
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Chronic Pain and Substance-Related Disorders