Anger has been defined with different shades of emphasis, but in psychology, there is general agreement that anger is a subjective feeling rooted in an attribution or appraisal of wrongdoing and coupled with an action tendency to undo that wrongdoing in ways that may range from resistance to retaliation. This is consistent with the cognitive-motivational view of all emotions.1 It also reflects Smedslund’s2 depiction of the lay perspective on anger.
Similar to fear and sadness, anger can assume any one of three forms: emotion, mood, or temperament.3 Emotion is a momentary episode, mood is relatively prolonged in duration, and temperament is a proneness to the particular feeling or emotion so that it recurs. These three forms are reflected in the varied and nuanced vocabulary of anger. As an emotion, anger can range in intensity from annoyance to rage; as a mood, it is tonic rather than phasic as implied by the words irritability or irascibility; as temperament, it is a propensity to frequent anger as captured in the word hostility, which, in affect science, is reserved for dispositional or attitudinal rather than situational anger.4,5
Some of these lexical boundaries may be ignored in common parlance. However, for scientists and professionals, proper classification and terminology facilitate comparisons across studies, integration of findings, and scholarly discourse. Hence, there is interest in choosing the right words and (when necessary) coining new terms for different phenomena. Along such lines, anger is further distinguishable from two other terms, aggression and violence. Aggression, in social psychology, refers to behavior (physical or verbal) that is intended to hurt. Violence is behavior that intentionally and actually culminates in physical injury or damage.
According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),6 a mental disorder is “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (p. 20). A conspicuous departure from the earlier version of the DSM has been the omission of the statement about significantly increased risk of “pain, disability, death, or important loss of freedom”7 (p. xxxi). By the new rule, a heightened risk of pain or other catastrophic consequences does not signal a mental disorder. However, aggressive or violent anger would almost certainly be regarded as a disorder inasmuch as it represents a marked disturbance in actions, thoughts, or emotional control. Yet, at present there are no DSM diagnostic labels for anger disorders. One exception is intermittent explosive disorder (IED), which is grouped under “Disruptive, Impulse-Control and Conduct Disorders” along with conditions such as pyromania, kleptomania, and oppositional defiant disorder. A diagnosis of IED refers to recurrently uncontrolled anger culminating in physical or verbal aggression that is very disproportionate to provocation. Nevertheless, the risks and deleterious effects of anger are increasingly well documented and extend beyond aggression and violence to a range of medical health problems. Prominent among these health problems are cardiovascular disease8,9 and pain.10,11
A relatively large and growing body of research has documented important associations between the experiences of anger and pain.12 Persons with chronic pain are more likely than others without pain to report high levels of anger. Among those with chronic pain, those who appear to readily express anger toward others and possibly those who seem to suppress anger report relatively higher levels of pain intensity and even pain-related disability.13 Ongoing research is investigating the hypothesis that endogenous opioid systems13 and other physiological mechanisms14 may play a role in determining the impact of anger and its expression on the experience of pain.
A recent article by Wootton15 offers an incisive review of the etiology of anger in pain; it also describes various psychological instruments for the assessment of anger. To complement that review, the present chapter explores the experience of anger in patients with pain and then expands on how to treat anger in the context of chronic pain.
Although underresearched compared with depression and anxiety, anger has been recognized as a problem that merits attention in individuals with chronic pain and one that is closely related to pain severity as well as depression.16 The scarcity of epidemiologic data in this area is partly due to an underdeveloped psychiatric nosology. IED has been reported by about 10% of pain patients assessed in an early study by Fishbain and colleagues.17 Interestingly, this exceeds the 12-month prevalence rate of IED in the community, which is about 4% according to the National Comorbidity Survey Replication study of U.S. households.18 Other than these data on IED, the co-prevalence of anger-related “disorder” and chronic pain is undeterminable.
Directing attention to emotions rather than psychiatric disorders, Fernandez and Milburn (1994) found that chronic pain patients rated their anger higher than sadness, fear, or any one of seven other basic emotions. In a study of 2400 school children in Iceland, Kristjansdottir19 found that anger was the most common concern in 76.5% of those with weekly back pain, 76.9% of those with weekly headache, and 78.3% of those with weekly stomach pain. This was higher than the prevalence of anxiety or sadness in pain. The relationship of anger to pain became further evident in a survey by Fernandez and collegues,20 which revealed that patients attributed the bulk of their anger to the pain itself rather than to circumstances extraneous to pain. In a data mining study across all geographical zones of the United States, Fishbain et al.21 found that anger was affirmed at a significantly higher frequency in chronic pain patients (37.5%) than community patients (28.5%); furthermore, chronic pain patients reported chronic anger at a rate (19.7%) that was much higher than that in acute pain patients or patients without pain.
This brings us to the question: “What is it about chronic pain that makes it highly comorbid with anger?” There are several possible answers. First, it should be noted that comorbidity simply means co-occurrence of diagnoses. Expressed in percentages, proportions, or odds ratios, it represents the relationship in static terms. Alternatively, the conditions may be dynamically related.22,23 For example, one condition may covary as a function of the other, as indexed in a correlation coefficient. Unfortunately, correlations do not permit inferences about causation. To overcome that limitation, there are experimental or prospective studies that can test for temporal succession—whether A preceded B or vice versa. However, this so-called “chicken versus egg conundrum” is itself an oversimplification.23 Indeed, anger may be a precipitant that suddenly triggers the onset of pain or an immediate consequence of pain. Furthermore, anger may be a predisposing factor that increases the probability of pain in the long run, anger may be an exacerbating factor that intensifies preexisting pain, and anger may be a perpetuating factor that prolongs the duration of preexisting pain. These represent additional possibilities in the dynamic interaction between pain and anger just as they have characterized other interactions between psyche and soma.
So far, no single study has appeared in which all of the above interactions are pitted against one another much like separate hypotheses of the relationships between anger and pain. However, as in the literature on depression and pain, trends appear across multiple studies. One particularly interesting model suggests that anger as a “trait” combined with a characteristic style of anger inhibition may predispose persons to the development of chronic pain, and emerging research offers some support.24 The weight of evidence favors a strong role of anger as a consequence of pain. This does not necessarily mean that the anger is hardwired as in a neurophysiological reflex arc. Neither should the anger be viewed as occurring in a vacuum or emerging mysteriously out of a “black box.” Although classical conditioning theory can partly account for the quick annoyance in response to toothache, the pain from a punch, or other types of acute pain, it is limited in explaining the anger of chronic pain. This is because chronic pain occurs within a broad psychosocial context, which can drive anger through various cognitive appraisal pathways.25 In other words, anger in chronic pain patients is the product of multiple and elaborate interpretations of the many entities and activities within the psychosocial context.
Encompassed within the psychosocial arena of chronic pain are a number of possible agents whose actions are construed (by the individual with pain) as wrongdoings. Each of these agent–action complexes can be viewed as an instantiation of the earlier stated definition of anger. The doctor’s failure to cure is perceived as an act of incompetence, the insurance company’s denial of coverage is viewed as a breach of agreement, and the lack of emotional support from a family member is often viewed as neglect or abandonment. Accordingly, clinicians may venture beyond the basic question: “Is the patient angry?” to the two questions: “Why is the pain patient angry?” and “Toward whom is the anger directed?” An instrument called the Targets and Reasons for Anger in Pain Sufferers26 (TRAPS) lists 10 common targets of anger in patients as broached by Fernandez and Turk:10
Person causing an injury or illness
Physicians and medical care providers
Psychologists and mental health professionals
Attorneys and the legal system
Insurance and third-party payers
Employers
Significant others
God, higher being, destiny
Whole world
Other
Using a 0 to 10 numerical scale, the patient rates his or her anger toward each of the above targets. Then, using a checkbox format, the patient identifies and ranks the reasons for his or her anger toward each target, with reference to the following:
Pain
Diagnostic or treatment difficulties
Implication that pain is psychogenic
Dispute, scrutiny, or arbitration
Inadequate coverage or compensation
Loss of employment or retraining
Lack of interpersonal support
Predetermined event; ill fate
Decline in functioning or appearance
Regarded as different or unimportant
Other
Okifuji, Turk, and Curran (1999) adapted the TRAPS for self-administration by 96 chronic pain patients, most of whom had low back or leg pain. They found that 65% of male and 71% of female patients reported some level of anger. The percentages of patients with anger toward targets were 60% toward health care providers, 20% toward attorneys, 30% toward insurance companies, 26% toward employers, and 39% toward significant others. Additionally, the vast majority, 70%, were angry at themselves. When actual anger ratings were averaged after a TRAPS interview of chronic pain patients, these patients were found to be angriest toward insurance companies and least angry toward psychologists.10 Results from the TRAPS reveal the scope of the psychosocial context of anger in chronic pain patients.
Clinical anecdotes of anger are common in case conferences on patients with pain. Such anecdotes can also be found in published work. For example, Roy describes a pain patient’s anger over loss of employment:
“When Mrs. Abrams resigned her position, she lost … a vital element of her sense of self. She lost her place … as a valued member of a helping profession. Above all, she lost a simple, yet a core, component of her identity. Redefinition of the self was called for, but the answer was far from acceptable. The answer in her case was that of a chronic patient. This radical change in identity extracts an enormous psychological cost. Some patients may experience relief, but not Mrs. Abrams, who took exceptional pride in her profession. She felt humiliated, unfairly treated by the world, sad, and even grief-struck and very angry.” (Roy, 2002, p. 4).
Graham, Lobel, Glass & Lokshina (2008) provide excerpts of written accounts of anger from two pain patients: “I am in constant pain due to your negligence. I wish I could make you understand what it feels like. … I feel so mad. … I hope you never have another good night’s sleep in your life. I know I won’t.’’ ‘‘I can’t believe that after all this I have to listen to a druggist [who] has no idea how I feel. … You make me feel like a criminal and a drug addict’’ (p. 201).
A single individual may harbor anger at multiple targets for a variety of perceived wrongdoings. This is illustrated in the following anecdote from a victim of a major industrial accident:
“Lured by their promise of jobs, the government gave them a permit to develop their industry. With the bare minimum staff, we worked longer and harder as management kept cutting corners, and then—Disaster!. Now, the jobs are gone, the factory has changed hands, they’ve taken the heap of profits, and left us with pain, unimaginable health problems, and a toxic environment. Where’s the justice? My wife gave birth to a baby who died after 4 weeks, then she died of cancer or depression, I’m not sure which. I’m stuck with pain every day—pain in the stomach and chest and difficulty breathing. I know I’m the next to go, because there is no cure and the pain only gets worse. The doctors don’t have all the answers and just keep giving me pain killers and steroids. Health insurance won’t pay for anything else. We need money just to stay alive but no one will give us even a basic job as long as they suspect we’re sick. We filed for compensation but that will take years and who knows what we’ll get after the sharks take their bite. The corporation is already talking about an out-of-court settlement so they can escape future liability while the CEO and upper managers still live it up; can you believe it? Now you know why I’m so angry and don’t trust any official working for the system; they’re not there to help us. Every time I feel the pain, the anger returns as I remember what happened that dreadful day. I remember my family members …I couldn’t even afford a proper funeral for them after using all my life savings to pay for fees and expenses. I cannot bring them back, and I may not stop sliding downhill, but I’ll stomach the poison and keep going as long as I can to get those criminals to pay. I don’t want to see any decent human being go through what we go through; I just want to see those responsible pay in some way. And many of us are hanging on just to see that day.”
Related posts:
Definitions and Classification of Pain
Work Disability and Chronic Pain: A Review of Psychosocial and Environmental Factors
Diagnosis and Management of Cervicogenic Headache
Mind/Body Interventions in the Management of Chronic Pain
Shingles, Postherpetic Neuralgia, and Postherpetic Itch
Medical Management of Cancer Pain
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