RAGE

You walk into the Starbucks across from the station to get a cup of Joe.  There are two people ahead of you in line. The place is full; the crowd mostly consists of students, with a sprinkling of businessmen, and a few moms grabbing a quick pick me up espresso and a snickerdoodle for junior.  The guy at the register is ordering one of those super poofy drinks with extra this, light this, with a hint of this, at a specific temperature.  You roll your eyes, check your watch, and make sure your handheld is on.  Mr. Triple Pumpkin Cinnamon Spiced Non-Fat De-Caf Venti Latte is informed that they are out of nonfat caramel syrup.  He throws his hand up in the air, begins a tirade of curse words, while repeatedly pounding his fists on the counter.  OK, this is moderately entertaining, but you feel bad for the college student barista.  But his barrage continues and escalates.  Patrons with children begin to exit the store.  He spews out a couple of words that are beyond offensive, even to a cop.  You approach him to tell him to knock it off or to leave.  He spits in your face, picks up a couple cups of hot something and throws them at you as you attempt to shield your face.  When you can see again he is reaching for something in his coat pocket.  You reach for your side arm while hitting the panic button on your transistor.  Is this guy psycho or simply an Adam Henry?  You wonder how far this is going to go as you make an executive decision about what type of objectively-reasonable force will be required to control this fool.

Anger Disorders

Anger disorders describe pathologically aggressive, violent or self-destructive behaviors symptomatic of and driven by, an underlying and chronically repressed anger or rage. Anger disorders result primarily from the long-term mismanagement of anger, a process in which normal, existential anger grows insidiously over time into resentment, bitterness, hatred and destructive rage. Anger disorders may also be caused or exacerbated by neurological impairment and substance abuse, both of which can inhibit one's ability to resist aggressive, angry or violent impulses.

For the most part, anger disorders cannot be blamed on genes or biochemistry. They arise from a failure to recognize and consciously address anger as it arises; before it becomes pathological, hostile and dangerous. The process for dealing with anger needs to start in childhood.  It needs to be reinforced throughout an individual’s lifetime.  Anger disorders can lead to death.  They can lead to massacres. They are the things that create your worst nightmare individually and globally.   

The Quintessential Anger Disorder:  Intermittent Explosive Disorder

Intermittent Explosive Disorder (IED for purposes of this article) is an impulse control disorder characterized by repeated failure to resist aggressive impulses that result in serious aggressive acts, violent behaviors and/or destruction of property. For people who have IED even minor incidents (someone not putting on a blinker) can drive them into a rage that is difficult to control. These outbursts are grossly out of proportion to any provocation or precipitating psychosocial stressor.  In fact, they can even happen without any provocation.

According to a recent study at Harvard Medical School, intermittent explosive disorder is on the rise. Approximately 16 million Americans (between 5% and 7% of the population) have the disorder.  IED can be described as the classic anger disorder.  Its main symptom is rage. 

This is how a tragic episode of IED/Rage usually works:

• Step 1:  An individual(s) experiences some insult, rejection, or stressful event.
• Step 2: An individual(s) then plots a vengeful rampage to restore personal honor or repay the perceived injury.
• Step 3: (S)he then reacts with a gross overreaction of pent-up aggression, anger, rage, and all too frequently, violence including death.

Yes, we know these types of cases: school shootings, work place massacres, fatal road rage incidents, etc. For a list of additional examples just read Officer.com’s news daily. 

The Facts

Intermittent Explosive Disorder is in the same class of psychiatric disorders as kleptomania, pyromania, and compulsive gambling.  The disorder is considered severe if individuals experience at least three rage attacks in one year. Statistically, individuals with IED average averaged 56 life-time attacks resulting in an average of $1600 worth of property damage.  Twenty three of these incidents resulted in someone requiring medical attention.

The first episode of rage usually occurs in early adolescence, around age 13 for males and age 19 for females. Additionally, the majority (over 80%) of individuals with IED have at least one additional mental disorder, most commonly generalized anxiety, a mood disorder, alcohol abuse, and/or attention deficit disorder.

During a rage attack the individual experiences racing thoughts, arousal, and a heightened level of energy. The individual may threaten or actually harm another person, and/or may purposefully break or damage an object of value. Immediately after the attack (s)he may feel a sense of relief. Other physical symptoms of a rage attack include tightness in the chest, palpitations, tingling sensations, tremor, hearing echoes, or a feeling of pressure inside the head. This is typically followed by fatigue, depression, embarrassment, regret and remorse.

Individuals with IED believe that others are basically hostile and untrustworthy. They feel that force is the only way to gain the respect of others. They interpret others' behavior as directed specifically against them, and frequently misinterpret the motives of others as manipulative or malicious. They will blame spells or attacks of violence on another individual, denying or minimizing their own role in the situation.  The problem behavior isn't continuous. It occurs in a single episode or series of episodes. The reaction time is within seconds to hours after perceiving a provocation. Rage attacks are time limited and usually only last 10 to 20 minutes; and then the behavior ceases automatically. In between periods of rage the individual may show absolutely no signs of impulsivity or aggression.

The consequences of intermittent explosive disorder are often severe and may result in job loss, school suspension, divorce, difficulties with other interpersonal relationships, impairment in social or occupational areas, accidents, hospitalization, injury, financial problems, incarcerations, or other legal problems. Individuals with IED do not only turn their violence towards others; one in six will engage in acts of self aggression, including suicide.

Diagnosis and Treatment for Intermittent Explosive Disorder

Intermittent explosive disorder is really a diagnosis of exclusion. Before a diagnosis of IED can be made, psychiatric professionals must rule out other possible causes for aggressive episodes, which include; personality disorders, psychosis, manic episodes, ADHD, substance abuse, brain injury, dementia, or other medical conditions; as well as childhood/adolescent disorders; oppositional defiant disorder, ADHD, conduct disorder.

The goal of treatment is to help the individual control aggressive impulses. People with intermittent explosive disorder may have an imbalance in the amount of serotonin and testosterone in their brains. A combination of medications and behavior modification therapy has been effective treatments for the disorder. Many different types of drugs are used to help control intermittent explosive disorder, including: anti-anxiety (Ativan), anticonvulsants (Tegretol), antidepressants (Paxil), and/or mood stabilizers (Lithium) may be prescribed. Rage management group counseling has also been helpful for many people with IED.

Mentally ill individuals experience anger as intently as the rest of the population.  These individuals are actually more prone to pent-up rage related to (and often justified) feelings of rejection.  Treatment is usually based on the underlying mental illness.  Failure to consciously acknowledge and confront disproportionate anger in the mentally ill will simply drive it deeper into the subconscious rendering it doubly dangerous

It is a misnomer to believe mental health treatment has a wonder drug for curing anger.  Nor can you behaviorally modify or cognitively rationalize anger away.   Everyone experiences anger; it is an emotion that is here to stay. The only real question is what we do with it.

Anger and the American Society

To deal with anger disorders we must acknowledge that some anger is a valid, necessary, appropriate and unavoidable human emotion. Anger is an existential given; people have had to reckon with their own anger for time immemorial. Our society tends to condemn anger, insisting that the effects of anger are always counterproductive and negative.  People spend billions of dollars trying to “manage” their anger, courts sentence offenders to “anger management classes”, etc.  Anger doesn’t need to equate to rage.  I can’t think of a single time or event in which rage has had any lasting benefits.

However, there are certainly positive aspects of anger. Anger often spurns innovation and growth. For example, if someone hadn’t gotten pissed off enough about how long it took to get somewhere, the wheel would never have been invented, let alone a car.  Chronic repression or suppression of anger is counterproductive and, ultimately, futile and dangerous. You simply can’t “control” any emotion, including anger.  You can, however, learn to control your reaction to anger. This is why we, as a culture, need to encourage the acceptance of anger as a natural phenomenon, and teach children, adolescents and young adults how to manage and express it more constructively.  The key is what you do with your anger. 

There is a difference between an anger disorder and plain old ugly and nasty anger. There is also an inherent danger in assigning a psychiatric diagnosis to every societal abhorrent behavior. Defining aggressive behavior as a mental illness has been the basis of several defense cases in an attempt to devolve a perpetrator's responsibility. Are all bullies mentally ill? How about serial killers? Spousal abusers? Child molesters? Or are they just really bad people, sociopaths who lack a conscience? Having an impulse control disorder is never a valid excuse to victimize another individual. Grow up, better yet grow a conscience.  Get professional treatment if you need it. Otherwise face the consequences of your aggressive behavior, you earned them.