Trait Anger and Axis I Disorders: Implications for REBT

ORI GIN AL ARTICLE

Trait Anger and Axis I Disorders: Implicationsfor REBT

Wilson McDermut Æ J. Ryan Fuller ÆRaymond DiGiuseppe Æ Iwona Chelminski ÆMark Zimmerman

Published online: 5 March 2009

� Springer Science+Business Media, LLC 2009

Abstract Anger has a prominent role in basic theories of emotion. And while

many psychiatric disorders can be conceived of as emotional disorders (e.g.,

depressive disorders, anxiety disorders), there are no disorders for which anger is

the cardinal feature. We analyzed diagnostic data on 1,687 (as later) psychiatric

outpatients and looked at the co-occurrence of high trait anger (as assessed by

criterion 8 of Borderline Personality Disorder) and Axis I disorders, and Borderline

and Antisocial Personality Disorders. The purpose was to examine whether dys-

functional anger met criteria necessary to be considered a valid diagnostic category.

Results showed that high trait anger was not fully accounted for by any particular

Axis I diagnosis, or any set of Axis I diagnoses, or by the combination of Axis I

diagnoses and Borderline and Antisocial PDs. Trait anger also accounted for sig-

nificant amounts of unique variance in several indicators of psychiatric impairment

and psychosocial functioning. We describe the anger disorder diagnoses of Eckhardt

and Deffenbacher (Anger disorders: Definition, diagnosis and treatment. Taylor &

Francis, Bristol, PA, 1995), and discuss the implications of those diagnoses for the

practice of REBT and CBT.

Keywords Anger � Anger disorders � Comorbidity � REBT � CBT �Nosology

W. McDermut (&) � J. R. Fuller � R. DiGiuseppe

Department of Psychology, St. John’s University, Marillac Hall SB15-9, 8000 Utopia Parkway,

Jamaica, NY 11439, USA

e-mail: [email protected]

W. McDermut � J. R. Fuller � R. DiGiuseppe

Albert Ellis Institute, New York, NY, USA

I. Chelminski � M. Zimmerman

Rhode Island Hospital, The Warren Alpert Medical School of Brown University,

Providence, RI, USA

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J Rat-Emo Cognitive-Behav Ther (2009) 27:121–135

DOI 10.1007/s10942-009-0092-2

Introduction

Although anger is a universal and normal aspect of human experience, research over

the last two to three decades has shown that anger can also be problematic and

dysfunctional (Averill 1983; Plutchik 1980). Research confirms the common

observation that anger1 can lead to aggressive behaviors (e.g., yelling, throwing

things). These behaviors, in turn, can result in negative outcomes, like arguments or

property damage. People with high levels of anger are more likely to experience

these negative outcomes (Deffenbacher et al. 1996). Violence is the most dramatic

example of the negative consequences of anger. Anger need not always lead to

aggression and violence, and aggression or violence can occur in the absence of

anger (e.g., instrumental aggression), however, anger increases the likelihood of

aggressive behaviors (Anderson and Bushman 2002), and may mediate violent

behavior in violence-prone individuals (Baumeister et al. 1996).

Anger can have a negative impact on interpersonal relations. Ironically, most

anger experiences are triggered by people we know and love (Averill 1983;

Kassinove et al. 1997). This unfortunate fact means that anger can result in family

discord, couple distress, and parent–child conflict (e.g., Dattilio et al. 1998; Ellis and

Dryden 1997). Anger can lead to an array of adverse psychological and health

consequences. The subjective experience of anger is usually described as unpleasant

(Tafrate et al. 2002). When angered, people are more likely to think irrationally

(Tafrate et al. 2002), exercise poor judgment (Kassinove et al. 2002), and behave in

a risky and erratic manner (Deffenbacher 2000). In our clinical experience, it is rare

(if not unheard of) to hear clients with anger problems say that they think more

clearly or make sound decisions in the throes of an anger episode. Finally, there is a

growing body of literature documenting an association between high levels of anger

and health problems, particularly hypertension and coronary heart disease (Suls and

Bunde 2005).

Among practicing clinicians, it is common to see clients for whom anger is a

problem (Lachmund et al. 2005). Indeed, an investigation of state anger (anger and

aggression at the time of treatment initiation) in psychiatric outpatients showed that

half of the participants reported moderate to severe levels of anger, and that the

level of anger was equivalent to the levels of depression and anxiety at intake

(Posternak and Zimmerman 2002).

1 Anger research in psychology and psychiatry has used the terms anger, irritability, hostility, and

resentment interchangeably. Though it is beyond the scope of this paper to define the nuances of these

terms we have included our definition of anger: ‘‘Anger is a subjectively experienced emotional state with

high sympathetic autonomic arousal. It is initially elicited by a perception of threat, although it may

persist after the threat has passed. Anger is associated with attributional, informational, and evaluative

cognitions that emphasize the misdeeds of others and motivate a response of antagonism to thwart, drive

off, retaliate against, or attack the source of the perceived threat. Anger is communicated through facial or

postural gestures or vocal inflections, aversive verbalizations, and aggressive behavior (p. 21, DiGiuseppe

and Tafrate 2007).’’ Anger and aggression have also been used interchangeably in the literature, though

they are not the same. Anger is an emotional state (described above), and aggression refers to behavior.

122 W. McDermut et al.

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Anger Nosology

Despite the abundance of angry clients and the frequency with which clinicians treat

such problems, clinical proficiency in understanding and diagnosing anger problems

remains inadequate (Lachmund et al. 2005). The problem of adequately diagnosing

angry clients stems from the fact that anger in the DSM-IV is a symptom that is

secondary to other psychiatric problems, for example explosive outbursts in

someone with PTSD. However, there are clients who can best be described as

having a primary anger disorder, i.e., their anger is not simply an offshoot of some

other primary problem (e.g., mania, GAD, PTSD, MDD). Among clinicians in

routine practice, there is considerable confusion about how to diagnose such

individuals (Lachmund et al. 2005).

For clinicians who specialize in the treatment of problematic anger, clients with a

primary anger problem are typical fare. In this nosological vacuum, anger

researchers have proposed a variety of systems for diagnosing anger problems

(e.g., DiGiuseppe and Tafrate 2007; Eckhardt and Deffenbacher 1995). Despite the

existence of these proposed diagnoses, there is little or no evidence relevant to the

construct validity of anger disorder diagnoses.

A number of authors have delineated criteria for ascertaining the validity of a

psychiatric diagnosis (Blashfield and Draguns 1976; Robins and Guze 1970). Many

of the accepted criteria used in psychiatric nosology parallel procedures involved in

construct and test validation used by psychologists. This study will apply some of

the procedures used in psychiatry and psychology to begin asking some basic

questions about the viability of an anger diagnosis. Robins and Guze (1970) assert

that valid diagnostic entities can be ‘‘delimited’’ from other disorders. Thus, a

primary focus of this study will be to examine co-occurrence rates to determine

whether or not making the diagnosis of an anger disorder is redundant. That is, if all

the individuals diagnosed as having an anger problem also carry a diagnosis of

mania or PTSD (two disorders characterized by anger), then making the additional

diagnosis of an anger disorder would be gratuitous.

We are aware of only two studies that have reported rates of Axis I disorders in

persons with high levels of dysfunctional anger. The first data set comes from

outpatients who sought psychotherapy specifically for their anger. These clients

were evaluated with the Structured Interview for Anger Disorders (SIAD;

DiGiuseppe and Tafrate 2007). Participants in the study were then diagnosed by

their therapists according to DSM-III-R (American Psychiatric Association 1987)

criteria. About 14 of 25 subjects had a diagnosable Axis I or II disorder. The

remaining 11 participants failed to meet criteria for an Axis I or II disorder and were

best described as having a primary anger disorder.

In the second study, comorbidity patterns were examined in 87 adults

(Kassinove and Tafrate 2006). Participants who scored in the upper quartile on the

Trait Anger Scale (TAS; Spielberger 1988) were considered high-anger-prone,

whereas those with TAS scores in the lowest quartile were low-anger-prone. Axis

I disorders were assessed with the MCMI-III (Millon et al. 1997). Compared to

low-anger-prone participants, high-anger-prone participants were much more

Trait Anger and Axis I 123

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likely to score in the clinical range across a wide spectrum of Axis I disorders,

though high anger was not associated with any one particular diagnosis, or class

of diagnoses.

With respect to Axis II disorders, Kassinove and Tafrate (2006) found that high-

anger-prone participants had higher rates of the majority of personality disorders

(PD). The most commonly occurring PD among the high anger participants was

Negativistic (Passive-Aggressive) PD, which occurred in 24% of high-anger-prone

participants. Of the ‘‘official’’ DSM-IV PDs, BPD was the next most common

(22%), followed by Antisocial, Narcissistic, and Dependent PDs (18%), and then

Paranoid PD (13%).

We are only aware of one other study that examined the association of

dysfunctional anger and PDs. This study looked at PDs as assessed by the MCMI-

III, and their relation to the Anger Disorders Scale (ADS; DiGiuseppe and Tafrate

2004) in 230 psychotherapy outpatients. The ADS correlated most highly with

Negativistic PD symptoms. The next highest correlations were with Borderline,

Sadistic, Paranoid, Schizotypal, and Antisocial PDs. Given the lack of research on

the co-occurrence of dysfunctional anger and psychiatric disorders, further research

is clearly warranted.

To summarize, the purpose of this study was to evaluate the validity of an anger

diagnosis in 1,687 psychiatric outpatients who participated in the Rhode Island

Methods to Improve Diagnosis and Services (MIDAS) project. High levels of trait

anger served as our proxy for an anger diagnosis. We applied some of the

procedures often used in the validation of psychiatric disorders: delimitation from

other disorders, discriminant validity, and incremental validity (Blashfield and

Draguns 1976; Robins and Guze 1970). It was hypothesized that the presence of

high trait anger would not be entirely accounted for by Axis I disorders (even those

with prominent angry symptomatology) or Borderline and Antisocial Personality

Disorder. In terms of discriminant validity, we expected that high anger would have

higher levels of psychiatric morbidity and worse psychosocial functioning,

compared to low anger subjects. As a test of incremental validity, we examined

whether or not trait anger would account for variance in measures of morbidity and

functioning above and beyond the variance accounted for by co-occurring disorders.

We discuss the implications of a proposed system of anger diagnoses (Eckhardt and

Deffenbacher 1995), for the practice of REBT and other forms of CBT.

Method

Participants

1,687 psychiatric outpatients participated in this study. On average, participants in

this sample were 37.6 years old (SD = 12.6). The majority (62.1%; n = 1,047)

were women, and 87.3% were white. Almost half (46.3%) were either married or

living with a partner.


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Materials

Axis I Diagnoses and Psychiatric Symptoms

The 1995 January DSM-IV patient version of the Structured Clinical Interview

for DSM-IV Disorders (SCID; First et al. 1995) was used. In addition, most

of the symptom items from the Schedule for Affective Disorders and

Schizophrenia (SADS; Endicott and Spitzer 1978) were incorporated into the

SCID. The SCID and SADS have strong psychometric properties which are

summarized elsewhere (Rogers 2001). Diagnostic reliability was established

through joint interviews of 26 patients. For most Axis I disorders, j = 1.00

(Zimmerman et al. 2002).

Trait Anger Rating

The anger ratings were based on an item from the Structured Interview for DSM-

IV Personality (SIDP; Pfohl et al. 1997). The specific item we used assesses

Criterion 8 of the DSM-IV’s BPD criteria set (American Psychiatric Association

1994). The criterion is written as follows ‘‘inappropriate, intense anger, or

difficulty controlling anger (e.g., frequent displays of temper, constant anger,

recurrent physical fights).’’ The SIDP-IV item that assesses this criterion consists

of the following ten questions:

How often do you lose your temper?

What kinds of things get you really angry?

Tell me what you’re like when you are very angry.

How long do you usually stay angry?

Do you throw or break things?

Have you ever hit anyone while you were angry?

Did you ever get into physical fights?

When you’re angry, do you ever give someone the silent treatment?

(IF YES): How long can you keep it up?

Is that a common reaction for you?

Are there any times when you feel very angry, but don’t show it?

(IF YES): How much of the time do you feel angry?

Like all SIDP items, this item was scored 0, 1, 2, or 3, where 0 means the

trait is ‘‘not present’’, 1 (‘‘subthreshold’’) means there is some evidence of the

trait but it is not sufficiently pervasive to be considered present, 2 (‘‘present’’)

means the trait is clearly present, and 3 (‘‘strongly present’’) means the trait is

present and associated with subjective distress or impairment in social or

occupational functioning, or intimate relationships. For purposes of counting the

symptom as present or absent, ratings were dichotomized into absent (0 or 1), or

present (2 or 3).


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Axis II Pathology

Personality Disorders (PDs) were assessed using the SIDP (Pfohl et al. 1997). The

SIDP, a semi-structured interview, inquires about the traits of the ten ‘‘official’’

DSM-IV PDs, as well as two appendix PDs (Passive-Aggressive/Negativistic PD

and Depressive PD), and Self-Defeating Personality Disorder which was included in

the appendix of the DSM-III-R (American Psychiatric Association 1987). As noted

above, items are rated 0 (‘‘not present’’), 1 (‘‘subthreshold’’), 2 (‘‘present’’), or 3

(‘‘strongly present’’). Raw ratings are then dichotomized into absent (0 or 1), or

present (2 or 3). The SIDP’s psychometric properties are reported in depth

elsewhere (e.g., Rogers 2001). For Axis II diagnoses, 29 patients were used to

evaluate reliability; j ranged between 0.61 and 1.00 (Zimmerman et al. 2005).

Global, Social, and Occupational Functioning

The Global Assessment of Functioning scale (GAF; American Psychiatric

Association 1994) was used to measure overall symptomatic and functional

impairment. Social functioning was assessed by two SADS items. Past social

functioning was rated from 1 (‘‘superior’’) to 6 (‘‘grossly inadequate’’). Current

social functioning was rated from 1 (‘‘superior’’) to 7 (‘‘grossly inadequate’’). The

occupational functioning item on the SADS assesses time out of work in the last

5 years and is rated from 1 (No missed work) to 9 (did not work). Clinical Global

Impression (CGI, Guy 1976) of depression was used as an overall rating of

depression.

Design and Procedure

Participants were consecutive admissions to the outpatient psychiatry department.

Upon presenting for their intake interview, the study was described to them, and all

participants provided written informed consent. The intake procedure involved the

SCID, then the SIDP, then a packet of questionnaires (not relevant to this study).

The research protocol was approved by the Rhode Island Hospital Institutional

Review Committee. Diagnostic ratings were made by clinical psychologists and

bachelor’s level research assistants who underwent 3 months of training. Only the

BPD and Antisocial Personality Disorder (ASPD) modules of the SIDP were

administered to the first 500 participants. Starting with the 500th participant,

everyone received the entire SIDP. In this study we have only reported results on

BPD and ASPD.

Data Preparation and Analytic Plan

High Versus Low Trait Anger

Ratings of the SIDP item representing BPD criterion 8 (inappropriate, intense anger)

served as our proxy for an anger diagnosis. Patients were designated as having high

trait anger if they were given a rating of 2 (present) or 3 (strongly present). They


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were designated as having low trait anger if they were given a rating of 0 (not

present) or 1 (subthreshold).

Axis I disorders in partial remission were considered present, but NOS diagnoses

were not counted as present for purposes of data analyses. The variables

representing number of hospitalizations and number of suicide attempts were

dichotomized (never hospitalized versus hospitalized once or more; never attempted

suicide versus one or more suicide attempts) for most relevant data analyses.

However, for calculation of effect sizes they were treated as continuously

distributed. The SADS ratings of past and current social functioning were

dichotomized into groups representing social functioning that is ‘‘fair or better’’

or ‘‘poor or worse.’’ However, the ordinally distributed ratings (e.g., 1–7) were used

for calculation of effect sizes. The SADS variable representing missed work was

also dichotomized, with 0 representing 1 day to less than a month of missed work,

and 1 representing 1 month or more of missed work. However, the ordinally

distributed ratings (1–9) were used for calculation of effect sizes. The measure of

effect size we used was Cohen’s d (Cohen 1988). In all regression analyses, the

predictor variable representing trait anger was the raw SIDP rating of BPD criterion

8 (0, 1, 2, 3).

Results

The mean GAF score of the sample was 53.5 (SD = 10.6) consistent with moderate

levels of psychiatric symptomatology, or moderately impaired psychosocial

functioning. Table 1 shows the demographic differences between participants with

and without high levels of trait anger. Participants with high trait anger were

significantly younger, were less likely to have a college degree, and were less likely

to be married.

Reliability of Anger Ratings

Inter-rater reliability data are available for a subset of 45 participants who

underwent joint interviews. For dichotomized anger ratings, raters demonstrated

exact agreement on 84% of ratings, with j of .64.

Table 1 Demographic characteristics of outpatients with and without high trait anger

Low anger (n = 1,227) High anger (n = 458) Statistic P

Age (SD) 38.9 (13.0) 34.1 (10.8) t(1,683) = 7.67 .001

% Women (n) 61.9 (761) 62.4 (286) v2 (1) = 0.04 NS

% Caucasian (n) 88.2 (1,084) 84.7 (388) v2 (1) = 3.65 .056

% College degree or more (n) 28.6 (352) 19.2 (88) v2 (1) = 15.38 .0001

% Married (n) 43.3 (532) 31.7 (145) v2 (1) = 18.78 .0001

% Ever divorced (n) 27.6 (339) 26.4 (121) v2 (1) = 0.23 NS

NS not significant


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Diagnostic Comorbidity

Table 2 shows the proportions of participants with high and low anger who meet

criteria for current and lifetime Axis I diagnoses. High trait anger participants

averaged one more current Axis I diagnosis (M = 2.6) than participants with low

anger (M = 1.6; t(1,685) = 11.3, p \ .001). The effect size of this difference was

.63. High trait anger patients also averaged one more lifetime diagnosis (3.8 vs. 2.7),

a difference which was also significant (t(1,685) = 10.84, p \ .001). The effect size

of this difference was .64.

Table 2 Current and lifetime Axis I diagnoses in patients with and without high trait anger

% With current Axis I

disorder

v2

% With lifetime Axis I

disorder

v2

Low anger

(n = 1,229)

High anger

(n = 458)

Low anger

(n = 1,229)

High anger

(n = 458)

% MDD (n) 43.7 (537) 52.6 (241) 10.70b 64.5 (793) 66.2 (303) 0.39

% Dysthymic disorder (n) 6.1 (75) 10.5 (48) 9.46c 8.3 (93) 11.1 (51) 6.08a

% BPI (n) 1.5 (19) 2.4 (11) 1.40 2.4 (30) 3.5 (16) 1.39

% BPII (n) 2.4 (30) 5.7 (26) 10.89c 3.2 (39) 6.8 (31) 10.84c

% Panic (n) 3.7 (46) 3.9 (18) 0.32 5.2 (64) 5.7 (26) 0.15

% PDA (n) 12.9 (158) 18.1 (83) 7.56b 16.8 (206) 23.6 (108) 10.57b

% Social phobia (n) 24.6 (302) 40.0 (183) 38.55d 27.7 (341) 43.2 (198) 36.80d

% Specific phobia (n) 8.1 (100) 16.8 (77) 26.74d 9.4 (115) 18.1 (83) 24.75d

% OCD (n) 6.5 (80) 11.6 (53) 11.78c 8.2 (101) 14.4 (66) 14.35c

% PTSD (n) 9.0 (110) 21.4 (98) 47.82d 17.0 (209) 32.3 (148) 46.87d

% GAD (n) 17.0 (209) 21.8 (100) 5.20a 17.4 (214) 21.8 (100) 4.31a

% Drug/alcohol (n) 9.8 (120) 17.9 (82) 20.98d 41.2 (506) 60.5 (277) 50.02d

% Any psychosis (n) 2.0 (24) 0.9 (4) 2.38 2.1 (26) 1.5 (7) 0.60

% Any somatoform (n) 5.5 (68) 10.5 (48) 12.75c 5.9 (72) 11.1 (51) 13.75c

% Any eating (n) 0.7 (9) 1.3 (6) 1.26 3.8 (47) 4.8 (22) 0.82

% Any impulse (n) 1.1 (13) 11.4 (52) 92.7d 4.9 (60) 22.3 (102) 114.2d

% IED (n) 0.2 (3) 10.0 (46) 110.2d 2.4 (30) 18.1 (83) 128.8d

% ASPD (n) – – – 2.6 (32) 16.2 (74) 104.1d

% BPD (n) – – – 2.2 (27) 33.8 (155) 347.2d

MDD Major depressive disorder; BPI Bipolar I disorder; BPII Bipolar II disorder; PDA Panic disorder with

agoraphobia; OCD Obsessive compulsive disorder; PTSD Posttraumatic stress disorder; GAD Generalized

anxiety disorder; Any anxiety disorder, any of the following: Panic disorder, panic disorder with agora-

phobia, specific phobia, social phobia, obsessive compulsive disorder, posttraumatic stress disorder,

generalized anxiety disorder; drug/alcohol, any drug or alcohol abuse or dependence; Any psychosis, any

of the following: Schizophrenia, schizophreniform disorder, schizoaffective disorder, delusional disorder,

brief psychotic disorder; Any somatoform disorder, any of the following: Somatization disorder, undif-

ferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic

disorder; Any eating, anorexia or bulimia; Any impulse, any of the following: Intermittent explosive

disorder, pathological gambling, trichotillomania, kleptomania; IED Intermittent explosive disorder; BPDBorderline personality disorder; ASPD Antisocial personality disordera p \ .05; b p \ .01; c p \ .001; d p \ .0001


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With respect to specific Axis I diagnoses, high trait anger (HTA) was associated

with the presence of the majority of current and lifetime diagnoses and categories of

diagnoses for which we assessed (Table 2).

We also looked at the association between high trait anger and the presence of

any of the Axis I disorders that have anger or aggression as a diagnostic criterion or

strongly associated feature. Specifically, we looked at the percentage of high anger

participants who meet criteria for any of the following current Axis I disorders

(Bipolar I, current episode hypomanic, manic or mixed; Bipolar II, current episode

hypomanic or mixed; PTSD, GAD, or IED). Just under half (44.1%) of the high trait

anger participants, also met criteria for one of the aforementioned Axis I disorders.

When we added Borderline PD and Antisocial PD to the pool of angry/aggressive

disorders (BPI, BPII, PTSD, GAD, IED), we found that 64.8% of high trait anger

participants had at least one of these disorders. Thus, 35.2% of the high trait anger

participants did not also have a diagnosis of one of the angry/aggressive Axis I

disorders or BPD or ASPD.

As seen in Table 3, participants with high trait anger exhibited more impairment

across a range of psychiatric and psychosocial variables. High anger was associated

with lower GAF (ES = .43), higher observer rated overall depression (ES = .24),

and current suicidality (ES = .37). High anger participants were more likely to have

had a psychiatric hospitalization and a suicide attempt. They also had more impaired

past and present social functioning, and higher work absenteeism. Effect sizes were

as follows: mean number of hospitalizations (ES = .19), mean number of suicide

attempts (ES = .18), mean past social functioning rating (ES = .33), mean current

social functioning rating (ES = .37), mean time out of work (ES = .35).

Table 3 Psychiatric morbidity and psychosocial impairment in patients with and without high trait anger

Low anger

(n = 1,229)

High anger

(n = 458)

Statistic p

GAF, mean (SD) 54.9 (10.4) 49.9 (10.4) t(1,685) = 8.75 .001

CGI (SD) 2.15 (1.2) 2.48 (1.2) t(1,685) = 4.92 .001

Suicidality rating, mean (SD) 0.86 (1.23) 1.44 (1.46) t(1,685) = 7.53 .001

% Ever hospitalized (n) 24.7 (316) 35.0 (142) v2 (1) = 16.56 .0001

% Ever attempted suicide (n) 22.9 (303) 42.5 (155) v2 (1) = 55.25 .0001

% Past social functioning rated

poor or worse (n)

26.0 (407) 42.5 (51) v2 (1) = 15.39 .0001

% Current social functioning

rated poor (n)

25.4 (383) 41.9 (75) v2 (1) = 22.03 .0001

% Out of work at least 1 month

in the last 5 years (n)

23.6 (275) 35.0 (183) v2 (1) = 23.57 .0001

GAF General assessment of functioning; SD standard deviation; suicidality rating, this item taken from

the Schedule for Affective Disorders and Schizophrenia rates level of suicidality on a scale from 0 (‘‘Not

at all’’) to 6 (‘‘Very Extreme,’’ e.g., suicide attempt with definite intent to die.)a p \ .05; b p \ .01; c p \ .001


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Linear and Logistic Regression Analyses

We regressed trait anger on indices of psychiatric morbidity and psychosocial

functioning, while controlling for the effect of Axis I pathology. Linear regressions

were conducted for the continuously distributed dependent variables (GAF, CGI,

and SADS suicidality). In the case of dichotomous dependent variables (ever

hospitalized; ever attempted suicide; poor past social functioning; poor current

social functioning; out of work for one or more months) we conducted logistic

regression analyses. For all regression analyses, we entered the predictor variables

in three blocks. In the first step we entered gender and total number of Axis I

diagnoses. In step 2 we entered trait anger ratings. In step 3 we entered anger X

gender and anger X number of Axis I diagnoses. In this way, we sought to determine

if ratings of trait anger could account for variance in measures of morbidity and

impairment, above and beyond the influence of number of Axis I diagnoses. The

inclusion of gender removes its influence at step 1 and ensures that moderation is

not happening via an interaction at step 3. Trait anger was a significant predictor of

GAF, above and beyond the effect of number of Axis I diagnoses. In addition, the

interaction between anger and number of diagnoses was significant in the prediction

of GAF, and added significantly to the amount of explained variance. Trait anger

was not a significant predictor of CGI, though the interaction between anger and

number of diagnoses was significant, and increased the amount of variance

explained. The introduction of trait anger increased the amount of explained

variance in the prediction of suicidality. At Step 3, with the addition of the

interaction terms, it was no longer significant. In the logistic regression analyses, the

addition of trait anger ratings at Step 2 significantly increased the amount of

explained variance in each of the measures of functioning: hospitalizations, suicide

attempts, past and current social functioning, and missed work).2

Discussion

We examined the degree of overlap between high trait anger (HTA) and other

disorders to ascertain if HTA is redundant with one or more Axis I disorders.

Though HTA was associated with a diverse range of disorders, anger was not

subsumed by any one (or even a few) diagnoses. Interestingly, 35.2% of the HTA

participants did not also have a diagnosis of one of the angry/aggressive Axis I

disorders (PTSD, BPI, BPII, GAD, IED) or BPD or ASPD. With respect to

discriminant validity, high trait anger was associated with more psychiatric

morbidity and psychosocial impairment. Tests of incremental validity showed that

after controlling for the presence of the number of Axis I diagnoses, anger

accounted for additional variance in several important indicators of psychiatric

morbidity and psychosocial functioning.

2 Because of space limitations, complete results of the regression analyses are not presented, but can be

obtained from the first author.


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Methodological limitations suggest cautious interpretation of these findings.

First, our sample is not a random sample of psychiatric outpatients and thus cannot

be assumed to generalize to all psychiatric outpatients. Second, our measures of

psychosocial functioning were coarse. It is necessary to acquire finer-grained

information, in order to determine whether or not trait anger is associated with other

types of impairment (e.g., legal), or distress. Given the nature of the problem, it may

be interesting to examine high trait anger in other settings, such as forensic samples.

Finally, and most importantly, we used a makeshift diagnosis, because the MIDAS

study was not intended to study the validity of anger diagnoses. Our ‘‘diagnosis’’ did

not highlight or differentiate the array of forms of anger expression, anger control,

or degrees of aggression.

We believe the data point to the importance of recognizing and addressing anger

problems in clinical populations. If we consider that the assessment of anger should

be as much of a priority for clinicians as depression, and anxiety, then how should

anger be ‘‘diagnosed’’? Though we believe anger was adequately assessed in this

study, we used a crude index of a multi-faceted phenomenon. Eckhardt and

Deffenbacher (1995) have proposed a diagnostic system for anger disorders. Their

diagnostic system is not meant to replace existing diagnoses that have anger as a

component, such as PTSD, or BPD, but rather to identify and describe anger

problems that are not secondary to existing psychiatric problems.

Eckhardt and Deffenbacher (1995) propose the following three disorders:

Adjustment Disorder with Angry Mood, Situational Anger Disorder (with or

without aggressive behavior), and General Anger Disorder (with or without

aggressive behavior). Each of these disorders must be accompanied by subjective

distress or functional impairment to warrant a diagnosis. A hypothetical case

example of Adjustment Disorder with Angry Mood would be an individual going

through a divorce, who experiences periods of anger and irritability without

apparent cause, and who becomes intensely angry when interacting with, thinking

about, or hearing about his/her estranged spouse. A hypothetical case example of

someone with Situational Anger Disorder is someone with ‘‘road rage’’, who

becomes intensely angry at ‘‘bad’’ drivers or the perceived ‘‘bad driving’’ of others.

If this individual reacts by driving menacingly, making obscene gestures, or forcing

the offending driver off the road, it would constitute Situational Anger Disorder

with Aggression. General Anger Disorder describes an individual who is chronically

and pervasively angry. Elevated anger is a near daily experience, and elicited by a

wide range of external events. This general disposition toward anger can be

accompanied by frequent aggressive behavior ranging from making sarcastic

remarks, to threats, to loud arguments, or physical confrontations.

Future Research Directions and Treatment Implications

We believe that the next step in the development of an anger nosology is to attain

some consensus about the ‘‘clinical description’’ (Robins and Guze 1970), or

‘‘descriptive validity’’ (Blashfield and Draguns 1976), of anger disorders. This

would involve identifying the inclusion criteria (i.e., core and cardinal features), and


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exclusion criteria in order to develop diagnostic categories that demarcate relatively

homogeneous categories.

The next step would be to determine the reliability of diagnostic ratings. It is

recommended that semi-structured interview methods, like the SIAD, be employed

as a supplement to the existing paper-and-pencil methods, because of their inherent

procedural validity. Therapists cannot control how test-takers interpret the questions

on self-administered paper-and-pencil questionnaires. An untoward consequence is

that paper-and-pencil techniques have the propensity to over-diagnose (Widiger

2002). In an interview format, a diagnostician can clarify the meaning of questions

and ask follow-up questions to improve the precision of the information gathered.

Following the development of diagnostic methods (ideally interview-based),

adequate reliability (e.g., inter-rater reliability) would need to be established. A

field trial of assessment techniques might be necessary at this stage to establish the

reliability of anger diagnoses.

According to Blashfield and Draguns (1976), ‘‘a classification is important to

clinicians if it helps them to treat their patients more adequately. And the primary

relevance of a classification for treatment is yielding accurate predictions about the

effectiveness of specific treatments for a particular patient (p. 146).’’ In short,

diagnosis implicitly guides treatment (First et al. 2004). In the next section we

discuss ways in which anger diagnoses can guide treatment.

Implications for Treatment

The very notion of a primary anger disorder implies that treatment will be different

for primary versus secondary anger. In an individual diagnosed with GAD, for

example, a clinician may want to treat the GAD, and perhaps treat the associated

irritability and anger on a symptomatic basis. For example, relaxation techniques

could be employed to reduce hyperarousal and thereby reduce anger. In addition, a

clinician may want to reframe the anger and irritability as a symptom of GAD, to

help the patient avoid misattributing anger to external sources, thereby helping the

client avoid unnecessary interpersonal conflict.

With regard to primary anger disorders such as those proposed by Eckhardt and

Deffenbacher (1995), the anger comes into sharper focus as a target of therapy. For

example, in the case of Situational Anger Disorder, therapists and their clients could

benefit from identifying cognitions about the anger-inducing situations. In the case

of ‘‘road rage’’ the individual may be harboring irrational demands about the

behavior of others (‘‘People should never disrupt or inconvenience me.’’), which is

often related to the irrational belief that ‘‘Other people should not be flawed.’’

Imputation of malicious intention (hostile attribution bias), which is associated with

anger and aggression, can be challenged empirically resulting in coping statements

like (‘‘Just because I think that driver cut me off on purpose, does not make it so.’’).

In a situation in which an individual responds aggressively, it is important to

encourage clients to engage in consequential thinking. For individuals who respond

to situations with anger, but no anger display, it may be helpful to discuss the

potential helpfulness of building assertiveness skills. Beliefs that inhibit assertive


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behaviors (‘‘I can’t stand it if others disagree with me;’’ ‘‘I don’t deserve to get my

way.’’) may need to be uncovered and challenged.

General Anger Disorder (with or without Aggression), on the other hand, implies

a characteristic pattern of irrational thinking and a negative approach toward others

and the world. Because a diverse array of stressors and events trigger anger, the

cognitive therapist can often make substantial progress by focusing, not so much on

the details of anger-inducing events, but rather on beliefs about others, conflict and

frustration, and the world. Individuals with this clinical presentation exhibit a

number of distorted processing styles including selective abstraction, arbitrary

inference, personalization, magnification, and minimization. Low frustration

tolerance is common, such that individuals implicitly react to stress by thinking

‘‘I can’t take it anymore.’’ They often report underlying beliefs about the

fundamental unfairness of the world, and often seem to hold the belief that ‘‘The

world is especially unfair to me.’’ Condemnation of others is also very common, and

therapists need to remind such clients not to judge others by one instance or a few

instances of behavior.

Prototypical Developmental Pathology

In our experience, the developmental history of clients with general anger plays an

important role in the formation of their disposition toward anger. There seem to be

at least two prototypical angry clients whose developmental trajectories have

predisposed them to anger problems. We have labeled them abused-demanding and

spoiled-entitled. The abused-demanding persons typically have a past history of

abuse and trauma, especially multiple traumas. They react to stress in the present by

thinking they have exceeded their quota of negative life events, therefore ‘‘I should

not have to deal with it anymore’’. In working with angry clients with this type of

history, therapists need to be judicious in their use of de-awfulizing techniques,

because of the risk of invalidating the client’s experience. However, de-awfulizing

approaches can still be employed, as in the following intervention: ‘‘I realize that

getting a parking ticket is a real pain, but you have to remind yourself that you have

faced, and survived, a lot worse things in your life.’’ Individuals resembling the

spoiled-entitled prototype were instilled with high self-worth by their caretakers,

and were shielded from having to experience intense negative affect, or the

frustrations of daily living. Treatment needs to focus on developing distress

tolerance and modifying the belief that they deserve special treatment from others.

The aforementioned treatment approaches are just a few of the approaches that

REBT and other CBT therapists can use depending on the nature of the anger

disorder of their clients. As with any disorder, there are certain trans-theoretical

client factors (e.g., readiness to change) that therapists need to take into account,

and there are basic qualities (e.g., empathy, acceptance) therapists need to embody.

Ultimately, treatment research will be necessary to determine which cognitive and

behavioral treatment components are most useful for which types of anger disorders.

Acknowledgment We would like to thank the anonymous reviewers for their helpful comments on a

previous draft of this paper.


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Trait Anger and Axis I Disorders: Implications for REBT

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