The prevalence and clinical correlates of anger attacks during depressive episodes in bipolar disorder

doi:10.1016/S0165-0327(02)00451-2

Journal of Affective Disorders

Volume 79, Issues 1–3, April 2004, Pages 291-295

Presented at the 42nd annual meeting of the NIMH New Clinical Drug Evaluation Unit, Boca Raton, FL, 2002.

https://doi.org/10.1016/S0165-0327(02)00451-2 Get rights and content

Abstract

Background: Anger attacks, characterized by sudden episodes of intense anger with autonomic arousal, have been described in patients with major depressive disorder (MDD). This study compared the prevalence and clinical significance of anger attacks in unipolar versus bipolar depression. Methods: Using the questionnaire of Fava et al. [Psychopharmacol. Bull. 27(3) (1991) 275–279], we assessed rates of anger attacks among outpatients with MDD (n=50) or bipolar disorder (BPD) (n=29) who were currently in a pure depressive episode. Results: Anger attacks were significantly more common among bipolar (62%) than unipolar (26%) depressed individuals. In a multiple logistic regression, the presence of anger attacks emerged as a significant predictor of bipolarity. Limitations: This preliminary finding should be confirmed in a larger sample. Conclusions: These results suggest that anger attacks may be a common feature of bipolar depression.

Introduction

Anger attacks are episodes of sudden, intense, and situationally inappropriate anger associated with autonomic arousal (Fava et al., 1991). Among patients with major depressive disorder (MDD), the prevalence of such symptoms during depressive episodes based on self-report has been estimated to range from 30 to 50% (Fava et al., 1991, Fava et al., 1993, Gould et al., 1996, Sayar et al., 2000).

In addition to the possible association of anger attacks with violence (Fava et al., 1993), they have also been found to predict treatment non-adherence (Mammen et al., 1997). Other measures of anger expression, such as higher lifetime aggression ratings, have been associated with suicidal behavior (Oquendo et al., 2000).

Irritability is often a prominent feature of bipolar disorder (BPD) as well, with previous descriptions focused on manic or mixed states (Perugi et al., 1997, Dayer et al., 2000). We have recently observed that irritability may also be prominent during pure bipolar depressive episodes (Deckersbach and Perlis, unpublished data) and hypothesized that anger attacks would likely be common as well. In this study, we present the first report of the prevalence and clinical correlates of anger attacks in a sample of outpatients with bipolar disorder in the midst of a depressive episode.

Section snippets

Methods

Participants were recruited for a case-control genetic association study of mood disorders through outpatient mood disorder clinics at the Massachusetts General Hospital. Participants were a convenience sample of individuals age 18 or above with a primary diagnosis of either BPD (n=122) or MDD (n=114) recruited from: (1) individuals inquiring about or enrolled in clinical trials of BPD or MDD treatments; (2) clinician referrals; or (3) advertisements. The study protocol was approved by the

Results

The depressed MDD (n=50) and BPD (n=29) groups were not statistically significantly different in age (38.2±13.8 vs. 42.9±11.9 years), sex ratio (50% female vs. 35% female), ethnicity (90% Caucasian vs. 97% Caucasian), severity of depressive symptoms by SQ (MDD: 17.7±4.9 vs. BPD: 16.6±6.1.) or irritability by SQ (MDD: 10.1±5.8 vs. BPD: 10.2±6.3) (P>0.15 for all comparisons). Age of onset of mood disorder appeared to be earlier among bipolar subjects, though this difference did not reach

Discussion

In a clinical sample of mood disorder patients, we found that the presence of anger attacks during pure depressive episodes was more than twice as common among BPD than MDD patients. This investigation is the first to systematically assess anger attacks among patients with bipolar disorder during pure depressive episodes. The presence of anger attacks was not associated with clear clinical differences among bipolar patients, though the small sample size limited statistical power in this

Acknowledgments

Supported in part by grants from the American Philosophical Society (Dr Perlis) and Millennium Pharmaceuticals, Inc. (Drs Rosenbaum and Smoller).

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Citation Excerpt :
Also, elevated levels of anger and hostility are often reported in depressed patients (Fisher et al., 2015; Riley et al., 1989). The prevalence of anger attacks ranged from 26% to 49% in individuals with MDD (Fava et al., 1996; Perlis et al., 2004; Sayar et al., 2000; Winkler et al., 2005, 2006) and from 28% to 53% in patients with dysthymia (Fava et al., 1997; Painuly et al., 2011). Patients with anxiety disorders also showed increased levels of anger; 29–32% experience anger attacks (Gould et al., 1996).
Patients with various psychiatric disorders may suffer from feelings of anger, sometimes leading to maladaptive (e.g., aggressive) behaviors. We examined to what extent depressive and anxiety disorders, relevant clinical correlates, and sociodemographics determined the level of trait anger and the prevalence of recent anger attacks.
In the Netherlands Study of Depression and Anxiety (NESDA), the Spielberger Trait Anger Subscale and the Anger Attacks Questionnaire were analyzed in patients with depressive (n = 204), anxiety (n = 288), comorbid (n = 222), and remitted disorders (n = 1,107), as well as in healthy controls (n = 470) based on DSM-IV criteria.
On average, participants were 46.2 years old (SD = 13.1) and 66.3% were female. Trait anger and anger attacks were most prevalent in the comorbid group (M = 18.5, SD = 5.9, and prevalence 22.1%), followed by anxiety disorder, depressive disorder, remitted disorder, and controls (M = 12.7; SD = 2.9, and prevalence 1.3%). Major depressive disorder, social phobia, panic disorder, and generalized anxiety disorder were most strongly associated to trait anger and anger attacks.
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Citation Excerpt :
Anger has been found to be common during prodromal phases of episodes (Skjelstad, Malt, & Holte, 2010). During depressive episodes, people with bipolar disorder report about twice the level of anger attacks (62%) reported by those with unipolar depression (Perlis et al., 2004). Elevated levels of anger have also been reported among those with bipolar II disorder (Benazzi, 2003; Benazzi & Akiskal, 2005) and among adolescents diagnosed with bipolar disorder (Rucklidge, 2006).
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Brief reportThe prevalence and clinical correlates of anger attacks during depressive episodes in bipolar disorder

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Acknowledgments

J. Affect. Disord.

Compr. Psychiatry

J. Affect. Disord.

Psychiatry Res.

Psychiatry Res.

J. Affect. Disord.

J. Psychiatr. Res.

Compr. Psychiatry

J. Affect. Disord.

J. Affect. Disord.

Psychiatry Res.

Compr. Psychiatry

Diagnostic and Statistical Manual of Mental Disorders

Brief report
The prevalence and clinical correlates of anger attacks during depressive episodes in bipolar disorder