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Introduction:

The importance of studying anger, irritability, aggression, and violence Anger, aggression, irritability, and violence (which will be referred to by the acronym AIAV in this editorial) are terms that have been used repeatedly to describe one of the most vexing of human struggles, with writings on it dating back to antiquity. Yet, it has continued to receive short shrift by psychiatry, particularly with respect to other symptomatology (e.g., anxiety, mania, depressed mood or psychosis). Psychology has attempted to address AIAV both diagnostically and therapeutically, but AlAV’s inclusion as a mainstream diagnostic focus remains elusive. Even with the fiscal costs to society of this enormous public health issue, healthcare professionals still grapple to properly understand it. The importance of doing so cannot be overstated.

For example, in the United States alone, the costs of intimate partner rape, physical assault, and stalking exceed $5.8 billion each year, nearly $4.1 billion of which was for direct medical and mental health care services. 2 Internationally, the WHO’s 2014 status report on violence prevention highlighted that 1.3 million people worldwide die each year as a result of violence in all its forms (self-directed, interpersonal and collective), accounting for 2.5% of global mortality.3

For victims of AIAV, it has also been shown that exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course.4 Lastly, with the recent rise of mass shootings in the United States, there has been a renewed (but distorted) focus on the relationship of gun violence to mental illness, and not AIAV in its broader context.^

Shortcomings of the Diagnostic and Statistical Manual of Mental Disorders (DSM)

Mental health professionals have increasingly been asked to diagnose, treat and account for AIAV. Yet, the nomenclature, models, and etiology of phenomena such as anger and aggression remain confusing for most clinicians. At the center of this is the DSM-5 ^, with its criteria being ubiquitously splashed across the internet, but with no actual home to house the all-too-common clinical issues of AIAV. The unintended consequences have included the overdiagnosis of Bipolar Disorders in adolescents, as public discourse has veered towards equating youth violence and mood swings with this disorder.7 Moreover, despite its revisions, and mental health professionals primary reliance upon it, the DSM has continued to prove unhelpful to clinicians in formulating (and ultimately treating) anger problems and aggression.

Of course, this is a problem intrinsic to the design of the DSM itself, with its consensus- driven, criteria-based/time-centric diagnostic approach, which doesnt lend itself well to application in clinical practice. This is because its design is inherently antithetical to the way physicians are trained: to recognize syndromes (not just clear-cut categories), as well as predispositions and precipitants to pathology, and associated etiologies that tend to present in predictable ways In addition, as has been amply demonstrated in the case of personality pathology 0 expressions of anger lie on a spectrum, ranging from mild irritability to overt physical aggression. Even the DSM-5 (in its Alternative Model for Personality Disorders section) now acknowledges that certain pathologies can indeed lie on a dimensional spectrum.^

Most observers would agree as to when anger (as a state) and aggression (as a behavior) become dysfunctional (whether the criteria are socio-cultural, legal, or scientific). However, the question whether anger or aggression should be subclassified (like, for example, anxiety disorders are in the DSM) remains vigorously debated. Like anxiety at lower levels, it has been argued that anger has evolved to protect and defend human beings against perceived threats, signaling to the individual and others of a boundary having been crossed (which confers survival). 1 However, unlike anxiety (which would encourage retreat), anger has always been viewed as an approach-state, that may or may not result in escalation to aggression.

This speaks to when a continuous (Gaussian) variable is classified as abnormal (i.e., a disorder) 3  4 especially so with children, where age-related developmental processes would also be pertinent. 5 Hence (as with anxiety) the same applies: When does anger become pathological or a disorder? For all its shortcomings, the DSMs subjective distress or impairment in psychosocial functioning criterion is arguably a helpful qualitative/ clinical benchmark here (at least in the decision to treat}, irrespective of continuing debates over anger aggression being a disorder that needs classification. Indeed, this is precisely where and why situational/contextual criteria are more helpful than the (existing) time-centric ones.

There has been a distinct categorical shift over successive iterations of the DSM when it comes to appression (though curiously anper has never been discussed). The construct of impulsive aggression has been reified in this time, starting out as passive-appressive personality - appressive type in DSM-I, then as explosive personality in DSM-II followed by the newly-minted Intermittent Explosive Disorder (IED), which first appeared in DSM- III as an Axis I Disorder.^ IED was then moved to the newly created Impulse control disorders section in the DSM-IV (1994), and has remained there in DSM-5 (2013).8

The inclusion/exclusion criteria permitted comorbid diagnoses, and frequency of appressive outbursts have also changed over successive iterations 8 In particular, there are arbitrary cut-off criteria for how frequently and what type of appression needs to occur in order to diagnose IED (at least several times a week of low intensity appression, for example). Of greatest concern is the confounding variable of comorbid diagnoses, with similar clinical as well as neurobiolopical findings; There is also still a paucity of research on subtypes of appression within disorders such as intermittent explosive disorder (IED)20 Hence, IEDs validity and reliability as a bona fide diagnosis has been questioned. 21 22

Otherwise, aggression is only mentioned cursorily across a range of DSM-5 disorders, with there never being any formal DSM definitions of it, anger or irritability.^ Irritability has been recognized as a primary presenting feature of depressive episodes in children and adolescents, and of bipolar disorders in adulthood. DSM-5 diagnoses that also encompass AIAV include: Disruptive Mood Dysregulation Disorder (DMDD), Conduct Disorder, Oppositional defiant disorder (ODD), Borderline Personality Disorder, Antisocial Personality Disorder, Major Depressive Disorder, and Post Traumatic Stress Disorder. An endophenotype that underpins these disorders has also been suggested by several auth ors.23 24 25

DSM-5 has attempted to address symptom complexes (such as non-suicidal self-injury and impaired impulse control, which are arguably epiphenomena of uncertain etiology rather than diagnoses in their own right). If so, why not then at least address anger and aggression? This would (true to its atheoretical paradigm) not have to etiologically explain AIAV. However, it would promote greater awareness of the public health implications of AIAV, while helping to consolidate clinical understanding of it as an epiphenomenon.

It would also draw rightful attention to established research-based findings that have occurred over the last four decades in the fields of psychology and neurobiology (which includes descriptions, imaging studies and rating scales).2^ 2 It is also long overdue, as a credible answer to the causes of dysfunctional anger. This would better inform public discourse and be an effective counter-narrative to the popular media — who tend to reflexively sensationalize violence/aggression, equating these all too easily with mental illness.^ Inadequate agreement on terminology: Review of the academic literature indicates first the need to better define, and then harmonize, nosology such as: anger, aggression, violence, hostility, irritability and explosivity. Definitions of irritability, for example, vary from the Oxford English Dictionary to a multitude of arbitrary definitions.. 29 30

Examples would include: interindividual differences in susceptibility to anger that may reach a pathological extent3, an aberrant response responding to threat,4 self-directed hostility31 a defining feature of anger31 a proneness to anger3* or the Research Domain Criteria (RdoC) domain (stemming from the original concept described in 195833) of Negative Valence Systems: an expression of frustrative non-reward, which is the reaction to blocked goal attainment as well as impairments in reward prediction.34 Some associate it with physiological arousal, while some do not.3^ 3^ Irritability has also been conflated with trait hostility, verbal aggression, the enactment of physical aggression and has even been referred to as a trait in its own right 3135 3d 37

Subtypes of, and relationship between, existing terms

The relationship between irritability and its proxy manifestations e.p., argumentativeness and temper outbursts or rape/anper attacks has also received scrutiny 3 3 4* .At present, these links in the chain are yet to be properly understood. This is apain where definitions and delineations of interrelated psychopatholopies (e.p., anper, impulse control, comorbid mood disturbance, response-inhibition) need to be more consistent, if research in this area is to yield valid statistical and etiolopical inferences.

Others have suggested subcomponents to irritability, such as poor frustration tolerance, that are necessary but not sufficient for its expression. 4 Anper also tends to be admixed by some, specifically when they refer to irritability as an emotional (feeling) state, which varies in intensity from mild annoyance to intense fury and rape. Much confusion therefore lies over whether irritability is exclusively a subjective experience or whether it should be more objectively defined and quantified. 42 43 As a subjective state, irritability has been shown to vary considerably, according to the type of mood state and by ape: i.e., with depressed mood more than manic mood states in children and adolescents, and with manic mood more than depressed mood states in adults.44

As defined by objective measures, irritability does not appear to correlate with ape45 However, if viewed as a subjectively articulated experience, an older individual may be more likely copnizant of their own threshold for appressive enactment, even though they may still behave in a verbally hostile (argumentative) manner.46

The introduction of the DMDD diagnosis, with persistent, rather than episodic irritability^ (however ill-defined) also exemplifies the importance of considering its duration. Then there are the frequency of such outbursts if clinicians are to successfully delineate age- appropriate developmental processes from trauma-based psychopathology and emergent mood disorders47 Some have even advanced the notion of parameters such tonic and phasic irritability, to better delineate DMDD from these other etiologies 3 Lastly, there is the link between description and actual experience, with the startling omission of subjectively experienced anger in the DMDD definition even.

Delineation of childhood from adult anger and aggression

Child and adolescent studies have been leading the way in understanding and refining criteria for pathological irritability, but applicability of such findings to adults remains sparse. 4 Questions remain as to whether irritability should be distinguished as an accompanying ‘epiphenomenon’, an intrinsic part oi a mood disorder, or an intrinsic part oi ADHD, ODD or developmental attentional deficits4. These two types’ of irritability can have very different prognostic implications for the onset of later disruptive versus affective disorders.5*

With respect to defining anger versus irritability, there still appears to be some descriptive overlap, but with irritability appearing to be more of a predisposition (proneness) not only to anger but also other affectively charged states e.g., anxiety or motor agitation.^ 52 The overlap with irritability appears when the construct of anger is elaborated upon. This would include description of its sympathetic hyperarousal, verbal and behavioral expressions, inflammatory cognitive components, and subjective angry feelings.^3 ^4

Anger: is it a phenomenon in its own right? In an attempt to distinguish anger from irritability, there has been the conceptualization of the anger attack.5 This has been defined as, a rapid onset of intense anger and a crescendo of autonomic arousal that occurs upon provocation described as trivial by the individual. This description appears to resemble some definitions of extreme irritability or IED (which oddly makes no mention of accompanying affective states, such as anger). It has also been described as a recognized feature of major depressive disorder.^^

Thus, though terminology in this area appears to have amassed (explosivity, hostility, imitability, anper, appression) researchers have yet to properly connect these phenomena with each other as necessary elements of the psychophysiolopical state of anper. Anger itself as an invariable component of hostility (that also causes subjective distress but is historically associated with malevolent intentions) has also continued to received inadequate attention as a multivariate phenomenon in its own right. This is because, it too is determined by context, and can be comprised of varied motivations that have historically (but not contemporaneously) been discussed. The latter may reflect the about turn in research away from psychodynamic understandings of anger towards purely psychometric approaches .^7 Review of the existing literature therefore indicates a focus on varying definitions rather than on deeper motivations for anger.54

Anper has been successfully categorized as both a state and a stable trait. State anper is defined as, a transient subjective emotional feeling of intense fury and rape.5 Of note, the oldest definition adds: physiologically, state anper varies from little or no chanpe in physiological arousal to marked sympathetic arousal, increased tension in facial and skeletal muscles, and release of adrenal hormones ^0 Trait anper has been defined as, a stable personality dimension of anger proneness or tendency to experience state anper^ State anper is evoked by very extreme external factors ^8 Trait anper, by contrast, is most strongly linked to appression because of perceived hostility in interpersonal situations i.e., hostile attribution bias (HAB), an offshoot of social
learning theory d2Within this paradigm, hostile attribution biases and ruminative (and selective) attention^3 would be crucial components of trait anper, as well as its beinp a predisposing factor for reactive (impulsive) aggression to ambiguous environmental cues that could be misinterpreted and thereby transform this trait into a state.^ Interestingly, recent research has identified emotional information processing as being as just as pertinent as HAB in misinterpretation of ambiguous events as hostile (though there were methodological limitations to this particular study)^5

Apparently, the key difference between an anper attack and irritability is that the experience of irritability is not necessarily rapid^ However, it is all too easy to see how an anper attack mipht blend into psychiatrically-defined concepts (such as explosivity and appression). However, anper as a term appears to have increasingly been eclipsed by hostility over the last decade. 

And then there is Hostility.
Hostility is similarly described as a trait 7, but it too appears inadequately parsed out from trait anper. Some authors have tried to delineate it as a cluster of core beliefs informing an antagonistic attitude. Hostility would therefore comprise both feelings (of disgust, resentment, indignation and recrimination) 70 as well cognitions (cynicism and suspicion)^ Yet, as in the case of irritability, the hyperarousal component that may underlie trait hostility may be underappreciated, particularly when it evolves into an irritable state.7 Then there is the subclassification of covert hostility (associated with irritability) and overt hostility (associated with appression). 7
 
Anper and hostility are also believed to have a close relationship with irritability and appression but apain this has not been clearly elucidated. 73 The role of afect in generating a hostile attitude similarly tends to be implied but not properly explained.^ Nor is the confounding variable of impulsivity included in descriptions of hostility.74 75 Hostility and anper (if indeed they are separate entities) have also been shown to have diametrically opposite associations with suicide7^

Could Amok be the actual cause of Mass Shootings?

With the prevalence of mass shootings in the United States, an older, (since debunked) culture-bound syndrome called Amok appears to capture this form of abrupt explosive anger and indiscriminate mass violence more aptly than any of the above current descriptors.77 It has since been asserted that Amok is: a) not a culture-bound syndrome b) an epiphenomenon, having several contributory factors, including (but not limited to): personality pathology, temperament, several different mental disorders, as well as coping abilities and cognitive distortions, all of which affect each other in how it actually manifests, and irrespective of which culture it occurs in. Culture-bound syndromes have since been eliminated altogether in DSM-5, in favor of its updated Cultural Formulation and Glossary of Cultural Concepts of Distress se4ions. Yet Amok(or a more contemporaneous, culturally-informed phenomenological description of it) is nowhere to be found in DSM-5.

Aggression is more robustly defined Aggression is most commonly subcategorized into two different types: impulsive (or reactive) and instrumental (premeditated).7 However, other descriptions have included: indirect versus direct aggression, verbal aggression, non-verbal aggression (intimidation) and physical aggression. Evolutionary psychologists have argued that these types of aggression evolved in order to maintain social/political order, or like instrumental aggression, to achieve a predetermined reward or goal (like winning a well-planned war)7
Explosivity refers to rapid and extremely destructive aggression that would be considered grossly disproportionate to the provoking stimulus^ Interestingly, there has not been much controversy over this term. In fact, the (now established) transdiagnostic dimension of impulsive aggression has seen several pharmacological studies claiming promising treatments for it specifically 0 What appears less well emphasized in the psychiatric (not psychological) literature are environmental triggers and cognitive/ affective predispositions to impulsive aggression.

Instrumental/ predatory aggression has long been associated with psychopathy and antisocial personality disorder, with it now understood that empathy deficits play a salient role, and little, if any, role for pharmacological treatments.

What then is violence?

Then there is violence, which, according to the oldest definition used in risk assessment, indicates actual bodily harm to persons and/or property, resulting from physical appression. 3 Even here, scholars have tried to delineate harms such as intimate partner violence, rape, robbery and even bullying.^ Moreover, different academic disciplines have cast their own lenses on it, with some focused on violence’s sheer eprepiousness, others on its hidden intent, its beinp entirely unnecessitated, and its lonp-term traumatizinp impact. 4

Time to de-rely on the DSM

That is why the decision by the NIMH to no lonper rely on DSM-5 categories to further research into brain circuitry is so pertinent to this transdiapnostic issue. Variation of symptoms, comorbidity, and limitation of sample sizes in research (to reduce heterogeneity as a confounding variable) in mental disorder field trials challenges the proper understanding of the full spectrum of mental health conditions and their symptom trajectories. 5Authors have also suggested that, with the burpeoninp number of comorbid diagnoses in children, they are the best population to which to apply RDoC constructs (i.e. brain networks), in order to plean greater clarity about neurobiolopical circuitry (including neurodevelopmental processes). ^

Subsequent research into brain circuitry has been both vigorous and illuminating in helping to advance a much more integrated understanding of the complex phenomenology behind the terms: Anger, Irritability, Aggression and Violence. This will be discussed in part two of this two-part article.

Conclusion (Part I: Evolution)

It is disappointing that an issue as important as AIAV remains so poorly conceptualized. DSM-5s categorical approach has proved to be entirely unhelpful in even defining it. Instead, AIAV is smattered across a range of different disorders. In addition, by marginalizing syndromes (such as Amok), the DSM has done a disservice to clinicians who have to address real world scenarios, (such as mass shootings). Unintended consequences of its approach have included the overdiagnosis of Bipolar Disorder, poor understanding of developmental considerations, and defining abnormality if there is also an evolutionary basis for AIAV. IED as the only AIAV disorder has also continued to fall woefully short in capturing the real-world spectrum of pathological anger and aggression by being too narrowly time-centric. Fortunately, the evolving transdiagnostic construct of impulsive aggression has allowed clinicians to formulate more evidenced-based treatment strategies. However, there remain crucial, but poorly understood, components of AIAV, specifically: situational, temperamental, cognitive and even sociocultural factors in its expression and enactment/inhibition.

In highlighting the poor agreement on terms as basic as anger, irritability, aggression and violence, this editorial hopes to promote more exacting standards for understanding how they are related. Moreover, though it behooves the DSM to at least include definitions of these terms in its glossary section, it is increasingly evident that its overly categorical approach has proven inferior to the transdiagnostic approach of the NIMH RdoC. The latter focuses on relevant brain circuitry that leads to enactment of AIAV. Could this prove to be more clinically pragmatic, and less ‘academic’, than the DSM-5? Perhaps the time has indeed come to de-rely on the DSM with particular respect to understanding AIAV.

Corresponding author:
Ashburn Psychological and Psychiatric Services, Ashburn, VA, USA.
George Washington University, Dept. of Neurobehavioral Sciences, Washington, D.C., USA.
Email: [email protected]
 
Conflict of Interests: None

Funding: None

Acknowledgements: None.

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