Anger attacks are characterized by sudden spells of

Transcription

1 original Article Anger attacks in obsessive compulsive disorder A b s t r a c t Nitesh Prakash Painuly, Sandeep Grover, Surendra Kumar Mattoo, Nitin Gupta Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Sandeep Grover, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh , India. drsandeepg2002@ yahoo.com Background: Research on anger attacks has been mostly limited to depression, and only a few studies have focused on anger attacks in obsessive compulsive disorder. Materials and Methods: In a cross-sectional study all new obsessive compulsive disorder patients aged years attending an outpatient clinic were assessed using the anger attack questionnaire, irritability, depression and anxiety scale (for the direction of the aggressive behavior) and quality of life (QOL). Results: The sample consisted of 42 consecutive subjects with obsessive compulsive disorder, out of which 21 (50%) had anger attacks. The obsessive compulsive disorder subjects with and without anger attacks did not show significant differences in terms of sociodemographic variables, duration of illness, treatment, and family history. However, subjects with anger attacks had significantly higher prevalence of panic attacks and comorbid depression. Significantly more subjects with anger attacks exhibited aggressive acts toward spouse, parents, children, and other relatives in the form of yelling and threatening to hurt, trying to hurt, and threatening to leave. However, the two groups did not differ significantly in terms of QOL, except for the psychological domain being worse in the subjects with anger attacks. Conclusion: Anger attacks are present in half of the patients with obsessive compulsive disorder, and they correlate with the presence of comorbid depression. Keywords: Anger attacks, obsessive compulsive disorder, depression Anger attacks are characterized by sudden spells of anger, associated with a surge of autonomic arousal, which includes such symptoms as tachycardia, sweating, flushing, and a feeling of being out of control. Anger attacks may occur either spontaneously or in response to a provocation, and should be experienced by the subjects as uncharacteristic of themselves and inappropriate to the situation in which they occur. [1] Anger attacks have been mostly studied in depression; the depressive subgroup with anger attacks appears to be distinct in terms of clinical correlates, personality features, and biological characteristics. [1-5] Anger attacks have also been studied in other disorders like anxiety, eating disorder, [6,7] and obsessive compulsive disorder (OCD). Whiteside and Abramowitz [8] reported the association between OCD symptoms and anger in 131 undergraduates. The study sample was divided into two groups based on self-reported OC symptoms and they were compared for Access this article online Quick Response Code: Website: DOI: / their tendency to suppress anger inward, express anger outward, and control their anger. Compared to subjects with low OC symptoms, the subjects with OC symptoms were found to experience more anger, have a tendency to suppress it inwardly, and report more difficulty in controlling their anger. However, on further analysis it was found that the difference between the two groups was attributable to depressive symptoms. In another study, Whiteside and Abramowitz [9] compared 71 OCD patients with 71 college students and reported the OCD patients to have increased levels of anger. However, the differences between the groups disappeared when depressive symptoms were covaried out of the analyses. They concluded that anger in OCD might result from comorbid depression or symptoms of general distress. In a recent study, Moscovitch et al. [10] studied anger in four anxiety disorders (panic disorder, obsessive compulsive disorder, social phobia, and specific phobia) in 112 subjects, of which 30 had OCD. They found that compared to the controls the patients with panic disorder, OCD, and social phobia experienced more anger, the anger in OCD patients being less than in panic disorder subjects and there being no group difference for anger when depression was controlled for. There are no studies on anger in OCD from India and other developing countries. Hence we tried to assess the Industrial Psychiatry Journal 115

2 prevalence and clinical correlates of anger attacks in OCD, including the quality of life and aggressive behavior toward family members and others. MATERIALS AND METHODS Setting The study was carried out at the postgraduate institute of medical education and research (PGIMER), Chandigarh. PGIMER is a multispecialty tertiary-care teaching hospital providing services to a major area of North India. Design Cross-sectional assessment. Sample All new patients aged years, who attended outpatient clinic of the Department of Psychiatry, PGIMER, Chandigarh (India), during the period 1 April 2003 to 30 June 2003 were assessed. Patients with diagnosis of OCD as per ICD-10 [11] were approached for participation in the study. Subjects with comorbid psychotic illness, substance use (except nicotine), and organic brain syndromes were excluded. Definition of anger attacks In this study, AA were considered to be present when a subject had at least one anger attack in a month with at least four psychological, behavioral, and autonomic symptoms of anxiety. This was done in line with the previous studies [1] and DSM-IV [12] diagnostic guidelines for panic disorder, as an attempt to conceptualize AA as a discrete syndrome rather than a symptom. Instruments The following instruments, as required, were used: Sociodemographic profile sheet Developed for this study, it recorded the relevant sociodemographic data on age, gender, education, marital status, and locality. Clinical profile sheet Developed for this study, it recorded information on duration of illness, duration of treatment, family history of psychiatric disorders, number and frequency of aggressive acts in the last 1 month (threatening to leave, refusal to talk or sulking, yelling, stamping out or slamming the door, breaking and throwing objects - not at a person, throwing objects at a person, threatening to physically hurt, trying to physically hurt), and direction of aggressive acts (toward spouse, parents, children, other relatives, friends, colleagues, others) and assessment for presence or absence of panic attacks. Anger attack questionnaire [1] A self-rated instrument designed to assess the presence/ absence of anger attacks (at least one anger attack in the last month comprising a minimum of 4 out of 13 listed autonomic, behavioral, and psychic symptoms). The first item has four possible responses. The remaining items record the presence/absence of 13 symptoms in Yes/ No response. This is the most commonly used scale for studying anger attacks. [1-5] The questionnaire was translated into Hindi language, following the standard protocol of translation and back translation. Irritability, depression, and anxiety scale [13] A self-rated scale for assessment of irritability in clinical situations it has 18 items 8 items for irritability and 5 each for depression and anxiety (considering the significant relationship between these three moods). Of the eight items for irritability, four each relate to outwardly and inwardly directed irritability. Each item has four possible responses. The correlations of irritability, depression, and anxiety subscales with other scales (of the respective type) are all highly significant and satisfy the requirements for concurrent validity. [13] The scale was translated into Hindi language, following the standard protocol of translation and back translation. World health organization quality of life BREF, Hindi version [14] World health organization quality of life BREF (WHOQOL-BREF) is a self-administered shorter/26 item version of the full/100 item WHOQOL, the only QOL instrument developed in multiple languages including Hindi. It measures subjective evaluation of respondent s health and living conditions through four domains of physical health, psychological health, social relationship, and environment. The items are scored from 1 to 5 for a total score range of The scale shows good discriminant and concurrent validity, and internal consistency and test--retest reliability; the psychometric properties being comparable to those of the full version (WHOQOL-100). [14,15] Procedure All new patients with a diagnosis of obsessive compulsive disorder as per ICD-10 [11] and fulfilling the inclusion and exclusion criteria were approached for participation in the study. After obtaining a written informed consent a qualified psychiatrist (either of the two authors NP, SG) assessed them using the socio-demographic and clinical profile sheets and then asked them to fill the anger attack questionnaire (AAQ), irritability, depression, and anxiety (IDA), and WHOQOL-BREF. For subjects not able to read or write Hindi language the scale items were read out and the responses recorded. The average time taken was minutes, on the higher side for the subjects who could not read or write Hindi. 116 Industrial Psychiatry Journal

3 Ethical considerations The Research Ethics Committee of the Department had cleared the study. All the subjects were recruited on the basis of a written informed consent assuring confidentiality and freedom of choice of participation. Statistical analysis On the basis of AAQ the whole sample was divided into two groups: those with anger attacks and those without anger attacks. The two groups were compared on socio-clinical and psychological variables using nonparametric (chisquare, Mann-Whitney U) and parametric (unpaired t) tests. Correlation analysis (Pearson s coefficient, and Spearman rho ) was carried out to assess the relationship between frequency of anger attacks and various socio-clinical and psychological parameters in the anger attack group. RESULTS Prevalence of anger attacks The sample consisted of 42 consecutive subjects with obsessive compulsive disorder, out of which 21 (50%) each were with and without AA. Sociodemographic profile In both the groups the mean age was around 30 years and majority of the subjects were unemployed and educated beyond matriculation. Even though the with-aa group had predominance of females and unmarried subjects and somewhat higher income, none of the differences was significant [Table 1]. Clinical characteristics The two groups were similar for the durations of illness, treatment, and family history. However, subjects with AA had significantly higher prevalence of panic attacks and comorbid depression and on IDA showed significantly higher irritability in both outward and inward domains [Table 1]. Direction of aggressive behavior, aggressive acts, and QOL Significantly more subjects with AA exhibited aggressive acts toward spouse and parents (P<0.001), toward children and other relatives (P<0.05); in the form of yelling and threatening to hurt (P<0.001), trying to hurt (P<0.01), and threatening to leave (P<0.05). However, the two groups did not differ significantly in terms of QOL, except for Table 1: Comparison of subjects with and without anger attacks across sociodemographic profile, clinical profile, depression, anxiety, and irritability scale Variable OCD with AA (N=21) OCD without AA (N=21) Comparative statistics Socio-demographic profile Age (years) (±11.66) (±12.61) t value=0.26 Gender Male 9 15 χ 2 =3.5 Female Marital status Married 6 12 χ 2 =3.5 Unmarried 15 9 Employment Employed 6 8 χ 2 = Unemployed Education Matriculate 9 6 χ 2 = >Matriculate Income/month (in rupees) (±1995.8) (±1617.6) t value=0.61 Clinical profile Duration of illness (in months) 57.09± ±56.52 t value=3.62 Duration of treatment (in months) 21.61± ±30.33 Mann Whitney U = 0.16 Family history 1 3 Fisher exact value =0.606 Panic attacks 12 5 χ 2 = 4.82* Co morbid depression 6 0 χ 2 with Yates correction=4.86* Duration of illness (in months) (±33.49) (±56.52) t value=3.62 Depression, anxiety and irritability scale Depression 5.76 (±3.47) 5.61 (±2.45) t value=0.15 Anxiety 7.23 (±3.81) 5.52 (±2.65) t value=1.68 Irritability-out 7.28 (±3.16) 3.57 (±2.37) t value=4.30*** Irritability-in 6.47 (±3.42) 3.38 (±2.83) t value=3.30** *P<0.05; **P<0.01;*** P<0.001 Industrial Psychiatry Journal 117

4 the psychological domain being worse in the subjects with AA [Table 2]. Correlation analysis In the AA group, the frequency of AA had significant positive correlation with the presence of comorbid depression. DISCUSSION The data on AA in diagnoses other than depression are sparse, especially from the eastern cultures. Our study, an attempt to fill this void, shows that in subjects with OCD 50% have AA and the OCD subjects with AA have more comorbid depression, have significantly higher irritability (both inward and outward), exhibit more aggressive acts toward their spouse, parents, children, and other relatives (i.e., toward their immediate and extended family) and have poorer QOL in psychological domain. Further, although there was no significant difference between the subjects with AA and without AA on the depression domain of IDA, the subjects with AA had higher severity of depression. The frequency of AA has positive correlation with the presence of syndromal comorbid depression but not with demographic, clinical, and psychological variables studied. Lack of difference between the two groups (those with AA and those without AA) on the sociodemo-graphic profile and duration of illness suggests that AA in OCD is probably not associated with these variables. Higher prevalence of AA in subjects with higher prevalence of panic attacks support the hypothesis by Fava et al. [2] of a close association of anger and anxiety in the fight--flight reaction occurring due to autonomic arousal. On the IDA scale, a significantly higher score on irritability (both inward and outward) in patients with AA further indicates the relationship between anger and irritability. Our findings also suggest that subjects with AA exhibit higher number of aggressive acts toward their family members and probably lead to an increase in burden on the family. However, our findings of a significant difference between the two groups only in the psychological domain and not in other domains suggest that AA have a significant impact on the sufferer s own mental state and lead to subjective distress, but do not influence other domains. One may hypothesize that the occurrence of AA against the family members (who tend to be the main support system for the patient) leads to the development of guilt and distress in the individual for manifesting such negative phenomena with the supportive family member(s), hence a poorer QOL at the psychological level. Table 2: Comparison of direction of aggressive behavior, aggressive acts, and quality of life between OCD with and without anger attacks between OCD with and without anger attacks Variable OCD with AA (N=21) OCD without AA (N=21) Chi-square value with Yates correction Direction of aggressive behavior Spouse *** Parents * Children *** Other relatives * Friends Colleagues Others Aggressive acts Threatening to leave * Refusal to talk Yelling *** Slamming Breaking objects Throwing objects Threatening to hurt *** Trying to hurt ** Quality of life Physical (±3.47) (±7.57) t value= Psychological (±4.76) (±3.23) t value=-2.04* Social 9.28 (±3.43) (±7.14) t value= Environment (±8.05) (±4.68) t value= General wellbeing 5.04 (±2.41) 5.95 (±1.85) t value= *P<0.05; **P< 0.01; ***P< Industrial Psychiatry Journal

5 Previous studies [8,9] have shown that anger in OCD is attributable to depression. In our study, subjects of OCD with AA had higher frequency of the presence of syndromal depression (30%); but comparable severity of depression (as per scores on IDA). Hence, mere presence of depressive symptoms is not sufficient, but severity of depression (as indicated by the presence of comorbid major depression) is more relevant to the manifestation of AA in patients with OCD. Also, our finding of the presence of AA in subjects with OCD without comorbid depression suggests that various other factors (e.g., personality variables) may be modulating the manifestation of anger and anxiety, but it is the presence of depression which tends to fuel the AA. Hence, in persons predisposed to manifesting irritability and anger, development of a depressive illness leads onto more frequent manifestation of AA. Because the patients of OCD with AA are more likely to present with greater psychological morbidity, there is a need to assess/identify the presence of AA in OCD patients, and, additionally focus the treatment on reducing/ managing the comorbid depression so as to reduce the additional distress. The generalizability of our results is restricted by the limitations of our study in the form of small sample size, lack of measurements for phenomenology, and severity of OCD, and lack of use of additional instruments for measuring depression (e.g., HDRS, MADRS, BDI). Future studies need to evaluate AA in OCD in larger samples, examine further the relationship of AA with OCD with/ without depression, and also examine the influence of treatment on the same. REFERENCES 1. Fava M, Rosenbaum JF, McCarthy M, Pava J, Steingard R, Bless E. Anger attacks in depressed outpatients and their response to fluoxetine. Psychopharmacol Bull 1991; 27: Fava M, Rosenbaum JF, Pava JA, McCarthy MK, Steingard RJ, Bouffides E. Anger attack in unipolar depression, Part 1: Clinical correlates and response to fluoxetine treatment. Am J Psychiatry 1993;150: Rosenbaum JF, Fava M, Pava JA, McCarthy MK, Steingard RJ, Bouffides E. Anger attacks in unipolar depression, Part 2: Neuroendocrine correlates and changes following fluoxetine treatment. Am J Psychiatry 1993;150: Fava M, Nierenberg AA, Quitkin FM, Zisook S, Pearlstein T, Stone A, et al. A preliminary study on the efficiency of sertraline and imipramine on anger attacks in atypical depression and dysthymia. Psychopharmacol Bull 1997;33: Fava M, Vuolo RD, Wright EC, Nierenberg AA, Alpert JE, Rosenbaum JF. Fenfluramine challenge in unipolar depression with and without anger attacks. Psychiatry Res 2000; 94: Fava M, Rappe SM, West J, Herzog DB. Anger attacks in eating disorders. Psychiatry Res 1995;56: Gould RA, Ball S, Kaspi SP, Otto MW, Pollack MH, Shekhar A, et al. Prevalence and correlates of anger attacks: a two site study. J Affect Disord 1996;39: Whiteside SP, Abramowitz JS. Obsessive compulsive symptoms and expression of anger. Cog Ther Res 2004; 28: Whiteside SP, Abramowitz JS. The expression of anger and its relationship to symptoms and cognitions in obsessivecompulsive disorder. Depress Anxiety 2005;21: Moscovitch DA, McCabe RE, Antony MM, Rocca L, Swinson RP. Anger experience and expression across the anxiety disorders. Depress Anxiety 2008;25: World Health Organization. ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4 th ed. (DSM-IV). Washington, DC: American Psychiatric Association; Snaith RP, Taylor CM. Irritability: definition, assessment and associated factors. Br J Psychiatry 1985;147: Saxena S, Chandiramani K, Bhargava R. WHOQOL-Hindi: a questionnaire for assessing quality of life in health care settings in India. World Health Organization Quality of Life. Nat Med J India 1998;11: Orley J, Saxena S, Herrman H. Quality of life and mental illness: Reflections from the prospective of WHOQOL. Br J Psychiatry 1998;172: How to cite this article: Painuly NP, Grover S, Mattoo SK, Gupta N. Anger attacks in obsessive compulsive disorder. Ind Psychiatry J 2011;20: Source of Support: Nil. Conflict of Interest: None declared. Industrial Psychiatry Journal 119