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The missing emotion

Wrath, people say, is not an emotion but a sin; and a deadly sin at that.

Yet anger is just as much an emotion as anxiety or misery. Like them, it is an inescapable part of life; like them, it can be necessary and useful; and like them, an excess can wreck lives. Mental health language, however, has not elevated the extreme into a syndrome comparable to depression or anxiety states. Perhaps if it did we would understand better the good and the ill in us. “Anger control” is widely taught (perhaps more widely than successfully); but why is it uncontrolled? What lies behind it? Aggression might indeed be a behaviour to be learned or unlearned; but what about the variety of emotions that are behind it?

Righteous fury: Righteous fury can make us reformers, as Dean Swift’s “saeva indignatio” made him.

Wrath: Whether justified or not, wrath can — like that of Achilles — change the fates of cities and people.

Tantrums: Tantrums typically, about trivia such as cold food or peanuts served in a bag — make us ridiculous, and sometimes dangerous. Crazy rages are the extreme of tantrums. Charles VI of France (“le Fou”) was afflicted. He flew into such a frenzy while hunting that he killed his companions, and it was a premonition of his decline into insanity.

Irritability: Irritability describes those of us who can’t, or don’t choose to, keep our tantrums in check. Psychiatry regards it as potentially part of depression, or mania, or autism, or ADHD, or indeed most disorders of mental health.

Resentment: Resentment is much more inward than the explosive kinds of anger. It is bitter, hateful, revengeful and enduring. It poisons those who harbour it, and endangers those who occasion it.

Great Day of His Wrath by John Martin. Public domain via Wikimedia Commons.
Great Day of His Wrath by John Martin. Public domain via Wikimedia Commons.

Disruptive mood dysregulation disorder (DMDD) is a newly minted psychiatric illness, describing a combination of gross irritability and resentment in young people. It has been invented for the American classification scheme (“DSM5”) but not, or not yet, accepted by the international scheme of the World Health Organization.

DMDD is defined in a way to make it a condition arising in young people, but one that can persist into adult life: it should not be diagnosed for the first time before age six or after age 18; and the onset needs to have been before age ten. Most of the features are also seen in oppositional-defiant disorder (ODD), so it is important to recognize that it is conceptualized as a more serious problem than ODD: severe verbal or behavioural temper outbursts at least three times a week, angry mood nearly all the time, all evident in different situations. These are some of the most common reasons for troubled youngsters to come to mental health services. One hope is that the diagnosis will promote good clinical practice – for instance, in discouraging a trend in some countries to over diagnose bipolar disorder in young children; and in allowing proper recognition of the emotional basis of many types of antisocial behaviour. It should allow more focussed research than has been possible previously. It could also give rise to some difficulty for clinical diagnosticians, because of the overlap with other conditions such as agitated depression and ADHD. Guidelines for clinicians and standards for clinical trials will need further development.

Shall we accept this new condition? Will it make a new pathology out of the normal human drive to overcome frustration? Or will it allow us to be more understanding towards children and teenagers who are taking their frustrations out on others — and losing their friends, and sometimes their futures, in the process? Can we understand the biology of the emotional extremes of anger; and might doing so invalidate legitimate rage? DMDD seems likely to put anger extremes into a central position in psychiatry. One thing is clear: it is not just a matter of bad behaviour.

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