Anger is a normal emotion that serves as a warning to others. It is a preparation for a fight, verbal or physical. When it results in a violent conflict, someone may get hurt, perhaps seriously. However, there are acts of violence that do not involve anger such as when a sociopath uses violence to get what he wants. Such individuals do not show genuine remorse.
However, for this blog I will write about selected aspects of anger that can lead to violence. Despite common belief, the vast majority of people with mental illness are not prone to violence. Actually, many forms of mental illness may be associated with reticence to act forcefully at all.
For protection against violence it is helpful to know what to look for. The best predictor of violence is a history of prior violence. So, anyone with a history of violent actions, which could be against people, animals or things, should be considered at high risk.
Other risk factors include being male, young, unemployed, impulsive, lower socioeconomic status, and/or under the influence of drugs (PCP is notorious for that) or alcohol. The concept of 'rhoid rage is well known. It is a potential consequence of using anabolic steroids to gain muscle mass.
While violence is not common among people with a mental illness, it may be seen in a small subset, especially people with sociopathy, borderline personality disorder, or individuals with paranoia from schizophrenia or dementia, for example. This is more likely in people who are not receiving treatment for their illness.
In many situations, violence is a consequence of preceding anger. Thus, it is helpful to recognize the early warning signs that someone is becoming angry enough that they may become violent. Many times anger follows after the person is afraid. The anger can be seen as a means of protecting the individual against what they fear. For example, a patient with an acute psychosis may become angry and belligerent because they are afraid someone is out to harm them or that they are feeling horrible and no one cares or is going to help them.
Often anger builds up, and it could be a "final straw" that pushes them beyond a point where they can readily control their temper. If you see someone who appears angry, it often helps to remain as calm as you can, and gently ask the person what is going on, "You seem to be angry. Can I help you?"
Evidence that someone is becoming progressively more angry may include getting red in the face, having an angry expression, clenching their fists, dilated pupils, pacing, or speaking in a loud and angry tone. Anyone who verbalized a threat must be taken seriously. If the threat is against a specific identifiable person, it is important to let that person know.
There are mental illnesses that are associated with an increase in anger: antisocial personality disorder, any illness that includes paranoid thoughts, borderline personality disorder, bipolar mania, PTSD, ADHD, and organic brain disorders such as a significant head injury. One of the tragic consequences of the wars in the Middle East is the fact that a large number of military men and women developed Post Traumatic Stress Disorder and/or Traumatic Brain Injury. This has resulted in too many relationship problems including divorce.
Of course, most of the time angry people are not violent. The majority of street violence takes place in the context of robbery or gang violence, and the perpetrator may not be angry. As noted in an earlier blog, mass murder is associated with certain personality traits along with a sense of being mistreated by at least a segment of society. Any associated anger is usually built up over time and does not have to be prominent when the mass murder actually takes place.
The bottom line is that violence is a fact of life, and we should take appropriate precautions. Anger is a common trigger for certain forms of violence, and it helps to recognize it early when it may be able to be defused.
Peter M. Hartmann, MD
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