Aging and Dementia

of the illness appear promising. As the disease progresses,the goal of treatment is relieving stress on family caregivers.Cognitive–behavioral strategies play an important part inhelping caregivers manage stressors more effectively, and in examining their role and involvement in providing care.

See also: Depression and personality disorders—older adults,Family caregivers

REFERENCES

Clare, L. (2002). We’ll fight it as long as we can: Coping with the onset ofAlzheimer’s disease. Aging and Mental Health, 6, 139–148.

Feinberg, L. F., & Whitlatch, C. J. (2001). Are cognitively impaired adultsable to state consistent choices? The Gerontologist, 41, 374–382.

Kuhn, D. R. (1998). Caring for relatives with early stage Alzheimer’s dis-ease: An exploratory study. American Journal of Alzheimer’s Disease,13, 189–196.

Marriott, A., Donaldson, C., Terrier, N., & Burns, A. (2000). Effectivenessof cognitive–behavioural family intervention in reducing the burden ofcare in carers of patients with Alzheimer’s disease. British Journal ofPsychiatry, 176, 557–562.

Mendez, M. F., & Cummings, J. L. (2003). Dementia: A clinical approach(3rd ed.). Woburn, MA: Butterworth–Heinemann.

Mittelman, M. S., Ferris, S. H., Shulman, E., Steinberg, G., Ambinder, A.,Mackel, J., & Cohen, J. (1995). A comprehensive support program:Effect on depression in spouse-caregivers of AD patients. The Gerontologist, 35, 792–802.

Moniz-Cook, E., Agar, S., Gibson, G., Win, T., & Wang, M. (1998). A pre-liminary study of the effects of early intervention with people withdementia and their families in a memory clinic. Aging and MentalHealth, 2, 199–211.

Teri, L., Logsdon, R. G., Uomoto, J., & McCurry, S. M. (1997). Behavioraltreatment of depression in dementia patients: A controlled clinicaltrial. Journals of Gerontology Series B: Psychological Sciences andSocial Sciences, 52B, P159–P166.

Whall, A. L., & Kolanowski, A. M. (2004). The need-driven dementia-compromised behavior (NDB) model: A framework for understandingthe behavioural symptoms of dementia. Aging and Mental Health,8(2), 106–108.

Whitlatch, C. J. (2001). Including the person with dementia in family caregiving research and practice. Aging and Mental Health, 5,Supplement, 72–74.

Yale, R. (1989). Support groups for newly-diagnosed Alzheimer’s clients.Clinical Gerontologist, 8, 86–89.

Yale, R. (1999). Support groups and other services for individuals withearly-stage Alzheimer’s disease. Generations, 23(Fall), 57–61.

Zarit, S. H., Stephens, M. A. P., Townsend, A., & Greene, R. (1998). Stressreduction for family caregivers: Effects of day care use. Journal ofGerontology: Social Sciences, 53B, S267–S277.

Zarit, S. H., Femia, E. F., Watson, J., Rice-Oeschger, L. & Kakos, B. (2004).Memory club: A group intervention for people with early-stage demen-tia and their care partners. The Gerontologist, 44(2), 262–270.

Zarit, S. H., & Whitlatch, C. (1992). Institutional placement: Phases of thetransition. The Gerontologist, 32, 665–672.

Zarit, S. H., & Zarit, J. M. (1998). Mental disorders in older adults:Fundamentals of assessment and treatment. New York: Guilford Press.

Zimmerman, S. I., & Sloane, P. D. (1999). Optimum residential care for people with dementia. Generations, 23(3), 62–68.

Anger—Adult

Christine Bowman Edmondson and DanielJoseph CahillKeywords: anger disorders, anger attacks, irritable depression, inter-mittent explosive disorder

COGNITIVE–BEHAVIORAL TREATMENT FOR ANGER

This article describes cognitive–behavioral therapyinterventions for anger in adult outpatient populations. Thus,it will not address interventions for reducing anger identifiedas being for children or adolescents. Readers interested incognitive–behavioral interventions for oppositional defiantdisorder, conduct disorder, or personality disorders arereferred to the relevant articles in the present volume.

This article may have some relevance for populationsthat include individuals with personality disorders, perpetra-tors of domestic violence, and prisoners insofar as indi-viduals from these populations have difficulties with anger.However, it should not be assumed that all individuals inthese populations have difficulties with anger. Therefore,this article mainly focuses on populations in which the cog-nitive, behavioral, physiological, and experiential aspects ofanger are problematic rather than on populations in whichthere are anger outbursts that are the manifestation of moregeneralized difficulties with cognitive and behavioral func-tioning. To facilitate the identification of individuals forwhich these interventions are appropriate, there is a sectiondescribing various types of anger disorders prior to thedescription of cognitive–behavioral interventions for anger.

ANGER DISORDERS

Anger is a common focus of treatment in a variety ofhealth and mental health treatment settings. An “anger dis-order” can be described as a symptom pattern consisting ofthe presence of anger attacks and/or irritability without thepresence of another mood or anxiety disorder. An “angerattack” has been described by researchers (Fava &Rosenbaum, 1999) as sudden episodes of anger character-ized by intense physiological reactions that are inappropri-ate to the situation and uncharacteristic of the personundergoing the attack. “Irritable depression” is a syndromecharacterized by the presence of an irritable mood for 5 daysor longer in conjunction with a decreased interest in regular

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Anger—Adult

activities and a number of the cognitive and vegetativesymptoms of depression (WHO, 2002).

Intermittent Explosive Disorder (IED) is often cited asa possible Diagnostic and Statistical Manual of MentalDisorders (DSM; American Psychiatric Association, 1994)diagnostic category for individuals with anger problems.However, IED criteria are delineated on the basis of its beingan impulse control disorder rather than an emotional disor-der. The WorlOverview, analysis, and evaluationcollect epi-demiological data on IED and another anger-relateddisorder referred to as “irritable depression.” This researchis an important step in operationally defining anger disor-ders in the DSM.

Other anger disorders have been proposed by Eckhardtand Deffenbacher (1995): General Anger Disorder(GAngD) and Specific Anger Disorder–Driving Situations.GAngD is characterized by experiencing anger daily orbeing in a chronically angry mood. In addition, people withGAngD are likely to be verbally aggressive and/or destroyobjects. Eckhardt and Deffenbacher (1995) proposed thatGangD has two subtypes: with physical aggression and with-out physical aggression. They emphasized that while peoplewith GAngD without aggression may engage in aggressionon occasion, it does not have the severity (i.e., sarcasm, loudarguments, and/or physical aggression) or frequency to meetthe criteria of GAngD with aggression.

Eckhardt and Deffenbacher (1995) also suggested thatthere were “Specific Anger Disorders,” in which anger isconfined to a circumscribed set of situations. Deffenbacher,Filetti, Lynch, Dahlen, and Oetting (2002) described the characteristics of high-anger drivers, which could bedescribed as having “Specific Anger Disorder–DrivingSituations.” Their research suggested that high-anger driversare at risk of injury and death resulting from aggressivebehavior associated with anger while driving. They alsoprovide data on the efficacy of relaxation interventions forhigh-anger drivers.

Currently, there are no published studies that investi-gate the efficacy of cognitive–behavioral treatment for IEDor irritable depression. Instead, studies of treatment for syn-dromes associated with these disorders (i.e., anger attacks)use primarily psychopharmacological interventions (Fava &Rosenbaum, 1999). It is likely that cognitive–behavioraltherapy in combination with psychopharmacological inter-ventions would maximize treatment efficacy for these disor-ders. Thus, cognitive–behavioral therapies that aredeveloped for these disorders should include componentsthat explore the use of medication and enhance compliancewith medication regimens. There is a body of literature thatprovides empirical support for cognitive and behavioraltherapies for anger defined in a manner that is similar toGAngD (Deffenbacher, Oetting, & DiGiuseppe, 2002).

Although IED, irritable depression, GAngD, and spe-cific anger disorder–driving anger disorders are promisingoperational definitions of anger disorders, anger problems,such as irritable mood (i.e., frequent and intense anger) andanger outbursts, can still be identified as targets of change in cognitive and behavioral therapy. Irritable mood and/oranger outbursts co-occur with important psychiatric syn-dromes such as depression (Haaga, 1999), posttraumaticstress disorder (Novaco & Chemtob, 1998), and substanceabuse (Awalt, Reilly, & Shopshire, 1997). The type of angerproblem that is the focus of treatment (i.e., an anger disorderversus irritable mood versus anger outbursts) and the comor-bidity of anger problems and other psychiatric syndromes allneed to be considered when using cognitive–behavioral ther-apy interventions to address anger problems.

Cognitive–behavioral interventions for anger are gener-ally effective across different populations; however, researchis lacking that addresses issues of relative efficacy, causalmechanisms of treatment, and the specificity of treatment fordifferent types of populations (Deffenbacher, Oetting, &DiGiuseppe, 2002). It is likely that more advances in the cognitive–behavioral treatment of anger will occur whencommonly accepted definitions of anger disorders are used toidentify participants for treatment outcome studies. Also, thedefinition and delineation of anger disorders would facilitatethe understanding of the cognitive and behavioral processesthat contribute to irritable mood and/or anger outbursts thatare associated with clinically significant distress and inter-ference with social and occupational functioning.

COGNITIVE–BEHAVIORAL THERAPY INTERVENTIONSFOR ANGER PROBLEMS

Deffenbacher (1999) suggests that the first goal oftreatment should be to establish good rapport. Good rapportprovides a foundation of trust that is essential for the successof treatment. In addition, Deffenbacher describes why it isimportant to build a common understanding of the present-ing problem and to reach agreement as to what the goals oftherapy should be for angry clients. Basic counseling skillssuch as empathy and positive regard are important for build-ing this rapport. In addition, self-monitoring can be useful innegotiating shared expectations for the therapy process and goals. Self-monitoring can also be a part of a “safety plan” or no-violence contract. Self-monitoringencourages clients to take an active role in their changeprocess. It enhances self-awareness of the intensity of irrita-ble moods and anger, which is important in avoiding aggres-sive behavior. It also provides the therapist with relevantexamples to use when highlighting important issues thatform the basis of negotiating a shared understanding of the

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problem and an agreement for treatment procedures andgoals. Self-monitoring is often used in conjunction with tech-niques such as relaxation training, cognitive restructuring,problem solving, and social skills training in order to trackprogress in using new skills outside of therapy sessions.

Relaxation training teaches clients to monitor levels of arousal and to use a variety of methods for loweringarousal in order to increase their ability to cope physio-logically or emotionally during anger-provoking situations(Deffenbacher, 1999). Two useful interventions are auto-genic relaxation training and progressive muscle relaxation.Autogenic relaxation training is useful when a quick andeasy method for achieving relaxation is needed. However,progressive muscle relation may be more helpful whenclients are not aware of their general level of physiologicalarousal and cues for anger outbursts. Relaxation training isa basic component of the stress inoculation protocols thathave demonstrated therapeutic efficacy for anger problems.

Cognitive restructuring is a method of identifying mal-adaptive thoughts, beliefs, or attributions that lead to angeroutbursts and learning appropriate responses. It is importantto help angry clients accept the rationale for changing theirthoughts (i.e., that thoughts influence feelings and the prob-lematic behaviors associated with them) and to convinceangry clients that they have a choice in how they decide tointerpret anger-provoking situations. Once the client acceptsthis rationale, techniques of rational emotive behavior ther-apy or cognitive therapy can be used to restructure problem-atic thinking. The inductive nature of cognitive therapytechniques may be more acceptable to some types of angryclients and may be a better technique if an angry individualis struggling with the rationale for cognitive restructuring.

Some angry clients may benefit from imaginal methodsfor cognitive restructuring more so than the verbal methodsthat comprise cognitive therapy and rational emotive behav-ior therapy. Deffenbacher (1999) describes how imagining a visual image of an anger-provoking agent literally as a“jackass” could be effective in humorously restructuring anangry person’s beliefs about another person who may be thesource of ongoing anger provocations.

Although self-instructions and affirmations of copingskills are not techniques of cognitive restructuring, they areimportant aspects of self-talk that should be increased asproblematic cognitions are decreased as a result of cognitiverestructuring. They are also important components of stressinoculation and problem-solving interventions for anger.

The efficacy of problem solving training has also beenevaluated in angry individuals. The structured nature of thisintervention is helpful in encouraging angry clients to stopand think about their response options before responding toanger provocation. Angry clients could particularly benefitfrom systematically determining whether it is best to respond

to their emotional reaction to a provocation versus the situa-tion that caused the provocation to occur. Then, the disciplineof systematically brainstorming response options and evalu-ating them will be most likely to encourage the selection ofthe most effective and appropriate response.

Social skills training has also received empirical sup-port for the treatment of anger problems. In these studies,the social skills training tends to focus on global social skillssuch as listening, assertive self-expression, and negotiatingresolutions to conflicts. However, angry individuals mayalso benefit from modifying microbehavioral aspects oftheir social interactions such as facial expressions, vocalintonation, voice volume, body postures, and gestures. Otherinterventions designed to enhance social functioning mayalso be needed for angry clients to repair the damage theiranger has done to their social functioning.

INNOVATIONS AND FUTURE DIRECTIONS

Exposure Techniques for Anger Problems

Exposure techniques have been applied to the reductionof anger. Imaginal exposure techniques may be moreamenable to practice settings than in vivo exposure tech-niques. Imaginal exposure involves the construction ofanger-inducing scenarios in order to inoculate against real-life situations. Grodnitzky and Tafrate (2000) provide adescription of clinical procedures utilizing imaginal expo-sure to reduce anger in adults.

Research on Cognitive and Behavioral Processes inIrritable Mood and Anger Attacks

It is important to conduct research designed to identifythe differential cognitive and behavioral deficits associatedwith irritable moods and anger attacks. Research on cogni-tive– behavioral therapeutic efficacy has outpaced efforts inthis realm. The benefits of identifying cognitive and behav-ioral processes unique to different anxiety disorders haveresulted in significant advances in their treatment of thesedisorders. Similar advances could be experienced in therealm of anger disorders.

Innovations in Cognitive–Behavioral Therapy of Anger Disorders

Practitioners and researchers interested in treatmentinnovations could contribute to advances incognitive–behavioral therapy for anger disorders by furtherdeveloping exposure techniques for anger problems. Inaddition, cognitive restructuring for anger problems wouldbe enhanced by innovations that use symbolic methods such

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Anger Control Problems

as visual imagery and metaphors to assist with the restructur-ing of irrational beliefs or dysfunctional schemas associatedwith anger. Social skills interventions would benefit from thedevelopment of more systematic approaches to modulatingnonverbal and paralinguistic behaviors in individuals withanger problems.

Finally, advances in cognitive neuroscience are con-tributing to the development of a better understanding of therole of biological factors in a variety of behavioral disorders,including anger problems. These advances neither mandatethe use of pharmacological interventions nor preclude theuse of cognitive–behavioral therapy. However, they do indi-cate that some people with anger problems may benefit frompharmacological interventions. Cognitive–behavioral thera-pists have developed treatment protocols that are designedto facilitate compliance with pharmacological interventionand/or the termination of pharmacological intervention inmood disorders and anxiety disorders. Cognitive–behavioraltherapists interested in anger disorders would do well to alsoinnovate in this area.

See also: Adolescent aggression and anger management, Angercontrol problems, Anger management therapy with adolescents,Disruptive anger

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Awalt, R. M., Reilly, P. M., & Shopshire, M. S. (1997). The angry patient:An intervention for managing anger in substance abuse treatment.Journal of Psychoactive Drugs, 29, 353–358.

Deffenbacher, J. L. (1999). Cognitive–behavioral conceptualization andtreatment of anger. Journal of Clinical Psychology, 55, 295–309.

Deffenbacher, J. L., Filetti, L. B., Lynch, R. S., Dahlen, E. R., & Oetting, E.R. (2002). Cognitive–behavioral treatment of high anger drivers.Behaviour Research and Therapy, 40, 895–910.

Deffenbacher, J. L., Oetting, E. R., & DiGiuseppe, R. A. (2002). Principlesof empirically supported interventions applied to anger management.Counseling Psychologist, 30, 262–280.

Eckhardt, C. I., & Deffenbacher, J. L. (1995). Diagnosis of anger disorders.In H. Kassinove (Ed.), Anger disorders (pp. 27–47). Bristol, PA:Taylor & Francis.

Fava, M., & Rosenbaum, J. F. (1999). Anger attacks in patients with depression. Journal of Clinical Psychiatry, 60, 21–24.

Grodnitzky, G. R., & Tafrate, R. C. (2000). Imaginal exposure for angerreduction in adult outpatients: A pilot study. Journal of BehaviourTherapy and Experimental Psychiatry, 31, 259–279.

Haaga, D. A. (1999). Treating options for depression and anger. Cognitiveand Behavioral Practice, 6, 289–292.

Novaco, R. W., & Chemtob, C. M. (1998). Anger and trauma:Conceptualization, assessment and treatment. In V. M. Follette & J. I. Ruzek (Eds.), Cognitive–behavioral therapies for trauma.New York: Guilford Press.

World Health Organization. (2002). Composite International DiagnosticInterview reference and training manual. Geneva: Author.

RECOMMENDED READINGS

Cognitive Behavioral Case Conference section of Cognitive and BehavioralPractice, 6, 271–292.

Deffenbacher, J. L. (1999). Cognitive–behavioral conceptualization andtreatment of anger. Journal of Clinical Psychology, 55, 295–309.

Anger Control Problems

Donald MeichenbaumKeywords: anger, exposure-based therapies, self-instructional train-ing, self-monitoring procedures, stress inoculation training

Anger-control problems are an often-overlooked disorderand they have received limited attention in the treatment literature. An examination of the American PsychiatricAssociation DSM-IV reveals nine diagnostic categories forAnxiety Disorders and ten diagnostic categories ofDepressive Disorders, but only three diagnostic categoriesfor anger-related problems, namely, Intermittent ExplosiveDisorders, and two Adjustment Disorders with Conduct-Disorder features. The dearth of research on anger is furtherhighlighted by DiGiuseppe and Tafrate (2001) who notedthat for every article on anger over the past 15 years, thereare ten articles in the area of depression and seven articles inthe area of anxiety. The absence of research activity onanger is somewhat surprising given that anger-relatedbehaviors are one of the most common psychiatric symp-toms that cut across some 19 different psychiatric condi-tions. Anger, hostility, and accompanying violence are oftencomorbid with other disorders. For example, veterans withPTSD have been found to be at increased risk for domesticabuse with as many as one-third of combat veterans withPTSD having assaulted their partners in the past year.Vietnam veterans with PTSD are six times more likely toabuse drugs compared to Vietnam veterans without PTSD,with anger being a significant relapse cue for substanceabuse. PTSD, substance abuse, mood disorders, anger, andaccompanying hostility and aggression go hand in hand andprovide clinicians with major challenges.

Besides the challenge of comorbidity, Novaco (1996)has highlighted several additional challenges to the treat-ment of patients with anger and aggressive behaviors. Thesechallenges include:

1. Angry patients may become angry during therapyand direct their aggression toward their therapist.

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