Kassinove and Tafrate (2002) developed a five-stage anger episode model to guide treatment (Figure 1). They recommend that the model be used as a reference point for joint practitioner-patient understanding of anger as well as an idiographic assessment strategy. Elements of the model have been validated by Kassinove, Sukhodolsky, Tsytsarev, and Solovyova (1997) and Tafrate, Kassinove, and Dundin (2002).
Triggers. Each episode begins with a triggering event. These triggers are usually unwanted behaviors of persons who are well-known or loved and are most likely to occur at home in the afternoon or evening hours. By objective standards, the triggers are usually negative and may consist of insults, neglect by loved ones, unfair treatment, and the like. Some triggers, however, are objectively neutral or may even be positive, as when unwanted compliments are repeatedly received from disliked persons. If fact, almost any stimulus can be a trigger for anger.
Appraisals. Aversive triggers lead to a general state of arousal (Berkowitz, 1990, 1993). In order for the arousal to then emerge as "anger," the triggers must be appraised or interpreted in specific ways. Tafrate, Kassinove, and Dundin (in press), using a community sample, found that adults high on the trait of anger endorsed a greater number of dysfunctional cognitions than did low-trait-anger adults and were particularly prone to believe that the triggering events for their anger were "awful" (as opposed to simply very bad) and "intolerable" (as opposed to difficult to manage), to engage in distortions, and to believe they were bad people (see Beck, 1999; Ellis, 1994). In addition, the angry person may believe that he or she does not have the skill to deal with the instigator. This conclusion, of course, may or may not correspond to reality.
The combination of triggers and appraisals leads to anger as a specific emotional response. The internal, private part of the response is the anger experience. The external, public part of the response represents the expression of anger.
Experiences. Private experiences may consist of thoughts about the importance of retaliation, images of harming others, or physiological arousal unseen by others. Adults high on the trait of anger seem to experience anger episodes of greater intensity and longer duration than do low-trait-anger adults. The most common physical sensations associated with anger are muscle tension, rapid heart rate, headache, and upset stomach.
Expressions. Study of the expressive behaviors associated with anger leads to some surprising conclusions. For example, aggression is not commonly reported by nonspecific samples of angry adults. The most common expressive pattern is verbal and consists of shouting, demanding, use of sarcasm, and profanity. Physical aggression is typically reported to occur only about 10% of the time. However, aggression is more common among high-trait-anger adults and is likely to be more prominent in selected samples (e.g.,
clients in criminal justice settings, schools for disturbed children). Differences in expressive patterns between men and women are minor.
Outcomes. Anger becomes a clinical problem when the outcomes are more negative than positive. Outcomes can be interpersonal, emotional, cognitive, and medical. At the interpersonal level, relationships are likely to be weakened following an anger episode as less time is spent with the person viewed as the instigator Also, angry people are avoided by others. This leads to additional problems such as job dissatisfaction, greater likelihood of disagreements at work, and more conflict with friends and romantic partners. Anger is also likely to be followed by other negative emotions such as continued irritation, sadness-depression, disgust, concern, and guilt. These are especially likely to emerge for persons high in trait anger. It is also important to note that some positive feelings may also emerge including a feeling of relief and satisfaction. Some people do report that their anger serves them well. Nevertheless, for high-trait-anger adults, short- and long-term outcomes of anger are twice as likely to be negative rather than positive.
Cognitively, anger is associated with rumination about the trigger. This rumination is likely to increase the intensity and duration of the episode, and sets the stage for additional anger as a negative distorting filter likely to be applied to further actions by the trigger. Angry adults who are high on trait anger also report more mental health problems such as depression, anxiety, panic attacks, substance use, and marital problems, all of which have strong cognitive elements.
The medical problems associated with anger are particularly problematic since they often are not linked to anger episodes by patients. Outcomes linked to a stimulus are likely to be those that are close in time. Thus, patients are most likely to see the interpersonal costs of anger. In contrast, many medical anger outcomes are like those associated with cigarette smoking—they do not appear for years. Nevertheless, the data show that longer term, persistent anger is associated with hypertension, stroke, myocardial infarction, and cancer. For example, Williams and her associates (2000) completed a large-scale prospective study of the relationship of trait anger to cardiovascular heart disease (CHD). Middle-aged men and women (n = 12,986), initially free of coronary disease, were followed for a mean of 53 months. Results indicated that among adults with normal blood pressure, the risk of coronary events increased directly with increasing levels of trait anger. High-anger adults were 2.6
times more likely to have a cardiac event than low-anger adults. The risk posed by high trait anger was found to be independent of other established biological risk factors. These and other data strongly suggest the importance of treating high-trait-anger persons.
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