Everyone experiences feelings of anger or irritability, but people with bipolar disorder are especially prone to these feelings and the adverse effects of anger. In fact, sudden feelings of anger or irritability are key symptoms of mania. Inappropriate anger attacks occur in up to 60 percent of people with bipolar disorder (Mammen et al. 2004). Moreover, up to 40 percent of people with bipolar disorder reported feelings of abnormal irritability, which is defined as feelings of excitability or annoyance (Deckersbach et al. 2004). However, anger and irritability can also be part of depression, and sometimes the most prominent aspect of depression, at least as experienced by the people around someone with bipolar disorder.

When you live with bipolar disorder yourself, you know the experience when your mood shifts and disrupts your normal life activities. These swings may be mild or severe, but for many people, the symptoms of mania may include excessive irritation or aggressive behavior, and depressive symptoms can include irritability, agitation, and anger. Also, during manic or depressive episodes, you may have developed negative thought patterns and beliefs that everything is bad. This habit of viewing things negatively may predispose you to becoming angry more easily than at times when you can see the world from a positive perspective.

Anger is natural and even a necessary emotion for survival, but it can be destructive when expressed inappropriately. Like an alarm, anger tells you something is wrong with a situation. In general, what causes anger?
* Stress—when faced with health, money, work, or personal problems
* Life events—when remembering bad things that have happened to you
* Frustration—when not in control of a situation or when overwhelmed by tasks
* Fear—when feeling that a relationship or a job may not work out
* Resentment—when feeling hurt, rejected, or oppressed
* Disappointment—when expectations aren’t met

Anger has three components that can be described as psychological, biological or physiological, and cognitive (Mayo Clinic 2007):
* Psychological anger refers to your feelings, which can vary in intensity from mild frustration and disappointment to sadness to intense rage.
* Biological or physiological anger refers to the body’s responses, when your heart rate or blood pressure rises or your muscles tense.
* Cognitive anger refers to your thoughts while you’re angry, such as believing that you’re justified to be angry or thinking that no one listens to you.

It is important to be aware of your feelings of anger and to identify when expressions of anger are unhealthy. Have you ever slammed your office door when you were frustrated at work? Have you ever yelled at the clerk in a store or a pharmacist on the phone when the person couldn’t help you fast enough? These ways of managing anger are not only ineffective, but may also lead to personal or legal problems. Anyone’s past life history can contribute to the way they react or overreact to situations. For instance, people who have been ridiculed, neglected, or victimized in the past may have built up negative feelings over time based on these events. Sometimes it is not the person or the event in the present that makes you feel angry, but it’s your way of thinking—based on your past personal experiences—that creates these angry feelings. By becoming aware of and avoiding potential triggers, you are less likely to experience the intensity of the conflict.

There are triggers that automatically spark certain symptoms of mania, but they also exist for anger and irritability, whether or not you have manic symptoms. Triggers for anger can lead to anger, and an angry response can lead to the other person’s angry response, which can itself be a new trigger and can escalate a situation quickly. Often this scenario involves circumstances where you believe you’ve been treated unfairly or your expectations have not been met.

Some people can tolerate more stress, frustration, and disappointment than others. The same situations, conflicts, or events may trigger anger for you and not for someone else. There are many different ways to express anger when you feel the intensity of the emotion. By reflecting on how you express your anger, you can determine whether you need to learn new skills to respond in healthier ways.

If you have been wronged, it is natural to feel angry. But how you express these feelings through words, gestures, or actions can be problematic due to the intensity of the anger emotion. It’s important to manage your reaction in a constructive, controlled way.
There are three basic ways to handle anger: controlled expression, suppression, and calming strategies (Mayo Clinic 2007).

Expressing Anger in a Controlled Manner
Verbalizing feelings using an assertive, reasonable tone of voice is, in the long run, typically more helpful to your efforts to achieve your life goals than outbursts or violence (though outbursts may feel better at the time!). Being assertive means that you clearly state your needs without hurting or overpowering others.

Suppressing Anger
Holding in your anger or stopping yourself from thinking about it can be a healthy reaction when you convert the energy to a positive, constructive behavior. The key is to make sure that you find a way to calm yourself or a healthy way to express your feelings that doesn’t lead to just suppressing the anger you have. It is also important to be careful not to turn the anger inward or plot schemes to retaliate. The danger is that anger turned inward can lead to sleep problems, high blood pressure, tension headaches, and increased depression.

Calming Strategies
Controlling your outward behavior and your internal responses to the anger can allow you to calm yourself and let the angry feelings fade away. Relaxation or visualization techniques such as counting to ten, meditation, breathing exercises, or even exercising can help ease your physical responses and help you focus on something positive.

In managing anger, the goal is to develop and strengthen your observing self, which allows you to make choices in your own long-term best interest, like you did in module 13 on psychosis. When thinking about managing anger, there are several approaches that can assist you. Here are the three Rs of anger control: retreat, rethink, and respond (Jacobs 1994).

Step back from a heated discussion and take a break, a time-out, or a breather, rather than jumping in and expressing the first thing that pops into your head. Learning skills to relax, such as meditation, breathing exercises, or exercise, and scheduling personal retreats, even during your lunch break, may help you control your temper.

Slow down and calm your racing thoughts and take your time to think about what’s happening before you respond. You will be more effective in resolving the conflict if you get in touch with your feelings, listen carefully to what others are saying, and try to brainstorm possible solutions to the issues.

When you’re feeling calmer, concentrate on using slower speech and a calm tone of voice that is not defensive or judgmental or insulting. Using silly humor, not sarcasm, can defuse the tension. Some people find it’s helpful to write a script and rehearse it in private in order to stick to the main concerns.
Remember to use “I” statements when describing the problem to avoid criticizing or placing blame. For instance, say, “I’m unhappy that you didn’t come home earlier,” rather than, “You should have been home earlier.” Talking to a person you can trust with your feelings, a friend or a therapist, can help you express your anger, especially when you cannot feel calm enough to talk directly to the person who angered you.

So often our bodies hold the tension that anger produces. You can convert the energy and release the tension through physical activity. Taking a walk or playing any sport (hitting a ball, shooting baskets, throwing a Frisbee) can redirect the energy in a healthy way. If you are in a location where you don’t have this opportunity, you could write your feelings in a journal, listen to music, or focus your thoughts on calmer, more positive times. This is also a good opportunity to use some of your “Zen monk” techniques (exercises 13.3 and 13.4).
It may seem the most difficult idea to accept, but forgiving the person you’re angry with and not holding a grudge against him or her for words or actions will help you to heal. This allows you to take control of the issue at hand for the long run and not have it control and consume you.


Excerpt from OVERCOMING BIPOLAR DISORDER: A Comprehensive Workbook for Managing Your Symptoms & Achieving Your Life Goals (New Harbinger Publications)

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