In my PT blog I have been posting numerous examples of murderously violent behavior perpetrated by pathologically angry individuals, usually men, including the Columbine High School shootings, Virginia Tech, as well as some more recent savage massacres in Los Angeles, Germany, Florida and Alabama to mention but a few. (See) Last week, in North Carolina, Robert Stewart opened fire at a nursing home, killing seven very elderly residents and a nurse. Police speculated that the forty-five-year-old Stewart, who did not commit suicide and is currently in custody, targeted the facility because his estranged wife once worked there. And just today, a forty-two-year-old gunman with a high-powered rifle killed thirteen victims, critically wounded four, and took at least forty-one people hostage in Binghamton, New York before finally shooting himself. Curiously, despite the clearly raging epidemic of anger-fueled violence in America and abroad, the almost one-thousand pages of the American Psychiatric Association's official diagnostic manual, the DSM-IV-TR, contain only a handful of diagnoses capable of accurately addressing this disturbing and growing phenomenon. This is a serious omission, demanding immediate attention.
The most commonly used psychiatric diagnoses for aggressive, angry or violent behavior are Oppositional Defiant Disorder, Attention-Deficit/Hyperactivity Disorder and Conduct Disorder (in children and adolescents), Psychotic Disorder, Bipolar Disorder, Antisocial, Borderline, Paranoid and Narcissistic Personality Disorder, Adjustment Disorder with Disturbance of Conduct, and Intermittent Explosive Disorder. This latter diagnosis is an impulse control disorder characterized by repeated "failure to resist aggressive impulses that result in serious assaultive acts or destruction of property." Of all the diagnoses, this one comes closest to accurately describing the escalating explosions of violence we are witnessing today. It is a classic anger disorder. According to a recent study by sociologist Ronald Kessler at Harvard Medical School, this anger disorder is on the rise, and may be present in more than fifteen million Americans. And this is only the proverbial tip of the iceberg.
By definition, in Intermittent Explosive Disorder, "the degree of aggressiveness expressed during an episode is grossly out of proportion to any provocation or precipitating psychosocial stressor." This is precisely the case in so many of the mass shootings in recent years. But a difference is that some reportedly have no prior history of aggressive episodes. Typically the perpetrator, often described by friends, family and co-workers as passive, polite and quiet, is triggered by some insult, rejection or stressful event, running amok (see my) on a vengeful rampage to restore honor or repay the injury to his fragile ego. Some cynically and nihilistically seek recognition, attention, infamy. But, in any case, their violence is a gross overreaction, a devastating nuclear detonation of pent-up aggression, anger and rage. Why?
I believe we are seeing a similar pattern in most of the other diagnoses traditionally applied to such angry, aggressive, violent individuals. Oppositional and Conduct Disorder are manifestations of underlying rage. The depressed, irritable mood and often furious manic behavior of Bipolar Disorder have deep roots in unconscious anger and resentment, as do the hostility, temper tantrums, rage and aggressive acting out in Antisocial, Borderline and Narcissistic Personality Disorder. Indeed, I tend to consider all these diagnoses variations of anger disorder, and believe it is crucial to explicitly recognize them as such.