It was a familiar scene in my office, where I practice as a clinical psychiatrist. The well-dressed woman sat across from me with a worried furrow between her brows.
“Doctor, my husband and children say I get too angry," she said. "I have trouble controlling my temper. Do you think I have bipolar disorder?”
After a thorough evaluation, I concluded that my patient’s verbal outbursts and tendency to throw dishes didn't stem from a severe mood disorder, but from uncontrollable anxiety. My patient was surprised. Perhaps you are, too.
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Anxiety has soared since the onset of the COVID-19 pandemic, with at least 40 million U.S. adults currently affected by at least one anxiety disorder, according to the Anxiety and Depression Association of America. As such, it's more important than ever to recognize possible consequences of these issues, and the possible causes behind them. One of the most misunderstood relationships is between anxiety and angry outbursts.
Understanding Anxiety Disorders
Anxiety disorders come in different shapes and sizes. Nonetheless, all of the examples below can produce enough fear and angst to interfere with the sufferer’s daily quality of life.
Social anxiety disorder, sometimes called SAD, refers to fear of negative evaluation by others in social or performance situations.
Obsessive-compulsive disorder, or OCD, features debilitating thoughts “running in a loop” that lead to unwanted repetitive actions.
Generalized anxiety disorder is the tendency to worry uncontrollably about usual and common life circumstances.
Panic disorder is felt in the body with symptoms like shortness of breath and a fast heartbeat.
When Anxiety Leads to Anger
It’s tempting to think of anxiety and anger as the opposite ends of a spectrum — that is, people who are fearful are anything but aggressive. But having an anxiety problem can actually increase the likelihood of angry outbursts. Both anger and anxiety involve some sort of emotional dysregulation and a perceived threat, according to psychiatrist Franklin Schneier, co-director of the Anxiety Disorders Clinic at New York State Psychiatric Institute.
That threat activates a part of the brain called the amygdala, which serves as a center that processes both fearful and threatening stimuli. The result? “It’s the classic fight or flight dilemma,” says Schneier.
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It seems logical that those with anxiety disorders would choose “flight,” or avoidance of the threatening situation. But this isn’t always the case. The presence of a threat is just as likely to produce irritability — or aggression. In fact, the bond between anxiety and anger can be so tight that it feels fitting to call the combination “anxry,” like the informal word “hangry” used for anger as a result of being hungry.
But while fear and anger can be closely related, they are not the same emotion. Although anger can sometimes lead to anxiety, our focus here is on the opposite, where fear is the underlying emotion and aggression is the behavior.
Why Anxiety Can Lead to Anger
Research backs up the claim that anxiety can lead to anger. Jesse Cougle, a professor of psychology at Florida State University, and his team studied the frequency of aggression across several different anxiety disorders, according to research published in the journal Depression and Anxiety. The researchers found elevated anger levels across all anxiety disorders.
There are several possible reasons for this link. For one, the very experience of anxiety is a type of emotional arousal that can be distressing. In other words, people with anxiety might have a tendency to overreact in general.
“When someone cuts them off in traffic or when there’s a perceived slight or an inconvenience — these can lead to anger because they’re already in a distressed and aroused state,” says Cougle.
Another possible cause might include the temptation to push aside the anxious feelings. “When you avoid feelings you don’t deal with them so well. Just avoiding anxiety — not acknowledging it because it’s too scary — can result in the anger building up until it’s uncontrollable and it explodes,” says Schneier.
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Take social anxiety. Those with SAD tend to avoid conflict and might go out of their way to appease others. But they also expect others to act in a negative way towards them. Feelings of rejection can lead to irritability or behaviors that are aggressive — the exact opposite of the timidity that one might expect of someone with social anxiety. For example, if you put a socially anxious teen in a setting where they can’t judge another’s intentions — like a high school dance — and when the teen returns home she lashes out at her parents for forcing her to go.
Another overlooked link between anxiety and anger involves lack of sleep. People with anxiety disorders have difficulty falling and staying asleep. Overtime, this pent up fatigue can lead to an irritable outburst.
How to Treat Anxiety and Anger
A 2021 study from researchers at Florida State University showed that reducing anxiety can have a beneficial effect on anger reduction. But which types of treatments work best?
One first line of defense is to be aware of negative emotions. It’s important for the “anxry” sufferer to be aware of their thoughts — particularly spiraling, catastrophic thoughts. This is where cognitive-behavioral therapy (CBT) comes in. The therapist can help the patient view thoughts differently and adjust their behavior.
“CBT approaches are useful for self-monitoring of anxious and angry thoughts and impulses," says Schneier. "[It's about] using the anger as information to either address the underlying conflict or calm oneself so it doesn’t get out of hand."
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Because people with “anxry” are more likely to drop out of treatment than those with anxiety alone, in some cases treatment should target both halves of the equation.
“We have treatments that are not focused on a single diagnosis. [...] They are trying to reduce things like ‘negative affectivity,’ a broad construct that both anger and anxiety have in common,” adds Cougle.
“Mindful emotional awareness” (or, simply, the practice of mindfulness) is one of these therapies. This refers to the ability to feel the first signs of anger or anxiety in our body, and accept those feelings without judgement.
Of course anger is associated with many other disorders including depression, bipolar disorder and borderline personality disorder, to name a few. Teasing out underlying anxiety can be difficult — both for the sufferer caught in the heat of the moment, and for their loved ones. The consequences of “anxry” are often frightening, so seeking professional diagnosis and treatment can bring much needed relief.