Helping the Angry Patient

High degrees of psychological and physical comorbidity complicate recovery from eating disorders .Co-occurring factors may include diagnosable disorders, or individual psychological traits. Spanish clinicians have found that anger is a highly comorbid factor in patients with eating disorders.

Dr. Eva Saldana and colleagues designed a study to analyze general levels of anger among three groups of patients with eating disorders (Actas Exp Psiquiatr 2014; 423:228). The authors note that in studies evaluating the mode of expression of anger in patients with eating disorders, there has usually been a clear difference between patients with restrictive-type AN (AN-R), who often internalize the expression of anger; in comparison, those with purging-type AN and bulimia nervosa (BN) would be viewed by some as expressing anger via binge eating and purging.

The study population included 58 adult women hospitalized in the Eating Disorders Unit of the Reina Sofia General Hospital of Murcia, Alicante, Spain. The patients were diagnosed with AN, BN, or eating disorders not otherwise specified (EDNOS). The authors found that 27.58% of the women had AN-R; 15.50% had purging-type AN, 41.37% had BN, and 15.51% had EDNOS. Anxiety and anger were assessed with the State-Trait Anxiety Inventory-2, and the eating disorders were analyzed with the Eating Disorders Inventory 3. More than a third of the patients had malnutrition: 21% had serious malnutrition, 27% had moderate malnutrition, and 17% had normal BMIs. The results were compared with those normative population provided by the questionnaire.

Patients had higher anger scores than did controls

The results were mixed. Patients had higher scores on the dimensions of anger temperament, anger reaction, and external and internal expression of anger than did controls. Significant differences were found on the scale of internal control of anger among patients with AN-R, who had higher mean scores than did patients with BN. The authors hypothesized that as BMI decreased, anger would increase; however, no differences were seen among the other diagnoses and no significant correlation was found between body mass index (BMI) and level of anger.

Scores for both internal and external control of anger were below the man for the normal population, and similarly, state anger and its subscales (feelings, physical expression and verbal expression) showed lower values than the mean for the normative population.

Low self-esteem also showed significant positive relations with anger temperament and the internal and external expression of anger and negative relations with physical and verbal expression of anger. The authors think that one area that needs further research is determining whether improvement in levels of anger might increase self-esteem in patients with eating disorders.

Psychodynamic treatment may determine causes of anger other than weight loss. These results highlight the potential importance of identifying and addressing anger during eating disorder treatment. They also suggest the need for finding ways to manage anger by using non-pharmacologic approaches, such as traditional breathing and relaxation techniques, thought-stopping, time-out exercises, or by mentally rehearsing anger-causing situations.