Have you ever been angry? Of course, we all have. Anger is a primal experience, and it may have impacted human history more than any other emotion. Growing awareness has made mental health more of a priority in recent years, and this has ballooned under the stress of the pandemic. But a persistent stigma makes many people reluctant to admit to their struggles, and anger is certainly no exception. If you struggle with anger, you are probably hurting the people you care about most, and you are almost certainly hurting yourself. There is a path out of anger, and recent research has shed light on how to turn away from anger and free yourself from it.

As a medical doctor who uses injections to manage severe chronic pain, the most obvious focus of my treatment is the body, specifically the parts that hurt. I use an integrative approach, which means that I address the whole person, mind and body. This includes considering a wide range of factors that may be contributing to their suffering, and a wide range of therapies that might improve their function, their well-being and their lives.  

Pain is unique among all the chronic diseases, for the simple reason that it hurts. Pain is defined by the fact that it is unpleasant, and these negative sensations are almost always linked to negative thoughts and emotions. These can include anxiety, depression, frustration and many others, but one of the most potent and dangerous of these is anger.  

Anger is a complex experience, and can be described in biological, behavioural and emotional terms. Anger begins on the cognitive level, when we are confronted with something that conflicts with our needs and values. This triggers a neurophysiological response, which creates a subjective feeling that can be ramped up by motivations and results in a motor expression, whether physical or verbal, whether it is expressed or repressed. 

Anger researchers have carefully dissected the anger experience for decades. The questionnaires that were first used when research began in the 1970s have been replaced by newer validated tools. A systematic review of anger studies found that the most widely used tool is the State Trait Anger Expression Inventory (STAXI). This distinguishes between the state, which is what you feel when it happens, and the trait, which is how it manifests in your personality and your life. Anger in, which is anger that is suppressed or internalized, is different from anger out, which is expressed verbally or physically.

While it is clear that anger and pain are linked, it is unclear how or why. Anger predisposes to pain, but it is also a consequence of pain. It can prolong the pain experience, but it can also make it worse. In one study of people with chronic pain after breast cancer at the University of Tulsa in Oklahoma, those who had suppressed anger had worse pain scores in a standardized cold water test and even their spinal reflex indicated more sensitivity to pain.

The physiology of anger and stress affects the entire body. This is because the nerves of the autonomic nervous system affect every organ, gland and cell. One of the best-studied examples of this is irritable bowel syndrome (IBS). Many studies have shown that stress affects the colon, and this is something many of us have experienced. This seems to be part of a broader effect on the gastrointestinal tract, with researchers at UC Irvine reporting altered muscle activity in the antrum of the stomach in IBS patients with anger. Here again it seems that those who suppress their anger have worse symptoms than those who express it. Another interesting example is the corrugator supercilii, the tiny muscles that furrow our brows when we are displeased.

For those who need it, anger management has typically been the first recommendation. These classes are available in most urban areas, and online courses have made this more accessible than ever. While the approach is standardized in some ways, it is ideally adapted to the context and the needs of each individual. Anger management has been studied as a treatment in people with HIV, alcoholics and smokers, in prisons, and in those with brain injury, post-traumatic stress disorder and of course in chronic pain. Results have been mixed, however, and they seem to depend on the individual and the way the course is delivered.

Perceived injustice is a key trigger for anger in people with chronic pain, and this is something we have all experienced. A sense of fairness is something we all have in common, but life isn’t always fair. Many of my patients have pain that began after a motor vehicle accident, and in most cases they were struck from behind while stopped at an intersection. It doesn’t get more unfair than that.  

It seems that the key to breaking this cycle is something called acceptance. My patients hate this term at first, because they don’t want to accept that they will have to deal with this pain for the rest of their lives. The key insight I give them is that this is all a mind game. I tell them that they only need to accept what is happening now, not that it will never improve.

Ironically, accepting what is can open the door to healing and create a new possibility for what might be. In an elegant study, researchers at Stanford and McGill Universities demonstrated that pain acceptance is the link between perceived injustice and chronic pain. This may be because acceptance can short-circuit anger before it can affect the brain and body. 

Acceptance and Commitment Therapy (ACT) is receiving growing attention as a modified approach to cognitive-behavioural therapy. This involves accepting your current sensations, thoughts and emotions and committing to doing what you can rather than being upset about what you can’t. Several studies have shown that ACT is an effective treatment for chronic pain, and it points to the power of mindfulness to improve our lives by helping us develop the power of self-regulation.

If you struggle with anger, whether you have pain or not, you are suffering. If you repress your anger, you are hurting yourself, and if you express it, you are hurting other people, too.  If you live or work with someone who is prone to anger, you might find it hard to have compassion for them, especially when their anger is directed at you. It is up to each one of us to mindfully regulate ourselves, to ensure that we bring more light than darkness to the world each day.  

The mental environment is one that we all share, and negativity is like a virus, so do your best to prevent its spread.