Depression With Anger Attacks

A number of phenomenologic studies have demonstrated the marked heterogeneity of unipolar depressivedisorders. We have recently identified a subtype of depression characterized by the presenceof irritability and anger attacks. These attacks are sudden spells of anger accompanied by symptomsof autonomic activation such as tachycardia, sweating, flushing, and tightness of the chest. They areexperienced by depressed patients as uncharacteristic of them and inappropriate to the situations inwhich they occur. Approximately one third of depressed outpatients present with anger attacks. Patientswith unipolar depression and anger attacks frequently experience significant anxiety and somaticsymptoms, and are relatively more likely to meet criteria for avoidant, dependent, borderline,narcissistic, and antisocial personality disorders than depressed patients without these attacks. Angerattacks subside in 53% to 71% of depressed outpatients treated with antidepressants, and the degree ofimprovement in depressive symptoms after antidepressant treatment is comparable in depressed patientswith and without anger attacks. In addition, the rate of emergence of anger attacks after treatmentwith antidepressants (6%-10%) appears to be lower than the rate with placebo (20%). Finally,antidepressants that affect serotonergic neurotransmission, known to be involved in the modulation ofaggressive behavior in animals and humans, may be particularly effective in this subtype of depression,but further studies are needed to support this hypothesis.