The objective of this study was to examine the relationship between anger management style, depression, anxiety and somatic symptoms in anxiety disorder and somatoform disorder patients. The subjects comprised 71 patients with anxiety disorders and 47 with somatoform disorders. The level of anger expression or anger suppression was assessed by the Anger Expression Scale, the severity of anxiety and depression by the Symptom Checklist-90-Revised (SCL-90-R) anxiety and depression subscales, and the severity of somatic symptoms by the Somatization Rating Scale and the SCL-90-R somatization subscale. The results of path analyses showed that anger suppression had only an indirect effect on somatic symptoms through depression and anxiety in each of the disorders. In addition, only anxiety had a direct effect on somatic symptoms in anxiety disorder patients, whereas both anxiety and depression had direct effects on somatic symptoms in somatoform disorder patients. However, the anxiety disorder group showed a significant negative correlation between anger expression and anger suppression in the path from anger-out to anger-in to depression to anxiety to somatic symptoms, unlike the somatoform disorder group. The results suggest that anger suppression, but not anger expression, is associated with mood, i.e. depression and anxiety, and somatic symptoms characterize anxiety disorder and somatoform disorder patients. Anxiety is likely to be an important source of somatic symptoms in anxiety disorders, whereas both anxiety and depression are likely to be important sources of somatic symptoms in somatoform disorders. In addition, anger suppression preceded by inhibited anger expression is associated with anxiety and somatic symptoms in anxiety disorders.
Somatization is a broad term describing a person's belief that a physical disease is present. It is also a kind of communication of emotional distress, consciously or unconsciously coded in the language of the body (Brodsky, 1984). Somatization represents a powerful method of coping with psychosocial distress in all cultures (Katon et al., 1982a). Somatoform disorders can be considered a typical mental disorder showing somatization (Koh, 2002).
Previous studies found that there is a consistent association of somatic symptoms with anxiety (Tyrer, 1976) as well as with depression (Katon et al., 1982a and Katon et al., 1982b). An association of somatization with depressive disorders is ubiquitous in primary practice worldwide (Katon et al., 1982a and Lipowski, 1990). Anxiety disorders are also often associated with both somatization and hypochondriasis (Katon, 1984 and Noyes et al., 1986). Some patients with panic disorder have occasional attacks that consist only of somatic symptoms (Beitman et al., 1987). Somatic symptoms of anxiety are characterized by sympathetic adrenergic arousal such as tachycardia and sweating (Kellner, 1991). Patients with anxiety disorder such as panic disorder have numerous somatic symptoms, and frequently these patients present with bodily complaints to general physicians. It has been reported that patients with either panic disorder or generalized anxiety disorder are more sensitive to bodily changes than nonanxious individuals (Hoehn-Saric et al., 2004).
In addition to depression and anxiety, anger plays a significant role in somatization (Koh, 2002 and Kellner, 1991). Previous studies have reported an association of anger suppression and somatic symptoms. Increased sympathetic nervous system activity induced by anger suppression has been linked to somatization (Kellner et al., 1992). Hwa-byung is known as an anger syndrome specific to Korean culture, which is characterized by a variety of somatic symptoms such as a feeling of a mass in epigastrium, hot sensation, palpitation, dyspnea, fatigue and emotional symptoms such as a fear of impending death and dysphoria, attributed to anger suppression ( Koh, 2002, Mezzich et al., 2000, Lin, 1983, Min et al., 1986 and Min, 1989).
Anger and depression have long been associated and causally linked (Koh et al., 2002, Fava et al., 1991, Gould et al., 1996, Tschannen et al., 1992 and Duckro et al., 1995). It has been reported that depressive disorder patients are more likely to experience anger than anxiety disorder or somatoform disorder patients (Koh et al., 2002). Depressive disorder patients have been reported to have more anger attacks compared with healthy volunteers (Fava et al., 1991) and anxiety disorder patients (Gould et al., 1996). However, the relationship between anger and anxiety has rarely been studied. In addition to separation and independence, conflicts around anger are particularly prominent in panic disorder patients. They often avoid expressing anger, because of their fear of anger expressed in the family. In a psychoanalytic formulation, unacceptable aggressive thoughts leading to a fantasy of punishment are viewed as a potential cause of anxiety (Gorman, 2000).
Anger suppression and anger expression have been described as styles with which people typically manage their anger (Spielberger et al., 1985). Herein, anger expression refers to an overt display of verbally and/or physically aggressive behaviors. Therefore, anger expression is likely to have more negative effects than positive effects as a catharsis.
In the previous study, the relation between anger management style, depression, and somatic symptoms was examined in depressive disorders and somatoform disorders. The depressive disorder patients showed both the path from anger-in to anger-out to depression to somatic symptoms and the path from anger-in to depression to somatic symptoms, whereas somatoform disorder patients showed the path from anger-in to depression to somatic symptoms (Koh et al., 2005). However, the relation between anger management style (anger expression or anger suppression), mood such as depression and anxiety, and somatic symptoms in anxiety disorders and somatoform disorders was not examined. Elucidating such interactions was expected to help in understanding the role of anger management style in mood such as depression and anxiety and in somatic symptoms of anxiety disorders and somatoform disorders.
In terms of the previous findings, we could consider the following hypothetical pathways in the interrelationship between anger management style, mood, and somatic symptoms in anxiety disorders and somatoform disorders. A path from anger-out to anger-in to anxiety to somatic symptoms could be proposed in anxiety disorders, whereas both the paths from anger-in to depression to somatic symptoms and from anger-in to anxiety to somatic symptoms could be proposed in somatoform disorders.
