B R I E F R E PO R T

International Journal of Neuropsychopharmacology (2006), 9, 215–219. Copyright f 2005 CINP

doi:10.1017/S1461145705005602 First published online 8 July 2005

Anger attacks in seasonal affective disorder

Dietmar Winkler1, Edda Pjrek1, Anastasios Konstantinidis1, Nicole Praschak-Rieder 2,

Matthäus Willeit2, Jürgen Stastny1 and Siegfried Kasper1
1
Department of General Psychiatry, Medical University of Vienna, Austria
2
Centre of Addiction and Mental Health, Toronto, Canada

Abstract
Previous research has linked aggression especially anger attacks with depression. The objective of the
present study was to examine the prevalence and clinical picture of anger attacks in seasonal affective
disorder (SAD) in comparison to non-seasonal depression. Thirty-six SAD patients and 24 non-seasonally
depressed controls were included in this evaluation. Anger attacks were assessed with the Anger Attacks
Questionnaire. The prevalence of anger attacks did not differ statistically significantly between seasonally
and non-seasonally depressed subjects. However, the monthly number of anger attacks was significantly
higher in SAD patients (p=0.009) and they presented with more vegetative symptoms and behavioural
outbursts during the anger attacks (p=0.006). SAD patients with anger attacks had significantly lower age
of onset (p=0.021) and obtained lower global seasonality scores than SAD patients without anger attacks
(p=0.001). Anger attacks are experienced as particularly intense in SAD patients and seem to contribute
considerably to their symptomatology.
Received 15 February 2005; Reviewed 16 March 2005; Revised 23 March 2005; Accepted 27 March 2005
Key words: Aggression, anger attacks, seasonal affective disorder.

Introduction According to the DSM-IV (APA, 2000) seasonal

affective disorder (SAD), winter type is a subtype
Previous research has suggested that depressed
of mood disorder with recurrent major depressive
patients often suppress aggression (Brody et al., 1999).
episodes in autumn or winter occasionally followed by
In contrast to these findings recent studies have found
hypomanic or manic episodes during the successive
that depressed subjects are more likely to express
spring/summer period. The prevalence of this dis-
anger than patients with other psychiatric disorders
order is up to 10 % in the general population, and the
(Koh et al., 2002). Aggression in the form of anger
rate of subjects suffering from the subsyndromal vari-
attacks, seems to be particularly prevalent in major
ant of SAD is even higher (Magnusson, 2000).
depression (Fava et al., 1993). Anger attacks are sud-
Several lines of evidence suggest that the sero-
den spells of inappropriate anger accompanied by
tonergic system is involved in the pathophysiology of
vegetative hyperarousal similar to panic attacks.
both anger attacks and SAD ; anger attacks have been
Anger attacks obtain clinical significance, not only
found to respond very well to treatment with SSRIs
because they increase personal suffering and compro-
(Fava et al., 1993 ; Mammen et al., 2004), and patients
mise social functioning ; Mammen et al. (1997) have
suffering from these attacks exhibit a greater central
reported that they were associated with lower treat-
serotonergic dysregulation than depressed patients
ment adherence in a sample of pregnant and post-
without anger attacks as measured by neuroendocrine
partum women. Furthermore, anger attacks have been
challenge tests (Fava et al., 2000). Likewise mono-
shown to increase cardiovascular risk (Fava et al.,
amine depletion studies (Neumeister et al., 1997),
1996a) and to have a deleterious impact on the well-
challenge tests (Schwartz et al., 1997) and neuroima-
being of patients’ offspring (Alpert et al., 2003).
ging studies (Willeit et al., 2000) have repeatedly
demonstrated abnormalities in brain serotonin func-
tion in SAD. The present research project was aimed to
Address for correspondence : D. Winkler, M.D., Department of assess the prevalence, frequency and symptom pattern
General Psychiatry, Medical University of Vienna, Währinger Gürtel
of anger attacks in SAD and to compare our findings to
18-20, A-1090 Vienna, Austria.
Tel. : +43.1.40400.3568 Fax : +43.1.40400.3099 non-seasonally depressed control subjects. Based on
E-mail : dietmar.winkler@meduniwien.ac.at preceding clinical reports yielding particularly high
216 D. Winkler et al.

levels of irritability in SAD patients (Winkler et al., difference in the prevalence of anger attacks (i.e. the
2002b) we formulated the a-priori hypothesis of higher rate of patients who fulfilled the above-mentioned
rates of anger attacks in SAD. criteria for anger attacks) between seasonal [41.7 %,
95 % confidence interval (CI) 25.5–59.2] and non-
Method seasonal depression (29.2 %, 95 % CI 12.6–51.0,
p=0.416). The monthly number of anger attacks was
Study subjects were consecutively recruited at the
significantly higher in SAD patients with anger attacks
outpatient clinic of the Department of General
(18.7¡16.7) than in non-seasonal major depression
Psychiatry (Medical University of Vienna) and
with anger attacks (5.3¡4.0 ; t=2.932, d.f.=17.102,
underwent semi-structured diagnostic interviews ac-
p=0.009). Additionally, SAD patients reported a sig-
cording to DSM-IV (First et al., 1996). SAD patients
nificantly higher number of vegetative and beha-
fulfilled the Rosenthal (Rosenthal et al., 1984) and
vioural symptoms (item 5, a-m of the Anger Attacks
DSM-IV criteria (APA, 2000) for SAD. The control
Questionnaire) during the anger attacks (8.7¡2.7 vs.
group consisted of patients with non-seasonal (recur-
5.3¡1.5; t=3.111, d.f.=20, p=0.006 ; Figure 1). Anger
rent) major depressive disorder according to DSM-IV.
attacks in our sample were characterized most
SAD patients and controls were clinically depressed at
frequently by the following symptoms: feeling like
the time of the interview. Subjects with past mania or
attacking others (86.4 %), palpitations or tachycardia
hypomania or present psychiatric comorbidity were
(81.8 %), feeling out of control (81.8 %), dyspnoea
excluded. Patients completed the German version of
(68.2 %), tremor (68.2 %) and hyperhidrosis (59.1 %). A
the Seasonal Pattern Assessment Questionnaire
total of 72.7 % experienced these anger attacks as un-
(Rosenthal et al., 1987) to obtain the Global Seasonality
characteristic, 86.4 % regretted these symptoms after-
Score (GSS). A GSS of o10 was required for SAD
wards. The prevalence (females 31.6 %, males 45.5 %,
patients ; Controls with a GSS of >6 were excluded by
p=0.405) and monthly number of anger attacks (fe-
the protocol. Anger attacks were assessed in all sub-
males 11.3¡12.8, males 18.1¡17.6; t=x1.043, d.f.=
jects with the Anger Attacks Questionnaire (Fava et al.,
20, p=0.309) were numerically higher in males than in
1991). According to this questionnaire study subjects
females, but gender differences were not statistically
were classified as suffering from anger attacks, if they
significant.
fulfilled all of the following criteria during the last 6
In the SAD sample patients with anger attacks had
months of their current depressive episode : (1) irrita-
significantly lower age of onset of illness (24.5¡7.5 yr)
bility, (2) overreaction to minor annoyances, (3) at least
than those without anger attacks (34.0¡15.1 yr;
one anger attack per month, (4) at least four of 13
t=2.437, d.f.=29.178, p=0.021) and they had a longer
autonomic arousal symptoms and behavioural out-
course of illness until diagnosed with SAD (12.2¡
bursts during the anger attacks. Both groups were
7.2 vs. 7.4¡5.8 yr; t=x2.221, d.f.=33, p=0.033).
examined during the same time of the year, i.e. during
Interestingly, SAD patients with anger attacks
autumn and winter. The psychiatric assessments for
obtained a lower mean GSS (12.8¡2.4) than those
this study were approved by the Ethics Committee of
without anger attacks (15.9¡2.4; t=3.761, d.f.=33,
the Medical University of Vienna. All subjects gave
p=0.001). We examined the subitems of the GSS to
informed consent prior to the study procedures.
identify the source of variation between the groups
Statistical analysis was carried out with SPSS for
employing a Bonferroni-type corrected level of stat-
Windows (SPSS Inc., Chicago, IL, USA). We used
istical significance (p<0.006) to obviate inflation of
Fisher’s exact test, and Student’s t test to assess group
type I error : there were no significant differences in
differences. The pf0.05 level of significance was
regard to duration of sleep (t=0.987, d.f.=34,
adopted in this report (unless otherwise specified). All
p=0.330), social activity (t=x0.197, d.f.=34, p=0.845),
statistical comparisons were two-tailed.
mood (t=x0.197, d.f.=34, p=0.845) and energy
(t=x0.114, d.f.=34, p=0.910) ; However, SAD
Results
patients without anger attacks reported significantly
Thirty-six SAD patients (24 women, 12 men) and 24 more often changes in appetite (t=4.549, d.f.=34,
controls with non-seasonal depression (14 women, 10 p<0.0001) and weight (t=4.274, d.f.=34, p=0.0001)
men) were included in this study. The mean age than those with anger attacks present. Further analysis
(¡S.D.) of SAD patients (39.7¡12.6 yr) and control confirmed that patients without anger attacks suffered
subjects (45.4¡14.9 yr) was not statistically signifi- more frequently from increased appetite (p=0.0001);
cantly different (t=x1.594, d.f.=58, p=0.116). There however, there were no significant group differences
was a numerically but statistically insignificant in regard to reduced appetite (p=0.046).
 Anger attacks in SAD 217

Feeling like attacking others

Palpitations or tachycardia
Feeling out of control
Shortness of breath
Shaking or trembling
Sweating
Lightheadedness or dizziness
Fear, panic, or anxiety
Hot flushes
Attacking physically or verbally
Chest tightness or pressure
Limb numbness or tingling
Throwing or destroying objects
Anger attacks as uncharacteristic
Guilt or regret after attacks

0% 20% 40% 60% 80% 100%

Rate in group of patients with anger attacks present

Figure 1. Clinical features of anger attacks in 15 SAD patients (dark grey bars) and seven non-seasonally depressed patients
(light grey bars). Symptoms are derived from item 5, a-m of the Anger Attacks Questionnaire (Fava et al., 1991). Asymmetrical
95 % confidence intervals are presented with the percentage of patients suffering from different symptoms.

Discussion tried to exclude any study subjects with categorically

To the best of our knowledge this is the first report on
anger attacks in SAD. We found higher rates of anger
attacks in SAD compared to non-seasonal depression,
but this difference did not reach the level of statistical
significance. This could be due to limited sample size
and points out the necessity to carry out similar stud-
ies in larger samples. The mean monthly number of
anger attacks in SAD patients significantly exceeded
the frequency in non-seasonally depressed subjects.
SAD patients were also more likely to report a larger
number of accompanying symptoms during the anger
attacks, suggesting that they experience the anger
attacks as particularly intense. When comparing SAD
patients with and without anger attacks it became
apparent that the subgroup with anger attacks had a
markedly lower age of onset of illness. This could be
indicative of a higher predisposition towards mood
disorders. The longer diagnostic latency in these sub-
jects on the other hand may be explained by the social
stigma that is associated with aggressive impulses. It
has previously been reported that anger attacks are
more frequent in depressed patients with comorbid
personality disorder (Tedlow et al., 1999). We have
defined personality disorder. However, if personality
is viewed as a dimensional construct, it cannot be
completely ruled out that some of our patients
exhibited greater personality pathology, which could
have influenced our results. Previous research has
likewise found that anger attacks are more prevalent
in bipolar disorder than in unipolar depression (Perlis
et al., 2004). We intended only to include patients with
a strictly unipolar course of illness to accomplish valid
intra-group comparisons, however, this may have
posed methodological difficulties, since it has been
argued before that major depressive disorder with
anger attacks is associated with bipolar variables (e.g.
positive family history for bipolar disorder) and might
be considered midway between unipolar depression
without anger attacks and bipolar II disorder (Benazzi,
2003).
Our data does not support the idea of gender dif-
ferences as previously reported for a sample of non-
seasonally depressed in-patients (Winkler et al.,
2005). It is nevertheless quite possible that our study
lacked statistical power (type-II error) to recognize a
true difference between groups. Our secondary find-
ing of a lower GSS in SAD patients with anger attacks
218 D. Winkler et al.
indicates that these patients were less seasonal than
those without anger attacks. Probably patients with
anger attacks attribute their symptoms rather to
psychosocial factors (e.g. problems with the family or
the spouse) than to a seasonal change. It would also be
interesting, if SAD patients with anger attacks are
more likely to experience non-seasonal affective epi-
sodes during their further course of illness.
It was surprising for us to see that the difference
in the GSS between the groups was almost entirely
due to the subitems appetite and weight. Patients with
anger attacks had fewer seasonal changes in regard to
these symptoms than patients without anger attacks.
Few studies have compared the effects of specific
emotions such as sadness and anger on eating
responses. However, research on the regulation of
appetite in healthy persons (Macht et al., 2002) and
studies in eating disorders (Deaver et al., 2003;
Stickney and Miltenberger, 1999) have identified at
least two complex types of emotion-induced changes
of eating; decreased eating induced by negative emo-
tions may be a consequence of an emotion-congruent
modulation. The affect regulation model on the other
hand provides evidence that increased eating occurs
because it provides momentary relief from negative
affect. This mood control eating may be present in the
majority of SAD patients, who suffer from atypical
depressive symptoms such as hyperphagia (Winkler
et al., 2002a). However, in line with the theory of
emotion-congruent modulation intense affects such as
aggression have repeatedly been shown to lower food
intake in rodents (Greeno and Wing, 1994; Krebs et al.,
1996; Robbins and Fray, 1980), which could explain
the lower rate of increased appetite and weight gain in
our subgroup with anger attacks.
In summary this study demonstrates that anger at-
tacks play an important role in the clinical picture of
SAD. Compared to other studies investigating anger
attacks in outpatients with unipolar major depression
(Fava et al., 1996b, 1991, 1997) we have found a rather
high prevalence in SAD patients, which is relevant as
anger attacks are a major source of the burden of
depression. Because of the potentially severe psycho-
social consequences of anger attacks, clinicians have to
be increasingly aware of these symptoms. Up to now
studies investigating the efficacy of light therapy have
not established if the presence of anger attacks in SAD
influences the outcome. As light therapy has been
suggested as treatment of choice for SAD (Partonen
and Loennqvist, 1998), it would be worthwhile to in-
vestigate the differential response of SAD patients
with and without anger attacks to bright-light therapy
in comparison to psychopharmacological treatment
with SSRIs, which have already been shown to be an
effective strategy for treating anger attacks (Fava et al.,
1993; Mammen et al., 2004).
Acknowledgements
None.
Statement of Interest
None.
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