Mr. A, a 27-year-old single Hindu male, educated up to intermediate, with no significant past history of any psychiatric or medical illness, presented with chief complaints of depressed mood, initial and terminal insomnia and diminished appetite, excessive easy fatigability, anhedonia, excessive irritability, frequent anger outbursts, physical and verbal abuse, acts of deliberate self-harm for a duration of 3-4 months with progressive increase in intensity of symptoms over the time. His pre-morbid history revealed impulsive traits, frequent irritability and outbursts of anger, inability to handle criticism and difficulty in maintaining friends and relationships. However, there was no history of physical violence or conflict with others. However, currently, there was a significant increase in intensity and frequency of anger outbursts and irritability along with the depressive symptoms. Birth and developmental history was unremarkable.
Depressive episode of moderate intensity was diagnosed and rating on beck depression inventory (BDI) and Hamilton Depression Rating Scale (HDRS) were 11 and 18 respectively. Escitalopram was started, which was gradually increased from 5 to 20 mg/day. Though his depressive symptoms showed response to medications, there was no improvement in anger and irritability.
Non-pharmacological treatment based on cognitive-behavioral approach was started mainly to deal with his anger-related problem. The total therapy lasted over 4 weeks, which included a total of 11 sessions of 45-90 min/session. The objective of the therapy was to decrease impulsivity, arousal and expression of anger, increase his capacity to tolerate anger, channel his energy in prosocial ways and exert a better control over tension and anxiety even in tense situations. Psychoeducation, activity scheduling, self-monitoring of anger and associated physical cues and negative thoughts, relaxation and distraction techniques and cognitive restructuring were used to attain the above objectives.
First, patient was psychoeducated about depression and nature and importance of anger. Second, he was asked to maintain a diary of his anger outbursts, which included recording the antecedents, behaviors and consequences of his anger. In addition, patient was also instructed to rate and record the intensity of anger on a scale of 0 to 10. An activity schedule was prepared in collaboration with the patient and he was advised to follow it regularly in a proper way. Themes that emerged out of the assessment was that trivial events like things not done as per subject's wish and cues like heartbeat, hot flushes and irregular breathing increased his anger. This often led to impulsive acts like self-harm or violent behavior, which later led to the deep sense of guilt and disturbed his inter-personal relationship(s). To control the autonomic cues, Jacobson's progressive muscular relaxation training and deep breathing was taught. Distraction technique was suggested in the form of moving away from the arousing situation, keep calm and at the same time imagine pleasurable image or fantasy and feel good about it. Cognitive restructuring helped in replacing anger-provoking thoughts with more rational ones. Patient was instructed to practice repeatedly.
Following 11 sessions of CBT, there was a significant improvement in his anger and impulsivity. He reported that whenever he got angry, he was able to identify the feeling that caused anger (e.g., fear, hurt, disappointment). Further, he could contain his anger, used positive thoughts and expressed it in a respectful way. Overall, there was about 70% improvement in his perceived ability to control his anger. A decrease in BDI and HDRS scores from moderate to mild severity was also noticed during this time, which finally resolved over time. Before termination of sessions, importance of practicing the techniques even after resolution of depressive symptoms was emphasized to manage his anger outbursts.