Introduction: Current psychiatric classification systems underestimate the part played by anger and aggressiveness in unipolar depression. This study was designed to assess the relevance of anger, irritability, aggressiveness, hostility, and psychomotor activation in major depressive disorder. Methods: A total of 222 newly admitted consecutive outpatients with major depressive disorder (mean age 48.9 years, 64.4% females) were enrolled in the study. They had no comorbid axis I or II DSM-IV disorder, and they received no treatment with antidepressants in the preceding 2 months. They were assessed with the SVARAD, a validated scale for the rapid assessment of the main psychopathological dimensions. Principal component analysis was performed on SVARAD items. Results: We obtained a three-factor solution accounting for 47.4% of total variance. The factors were interpreted as ‘anger/irritability’, ‘depression’, and ‘anxiety’, respectively. The anger/irritability dimension was clinically relevant in 23% of patients. Anger/aggressiveness was especially frequent (21.6%), whereas psychomotor activation was infrequent (0.9%). Discussion: In depressive disorders, there are psychopathological dimensions other than depressed mood and anxiety that deserve greater clinical recognition and research. Our study suggests that one of these symptom clusters includes anger, irritability, aggressiveness, and hostility. The relevance of this dimension was not related to concurrent pharmacological treatment. Misdiagnosis of bipolar II disorder is also unlikely to explain our findings. Possibly, personality factors might at least partly explain the occurrence of anger and aggressiveness in several depressed patients. Attachment theory suggests that anger might also be conceived as part of the protest-despair-detachment reaction to a loss, either actual or symbolic.

1.
Pancheri P, Picardi A, Pasquini M, Gaetano P, Biondi M: Psychopathological dimensions of depression: A factor study of the 17-item Hamilton Depression Rating Scale in unipolar depressed outpatients. J Affect Disord 2002;68:41–47.
2.
Posternak MA, Zimmerman M: Anger and aggression in psychiatric outpatients. 2. J Clin Psychiatry 2002;63:665–672.
3.
Demyttenaere K, De Fruyt J: Getting what you ask for: On the selectivity of depression rating scales. Psychother Psychosom 2003;72:61–70.
4.
Hirschfeld RM: Bipolar spectrum disorder: Improving its recognition and diagnosis. J Clin Psychiatry 2001;62:5–9.
5.
Klerman GL: The spectrum of mania. Compr Psychiatry 1981;22:11–20.
6.
Akiskal HS, Mallya G: Criteria for the ‘soft’ bipolar spectrum: Treatment implications. Psychopharmacol Bull 1987;23:68–73.
7.
Akiskal HS, Pinto O: The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr Clin North Am 1999;22:517–534.
8.
Fava GA, Kellner R, Lisansky, Park, Perini GI, Zielezny M: Hostility and recovery from melancholia. J Nerv Ment Dis 1986;174:414–417.
9.
Fava M, Rosenbaum J, McCarthy M, Pava J, Steingard R, Bless E: Anger attacks in depressed outpatients. Psychopharmacol Bull 1991;27:275–279.
10.
Sato T, Bottlender R, Schröter A, Möller H-J: Frequency of manic symptoms during a depressive episode and unipolar ‘depressive mixed state’ as a bipolar spectrum. Acta Psychiatr Scand 2003;107:268–274.
11.
Biondi M, Picardi A, Pasquini M, Gaetano P, Pancheri P: Dimensional psychopathology of depression: Detection of an ‘activation’ dimension in unipolar depressed outpatients. J Affect Disord 2004;in press.
12.
Pancheri P, Biondi M, Gaetano P, Picardi A: Costruzione della ‘SVARAD’, una scala per la valutazione rapida dimensionale. Riv Psichiatr 1999;34:72–83.
13.
Pancheri P, Picardi A, Gaetano P, Pasquini M, Puzella A, Di Fabio F, Biondi M: Validazione della scala per la valutazione rapida dimensionale ‘SVARAD’. Riv Psichiatr 1999;34:84–93.
14.
Pancheri P, Biondi M, Gaetano P, Picardi A, Pasquini M: Impiego della scala per la valutazione rapida dimensionale SVARAD in una popolazione clinica ambulatoriale di 1124 soggetti. Riv Psichiatr 2001;36:204–216.
15.
Cattell RB: The scree test for the number of factors. Multivariate Behav Res 1966;1:245–276.
16.
Norusis MJ: SPSS for Windows Professional and Advanced Statistics, Release 8.0. Chicago, SPSS Inc, 1998.
17.
Comrey AL, Lee HB: A First Course in Factor Analysis. Hillsdale, Erlbaum, 1992.
18.
Wehr TA, Goodwin FK: Can antidepressants cause mania and worsen the course of affective illness? Am J Psychiatry 1987;144:1403–1411.
19.
Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M: Is this patient clinically depressed? JAMA 2002;287:1160–1170.
20.
Akiskal HS: The prevalent clinical spectrum of bipolar disorders: Beyond DSM-IV. J Clin Psychopharmacol 1996;16:4S–14S.
21.
Ghaemi SN, Boiman EE, Goodwin FK: Diagnosing bipolar disorder and the effect of antidepressants: A naturalistic study. J Clin Psychiatry 2000;61:804–808.
22.
Goldberg DP, Bridges P, Duncan-Jones P, Grayson DA: Dimensions of neurosis seen in primary care settings. Psychol Med 1987;17:461–470.
23.
Abraham K: Notes on the psychoanalytical investigation of manic-depressive insanity and allied conditions; in Abraham K: Selected Papers of Karl Abraham. London, Hogarth Press, 1948.
24.
Freud S: Mourning and melancholia; in Strachey J (ed): Standard Edition of the Complete Psychological Works of Sigmund Freud, vol 14. London, Hogarth Press, 1975.
25.
Guidano VF: Complexity of the Self. New York, Guilford Press, 1987.
26.
Leopardi G: Zibaldone. Milano, Mondadori, 1996.
27.
Stanghellini G: Dysphoria, vulnerability and identity: An eulogy for anger. Psychopathology 2000;33:198–203.
28.
Pull CB, Pichot P, Pull MC, von Frenckell R: The principal dimensions of manifest depression: A factor analysis of manifest depressive symptomatology. Neuropsychobiology 1979;5:207–212.
29.
Overall JE, Hollister LE: Phenomenological classification of depressive disorders. J Clin Psychol 1980;36:372–377.
30.
Riley WT, Treiber FA, Woods MG: Anger and hostility in depression. J Nerv Ment Dis 1989;177:668–674.
31.
Moreno JK, Selby MJ, Fuhriman A, Laver GD: Hostility in depression. Psychol Rep 1994;75:1391–1401.
32.
Koh KB, Kim CH, Park KP: Predominance of anger in Depressive Disorders compared with Anxiety Disorders and Somatoform Disorders. J Clin Psychiatry 2002;63:486–491.
33.
Bagby RM, Kennedy SH, Dickens SE, Minifie CE, Schuller DR: Personality and symptom profiles of the angry hostile depressed patient. J Affect Disord 1997;45:155–160.
34.
Perugi G, Akiskal HS, Micheli C, Musetti L, Paiano A, Quilici C, Rossi L, Cassano GB: Clinical subtypes of bipolar mixed states: Validating a broader European definition in 143 cases. J Affect Disord 1997;43:169–180.
35.
Koukopoulos A, Koukopoulos A: Agitated depression as a mixed state and the problem of melancholia. Psychiatr Clin North Am 1999;22:547–564.
36.
Dayer A, Aubrey J-M, Roth A, et al: A theoretical reappraisal of mixed states: Dysphoria as a third dimension. Bipolar Disord 2000;2:316–324.
37.
Hantouche EG, Angst J, Akiskal H: Factor structure of hypomania: Interrelationships with cyclothymia and soft bipolar spectrum. J Affect Disord 2003;73:39–47.
38.
Benazzi F, Akiskal H: The dual factor of self-rated MDQ hypomania: Energized-activity versus irritable-thought racing. J Affect Disord 2003;73:59–64.
39.
Akiskal HS, Azorin JM, Hantouche EG: Proposed multidimensional structure of mania: Beyond the euphoric-dysphoric dichotomy. J Affect Disord 2003;73:7–18.
40.
Musalek M, Lesch OM, Kieffer W: Dysphoric states in the course of manic-depressive illness. Psychopathology 1987;20:107–114.
41.
Gabriel E: Dysphoric mood in paranoid psychoses. Psychopathology 1987;20:101–106.
42.
Berner P, Gabriel E, Katschnig H, Kieffer W, Koebler K, Lenz G, Simhandl C: Diagnostic Criteria for Functional Psychoses, ed 2. London, Cambridge University Press, 1992.
43.
Berner P, Musalek M, Walter H: Psychopathological concepts of dysphoria. Psychopathology 1987;20:93–100.
44.
Guidano VF, Liotti G: Cognitive Processes and Emotional Disorders. New York, Guilford Press, 1983.
45.
Arciero G, Guidano VF: Experience, explanation, and the quest for coherence; in Neimeyer RA, Raskin JD (eds): Constructions of Disorder. Washington, American Psychological Association, 2000.
46.
Picardi A, Mannino G, Arciero G, Gaetano P, Pilleri MF, Arduini L, Vistarini L, Reda MA: Costruzione e validazione del QSP, uno strumento per la valutazione dello stile di personalità secondo la teoria delle ‘organizzazioni di significato personale’. Riv Psichiatr 2003;38:13–34.
47.
Picardi A: First steps in the assessment of cognitive-emotional organisation within the framework of Guidano’s model of the Self. Psychother Psychosom 2003;72:363–365.
48.
Akiskal HS: Le déprimé avant la dépression. Encéphale 1995;18:485–489.
49.
Cloninger CR, Bayon C, Svrakic DM: Measurement of temperament and character in mood disorders: A model of fundamental states as personality types. J Affect Disord 1998;51:21–32.
50.
Biondi M, Picardi A: Clinical and biological aspects of bereavement and loss-induced depression: A reappraisal. Psychother Psychosom 1996;65:229–245.
51.
Bowlby J: Attachment and loss. New York, Basic Books, 1980, vol 3: Loss.
52.
Montgomery SA, Schatzberg AF, Guelfi JD, Kasper S, Nemeroff, C, Swann A, Zajecka J: Pharmacotherapy of depression and mixed states in bipolar disorder. J Affect Disord 2000;59:S39–S56.
53.
Fava M: Depression with anger attacks. J Clin Psychiatry 1998;59:18–22.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.