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Anger, Aggression and Addiction

By: the Dual Diagnosis Recovery Network

Anger, aggression and addiction are intertwined in many ways, Anger has been implicated in relapse as stated in the language of Alcoholics Anonymous. For decades the self-help programs have warned those in recovery from addiction to avoid becoming hungry, angry, lonely, and tired. These emotions are also a confounding factor in situations where another psychiatric disorder coexists with addictive disorder For example, anger and aggressive acting out are symptoms of bipolar illness, paranoid schizophrenia, post traumatic stress disorder, attention deficit disorder, and personality disorders such as antisocial borderline and paranoid character disturbances. Toxicity from stimulant drugs such as cocaine and methamphetamine lead to paranoia, hyperarousal and often to violence, with violence being the number one cause of death for those addicted to stimulant drugs. Anger and rage can be viewed from another perspective. They are emotions that helped the individual cope with early life chaos and abuse. In this regard, anger can be perceived as a learned coping strategy secondary to early life experience.

Complicating the search for understanding is the fact that DSM has no means to describe or classify anger and aggression. This seems inconsistent as the manual places such emphasis on the other two core emotions -- anxiety and affective conditions Anger, aggression and even violence are mentioned as symptoms of psychiatric disorders but do not have a systematic classification system.

This article will focus on two different but overlapping sets of classes. The first section will focus on anger as a symptom of certain psychiatric disorders. In this case the focus will be the addictive disorders. The second set of glasses views anger and rage as learned coping and survival skills. In this context, anger and rage are described as purposeful and are utilized in an attempt to establish control in situations where the individual is fearful of being out of control.

Alcohol, Drugs and Aggression

Over time alcohol and drugs have been linked to anger and aggression. Alcohol, stimulants (cocaine and methamphetamine), anabolic steroids, marijuana and other drugs have either been used to ameliorate uncomfortable emotional states or have been implicated in the precipitation of anger and aggression. Not only do many of the mood altering substances impair perception but also there is proof that alcohol and drugs -- through their ability to alter neurotransmitter levels alter mood state.


Alcohol can have a disinhibiting effect and can also be used as an excuse to explain one’s behavior. During the later stages of dependence, alcohol can cause a decrease in the neurotransmitter serotonin. Most significant from a psychological or psychiatric perspective is the relationship between serotonin and depression, sleep regulation, aggression and suicide. From studies of rodents and nonhuman primates, if serotonin’s availability is curtailed or its transmission impeded, animals become more aggressive and impulsive. Rats with low serotonin levels will attack and kill other rodents. This would indicate that the relationship between aggression and alcoholism is more than just a perceptual inhibition.

Stimulant Drugs

The leading causes of death for cocaine and methamphetamine addicts are violence, suicide and accident. All are violent and also may have strong connections to toxic alterations of the neurotransmitters norepinephrine and dopamine. During toxic episodes stimulant drugs can create an elevation of both norepinephrine and dopamine. Increased norepinephrine levels create a state of hyperarousal. This is similar to the “fight or flight” response that manifests during times of real or perceived danger. Combine this with continued elevations of dopamine and there is a potential for a paranoid state. As dopamine starts to elevate in the brain, the user experiences context appropriate paranoia. A good example of this is the sense that every sound outside of your apartment is a narcotics agent causing the individual to constantly look thru the peephole in the door. As dopamine levels continue to elevate with continued use of a stimulant drug a presentation develops that looks like delusional (paranoid) disorder. Persecutory, jealous and other delusions can exist. A man in a treatment program once described a paranoid delusion that occurred in the early morning hours after a night of heavy free base usage. He believed that there were unmarked police cars parked up and down his street. In order to check and see if they were there, he would walk out of his house every fifteen minutes to look inside his mailbox while scanning the street for unmarked police cars. He felt that this was the only inconspicuous way he could check for signs of trouble.


“Let’s get "mellow” and “let’s chill out” are subjective terms used to describe the cannabis experience. These phrases seem to indicate a desired experience secondary to inhalation. It appears that many marijuana users are using the drug to reduce levels of anger and/or anxiety. Clinicians should look for these emotional expressions in the patient and if they do not disappear quickly (remember the abstinence syndrome can manifest as anxiety and irritability lasting for up to three days after cessation and these symptoms can come back in an exaggerated fashion in 3-6 weeks) they should be treated as an underlying problem and a relapse issue.

Anabolic Steroids

“Stacking” and “pyramiding” anabolic steroids can create symptoms from rage to psychosis. “Stacking” means that more than one anabolic steroid is being used at the same time. For example, an injectable can be added on top of oral ingestion. “Pyramiding” refers to the escalation of dose of the steroids. As the dose levels increase, rage and aggression may be a symptom of the drug experience.

Anger As a Learned Coping Survival Skill

Many alcoholics and addicts enter treatment with backgrounds of neglect and abuse. As a way of trying to cope with an unmanageable situation as children, they made conscious decisions never to let anyone get close or hurt them again. Generally this decision is made between the ages of 8 and 14 years of age. A woman when asked in group when she decided to never let anyone hurt her again, responded by stating the she remembers her parents physically fighting and decided at age 11 that she would not put up with this. She decided to run away from home every time there was fighting. A man related a story about his father beating him with a belt when he was drunk. He made a decision at age 12 to never let this happen to him again. Whenever his father came after him with the belt he would attack him. These modus operandi are repeated during their lives. For example, in group the aggressive patient might dare the therapist to confront while the one who ran away would push his/her chair a foot or more outside of the group circle.

Coping decisions — These learned coping strategies can present in many and varied ways. Four strategies that can be observed are as follows:

Withdrawal — When situations arise where an individual feels out of control or powerless, they can turn away. This strategy was evident in the above story of the lady who decided as a child to run away from crisis. Others may withdraw using a reactive depression to avoid confrontation.

Avoidance — Still others will turn to alcohol and drugs to avoid reality. Patients with narcissistic and antisocial disorders will utilize a narcissistic maneuver to keep a clinician from getting too close to their core. This patient may walk out of a session when the heat gets turned up too high or they do not get what they feel they deserve.

Attack self — Clinicians can recall patients that harm themselves when a real or perceived sense of abandonment exists. Termination of therapy can cause certain patients (for example borderline character disordered patients) to experience increased anxiety and resulting impulsive behavior such as cutting, burning, sexual acting out or use of food, alcohol and drugs.

Attack others — In order to cope with a stressful situation, patients may put others down to enhance their self-image. These put downs can take the form of verbal defamation all the way to sadistic behavior.

Treatment Considerations

Any time that a patient is being treated for two or more disorders that are in any way related to each other (for example alcoholism and bipolar illness with anger as an attendant feature), the treatment team must help the patient integrate all of the concepts into a related whole. If the staff fails to accomplish this, then it is left to the patient to do the integration. This generally fails.

Where there is a psychiatric disorder such as depression, a treatment approach can be developed depending on the severity of the presentation. In moderate to severe depression a medication is typically utilized. Psychotherapy is an appropriate adjunct. In situations where there is addiction, the initial step is to discontinue alcohol and drug use and manage any medical or psychiatric problems that coexist.

To date there are three empirically proven psychotherapeutic approaches helpful in managing anger and aggressive behavior. These approaches are cognitive, behavioral, and relaxation therapies often used in combination. The difficulty arises when the anger and aggression (or any of the above stated coping strategies) is part of some developmental theme such as abandonment, authority, or sexuality. When early hurt doesn’t manifest itself in the present, the cognitive, behavioral and relaxation approaches dont’ generally contain the rage. In these instances a form of therapy that is insight oriented may help to address the early life issues. These early issues such as neglect and abuse seem to be right brain oriented and need a therapeutic approach that creates enough excitation to be effective.

The resolution of aggression, like addiction, cannot be solved in 10 easy steps as some books might suggest. The relationship between anger, aggression and addiction is complex and multidetermined. The therapeutic answer requires a combination of considerations. Treatment planning needs to encompass the issues of environment use of medication, and proper choice of psychotherapeutic approach.*

Cardwell C. Nuckols, Ph.D. is an internationally recognized expert in Behavioral Medicine and Addictions Treatment. He is the President of American Enterprise Solutions, Inc.

Dual Diagnosis Recovery Network
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