Bipolar Anger Unveiled: Understanding the Rage Within

Bipolar rage has long been overshadowed by mania and sadness. But it’s time to take a hard look at the isolating effects of anger.

Tick-tock, tick-tock goes the anger clock.

Jeffrey M.’s wife has just said something thoughtless and offhanded, his four children are bickering, and with every passing day his head spins, his rage builds, and soon he’s feeling like Mount Vesuvius with a red cloud deep inside his chest.

“When I get angry, the children look at me like deer stuck in the headlights,” says Jeffrey, an information technology specialist who lives in Calgary, Alberta. “They’re stunned that Dad’s exploded again … I’m an adult, and I should be more conscious of what’s going on, more in control of my emotions.”

Jeffrey was diagnosed with bipolar 2 disorder, after years of being told he had depression and obsessive-compulsive disorder (OCD). Rituals of obsessive thinking fuel his rage. He can be angry for days on end, and though he doesn’t yell the whole time, he’s just “not a happy person to be around.”

He first sought help for anger issues when he was 16 years old, after originally seeking help for OCD, but he’s unexpectedly forgiving about why the bipolar diagnosis was so long in coming: “I never went in to the doctor really angry or on a high,” he says simply.

Jeffrey, like many people with bipolar disorder, blames the condition for the volatility of his anger and rage.

The Difference Between Anger and Bipolar Rage 

But mood specialists are careful to distinguish between occasional hot flashes of anger and the long-simmering irritability and rage — angry outbursts lasting over several days, during both manic episodes and agitated states of depression — that are symptomatic of bipolar disorder. During a manic episode, experts say, mood changes can swing from irritability to euphoria to depression — all within 25 minutes.

“Instantaneous anger that lasts a few minutes and occurs twice a week is not bipolar, it’s being angry,” says David L. Dunner, MD, FACPsych, director of the Center for Anxiety and Depression in Mercer Island, Washington. “Irritability can be present during highs and lows, but irritability without elated mood makes me suspect the illness may not be bipolar.”

In other words, just because you have a head-turning temper tantrum doesn’t mean you have bipolar disorder. Anger is a common response to both physiological illnesses, like cancer and heart disease, and mental illnesses, such as intermittent explosive disorder, major depressive disorder, and substance-induced mood disorder.

“As bipolar disorder receives more media attention, it’s easy for any type of abhorrent behavior to be attributed to it when, in fact, this has to do with one’s temperament,” says Ron Remick, MD, medical director of the Psychiatric Clinics at the Mood Disorders Association of British Columbia. 

“Individuals with bipolar are not angry, hostile, irritable people with short fuses,” he emphasizes. “If people with bipolar illness have anger issues, they have anger issues.”

It is, however, a side of bipolar disorder that has long passed under the radar screen. Many people with bipolar say that uncontrolled anger has destroyed their marriages, families, and personal relationships; ruined their careers; and left them emotionally isolated.

Jeffrey, for one, is on the verge of divorce and accepts most of the blame — or, at least, places it squarely on his anger. “It’s hardest on my wife,” he admits, “even harder than on me. I’ll deflect it, blame her, and won’t own up to my rage, in this weird, twisted game. There are only so many times I can apologize.”

Anger and Irritability in Depression: A Sign of Bipolar Disorder?

An ongoing debate in psychiatric circles revolves around whether people who get very angry or irritable during depression are at a higher risk for developing bipolar disorder, or in fact, already have the disorder. 

One study revealed that increased anger and irritability in individuals with unipolar depression might predict a transition to bipolar disorder, aiding early detection. It found that those with bipolar disorder often display more severe anger, particularly aggressive reactions, suggesting a potential shift to a bipolar diagnosis.

The research also noted that emotional instability, frequently misinterpreted as a personality disorder, is more common in bipolar disorder, emphasizing the complexity of emotional regulation in this condition.

“She’s just being a normal teenager,” the doctor told Sharon L.’s perplexed family back in the 1970s, two decades before she was diagnosed with bipolar 2.

Growing up in Nashville, Tennessee, Sharon says her family recognized that something was wrong with her behavior while she was still in high school. In college, she was angry and promiscuous, her attention span was “that of a gnat,” and she ran into trouble at almost every turn she took.

These days, Sharon — who’s been married three times and works part-time (“no pressure”) for an aromatherapy company — takes three different medications, consults a psychiatrist for consistent dose management, and sees a psychologist, usually in the darker, winter months. She blames the medications for a 25-pound weight gain but acknowledges that they’ve helped tame and control an anger that’s “so volatile, so scary, I could have easily killed somebody.”

Even with all those controls in place, “one thing will trip it up and I’ll go ‘ballistic,’” she says. ‘I’m grateful I haven’t taken a life. I’m grateful I haven’t taken my own life.”

Irritation is Exasperating and Exhausting

Irritability, though less dramatic than outright anger, can be just as sapping over time. Though more typical of unipolar depression than bipolar disorder, experts say that people in the depressive phase of bipolar tend to experience a slowdown in their responses. In the manic phase, they often develop irritability or anger when thwarted.

“I’m often struck by how my patients suffer as much as a result of irritability as from depression,” says Roy Perlis, MD, associate chief for research in the department of psychiatry and director of the Center for Quantitative Health at Massachusetts General Hospital.

“Consequences of irritability or anger — such as shouting or sending inflammatory emails — can be tremendous, yet these two emotions do tend to receive less attention than euphoria or sadness.”

Sharon knows what Dr. Perlis is talking about. These days, she says she feels more irritable than angry — especially following a confrontation with her older daughter, who “talks back,” inciting Sharon to even greater anger. “I have found I direct my anger more at the ones I love,” she says. “I’ve learned to lower my voice and not scream, but sometimes I can’t help it.”

Without medication, she says these arguments might easily erupt into major battles. Instead, she now finds herself walking away, dejected. “I don’t have enough energy to muster up any anger,” she says.

But while many patients blame their angry and violent outbursts on the disorder, experts are quick to point out that the diagnosis, in and of itself, cannot be held solely accountable.

Substance Abuse Can Play a Factor in Angry Outbursts

David L. Dunner, MD, FACPsych, director of the Center for Anxiety and Depression in Mercer Island, Washington, says he has documented few serious behavior problems among his bipolar patients. His research suggests that anger problems are more often associated with a history of substance abuse.

“Use of street drugs may cause mood changes such as anger or depression when elated, but that behavior may be related to drugs more than bipolar disorder,” says Dr. Dunner, who’s also professor emeritus of psychiatry at the University of Washington.

It’s a question of what comes first, Dunner says, since a third of people with bipolar disorder have a history of substance abuse.

For patients seeking help with anger, Dunner first obtains an accurate diagnosis and then proceeds with a treatment strategy that can include medications ranging from anticonvulsants to antipsychotics, minor tranquilizers, and mood stabilizers.

While bipolar disorder is not the sole cause of anger, its diagnosis plays a definite factor in how it’s treated. Tricyclic antidepressants can cause more rapid cycling in an individual with bipolar disorder, and the diagnostic rating scales “don’t do a great job of measuring irritability,” according to Perlis.

Jeffrey would surely agree. Even today, he says, rituals of obsessive thinking feed his rage.

“I hear this noise, loud inside of me, turning and turning,” Jeffrey says, trying to describe what happens. “I’ve identified it and am trying to understand what causes it, to learn coping strategies, how to recognize that feeling coming before I let it go, when it explodes and goes away.”

With his marriage on the rocks and his fear that the disorder “gets in the way of being a good dad,” Jeffrey has begun seeing a psychologist, identified through his church group, who’s helping to provide coping strategies.

“It’s going really well,” he says, with conviction.

In addition, he receives medications for both bipolar disorder and OCD from a general practitioner.

Although his wife Stephanie recognizes that the past has been difficult, she is hopeful that with his commitment to treatment, Jeffrey may heal, and they will finally be on the same plane.

Editorial Sources and Fact-Checking 

Mesbah R et al. Anger and Cluster B Personality Traits and the Conversion From Unipolar Depression to Bipolar Disorder. Depression and Anxiety. January 2021.

Learn more:
Bipolar Disorder & Anger: Understanding and Getting Control of Irritability

Updated: Originally printed as “Stuck on the Rage Road,” Fall 2008