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Although both sexes expressed and demonstrated great strain in attempting to contain aggressive impulses, particularly anger, they had different ways of coping with the problem. The difficulty in mastery of aggressive impulses therefore assumed different clinical forms, and they will be discussed separately in the two groups.
In at least 50% of the male patients, the fear of losing control of oneself was expressed clearly, directly, and early in the psychiatric encounter. The patient’s statement or first association with loss of control was that of “doing something terrible” or “hurting somebody,” or “running amok” or “going crazy, shooting people.” Beyond these statements was a blank wall, the patient having no idea whatsoever, in his conscious mind, of who would his prospective target be and why. Many times, the patient expressed regret at having even admitted the problem. He would then start to backtrack with a laugh and, in a joking tone, would make a quick denial of any serious intent—”Of course, I would never do anything like that.”
Encouraged to recognize and discuss angry or hostile feelings, he would worriedly submit that he had become more irritable with the children. or rude with friends. Extreme sensitivity to noises had been noted. A frequent report was that of an attack of nerves after witnessing a fight, hearing of a burglary or mauling incident in the neighborhood. Many patients made it a point to avoid exposure to any situation potentially violent, because they “become nervous.” All of this avoidance behavior and small outbursts at home or in the office indicated the mounting level of tension within him and the approach to exploding point.
He then reinforced his controls by reminding himself that he is a man of peace. He insisted that anger and similar feelings were completely alien to his nature. “1 always avoid unpleasantness”; “Being Catholic, I avoid violence”; “I am always careful never to hurt others”; “I am so easy to get along with” were the remarks made over and over again by these patients. This denial of capacity to harbor hostile feelings was quite rampant. The remark “I have never gotten angry in my life” was heard from a large number of these patients, who found such an impulse the hardest to acknowledge in themselves. Indeed, the standard preface to an aggressive verbal thrust was, “I don’t like to criticize, but....”
As tension increased, generated by a continuing frustration, either with himself or with an interpersonal impasse, symptoms appeared, indicating that the mechanism of denial was no longer serving him well. Difficulty in concentration, erratic performance at work, inability to make decisions, obsessive thoughts about non- related issues, were reported. Finally, brief episodes of staring into space or looking stunned were noted by family members and also observed by this writer. The patient looked like he was out of contact, yet he could be engaged in conversation. He did not look dazed or bewildered but rather gave an impression of one whose thought processes were temporarily suspended. I sometimes had an initial suspicion of a brewing catatonic storm only to have the patient come out of it in a matter of minutes. The patient would often claim that his mind was blank at the time or that he was so tired from thinking that he could not tell how his mind was working. Only in retracing his reactions were the links of his angry, resentful, hostile feelings to frustrating or humiliating situations uncovered. This followed a circuitous route, the patient often resorting to denial and displacement with great facility to conceal his feelings from himself.
There are two ways of displacing aggressive impulses—via somatizations and phobia-formations. After a particularly difficult interpersonal encounter which generated hostile feelings, the patient quickly developed chest pains, headache, gastric distress, or some somatic disturbance. A visit from a parent toward whom ho6tile feelings could not be expressed; a recurrent problem with the wife with whom confrontation was either impossible or dangerous— such incidents brought on a flurry or exacerbation of somatic complaints, He also suppressed anger by rationalizing that it would be bad for his health—his heart, his blood pressure, etc.—to let go of his feelings.
Phobia formation was observed, in certain instances, to follow similar aggression-provoking incidents. The phobia functioned to disarm the patient, as it were, by rendering him fearful and helpless. The phobia could be fear of anything—crossing the street, facing people, etc. Although it developed in an acute fashion as an emergency measure, some phobias had become chronic, indicating that the mechanism had now become well entrenched but still serving the original purpose—that of disarming the patient and helping him control his impulses.
Not wanting to beat up younger siblings two men took it out on their wives. One man unleashed his anger on the houseboy. Two fathers reported giving their teenage sons severe physical beatings. One father slapped his daughter. One fired a gun in the air. All were greatly upset by their behavior, their reaction a mixture of guilt and regret at the outburst. A desperate concern was that of finding a way to undo or make up for the deed.
There were five cases wherein a frank display of violence, which may or may not have directly involved the patient, served as the precipitating factor in the illness and brought the patient to the psychiatrist. In capsule form, these cases were as follows:
1. A married man, heading his parents’ business, had a heated argument with his mother. In a fit of anger following some remarks she made, he took his gun and fired it in the air. Within the next half hour he had made an appointment with the psychiatrist. When seen, he was suffering from severe headache and was sure that he had lost his mind.
2. A father slapped his daughter for disobeying his orders about dating. She was his favorite child. Right after the incident, he suffered from poor balance, dizziness, and had difficulty standing without support.
3. An adolescent boy went on a hunting trip with an older brother whom he both envied and admired. During the hunting trip he handled the rifle a few times, apparently enjoying himself. The following day he developed a severe phobic reaction. He became afraid of people and strangers, in particular. He refused to come out of his room or go downstairs alone.
4. A young executive who risked his life crossing picket lines to get to work witnessed another loyal employee being mauled by the picketeers. Enraged but helpless to do anything, he developed severe headache. That night he had difficulty reading and corn plained of pain in his eyes.
5. A businessman sat through a stormy Board of Directors meeting during which he witnessed a quarrel between his older brother and a woman member. The brother kicke& some chairs and walked out, slamming the door after him. When the session ended, the patient discovered that he could neither stand nor walk and fell to the floor. He was rushed to the hospital. After four hours, his legs regained mobility.
Female patients likewise complained of harboring onerous hostile thoughts and feelings without finding ready avenues for their expression. Like the male patients the mechanisms which were readily exploited by women to avoid losing control of themselves and directly releasing their impulses consisted of somatizations and phobia-formation.
Somatizations, in particular, were a favorite displacement for angry feelings. Headache, chest pains, shortness of breath, and numbness of hands and mouth areas had a high correlation with unexpressed rage. These were also quite effective in repressing any awareness of the provocative role anger played in symptom-formation. Thus, even a direct statement linking cause and symptom was often devoid of meaning—”Every time I have a grudge, I get awful chest pains”; “Whenever I get angry, I cannot sleep”;. “I get this headache each time I try to make my husband listen to me.” The component of anger, despite knowledge of its source, was soon dissipated and its meaning lost as soon as the somatic symptom came forth.
Women did not seem to find as much difficulty as the men in verbalizing irritation, resentment, and even anger. Probably this is because she would temper her vituperations with petulance, whining, self-pity, injured airs, pouts, and tears—all of which tend to dilute her aggressiveness. “I think I’m sick, from years of keeping it all to myself,” was one woman’s direct, angry opening statement when first seen.
Several tried counteracting anger with other measures. Eight women took tranquilizing pills specifically to dampen rage. One woman, however, took a handful of Noludar pills to give her courage whenever she ventured forth to wage war on her mother- in-law. Obsessional thoughts raged on uncontrollably to cover up angry feelings in women whose personality tended toward obsessive- compulsive mechanisms. One elderly woman fought four-letter words which had a penchant for coming to mind whenever she was praying. Her prayers were intended to help her with a delinquent son whom she wanted to throw out. One housewife, also quite religious, exhausted herself in self-debates as to whether she was really married to her husband or not. In reality, there was no basis for doubting it, yet she weighed every bit of detail of the wedding for or against its validity. The frustrations and resentments of her married life were elaborately concealed by these mechanisms.
Children and maids often bore the brunt of angry feelings originally intended for the parents or the husband. More frequent scolding and in several instances, physically hurting the maids or the children, by spanking, pinching or slapping were clear displacements of aggression, although justifications for such acts were claimed. With the children, guilt and regret were often expressed afterward. With the maids, there was less undoing.
Women had a tendency to focus anger on one person, usually someone outside the family, and vent on that person all kinds of accusations. It approximated the proportions of a delusion. A Western psychiatrist would seriously entertain an impression of paranoidal processes. However, the situation was one where the patient knowingly exaggerated the truth to make herself the object of pity and also allowed her to ventilate her angry feelings. Thus, she could choose as her object a maid, an in-law, a neighbor, even a friend. Whenever the Filipino woman patient, particularly the young, single and emotionally unstable, cried out that everyone was talking about her or that the boys were always trying to get fresh with her or that an envious rival was out to discredit her, she was nor being paranoid. She knew in each case what she was saying; she recognized reality limits and in a distorted way was helping herself to feel better.
The hysterical outburst seemed to be the ace up the woman’s sleeve when tensions become unbearable and she had to let go. At least 80 women in the group mentioned having had one or more hysterical outbursts. Western (American) female patients are not completely exempt from this type of behavior, but they show it less frequently. They tend to have better behavior control and instead give verbal expression to their anger. The standard form of the outburst in Filipino patients is that of shouting, screaming, crying, finally collapsing in a state of exhaustion. The whole episode usually takes about five, no more than ten, minutes.
Each woman added her own particular touch. Throwing and breaking things was common. One housewife threw all the plates on the floor after her silent endurance of non-cooperation from a sister-in-law was exhausted. Two women tried to put their house on fire. Another two had fired a gun; one was about to, but her husband stopped her. Others thrashed about, head-banged, or pounded doors and furniture: In one extreme case, a 35-year-old housewife screamed, shouted, cried, tore off her clothes, cut her hair, struck the maids, ran in the rain, and finally sprawled and kicked on the floor. A few, with less propensity for histrionics, impulsively and without serving notice left home and husband, either returning to mother or, in the case of two women, suddenly moving into an apartment to get the husband away from his family. One woman had the habit of driving the family jeep at high speed whenever enraged. Two young girls in fights with boyfriends resorted to a pattern of scratching them, tearing their shirt, and crying at the same time.
Rarely did these hysterical outbursts occur outside the home. Less than ten episodes took place in the office, inside the family car, or had commenced in church, finally reaching its climax at home. Hardly anyone was hurt physically, and only in rare instances did the woman have to be subdued physically. The whole outburst has little aggressive contents. In some, it resembled very much a childish temper-tantrum. In most, it served merely as a momentary release of tension. The patient tended to regard it without much regret or embarrassment. There was little ability to correlate it with the frustrating situation or with the pent-up anger which had triggered it off in the first place.