Angry Society, Hwa-byung and Korean Medicine

 Anger is a basic emotion intended to deal with survival and self-protection. Anger takes place naturally as a reaction to stimuli. However, if anger is not controlled outside of one's own control, it turns aggressive and destructive or, in the worst-case scenario, gives negative effects on others, the society, or sometimes even oneself. This is when anger becomes a negative emotion. Along with depression and anxiety, anger is on of the three negative emotions of human beings and is the most dangerous emotion that not only experiences intense displeasure, but also destroys human relationships by triggering aggressive behavior.

Anger may simply be an emotion, but due to the human body’s reaction to the emotion, anger causes a variety of physical symptoms. However, anger is not a persistent one. After it is triggered, it does not stay in the anger state, but changes to different aspects. When we say the anger is successful, it naturally disappears, but when frustrated, it turns into different emotions―such as anxiety or depression. And the emotions implemented in this way are sometimes diagnosed as clear diseases, namely, anxiety disorders and mood disorders. In other words, it simply began with anger, but resulted in anxiety and depression, until it is finally diagnosed as a mental disorder. This is why anger is not treated as a major emotion when classifying or diagnosed as mental disorder. And hospitals or clinics for psychiatry may not be that much interested in treating anger since it is not included in the diagnosis of mental disorders. However, to the point that the term “angry society” is widely used by the people, it is now becoming a social problem. Moreover, the relationship between anger and cardiovascular diseases centered on hypertension can no longer be ignored in the medical field.

It is Hwa-byung that describes anger as a disease in the medical field. Hwa-byung deals directly with anger. Starting with resentment and chagrin, it is closely related to the explosion of anger and causes various physical symptoms such as surge or frustration, which is sometimes diagnosed as depression or somatoform disorder. If we observe the phenomena arising from the anger in everyday life, we can tell that it has the same context with Hwa-byung. The symptoms of Hwa-byung―such as resentment, chagrin, chest tightness, surge, and hot flash―are highly related to anger, and the two shows the same flow: switch from anger to depression or anxiety and showing of various physical symptoms. Thus, Hwa-byung can become a useful concept of disease for diagnosing, treating, and assessing anger. Moreover, there are medicines as well as treatments which provide solutions to resolve anger.

Anger is the primary emotion that we experience when stressed which then leads to anxiety and depression. And because of this, Hwa-byung is necessary to understand the mental health since it directly deals with anger. Moreover, we can find a solution to the overall mental health focusing on both Hwa-byung and anger. Understanding Hwa-byung, which was created under the concept of disease in Korean Medicine, can give us a clue to solving the anger issues of our society.

1. Anger

Anger is an emotion that helps you protect yourself from attacks by others in response to a state of physical pain, and helps you act toward your goal when you’re frustrated and your goal is blocked by the outside world. However, under short-term, chronic, or traumatic stress experiences, humans experience a disruption of emotional or physiological homeostasis; and for the individual's response to stress, the following events take place: emotional arousal which is mainly caused by stress factor; physiological activation of the central nervous system; increase of hormones in the hypothalamus-pituitary-adrenal (HPA) axis; and finally, appearance of coping responses at the psychological and behavioral levels. And, the disruption of emotional or physiological homeostasis can cause psychiatric disorders or mental and physical disorders, including difficulty in controlling emotions. Chronic stress raises the base levels of hormones, disrupting the rhythm of hormone release.

Anger is a response to a stimulus. When an individual receives a stimulus, one becomes resistant through judgment in a very short time, and when one resists, the autonomic nervous system operates and the sympathetic nervous system shows hyperactivity, causing various reactions in the human body. In response to stress, the first reaction of individuals is resistance, and, emotionally, anger. When resistance and anger occur together, this is when aggression appears, which is sometimes led to behavioral anger. This kind of short-term response occurs in a state where the sympathetic nervous system is overactive, and when this state is kept unresolved after series of stressful events, it then transforms into anxiety or depression, resulting to various physical symptoms. It can be seen that changes in the human body in response to the external stimuli eventually result in various changes over time in the process of overcoming or failures while the human body resists to the stimulus. It primarily starts with anger and is switched to anxiety, depression, and various physical symptoms.

The key characteristic of anger is a matter of control. Which means, the activation, expression, and experience of anger occur without proper control. In addition, the emotion of anger is mainly caused by: anger due to personality disorders, post-traumatic anger, attention deficit hyperactivity disorder (ADHD), alcohol-related disorders, neurosis, and depression. In Korean society, pathological anger appears in the form of Hwa-byung. And combining these studies together, we can see that under mental disorders, anger is not separately treated like anger disorder. Rather, it is explained throughout the types of mental disorders, informing us that Hwa-byung can result to mental disorders.

nger is also associated with physical diseases; in particular, it is closely related to cardiovascular diseases because it affects the autonomic nervous system in hypertension state. There are different explanations for anger suppression and anger expression in anger: anger expression is known to be associated with the risk of cardiovascular diseases such as stroke or ischemic heart disease, while emotional suppression, including anger, increases mortality from cardiovascular diseases or cancer. Studies have shown that anger suppression is closely associated with cancer or pain conditions such as more severe chronic back pain, higher pain sensitivity, and higher pain intensity.

Anger is an immediate response to a stimulus; it disappears over time. If anger is just an immediate response and an emotion that disappears naturally over time, then securing time and removing the stimulus will be all the countermeasures. However, anger sometimes appears as a kind of temperament or personality. In other words, the response is sensitive to stimuli, and therefore, can be a problem if the response is impulsive or sometimes aggressive.

There is a state of anger as a state felt at the moment―like a subjective feeling expressed in various intensity levels ranging from a state not knowing what to do to fierce anger―which is evaluated as state anger. However, there is also a characteristic called trait anger which is our own personality tendency that we usually feel, such as the tendency to be conscious of being angry and experiencing frustration in a wide range of situations. Anger attitude or trait anger may be broadly divided into feeling anger emotions (emotion), taking aggressive actions (behavior), and recognizing to be cynical and pessimistic (cognition). Anger gives multidimensional problems, including pathological problems, disease problems, and personality problems starting with physiological phenomena. Spectrum disorder is a mental disorder that includes several linked status and sometimes extends to include a single symptom with several characteristics.

Schizophrenia, mood disorder, and autism are described as separate spectrum disorders in the field of psychiatry, but from the perspective of the human body's response to stimuli, mood (affective) disorders, neurotic, stress-related, and somatoform disorders covered in mental and behavioral disorders of ICD-10 (International Classification of Diseases) can be considered as a spectrum disorder.

2. Hwa-byung

Hwa-byung, an anger syndrome listed in DSM-IV, is introduced as a syndrome caused by suppression of anger and the symptoms include insomnia, fatigue, panic, fear of impending death, depressive affect, indigestion, loss of appetite, difficulty in breathing, tachycardia, general pain, and feeling to have lumps in the upper abdomen.

In Western psychiatry, emotional responses such as resentment, chagrin, and anger were considered to be improperly suppressed and accumulated over a long period of time, and it suggests that Hwa-byung is a kind of anger disorder. In Korean neuropsychiatry, Hwa-byung is considered that a prolonged accumulation of anger feelings is changed to heat, and then the heat affects the heart, resulting in Hwa-byung. In other words, it was seen as a disease caused by suppression of the long-term stress-induced anger, resulting in symptoms such as heat, frustration, surge, and feeling to have lumps.

After all, from a psychiatric point of view, both Western and Korean medicine see Hwa-byung as a mental disorder that is closely related to anger. There is also an opinion that Hwa-byung can be seen as a type of functional somatic syndrome. Functional somatic syndrome refers to a physical condition that is not well-explained, and includes chronic fatigue syndrome, fibromyalgia, chronic systemic pain, temporomandibular joint disorder, and irritable bowel syndrome. In addition, psychological trauma or stress makes it easy to develop the functional somatic syndrome; in Hwa-byung, characteristic physical symptoms such as heat, frustration, surge, and Globus pharyngis occur due to the suppression of anger.

Hwa-byung becomes more vulnerable to stress with repeated anger, developing into several mental disorders or comorbidity. Thus, considering the relationship between the human body's response to stress, the progress of Hwa-byung, and the emotional problems in response to Hwa-byung, mental disorders can be approached from a spectrum perspective.

The concept of Hwa-byung keeps changing as times change. It has had the nature of chronic disorder caused by continuous suppression of anger, but nowadays, changes are seen in the pattern of Hwa-byung with the decreased level of patience and the prominence of anger explosions and behavioral symptoms. Despite the fact that aspects that are different from previous diagnostic guidelines are already seen and the concept of acute Hwa-byung is being brought up, people still focus on the expression of anger rather than the patience of typical Hwa-byung, including the anger behavior caused by the immediate expression of anger in the diagnostic tool. There are also differences by gender and age, indicating that Hwa-byung is expanding to universal disease, not specific targets.

The prevalence of Hwa-byung is very high, ranging from 4.2% to 13.3%. Many cases are seen in which Hwa-byung results to depressive disorder, somatization disorder, anxiety disorder, or even comorbidity; especially in the case of depression, it is explained that the comorbidity rate is over 60%. The prevalence rate of depression also ranges from 4-7%, which is similar to that of Hwa-byung. Among the classifications of diseases and causes of death, as described in the Korean Medicine, Hwa-byung is equivalent to mental and behavioral disorders, which include mania and depression. Since this code is a code described in the field of Korean Medicine, it can be said that it is used as a diagnosis name for Korean Medicine when it is difficult to apply a general code. It can also be used in the clinical field of Korean Medicine. In the case of the diagnosis of depression, which is used both in Western and Korean medicine, it is surveyed that the number of people with depression increased from 601,152 to 796,364. It can be said that the content of the traditional Korean Medicine disease concept is gradually decreasing because the Korean standard classifications of diseases and causes of death are actively used in the medical field of Korean Medicine. However, the concept is still widely used because of the clear characteristics of Hwa-byung. Since depression has a high comorbidity rate with Hwa-byung, it is necessary to present the necessity to treat Hwa-byung among patients who are treated for depression through studies on Hwa-byung and depression in the future.

Although emotions are said to be functional, they become the subject of treatment when emotions go beyond the range of control. “Antidepressants,” which treat depression (mood disorder) with symptoms of depression, and “anti-anxiety drugs,” which treat anxiety disorders with symptoms of anxiety, can be immediately known by their names that problems in emotions lead to disease and medication. However, the emotion of anger, which is easily encountered in everyday life, is not diagnosed as an anger disorder. Besides, the “anti-anger drug” that treats anger has not been yet developed. These days, when anger is constantly rising, the pain you have is not even diagnosed as a disease, and, on top of that, you can't find a drug to calm it down in hospitals or pharmacies. People are suffering a lot from the angry society. However, if one evaluates anger as a response to a stimulus and judges that it is an emotion that disappears naturally over time, no one could solve the problem. The measures for diagnosis and treatment should be established from the point of view that anger is a response to a stimulus, is a personality or characteristic of an individual, and causes various mental and physical symptoms that can lead to diseases and disorders. Hwa-byung, which started from the concept of disease in Korean Medicine, can occupy an important position in solving anger. Korean Medicine is presented to solve the problems in anger and Hwa-byung, and on the spectrum of anger due to these.

1) Since anger is the emotion that is first revealed by stimulation, it is very important as a starting point in terms of the spectrum of mental disorders that encompasses anxiety disorders and mood disorders. In Korean Medicine, anger is defined as the most lethal emotion among the seven feelings. In addition, emotions are complex products that are linked not only to mental problems but also to physical symptoms. Especially, since it has characteristics and works based on changes in qi, it also has connection with the treatment strategy. Through this perspective, we can approach the development of countermeasures and treatments for resolving anger, and it is expected that a solution for all mental disorders through the spectrum of mental disorders will be prepared.

2) Anger is approached from the perspective of constitution and temperament because both the state and the human characteristics are important. If seven feelings are to see the state, anger is considered to be one of the characteristics of the Aenohuirak (sorrow, anger, joy, and pleasure) suggested by Sasang Constitutional Medicine. There is also a study that analyzed the relationship between the constitution of Sasang Constitutional Medicine and anger that corresponds to this. This means that the constitution is related to the personality of humans and also to aggression or impulsivity, suggesting that anger management measures can be created according to constitutional deviations. In addition, it is expected that the temperament, the response to stress, and the concept of ordinary symptoms explained in Sasang Constitutional Medicine can serve as an axis to explain the spectrum of mental disorders.

3) Korean Medicine has a model for mental disorders caused by anger and it is Hwa-byung. The “Hwa” in Hwa-byung reflects the characteristics of anger and is a concept consistent with the five elements of the theory of Korean Medicine. And because of its clear characteristics, treatment strategies need to be established accordingly. Even if there is no possibility for the development of anti-anger drugs, we have what we call cheongyeol (antipyretic) drugs, where anger can be controlled through the mechanism of cheongyeol. Acupuncture also stems from the accumulation of resentment and chagrin in Hwa-byung. Especially, emotional suppression means condensation of emotions and response to specific blood levels corresponding to this, and therefore, a treatment strategy can be established. In Korean Medicine counseling, methods to control anger are sought in the same way as yangsaeng (maintaining body and mind healthy for longer life).

4) Lastly, we need to pay attention to Hwa-byung that changes according to the times and environment. There is a need to apply the concept of Hwa-byung according to the various situations that are currently taking place. In Hwa-byung that has paid attention to the manifestation of physical symptoms due to the accumulation of resentment and chagrin, issues of expression of anger, especially behavior, have been raised according to changes of time, and immediate responses have become an issue, which are raising issues such as acute Hwa-byung. It should be approached in consideration of the diversity of issues such as gender, age, and period. As the times change, the patterns of trauma are also changing and infectious diseases such as COVID-19 are causing a variety of problems. And in such situations, access to Corona Red beyond Corona Blue can be attempted through Hwa-byung.

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