Hwa-byung (anger syndrome) is a psychiatric condition wherein patients suppress rather than express negative emotions such as anger. Anger has unique features in Korean culture, ¹ such that hwa-byung is classified as a culture-related syndrome in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).² Hwa-byung usually develops in people who suppress their anger in repetitive conflict situations over a long period of time to avoid endangering amicable social relationships.³ Generally, individuals with hwa-byung recognize anger as the cause of their illness,⁴ but use defense mechanisms such as suppression, inhibition, and compliance to cope.³ While anger is the principal psychological symptom of hwa-byung, other symptoms include fatigue, panic, fear of impending death, depressive affectivity, indigestion, anorexia, shortness of breath, tachycardia, systemic pain, and the sensation of a lump in the epigastric region. ² Elderly women and individuals with lower educational and economic status are at higher risk for developing hwabyung compared to the general population.⁵

Anger is defined as an emotion that includes a state of physiological arousal and coexists with imaginative or intentional behaviors that culminate in inflicting injury on others.⁶ Alternatively, aggression is defined as destructive and punitive behavior towards others.⁶ There is a significant correlation between anger and aggression; people who exhibit higher trait anger are more likely to react aggressively.⁶ If anger and aggression are not well-controlled in terms of intensity, frequency, and duration, they can produce negative effects on health, such as high blood pressure, cardiovascular diseases,⁷ pain,⁷⁸ digestive symptoms,⁸ and mental disorders including hwa-byung,⁹ depression,¹⁰ dementia,¹¹ and suicide.¹²

Until recently, hwa-byung was generally regarded as a common emotional expression or variant of depression among Koreans.⁹ Thus, most hwa-byung patients are diagnosed with depression in accordance with the DSM-IV criteria in clinical settings.¹³ A recent study examined differences between hwabyung and clinical depression and determined that hwa-byung was more likely to be a unique psychiatric syndrome rather than a variant of depression.¹ However, few studies have examined the differences between anger and aggression in hwabyung and depression. Moreover, despite the fact that hwabyung is more prevalent in elderly people, no study to date has examined these differences in elderly patients. Therefore, we investigated differences in anger, aggression, and depression severity in elderly South Koreans with hwa-byung and depression.

In this study, we identified specific differences in the magnitude of anger, aggression, and depressive symptoms between elderly patients with hwa-byung, those with depression, and control subjects. Specifically, state anger score in the STAXI, verbal aggression and anger scores in the AQ, and unpleasant encounter scores in the RI were significantly associated with hwa-byung. Our data show clear differences in the clinical manifestations of hwa-byung and depression in elderly South Korean patients.

When comparing the severity of depressive symptoms between patients with hwa-byung, patients with depression, and control subjects, the hwa-byung group showed significantly higher scores on the observer-rated HDRS and the self-reported BDI and GDS scales than the depression and control groups. Notably, patients with hwa-byung or depression in this study displayed stabilized symptoms following pharmacological treatment as outpatients. It is therefore possible that patients with hwa-byung, who experience high degrees of anger and chiefly use defense mechanisms for emotional control, were more liberal in the evaluation of their depressive symptoms than were patients with depression. Min et al.²⁷ suggested that comorbidity and mixed forms of anger, anxiety, and depressive disorders are quite common and that the chronic suppression of anger related to stress can lead to symptoms of depression. Min et al.²⁷ specifically found that HDRS score was significantly correlated with most symptoms of hwa-byung. Although our study did not examine correlations between depressive scale items and hwa-byung symptoms, it is possible that the symptoms of hwa-byung influence depressive symptoms. As our study did not evaluate responsiveness to drug treatment, character, or defense mechanisms, these issues should be addressed in future studies comparing hwa-byung and depression.

We also compared the experience and expression of anger and aggression between different groups. Patients with hwabyung had significantly higher scores than depression patients for 3 STAXI subscales: state anger, which measures the baseline sensation of anger; trait anger, which assesses the tendency to feel anger and aggression during ordinary circumstances; and anger expression, which measures the expressive aspect of anger. Furthermore, patients with hwa-byung showed significantly higher scores than patients with depression for physical aggression, verbal aggression, anger, and hostility on the AQ. Patients with hwa-byung also showed significantly higher RI subscale scores than patients with depression. Notably, the RI measures anger reactions to circumstances that normally evoke anger, including unpredictable disruptions and disturbances, embarrassing circumstances, personal disrespect, and unpleasant encounters. These results are consistent with the results of other studies in adult patients with hwa-byung.³²⁸ Depression patients also had significantly lower scores than control subjects for anger reaction, anger-in, anger-out, and anger control on the STAXI; verbal aggression and hostility on the AQ; and anger reaction to unpredictable disruptions and disturbances, embarrassing circumstances, and personal disrespect on the RI. This is consistent with the idea that depression patients have an impaired ability to recognize internal emotional states including anger,²⁹ and may be fearful of expressing anger.³⁰ Future studies should examine this trait as a key factor for differentiating clinical depression from hwa-byung.

To investigate the effects of anger and aggression on the development of hwa-byung, ORs were computed using the STAXI, AQ, and RI subscales. For the STAXI, increases in state anger score significantly increased the risk of hwa-byung (OR: 1.27; 95% CI: 1.092-1.477). On the AQ, increases in anger score also significantly increased the risk of hwa-byung (OR: 1.12; 95% CI: 1.001-1.259), whereas increases in verbal aggression score decreased the risk of hwa-byung (OR: 0.90; 95% CI: 0.805-0.994). For the RI, increases in the score for anger reaction to unpleasant encounters significantly increased the risk of hwa-byung (OR: 1.33; 95% CI: 1.096-1.622). These relationships are in agreement with the concept that hwabyung is caused by a continued state of high anger, emotional suppression, and the partial or insufficient expression of anger and aggression.³ Therefore, hwa-byung may be preventable or treatable with education and re-training for the appropriate expression of feelings. These findings were obtained in a retrospective fashion, such that causal relationships with hwa-byung remain unclear. Future studies are needed to identify methods for the prevention and treatment of hwa-byung.

The present study had several limitations. First, small sample sizes limited the statistical power of our study. Second, there were significant differences in age and sex between the 3 groups, and subjects were sampled from different regions, such that our cohort may not be representative of the entire elderly population in South Korea. Third, we did not select patients based on whether they were receiving treatment, nor did we analyze medication data. Finally, although a hwabyung scale with verified utility and reliability was used to diagnose hwa-byung, the results in our cohort may not be accurate because the scale was not developed for patients over the age of 65.

This study is the first of its kind to investigate differences in symptomatic manifestations of anger, aggression, and depression between elderly patients with hwa-byung, those with depression, and control subjects. Moreover, this study explored the effects of anger and aggression on the development of hwabyung. Elderly patients with hwa-byung generally showed significantly higher scores than depression patients on the HDRS, BDI, and GDS and on subscales of the STAXI, AQ, and RI. Additionally, high scores on the state anger STAXI subscale, AQ anger subscale, and anger reaction to unpleasant encounters RI subscale were associated with an increased risk of hwa-byung, whereas a high score on the verbal aggression AQ subscale decreased the risk of hwa-byung. These findings identify emotional suppression as a pathological basis for hwa-byung and show important clinical differences between hwa-byung and depression that should be considered in future studies and clinical contexts.