1. Background and Purpose
Among negative emotions, depression, anxiety and anger, Hwabyung is a traditional concept of Korea’s disorder caused by the anger. According to American Psychiatry Association (APA)’s 『Diagnostic and Statistical Manual of Mental Disorders (DSM)』 Hwabyung is not classified as anger related disorder, but
instead at 4th addition’s appendix it had been described as Korea’s Culture Bound Syndrome. However, Hwabyung had been removed from 5th addition of DSM as the overall concept of Culture Bound Syndrome shrunk.
Hwabyung is a neuropsychiatric disease that is frequently observed in primary care and has a prevalence of approximately 4.2~13.3% in Korea. However, close attention is needed in clinical practice, as Hwabyeong shows chronic progression and is often accompanied by other diseases. Moreover, the morbidity is prolonged, and Hwabyung may show similar symptoms to that of physical illnesses, such as climacteric syndrome and thyroid dysfunction.
In Korea, the Clinical Practice Guidelines for Hwabyung was published in 2013; however, the guidelines were not developed according to the methodology of evidence-based medicine. the guidelines did not reflect recent changes in the clinical setting or the latest evidence, and therefore, had to undergo a revision.
Considering the culture-bound nature of Hwabyung, most studies have been conducted in Korea with a relative lack of international clinical trials or clinical practice guidelines. thus, we aimed to include more studies that may involve Hwabyung patients, even if they offer indirect findings, to garner more evidence for the guideline revisions.
Current medical community does not handle ‘anger disorder’ as a individual form of disorder. Yet few studies, studies about other psychiatries or physical disorders measure anger index as a accompanied emotional characteristic of disorder, but these studies only verify association between anger and its original disorders. this Clinical Practice Guidelines development committee judged that Hwabyung should be considered when some disorders accompany anger and the necessity of develop Guidelines for ‘Hwabyung comorbid with other disorder’.
As a part of this process, we selected studies examining anger symptoms in depression and hypertension, which were reported to be highly comorbid with Hwabyung according to the 2013 Clinical Practice Guidelines for Hwabyung. We also selected studies examining anger symptoms in climacteric women,
which are considered as traditional Hwabyung manifestations. Moreover, occupational stress has surfaced as a major issue in recent years; therefore, we determined it necessary to include mind-body intervention for anger management in workers in addition to the traditional Hwabyung treatment plans among the working population.
To revise the Clinical Practice Guidelines for Hwabyung, a steering committee and development committee were organized within the Korean Society of Oriental Neuropsychiatry, and revision plans were established by analyzing and reviewing the existing Clinical Practice Guidelines for Hwabyung. We
have strived to re ect the latest evidence, expert experiences, patient values and preferences, and primary care in traditional Korean medicine in these proposed clinical practice guidelines (CPGs) according to evidence-based medicine methodologies. the revised Standard Korean Medicine CPGs for Hwabyung deals with the etiology and pathology of Hwabyung more thoroughly compared to the existing CPGs for Hwabyung and contain clinical questions pertaining to counseling and meditation that are utilized in clinical practice.
For these CPGs, key questions were selected through a process equivalent to that of de novo development, and systematic reviews and meta-analyses were conducted regarding Korean and foreign studies related to Hwabyung. the level of evidence and strength of recommendations were written based on these
results, and these guidelines were finalized per expert agreement through a Delphi survey.
2. Overview of disease
1) Hwabyung
Hwabyung is a syndrome characterized by explosive manifestations of negative emotions, such as anger, as a result of failure to relieve these emotions. Physical symptoms include chest pressure, a sensation of heat, surges of anger, and a sense of epigastric mass; other symptoms include a feeling of unfairness and anger, bitterness, and han (恨). these symptoms are related to distinct stress events.
Although the existing classification of mental disorders clearly distinguishes between mood disorders, such as depression (depressive disorder) and anxiety disorder, it fails to appropriately describe the criteria and scope of mental disorders related to anger. thus, western medical institutions only treat Hwabyung
patients for other comorbidities and manifested symptoms, as opposed to giving the diagnosis of, and subsequently, treating Hwabyung. therefore, Hwabyung care is exclusively given by Korean medicine doctors (KMDs).
