Hwabyung (Korean “anger syndrome”): symptoms, causes, how it differs from depression and what helps

Hwabyung is a Korean term for a state in which anger, built up over a long time of holding in a sense of being wronged, comes out as physical and emotional symptoms. The Korean Medicine clinical practice guideline for hwabyung, published in 2021 by the Korean Society of Oriental Neuropsychiatry (here, the hwabyung guideline), describes it as a syndrome in which negative emotions such as anger that cannot be resolved burst out in the form of hwa (anger, fire). Physical symptoms include a tight, heavy chest, a feeling of heat, a surge rising up from inside and a feeling of a lump in the throat or the pit of the stomach; emotionally, there is a feeling of being treated unfairly and resentful, and a lasting knot of grievance or han, and these symptoms are tied to clear stressful events (Korean Society of Oriental Neuropsychiatry, 2021). One analysis notes, however, that its onset is relatively gradual rather than right after an event, and not closely tied to a specific event (Joe et al., 2017).

Hwa means both anger and fire, and byung means illness. The Korean psychiatrist Sung Kil Min describes hwabyung as a chronic anger syndrome in which anger that has been held in for a long time and become dense is partly suppressed and partly expressed. The most typical symptom is a feeling of heat, mainly in the upper body, which can come with flushing, a sense of boiling inside, sweating and not being able to stand hot places, so that people want to go outside. Palpitations and a dry mouth are also typical, and it can show in behaviour as irritability or quarrels, tears of anger, pleading talk that is hard to stop, and frequent sighing (Min, 2008). A study of patients who saw themselves as having hwabyung proposed feelings of unfairness, subjective anger, expressed anger, heat, a pushing-up feeling in the chest, a dry mouth and sighing, which were linked with anger only, as core symptoms for the diagnostic criteria, and also proposed a stuffy chest, han and hatred, linked with both anger and depression, as characteristic symptoms (Min et al., 2009).

In everyday Korean, people use “I’ve got hwabyung” more loosely. Min notes that people use the word not only for built-up anger but also for bodily discomfort from long-term stress, or for how they feel after a shocking event (Min, 2008). So the same word can mean different things to different people.

mind.io does not offer a hwabyung test. Researchers and clinicians assess it with interviews and tools such as the Hwa-Byung Scale (Kwon et al., 2008), but this guide gives no items or cut-off scores. The depression check-in (PHQ-9) and the anxiety check-in (GAD-7) are not hwabyung tests, but they look at depressive and anxiety symptoms over the past 2 weeks, which often come with hwabyung. No self-check result is a diagnosis.

Korean psychiatrists have discussed hwabyung since the 1960s and studied it systematically since 1977 (Min, 2008); in English-language research, it was first introduced in a 1983 case report in an American psychiatry journal. The three patients in the report felt a lump in the pit of the stomach that could not be found on examination, along with a fear of impending death that medical reassurance did not easily dispel (Lin, 1983). In 1994, hwabyung was listed in the appendix glossary of culture-bound syndromes in the fourth edition of the American Psychiatric Association’s diagnostic manual (DSM-IV) (Min, 2008). A study citing the US diagnostic criteria summarised anger as its main psychological symptom, with fatigue, panic, fear of impending death, low mood, indigestion, loss of appetite, shortness of breath, a fast heartbeat, aches all over and a feeling of a lump in the pit of the stomach as other symptoms (Im et al., 2017).

The fifth edition (DSM-5), published in 2013, replaced the concept of “culture-bound syndromes” with three concepts, including “cultural syndromes” (Lee et al., 2014), and the hwabyung guideline explains that hwabyung was dropped from DSM-5 as that concept narrowed (Korean Society of Oriental Neuropsychiatry, 2021). Korea’s own classification of diseases has included hwabyung as a Korean Medicine diagnosis code (U22.2) since its sixth revision (Kwon et al., 2024). According to the hwabyung guideline, however, Western medical clinics do not diagnose hwabyung itself but treat the conditions and symptoms that come with it, and care under the name hwabyung is given by Korean Medicine doctors (Korean Society of Oriental Neuropsychiatry, 2021).

Whether hwabyung is a disorder of its own has long been debated. A study that interviewed 109 Korean Americans found major depression more often among those who said they had had hwabyung, and suggested it may be a culturally familiar way for Koreans with depression to express it (Lin et al., 1992). Min, by contrast, argued that its symptoms centre on anger and differ from depression, and proposed classifying it as a new “anger disorder” (Min, 2008). Since the 1970s, Korean doctors have explained hwabyung between the traditional idea of constrained fire and the DSM’s depressive disorders (Suh, 2013), and a 2021 review noted that hwabyung is not reflected in DSM-5 (Suh et al., 2021).

How common hwabyung is depends heavily on how it is defined and who is surveyed. The hwabyung guideline gives a prevalence of 4.2 to 13.3% in Korea (Korean Society of Oriental Neuropsychiatry, 2021). A survey of a rural area reported in 1990 found hwabyung in 4.1% of residents (Min, 2008), and in a study of 2,807 women aged 41 to 65 in 7 large cities and 6 provinces, 4.95% said they had experienced hwabyung. In that study, the share was higher among women of lower socioeconomic status, women living in rural areas, women who were divorced or separated, and women who smoked or drank (Park et al., 2001).

A 2017 study that used set diagnostic criteria and interviews found a lower rate. Of 290 people aged 12 to 75 with no psychiatric history, 2.1% (6 people) met the criteria for hwabyung, and 3 of them were men. The researchers suggested earlier rates were higher because most past studies counted people who labelled themselves as having hwabyung. This study, however, recruited its sample in a single city (Joe et al., 2017).

Hwabyung is known to be more common in women from middle age on, but it is not limited to women. In Korean health-insurance figures cited in the hwabyung guideline, 13,757 people were treated under the hwabyung code (U22.2) in 2017, 2,841 of them men. The number of men had risen by 25.9% since 2013, while the number of women had fallen by 6%. People in their 60s were the largest age group (22.6%), but among men alone, those in their 40s were the largest (20.3%) (Korean Society of Oriental Neuropsychiatry, 2021). In 2019, 14,064 people were treated for hwabyung (Suh et al., 2021). These numbers count people treated, not how many people actually live with hwabyung.

Younger people are not exempt either. In a 2024 online survey of 449 Korean adults born between 1980 and 2005, 36.3% scored above the symptom cut-off of the Hwa-Byung Scale, at similar rates among men (84 of 240) and women (79 of 209). With other factors taken into account, women were more likely to score above it (odds ratio 2.314), but these were self-reported answers from a survey company’s panel, not diagnoses, and the researchers noted that the sample may not represent the whole generation (Kwon et al., 2024).

In a 1992 study that interviewed 109 Korean Americans, 12% said they had experienced hwabyung, with no apparent sociodemographic differences between those who said so and those who did not (Lin et al., 1992).

Hwabyung often comes with depression and anxiety. In a study of 280 patients treated for depressive, anxiety, somatoform or adjustment disorders or who labelled themselves as having hwabyung, 183 met research diagnostic criteria for hwabyung; 47 of them had hwabyung alone, and the rest also had other diagnoses, most often major depressive disorder or generalised anxiety disorder (Min & Suh, 2010). The Korean national mental health portal likewise describes hwabyung as emotional symptoms such as heartache, anger, hatred and low mood together with physical ones such as chest pain, heat and tightness, and says it looks like a mix of depressive disorder and somatic symptom disorder (National Mental Health Information Portal, 2020).

There are differences, though. In a study of 89 patients who labelled themselves as having hwabyung, feelings of unfairness, subjective anger, expressed anger, heat, a pushing-up feeling in the chest, a dry mouth and sighing were linked with anger but not with depressed mood (Min et al., 2009). In a study comparing older patients, on the other hand, the 58 with hwabyung had higher depression scores as well as more anger than the 180 with depression (Im et al., 2017). That is why, if you feel you have hwabyung, it is worth checking for depression and anxiety too.

Hwabyung symptoms can also be linked with thoughts of suicide. A 2024 online survey of 457 Korean adults born between 1980 and 2005 with no history of mood disorders found that people with higher hwabyung symptom scores were slightly more likely to say they had thought about taking their own life in the past week. The link remained after depressive symptoms were taken into account but was only borderline significant (odds ratio 1.05), and the link with depressive symptoms was clearer (odds ratio 1.41) (Kwon, 2024). If you have thoughts of dying or of harming yourself, do not carry them alone: call or text 988 now in the US or Canada, call Samaritans on 116 123 in the UK or Ireland, or find a line at findahelpline.com elsewhere. In Korea, call 109 (24 hours, free). If you live outside Korea, a family doctor or your local mental health services are another place to start. If you are in immediate danger, contact your local emergency services.

Hwabyung also differs from intermittent explosive disorder, often called “anger disorder” in Korea. Intermittent explosive disorder is marked by short, repeated outbursts of aggression, such as verbal abuse, hitting or breaking things (WHO, 2025), whereas the anger in hwabyung is mainly felt inside and lasts a long time, partly held in and sometimes let out (Min et al., 2009). The core of the hwabyung criteria is an inner experience, such as feeling wronged and subjective anger, not aggression (Suh et al., 2021). Anger that erupts in outbursts is covered in how to manage anger.

Palpitations, heat and breathlessness can arrive together and feel like a panic attack, but Min explains that these hwabyung attacks usually come on and fade more slowly than panic attacks (Min, 2008). Even so, do not try to tell them apart yourself. Call your local emergency number at once (119 in Korea), rather than assuming it is hwabyung or panic, if chest pain or tightness comes on suddenly and does not go away, if the pain spreads to your arm, neck, jaw or back, or if chest pain comes with sweating, nausea, light-headedness or shortness of breath (NHS, 2023). The hwabyung guideline also says that physical conditions such as menopausal symptoms or thyroid problems can cause symptoms like hwabyung, so they should be ruled out early (Korean Society of Oriental Neuropsychiatry, 2021). For panic attacks, see panic attacks: what to do.

The cause most often named is unfair treatment that keeps repeating. According to Min, patients explain that they had to hold in their anger so as not to damage harmonious relationships, and that as anger-provoking situations repeated, the suppressed anger built up and grew dense. The most common trigger was unfair treatment within the family, such as violence by a husband or mother-in-law, and poverty, violence, discrimination, isolation, exploitation, business failure or missed promotion, loss of property, unfair court rulings, betrayal or fraud were also triggers (Min, 2008). If there is violence at home, your safety comes before managing anger. In immediate danger, call your local emergency number (112 in Korea). In Korea, the Women’s Emergency Line 1366 (24 hours) takes calls about domestic and dating violence; in the US, the National Domestic Violence Hotline answers at 1-800-799-7233; in the UK, the National Domestic Abuse Helpline is 0808 2000 247.

The Korean idea of han often comes up too. Min describes han as a complex feeling that mixes longing, sorrow, regret and low mood with hatred and a wish for revenge, and sees it as arising from personal or collective trauma, unmet wishes, suppressed anger or a sense of being wronged (Min, 2008). One analysis also distinguishes hwabyung from post-traumatic embitterment disorder, which centres on bitterness right after an unjust event, because hwabyung usually begins gradually amid long-term stress rather than after a single event (Joe et al., 2017).

A review that pooled 7 qualitative studies of patients’ experiences found four shared themes: anger flaring up, blaming a particular person or situation, physical and emotional symptoms that feel hard to control, and coping by putting up with things, compromising and getting by for now. The researchers concluded that because people with hwabyung feel as if they are losing control through emotional dysregulation and physical symptoms, professional support should be offered to help them cope (Suh et al., 2021).

Hwabyung has mostly been studied alongside the experiences of middle-aged women in a patriarchal family culture. The review that proposed this kind of explanation also warned, however, that applying it to all Koreans could reinforce stereotypes, and that not all Koreans hold traditional values (Lee et al., 2014). The studies above fit better with seeing hwabyung not as “a Korean women’s illness” but as distress that can arise in people who have long held in anger in situations they feel are unfair.

The 2021 hwabyung guideline used systematic reviews and expert consensus to give each treatment a grade of recommendation (A to D) and a level of evidence (high to very low). The strongest recommendation (A, moderate-certainty evidence) is for counselling, based on group counselling reducing hwabyung symptoms and anger scores compared with a waiting list. When the guideline was written, the only counselling approach with evidence in people with hwabyung was acceptance and commitment therapy (ACT). This recommendation rests on 2 quasi-randomised trials against a waiting list, with 39 people in total, and the general tendency to get angry (trait anger) did not change significantly (Korean Society of Oriental Neuropsychiatry, 2021).

Meditation is graded “should be considered” (B, moderate), based on 1 randomised trial that split 22 people with hwabyung between meditation and a waiting list; hwabyung symptoms, depression and anxiety fell more with meditation. Relaxation methods such as deep breathing, progressive muscle relaxation and autogenic training are also graded “should be considered” (B), but with very low certainty: the only study in people with hwabyung was a case report. The emotional freedom technique (EFT) did no better than the treatment it was compared with, but anger fell in both groups, so it is graded “may be considered” (C, low) (Korean Society of Oriental Neuropsychiatry, 2021).

Herbal medicine is graded “should be considered” (B, moderate), even though, pooled across randomised trials, it did not reduce hwabyung symptoms significantly more than placebo. The guideline gives as reasons that the placebo groups improved far more than usual and that hwabyung scores fell to a clinically meaningful degree after herbal treatment. For safety, it reports that in one trial mild indigestion was more common with the herbal medicine (27%) than with placebo (4.5%). Acupuncture worked better than no treatment but not significantly better than sham acupuncture, so it is graded “may be considered” (C, low); the guideline adds that the sham may not have been entirely free of needling effects. Pharmacopuncture, moxibustion and cupping, used for particular accompanying symptoms, are all graded “may be considered” (C, very low). The guideline also says that because people with hwabyung often have other stress-related conditions such as depression, anxiety or insomnia, herbal medicine should be given with interactions with the Western medicines they already take in mind (Korean Society of Oriental Neuropsychiatry, 2021). If you take prescribed medicines, tell your Korean Medicine doctor; if you take herbal medicine, tell your prescribing doctor too.

The guideline itself states that evidence is severely lacking because hwabyung research has been done only in Korea (Korean Society of Oriental Neuropsychiatry, 2021). Later systematic reviews point to the same limits. A review of 9 studies of mind-body approaches (5 of them randomised trials) reported that art therapy lowered hwabyung scores compared with a waiting list, but found problems with the reliability of diagnosis, assessor blinding and suitable control groups (Kwon & Lee, 2024), and a review of 9 psychotherapy studies (7 controlled trials) concluded that limits such as the lack of suitable control groups make high-quality evidence hard to obtain (Kwon & Lee, 2025). So be wary of anything advertised as a sure cure for hwabyung.

Psychiatrists diagnose and treat the conditions that come with it, such as depression or anxiety disorders, rather than hwabyung itself (Korean Society of Oriental Neuropsychiatry, 2021). Writing in 2008, Min noted that there had been no systematic drug trials for hwabyung itself, and suggested combining psychotherapy and medication to reduce anger, using anger management or cognitive behavioural therapy, and adding family intervention where an oppressive family situation is closely involved (Min, 2008). The hwabyung guideline also advises considering specialist psychiatric care, hospital admission and combined Western medical treatment when symptoms are severe or there is a psychiatric emergency (Korean Society of Oriental Neuropsychiatry, 2021). Use medicines only on prescription, and if you already take one, do not stop it suddenly on your own: talk to the prescriber first.

Neither holding anger in at all costs nor letting it all out is likely to be the answer. In one experiment, people who hit a punching bag while thinking about the person who had angered them became angrier and more aggressive (Bushman, 2002). Researchers who studied older patients suggested that expressing anger appropriately, rather than suppressing it, may lower the risk of hwabyung (Im et al., 2017). Ways to calm anger in the moment and to say calmly how you feel, such as “I” statements, are in how to manage anger, and breathing and relaxation to ease bodily tension are in how to relieve stress.

The meditation programmes the hwabyung guideline presents as usable for hwabyung are loving-kindness meditation and mindfulness-based stress reduction (MBSR). Because results can depend on the instructor’s skill, the guideline advises practising after guidance from an experienced Korean Medicine doctor (Korean Society of Oriental Neuropsychiatry, 2021). If life feels empty or you feel small and pitiful, see also how to build self-compassion.

The diagnostic criteria in the hwabyung guideline include difficulties with daily functioning, such as housework, work or relationships (Korean Society of Oriental Neuropsychiatry, 2021). If your symptoms have lasted a long time and these difficulties have appeared, do not struggle alone: see a doctor. If you have chest pain that comes and goes, or chest pain that went away quickly but still worries you, get it checked by a doctor (NHS, 2023).

If you live outside Korea, start with a family doctor or your local mental health services. In Korea, you can see a psychiatrist, or contact your city, county or district mental health welfare centre for counselling and referral to other services. The mental health crisis line 1577-0199 (24 hours) connects you to a nearby centre for counselling, mental health information and directions to medical services (Ministry of Health and Welfare, 2025). In 2026, a “mental health counselling voucher” (formerly the national “mind investment” programme) funds 8 sessions of professional counselling (at least 50 minutes each) for people with emotional difficulties such as depression or anxiety. You need proof such as a referral from a community mental health centre or university counselling centre, a psychiatrist’s diagnosis or opinion, or a PHQ-9 score of 10 or more from the national health check-up, and the co-payment ranges from 0 to 50% depending on health-insurance premiums. A mind.io self-check result does not count as proof (Ministry of Health and Welfare, 2026).

If you are so worn out that you wish you could disappear, do not carry this alone: call or text 988 now in the US or Canada, call Samaritans on 116 123 in the UK or Ireland, or find a line at findahelpline.com elsewhere. In Korea, call 109 (24 hours, free) or the mental health crisis line 1577-0199 (24 hours). If you live outside Korea, a family doctor is also a place to start. If you are in immediate danger, contact your local emergency services.

Q. Is there a hwabyung test? A. mind.io does not offer a hwabyung test. The hwabyung guideline points to a hwabyung interview, a structured diagnostic interview for hwabyung and a hwabyung symptom scale for assessment (Korean Society of Oriental Neuropsychiatry, 2021). The PHQ-9 and GAD-7 are not hwabyung tests; they look at depressive and anxiety symptoms over the past 2 weeks. Whatever any score says, if you have thoughts of ending your life, call or text 988 now in the US or Canada, call Samaritans on 116 123 in the UK or Ireland, or find a line at findahelpline.com elsewhere; in Korea, call 109 (24 hours, free). If you live outside Korea, a family doctor is also a place to start. If you are in immediate danger, contact your local emergency services.

Q. Is hwabyung only for middle-aged women? A. No. It has mostly been reported in women from middle age on, but of the 13,757 people treated for hwabyung under Korean health insurance in 2017, 2,841 were men, and among men those in their 40s were the largest group (Korean Society of Oriental Neuropsychiatry, 2021). In a 2024 online survey of younger adults, men and women scored above the Hwa-Byung Scale cut-off at similar raw rates (Kwon et al., 2024).

Q. If my chest feels tight and my heart pounds, is it hwabyung? A. It may be, but do not decide that yourself. Call your local emergency number at once (119 in Korea), rather than assuming it is hwabyung or panic, if chest pain or tightness comes on suddenly and does not go away, if the pain spreads to your arm, neck, jaw or back, or if chest pain comes with sweating, nausea, light-headedness or shortness of breath (NHS, 2023). Even without these signs, physical conditions such as thyroid problems or menopausal symptoms can cause similar symptoms, so it is worth getting checked (Korean Society of Oriental Neuropsychiatry, 2021).

Q. Should I see a Korean Medicine clinic or a psychiatrist? A. You can start with either. Care under the name hwabyung takes place in Korean Medicine clinics, while psychiatrists diagnose and treat the depression or anxiety that comes with it. The hwabyung guideline advises considering specialist psychiatric care when symptoms are severe or there is an emergency, and taking interactions between Western medicines already taken and herbal medicine into account (Korean Society of Oriental Neuropsychiatry, 2021). If you see both, tell each of them what you are taking.

Q. Doesn’t letting anger out help? A. In one experiment, people who hit a punching bag while thinking about the person who had angered them became angrier and more aggressive (Bushman, 2002). How to put anger into words calmly is covered in how to manage anger.

Q. Can hwabyung be cured? A. No one can promise that. Older studies of patients who came for treatment found that it had already lasted more than 10 years on average by the time they sought care (Min, 2008). Some studies found symptoms eased with approaches such as counselling or meditation, but most were small, and the guideline itself says evidence is severely lacking (Korean Society of Oriental Neuropsychiatry, 2021). Still, some people’s symptoms do ease, so rather than enduring it alone, look for help.

Q. I feel so wronged and exhausted that I have thoughts of dying. A. Please do not carry this alone. Call or text 988 now in the US or Canada, call Samaritans on 116 123 in the UK or Ireland, or find a line at findahelpline.com elsewhere; in Korea, call 109 (24 hours, free) or the mental health crisis line 1577-0199 (24 hours). If you live outside Korea, a family doctor or your local mental health services are another place to start. If you are in immediate danger, contact your local emergency services. Tell someone you trust how you feel right now.

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