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Effectiveness of an Anger Intervention for Military Members with PTSD: A Clinical Case Series

Effectiveness of an Anger Intervention for Military Members with PTSD: A Clinical Case Series Abstract Objective Problematic anger is a significant clinical issue in military personnel, and is further complicated by comorbid post-traumatic stress disorder (PTSD). Despite increasing numbers of military personnel returning from deployment with anger and aggression difficulties, the treatment of problematic anger has received scant attention. There are currently no interventions that directly target problematic anger in the context of military-related PTSD. The aim of this case series is to examine the effectiveness of an intervention specifically developed for treating problematic anger in current serving military personnel with comorbid PTSD. Methods Eight Australian Defence Force Army personnel with problematic anger and comorbid PTSD received a manualized 12-session cognitive behaviorally based anger intervention, delivered one-to-one by Australian Defence Force mental health clinicians. Standardized measures of anger, PTSD, depression, and anxiety were administered pre- and post-treatment. Results The initial mean severity scores for anger indicated a high degree of pre-treatment problematic anger. Anger scores reduced significantly from pre to post-treatment (d = 1.56), with 88% of participants exhibiting meaningful reduction in anger scores. PTSD symptoms also reduced significantly (d = 0.96), with 63% of participants experiencing a clinically meaningful reduction in PTSD scores. All of those who took part in the therapy completed all therapy sessions. Conclusions This brief report provides preliminary evidence that an intervention for problematic anger not only significantly reduces anger levels in military personnel, but can also significantly reduce PTSD symptoms. Given that anger can interfere with PTSD treatment outcomes, prioritizing anger treatment may improve the effectiveness of PTSD interventions. Problematic anger is one of the most common issues reported by military personnel and veterans,1 with increased levels not only resulting in significant distress and functional impairment but also possible aggression and interpersonal violence.2,3 Despite increasing numbers of military personnel returning from deployment exhibiting problematic anger and aggression,4 the treatment of problematic anger within this population has received comparatively little research attention. Anger is a normal human emotion, but is typically considered problematic when it occurs at a frequency, intensity, or duration which compromises cognitive function and perception, causes significant distress or interferes with general functioning or interpersonal relationships or is associated with aggressive behavior. Problematic anger is also frequently associated with post-traumatic stress disorder (PTSD), a severe and disabling condition experienced following exposure to traumatic events including military-related trauma.5 While anger plays a critical role in the development and maintenance of PTSD across a range of traumatic experiences (including natural disasters, sexual assault, and traumatic injury), its potentiating effect is especially strong for traumatized military personnel.6,7 There are a range of possible reasons for this strength of association. First, individuals selected for military service may enter the military with higher levels of anger or hostility.7 Second, anger may be reinforced during military training and deployment, where it can be an adaptive and necessary mobilizing response to threat.8 Third, it may be accounted for by the nature of the trauma, such as being exposed to combat or being exposed to a morally injurious event.9,10 Finally, anger may be exacerbated by other common comorbid difficulties including chronic pain, sleep difficulties, and traumatic brain injury or comorbid diagnoses, such as depression or alcohol/substance use disorders.11–14 Research has found that when veterans receive treatment for PTSD, anger significantly interferes with the efficacy of the treatment,8,15 with motivation to engage in treatment6 and increases dropout.16 Researchers have proposed that problematic anger may need to be targeted first in order to increase the effectiveness of evidence-based treatments for PTSD.8,15 While there are a series of studies examining anger interventions in veterans showing encouraging effectiveness,17 none of these have been investigated specifically in veterans with problematic anger and comorbid PTSD. FIGURE 1. View largeDownload slide Pre and post-treatment DAR-5 scores for the eight participants. FIGURE 1. View largeDownload slide Pre and post-treatment DAR-5 scores for the eight participants. PTSD and anger are highly correlated and there is a potential association between anger and aggression, and violence. Anger limits PTSD treatment effectiveness, therefore a targeted and effective intervention for anger in the context of PTSD could serve as a useful precursor to more intensive PTSD treatment. Interventions that target anger directly in the context of PTSD are scarce, and a general lack of research evaluating the efficacy of anger treatments has been noted.16 Two studies have examined the effectiveness of anger-focused interventions for veterans with PTSD.18,19 One of these was group-based (Gerlock18), which may not be feasible or desirable for current serving members, due to a range of factors including concerns about confidentiality and perceptions of negative impacts on their career. The other study (Chemtob et al19) demonstrated promising results but with very high levels (47%) of dropout. It remains unclear as to whether an intervention for anger in the context of PTSD that does not use current trauma-focused methods to target PTSD directly can result in improvements in problematic anger. The aim of this brief report case series is to examine the effectiveness of a purpose-developed intervention that directly targets problematic anger in active serving military members with PTSD, as well as to measure whether the intervention impacts any important secondary outcomes, including PTSD, depression, and anxiety. Method Participants Active serving army members with recent anger problems and diagnosed PTSD were recruited from two Australian Defence Force (ADF) sites. Participants were referred into the study by their treating Medical Officer or military psychologist following a positive screen for PTSD and problematic anger. PTSD was diagnosed by the study assessor using the Clinician Administered PTSD Scale [CAPS: 20]. Exclusion criteria included psychosis, moderate to high risk of harm to self and/or others, recent engagement in anger-focused treatment. A further consideration was whether participation in the trial would result in adverse employment-related consequences. All procedures were approved by the Australian Defence Human Research Ethics Committee. Trial procedures were described, eligibility was confirmed, and suitable participants were allocated to the next available trial clinician. Fifteen participants consented to participate. Three participants withdrew prior to the first assessment for reasons unrelated to the treatment (i.e., time and availability constraints). The final sample (n = 12) were all male with a mean age of 36.3 years (standard deviation [SD] = 6.1; range = 27–48). The majority were married and had children (n = 11). At intake, 83% (n = 10) of participants met diagnosis for major depression, one person (8%) met criteria for alcohol abuse, and 50% (n = 6) met criteria for alcohol dependence, as determined by the Mini International Neuropsychiatric Interview Version 5.5 (MINI). Of the 12 participants who completed treatment, 8 completed the post-treatment assessment which was administered 3 mo after the pre-treatment assessment. Participants received 12 weekly 60-min sessions of individual face-to-face therapy using the Managing Anger manual. There were no significant differences between completers and non-completers on any of the demographic or baseline variables. All subsequent analyses were conducted on the eight completers. Measures The pre- and post-treatment assessments comprised two parts, a structured interview, and a self-report booklet. At pre-treatment, PTSD diagnosis was confirmed using the Clinician Administered PTSD Scale-5 interview (CAPS-5; Blake et al20) and major depression and alcohol abuse and dependence were assessed using the MINI version 5.5 (Sheehan et al21). Anger reactions were assessed using the Dimensions of Anger Reactions Scale-5 [DAR-5;22] and the State-Trait Anger Expression Inventory-2 [STAXI-2;23,24] was used to assess trait anger (stable indication of anger problems) and state anger (situationally dependent anger). PTSD symptoms were assessed using the PTSD Checklist-5 [PCL-5;25]. Anxiety and depression symptoms were assessed using the Hospital Anxiety and Depression Scale [HADS;26]. Post-treatment, anger was assessed using the DAR-5 and STAXI-2, PTSD symptoms were assessed with the PCL-5, anxiety and depression was assessed with the HADS. Intervention For the purposes of this trial, an intervention manual was developed that addressed problematic anger in the context of PTSD.27 Based on the conceptual and empirical work of Chemtob and colleagues,28–30 a 12-session cognitive behavioral treatment was developed to target anger in the context of military PTSD. The content of each session was as follows: Session 1 – treatment engagement, an overview, anger and PTSD psychoeducation, anger monitoring, and short circuits (brief behavioral strategies like time out); Session 2 – motivational enhancement (discussing the costs and benefits of anger), introducing the anger model, functional analysis of provocation situations (“walk through” a scenario, identify patterns and themes, and understand how anger behaviors are reinforced), relaxation strategies and short circuits; Session 3 – brief cognitive intervention (self-instruction training), anger drills (inoculation training involving imaginal rehearsal of coping with anger provocations), short circuits; Session 4 – cognitive intervention (thought disputation), relaxation strategies, and anger drills; Sessions 5–8 – anger drills and cognitive intervention (generating more beneficial cognitions, and application of cognitive skills to particular anger-related themes); Sessions 9 and 10 – behavioral intervention (including assertive communication), anger drills and continuation of theme-based cognitive intervention; and Sessions 11 and 12 – treatment summary, review strategies, anger management plan, PTSD treatment psychoeducation. Each session (except Session 1) also contained homework review and assignment. Participants all received a workbook which they used throughout treatment to review information delivered in the sessions and complete written homework activities. The trial therapists were defense clinicians who were experienced in cognitive behavioral interventions. They were trained in the intervention by two experts in anger in veterans and the developers of the manual (DF and TM) and took part in fortnightly group supervision sessions with the anger experts. The supervision sessions were also used to ensure adherence to the treatment manual. The four clinicians who provided the treatment each saw three participants, and all of the participants completed all of the therapy sessions. RESULTS The initial mean severity scores for anger (DAR-5 = 18.0, SD = 4.38; STAXI State = 28.25, SD = 12.34; STAXI Trait = 29.75, SD = 5.34) indicate a high degree of pre-treatment problematic anger, with seven of the participants (88%) reporting DAR-5 scores above the cut-off point for problematic anger [>12; 21, 30]. Mean pre-treatment PCL-5 scores were 46.4 (SD = 15.71) indicating moderately high PTSD symptom severity. Mean pre-treatment HADS anxiety (11.9; SD = 3.56) and depression scores (12.5; SD = 4.31) were above the threshold for caseness for anxiety and depression (>8). Individual pre- and post-treatment DAR-5 scores for each of the eight individuals are presented in Table I, as well as an indication of whether the pre- to post-treatment change was a reliable change, determined by a decrease of greater than 4.5 on the DAR-5.22 Six of the eight participants (75%) demonstrated reliable change in reduction of anger scores at post-treatment (see Fig. 1). Change in DAR-5 scores from pre- to post-treatment for each participant can also be seen in Table II. Table I. Pre- and Post-treatment Raw Scores for Outcome Measures and Effect Sizes. Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Note. DAR-5, dimensions of anger reactions-5; HADS, Hospital Anxiety and Depression Scale; M, mean; PCL-5, Post-traumatic Stress Disorder Checklist; RC, reliable change; SD, standard deviation; Ss, participants; STAX2, State-Trait Anger Expression Inventory-2. Table I. Pre- and Post-treatment Raw Scores for Outcome Measures and Effect Sizes. Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Note. DAR-5, dimensions of anger reactions-5; HADS, Hospital Anxiety and Depression Scale; M, mean; PCL-5, Post-traumatic Stress Disorder Checklist; RC, reliable change; SD, standard deviation; Ss, participants; STAX2, State-Trait Anger Expression Inventory-2. Table II. Mean Item Outcomes for the DAR-5. Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Table II. Mean Item Outcomes for the DAR-5. Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 As can be seen in Table I, post-treatment outcome measures indicated significant changes in the DAR-5, STAXI Trait, PCL-5, and HADS Anxiety scores. On the primary anger measures, the effect sizes for the change in DAR-5 and STAXI Trait scores were very large (d = 1.56, and 2.03, respectively). Notably, there were large effect size reductions across each of the five DAR-5 items assessing frequency (d = 1.37), intensity (d = 1.98), duration (d = 1.07, interpersonal aggression (d = 1.53), and interference in relationships (d = 0.98) (see Table II). PTSD symptoms as measured by the PCL-5 also reduced significantly with a large effect size (d = 0.96). Five out of eight participants indicated a clinically meaningful reduction in PTSD symptoms, with a reduction in PCL-5 scores of 10 or more.25 DISCUSSION Problematic anger is ubiquitous in military veterans with PTSD and is not only associated with significant distress and functional impairment, but often aggression and interpersonal violence.2,3 Given the scope of the problem in this population, in addition to findings that anger attenuates PTSD treatment outcomes in military veterans8,15 it is critical that methods are explored to directly address problematic anger in the context of military PTSD. The question remained, however, as to whether meaningful reductions in anger could be achieved without directly treating the PTSD either first or concurrently. The findings of this case series suggest that problematic anger comorbid with PTSD in military populations can be targeted directly via a primary intervention for anger. Such an intervention appears to not only significantly reduce anger levels but also PTSD symptoms. Participants were currently serving military members with military-related PTSD, who had comorbid psychiatric conditions, had experienced multiple service related traumatic events, and had significant ongoing life stressors, including the impact of their PTSD and anger on their current and future employment status. The study findings are particularly promising for the military population where, for some, balancing the role of anger as a perceived adaptive coping and motivational mechanism. However, the potential for problematic anger to be a significant barrier to treatment efficacy is an ongoing challenge. All of those who took part in the therapy completed all of the therapy sessions. While the incidence of aggression was not directly measured, the very large effect size reductions in the DAR-5 item focusing on interpersonal aggressive intent when angry, suggests the intervention may be important in reducing aggression and violence in those troubled by trauma-related anger. A strength of this study is its use of a manualized treatment and standardized assessment tools. However, it is limited by a small sample size, gender, and lack of a control group. Follow-up assessments would have significantly strengthened the study findings. Future research should follow up on these case series findings and test the effectiveness of the intervention under randomized controlled conditions and further explore the impact of the treatment on direct indicators of aggression and violence. Funding This trial was funded by the Australian Department of Defence. The study sponsor had no role in the study design, data collection, analysis, interpretation, or writing of this report. References 1 Sayer NA , Noorbaloochi S , Frazier P , Carlson K , Gravely A , Murdoch M : Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care . Psychiatr Serv 2010 ; 61 ( 6 ): 589 – 97 . Google Scholar CrossRef Search ADS PubMed 2 Elbogen E , Johnson SC , Wagner HR , Sullivan C , Taft CT , Beckham JC : Violent behaviour and post-traumatic stress disorder in US Iraq and Afghanistan veterans . Br J Psychiatry 2014 ; 204 : 368 – 75 . Google Scholar CrossRef Search ADS PubMed 3 McManus F , Grey N , Shafran R : Cognitive therapy for anxiety disorders: current status and future challenges . Behav Cogn Psychother 2008 ; 36 ( 6 ): 695 – 704 . Google Scholar CrossRef Search ADS 4 Thomas JL , Wilk JE , Riviere LA , McGurk D , Castro CA , Hoge CW : Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq . Arch Gen Psychiatry 2010 ; 67 ( 6 ): 614 – 23 . Google Scholar CrossRef Search ADS PubMed 5 Forbes D , Elhai JD , Miller MW , Creamer M : Internalizing and externalizing classes in posttraumatic stress disorder: A latent class analysis . J Trauma Stress 2010 ; 23 ( 3 ): 340 – 9 . Google Scholar PubMed 6 Novaco RW , Chemtob CM : Anger and combat-related posttraumatic stress disorder . J Trauma Stress 2002 ; 15 : 123 – 32 . Google Scholar CrossRef Search ADS PubMed 7 Orth U , Wieland E : Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: a meta-analysis . J Consult Clin Psychol 2006 ; 74 ( 4 ): 698 . Google Scholar CrossRef Search ADS PubMed 8 Forbes D , Parslow R , Creamer M , Allen N , McHugh T , Hopwood M : Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder . J Trauma Stress 2008 ; 21 ( 2 ): 142 – 9 . Google Scholar CrossRef Search ADS PubMed 9 Elbogen E , Wagner HR , Fuller SR , Calhoun PS , Kinneer PM , Beckham JC : Correlates of anger and hostility in Iraq and Afghanistan war veterans . Am J Psychiatry 2010 ; 167 ( 9 ): 1051 – 8 . Google Scholar CrossRef Search ADS PubMed 10 Litz BT , Stein N , Delaney E , et al. : Moral injury and moral repair in war veterans: a preliminary model and intervention strategy . Clin Psychol Rev 2009 ; 29 ( 8 ): 695 – 706 . Google Scholar CrossRef Search ADS PubMed 11 Lasko NB , Gurvits TV , Kuhne AA , Orr SP , Pitman RK : Aggression and its correlates in Vietnam veterans with and without chronic posttraumatic stress disorder . Compr Psychiatry 1994 ; 35 : 373 – 81 . Google Scholar CrossRef Search ADS PubMed 12 Taft CT , Pless AP , Stalans LJ , Koenen KC , King LA , King DW : Risk factors for partner violence among a national sample of combat veterans . J Consult Clin Psychol 2005 ; 73 : 151 – 9 . Google Scholar CrossRef Search ADS PubMed 13 Grafman J , Schwab K , Warden D , Pridgen A , Brown H , Salazar A : Frontal lobe injuries, violence, and aggression: a report of the Vietnam Head Injury Study . Neurology 1996 ; 46 : 1231 – 8 . Google Scholar CrossRef Search ADS PubMed 14 Savarese V , Suvak M , King L , King D : Relationships among alcohol use, hyperarousal, and marital abuse and violence in Vietnam veterans . J Trauma Stress 2001 ; 14 : 717 – 32 . Google Scholar CrossRef Search ADS PubMed 15 Lloyd D , et al. : Comorbidity in the prediction of cognitive processing therapy treatment outcomes for combat-related posttraumatic stress disorder . J Anxiety Disord 2014 ; 28 ( 2 ): 237 – 40 . Google Scholar CrossRef Search ADS PubMed 16 Taft CT , Creech SK , Kachadourian L : Assessment and treatment of posttraumatic anger and aggression: a review . J Rehabil Res Dev 2012 ; 49 ( 5 ): 777 – 88 . Google Scholar CrossRef Search ADS PubMed 17 Morland LA , et al. : Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial . J Clin Psychiatry 2010 ; 71 ( 7 ): 855 – 63 . Google Scholar CrossRef Search ADS PubMed 18 Gerlock AA : Veterans’ responses to anger management intervention . Issues Ment Health Nurs 1994 ; 15 ( 4 ): 393 – 408 . Google Scholar CrossRef Search ADS PubMed 19 Chemtob C , Novaco RW , Hamada RS , Gross DM : Cognitive-behavioral treatment for severe anger in posttraumatic stress disorder . J Consult Clin Psychol 1997 ; 65 ( 1 ): 184 . Google Scholar CrossRef Search ADS PubMed 20 Blake DD , Weathers FW , Nagy LM , et al. : The development of a clinician-administered PTSD scale . J Trauma Stress 1995 ; 8 ( 1 ): 75 – 90 . Google Scholar CrossRef Search ADS PubMed 21 Sheehan DV , Lecrubier Y , Sheehan KH , et al. : The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10 . J Clin Psychiatry 1998 ; 59(Suppl 20) : 22 – 33 . Google Scholar PubMed 22 Forbes D , Alkemade N , Mitchell D , et al. : Utility of the Dimensions of Anger Reactions-5 (DAR-5) Scale as a brief anger measure . Depress Anxiety 2014 ; 31 : 166 – 73 . Google Scholar CrossRef Search ADS PubMed 23 Spielberger CD , Sydeman SJ , Owen AE , Marsh BJ : Measuring anxety and anger with the State-Trait Anxiety Inventory (STAI) and the State-Trait Anger Expression Inventory (STAXI). In: The Use of Psychological Testing for Treatment Planning and Outcomes Assessment , pp 993 – 1021 . Edited by Maruish ME Mahwah, NJ, US , Lawrence Erlbaum Associates Publishers , 1999 . 24 Spielberger CD : State-Trait Anger Expression Inventory-2nd Edition: Professional Manual . Lutz, FL , Psychological Assessment Resources , 1999 . 25 Weathers FW , Litz BT , Keane TM , Palmieri PA , Marx BP , Schnurr PP : The PTSD Checklist for DSM-5 (PCL-5). ( 2013 ) Scale available from the National Center for PTSD at www.ptsd.va.gov; accessed February 20, 2017. 26 Zigmond A , Snaith R : The Hospital Anxiety and Depression Scale . Acta Physiol Scand 1983 ; 67 : 361 – 70 . 27 Forbes D , Howard A , Cash R , McHugh T ( 2014 ). Managing Anger. Phoenix Australia. 28 Chemtob C , Roitblat H , Hamada RS , Carlson JG , Twentyman CT : A cognitive action theory of post-traumatic stress disorder . J Anxiety Disord 1988 ; 2 ( 3 ): 253 – 75 . Google Scholar CrossRef Search ADS 29 Deffenbacher JL : Cognitive-behavioral conceptualization and treatment of anger . Cogn Behav Pract 2011 ; 18 ( 2 ): 212 – 21 . Google Scholar CrossRef Search ADS 30 Novaco RW : Perspectives on anger treatment: discussion and commentary . Cogn Behav Pract 2011 ; 18 ( 2 ): 251 – 5 . Google Scholar CrossRef Search ADS © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Effectiveness of an Anger Intervention for Military Members with PTSD: A Clinical Case Series

Military Medicine , Volume 183 (9) – Sep 1, 2018
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© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Objective Problematic anger is a significant clinical issue in military personnel, and is further complicated by comorbid post-traumatic stress disorder (PTSD). Despite increasing numbers of military personnel returning from deployment with anger and aggression difficulties, the treatment of problematic anger has received scant attention. There are currently no interventions that directly target problematic anger in the context of military-related PTSD. The aim of this case series is to examine the effectiveness of an intervention specifically developed for treating problematic anger in current serving military personnel with comorbid PTSD. Methods Eight Australian Defence Force Army personnel with problematic anger and comorbid PTSD received a manualized 12-session cognitive behaviorally based anger intervention, delivered one-to-one by Australian Defence Force mental health clinicians. Standardized measures of anger, PTSD, depression, and anxiety were administered pre- and post-treatment. Results The initial mean severity scores for anger indicated a high degree of pre-treatment problematic anger. Anger scores reduced significantly from pre to post-treatment (d = 1.56), with 88% of participants exhibiting meaningful reduction in anger scores. PTSD symptoms also reduced significantly (d = 0.96), with 63% of participants experiencing a clinically meaningful reduction in PTSD scores. All of those who took part in the therapy completed all therapy sessions. Conclusions This brief report provides preliminary evidence that an intervention for problematic anger not only significantly reduces anger levels in military personnel, but can also significantly reduce PTSD symptoms. Given that anger can interfere with PTSD treatment outcomes, prioritizing anger treatment may improve the effectiveness of PTSD interventions. Problematic anger is one of the most common issues reported by military personnel and veterans,1 with increased levels not only resulting in significant distress and functional impairment but also possible aggression and interpersonal violence.2,3 Despite increasing numbers of military personnel returning from deployment exhibiting problematic anger and aggression,4 the treatment of problematic anger within this population has received comparatively little research attention. Anger is a normal human emotion, but is typically considered problematic when it occurs at a frequency, intensity, or duration which compromises cognitive function and perception, causes significant distress or interferes with general functioning or interpersonal relationships or is associated with aggressive behavior. Problematic anger is also frequently associated with post-traumatic stress disorder (PTSD), a severe and disabling condition experienced following exposure to traumatic events including military-related trauma.5 While anger plays a critical role in the development and maintenance of PTSD across a range of traumatic experiences (including natural disasters, sexual assault, and traumatic injury), its potentiating effect is especially strong for traumatized military personnel.6,7 There are a range of possible reasons for this strength of association. First, individuals selected for military service may enter the military with higher levels of anger or hostility.7 Second, anger may be reinforced during military training and deployment, where it can be an adaptive and necessary mobilizing response to threat.8 Third, it may be accounted for by the nature of the trauma, such as being exposed to combat or being exposed to a morally injurious event.9,10 Finally, anger may be exacerbated by other common comorbid difficulties including chronic pain, sleep difficulties, and traumatic brain injury or comorbid diagnoses, such as depression or alcohol/substance use disorders.11–14 Research has found that when veterans receive treatment for PTSD, anger significantly interferes with the efficacy of the treatment,8,15 with motivation to engage in treatment6 and increases dropout.16 Researchers have proposed that problematic anger may need to be targeted first in order to increase the effectiveness of evidence-based treatments for PTSD.8,15 While there are a series of studies examining anger interventions in veterans showing encouraging effectiveness,17 none of these have been investigated specifically in veterans with problematic anger and comorbid PTSD. FIGURE 1. View largeDownload slide Pre and post-treatment DAR-5 scores for the eight participants. FIGURE 1. View largeDownload slide Pre and post-treatment DAR-5 scores for the eight participants. PTSD and anger are highly correlated and there is a potential association between anger and aggression, and violence. Anger limits PTSD treatment effectiveness, therefore a targeted and effective intervention for anger in the context of PTSD could serve as a useful precursor to more intensive PTSD treatment. Interventions that target anger directly in the context of PTSD are scarce, and a general lack of research evaluating the efficacy of anger treatments has been noted.16 Two studies have examined the effectiveness of anger-focused interventions for veterans with PTSD.18,19 One of these was group-based (Gerlock18), which may not be feasible or desirable for current serving members, due to a range of factors including concerns about confidentiality and perceptions of negative impacts on their career. The other study (Chemtob et al19) demonstrated promising results but with very high levels (47%) of dropout. It remains unclear as to whether an intervention for anger in the context of PTSD that does not use current trauma-focused methods to target PTSD directly can result in improvements in problematic anger. The aim of this brief report case series is to examine the effectiveness of a purpose-developed intervention that directly targets problematic anger in active serving military members with PTSD, as well as to measure whether the intervention impacts any important secondary outcomes, including PTSD, depression, and anxiety. Method Participants Active serving army members with recent anger problems and diagnosed PTSD were recruited from two Australian Defence Force (ADF) sites. Participants were referred into the study by their treating Medical Officer or military psychologist following a positive screen for PTSD and problematic anger. PTSD was diagnosed by the study assessor using the Clinician Administered PTSD Scale [CAPS: 20]. Exclusion criteria included psychosis, moderate to high risk of harm to self and/or others, recent engagement in anger-focused treatment. A further consideration was whether participation in the trial would result in adverse employment-related consequences. All procedures were approved by the Australian Defence Human Research Ethics Committee. Trial procedures were described, eligibility was confirmed, and suitable participants were allocated to the next available trial clinician. Fifteen participants consented to participate. Three participants withdrew prior to the first assessment for reasons unrelated to the treatment (i.e., time and availability constraints). The final sample (n = 12) were all male with a mean age of 36.3 years (standard deviation [SD] = 6.1; range = 27–48). The majority were married and had children (n = 11). At intake, 83% (n = 10) of participants met diagnosis for major depression, one person (8%) met criteria for alcohol abuse, and 50% (n = 6) met criteria for alcohol dependence, as determined by the Mini International Neuropsychiatric Interview Version 5.5 (MINI). Of the 12 participants who completed treatment, 8 completed the post-treatment assessment which was administered 3 mo after the pre-treatment assessment. Participants received 12 weekly 60-min sessions of individual face-to-face therapy using the Managing Anger manual. There were no significant differences between completers and non-completers on any of the demographic or baseline variables. All subsequent analyses were conducted on the eight completers. Measures The pre- and post-treatment assessments comprised two parts, a structured interview, and a self-report booklet. At pre-treatment, PTSD diagnosis was confirmed using the Clinician Administered PTSD Scale-5 interview (CAPS-5; Blake et al20) and major depression and alcohol abuse and dependence were assessed using the MINI version 5.5 (Sheehan et al21). Anger reactions were assessed using the Dimensions of Anger Reactions Scale-5 [DAR-5;22] and the State-Trait Anger Expression Inventory-2 [STAXI-2;23,24] was used to assess trait anger (stable indication of anger problems) and state anger (situationally dependent anger). PTSD symptoms were assessed using the PTSD Checklist-5 [PCL-5;25]. Anxiety and depression symptoms were assessed using the Hospital Anxiety and Depression Scale [HADS;26]. Post-treatment, anger was assessed using the DAR-5 and STAXI-2, PTSD symptoms were assessed with the PCL-5, anxiety and depression was assessed with the HADS. Intervention For the purposes of this trial, an intervention manual was developed that addressed problematic anger in the context of PTSD.27 Based on the conceptual and empirical work of Chemtob and colleagues,28–30 a 12-session cognitive behavioral treatment was developed to target anger in the context of military PTSD. The content of each session was as follows: Session 1 – treatment engagement, an overview, anger and PTSD psychoeducation, anger monitoring, and short circuits (brief behavioral strategies like time out); Session 2 – motivational enhancement (discussing the costs and benefits of anger), introducing the anger model, functional analysis of provocation situations (“walk through” a scenario, identify patterns and themes, and understand how anger behaviors are reinforced), relaxation strategies and short circuits; Session 3 – brief cognitive intervention (self-instruction training), anger drills (inoculation training involving imaginal rehearsal of coping with anger provocations), short circuits; Session 4 – cognitive intervention (thought disputation), relaxation strategies, and anger drills; Sessions 5–8 – anger drills and cognitive intervention (generating more beneficial cognitions, and application of cognitive skills to particular anger-related themes); Sessions 9 and 10 – behavioral intervention (including assertive communication), anger drills and continuation of theme-based cognitive intervention; and Sessions 11 and 12 – treatment summary, review strategies, anger management plan, PTSD treatment psychoeducation. Each session (except Session 1) also contained homework review and assignment. Participants all received a workbook which they used throughout treatment to review information delivered in the sessions and complete written homework activities. The trial therapists were defense clinicians who were experienced in cognitive behavioral interventions. They were trained in the intervention by two experts in anger in veterans and the developers of the manual (DF and TM) and took part in fortnightly group supervision sessions with the anger experts. The supervision sessions were also used to ensure adherence to the treatment manual. The four clinicians who provided the treatment each saw three participants, and all of the participants completed all of the therapy sessions. RESULTS The initial mean severity scores for anger (DAR-5 = 18.0, SD = 4.38; STAXI State = 28.25, SD = 12.34; STAXI Trait = 29.75, SD = 5.34) indicate a high degree of pre-treatment problematic anger, with seven of the participants (88%) reporting DAR-5 scores above the cut-off point for problematic anger [>12; 21, 30]. Mean pre-treatment PCL-5 scores were 46.4 (SD = 15.71) indicating moderately high PTSD symptom severity. Mean pre-treatment HADS anxiety (11.9; SD = 3.56) and depression scores (12.5; SD = 4.31) were above the threshold for caseness for anxiety and depression (>8). Individual pre- and post-treatment DAR-5 scores for each of the eight individuals are presented in Table I, as well as an indication of whether the pre- to post-treatment change was a reliable change, determined by a decrease of greater than 4.5 on the DAR-5.22 Six of the eight participants (75%) demonstrated reliable change in reduction of anger scores at post-treatment (see Fig. 1). Change in DAR-5 scores from pre- to post-treatment for each participant can also be seen in Table II. Table I. Pre- and Post-treatment Raw Scores for Outcome Measures and Effect Sizes. Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Note. DAR-5, dimensions of anger reactions-5; HADS, Hospital Anxiety and Depression Scale; M, mean; PCL-5, Post-traumatic Stress Disorder Checklist; RC, reliable change; SD, standard deviation; Ss, participants; STAX2, State-Trait Anger Expression Inventory-2. Table I. Pre- and Post-treatment Raw Scores for Outcome Measures and Effect Sizes. Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Ss DAR-5 STAXI-2 State STAXI-2 Trait PCL-5 HADS Anx HADS Dep Pre Post RC Pre Post Pre Post Pre Post Pre Post Pre Post 1 14 8 Yes 17 17 27 19 36 36 12 11 9 13 2 11 6 Yes 17 16 24 16 19 8 8 3 6 2 3 17 11 Yes 25 21 31 24 59 39 18 10 17 11 4 17 11 Yes 15 22 23 17 36 26 8 10 14 11 5 21 17 No 35 25 32 31 57 56 14 14 16 14 6 21 10 Yes 48 17 34 21 60 32 15 9 17 7 7 18 17 No 27 25 28 21 41 40 10 8 8 9 8 25 10 Yes 42 20 39 26 63 23 10 6 13 5 M 18 11.25 28.25 20.38 29.75 21.88 46.38 32.5 11.88 8.88 12.5 9 SD 4.38 3.92 12.34 3.54 5.34 4.97 15.71 14.12 3.56 3.31 4.31 4.12 p 0.003** 0.121 0.001** 0.030* 0.039 0.068 ES 1.56 0.62 2.03 0.96 0.90 0.76 Note. DAR-5, dimensions of anger reactions-5; HADS, Hospital Anxiety and Depression Scale; M, mean; PCL-5, Post-traumatic Stress Disorder Checklist; RC, reliable change; SD, standard deviation; Ss, participants; STAX2, State-Trait Anger Expression Inventory-2. Table II. Mean Item Outcomes for the DAR-5. Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Table II. Mean Item Outcomes for the DAR-5. Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 Item Question Pre Post p ES 1 I found myself getting angry at people or situations 3.75 2.88 0.006 1.37 2 When I got angry, I got really mad 4.13 2.38 0.001 1.98 3 When I got angry, I stayed angry 3.38 2.13 0.019 1.07 4 When I got angry at someone I wanted to hit them 3.63 2.00 0.003 1.53 5 My anger prevented me from getting along with people as well as I would have liked to 3.13 1.88 0.028 0.98 As can be seen in Table I, post-treatment outcome measures indicated significant changes in the DAR-5, STAXI Trait, PCL-5, and HADS Anxiety scores. On the primary anger measures, the effect sizes for the change in DAR-5 and STAXI Trait scores were very large (d = 1.56, and 2.03, respectively). Notably, there were large effect size reductions across each of the five DAR-5 items assessing frequency (d = 1.37), intensity (d = 1.98), duration (d = 1.07, interpersonal aggression (d = 1.53), and interference in relationships (d = 0.98) (see Table II). PTSD symptoms as measured by the PCL-5 also reduced significantly with a large effect size (d = 0.96). Five out of eight participants indicated a clinically meaningful reduction in PTSD symptoms, with a reduction in PCL-5 scores of 10 or more.25 DISCUSSION Problematic anger is ubiquitous in military veterans with PTSD and is not only associated with significant distress and functional impairment, but often aggression and interpersonal violence.2,3 Given the scope of the problem in this population, in addition to findings that anger attenuates PTSD treatment outcomes in military veterans8,15 it is critical that methods are explored to directly address problematic anger in the context of military PTSD. The question remained, however, as to whether meaningful reductions in anger could be achieved without directly treating the PTSD either first or concurrently. The findings of this case series suggest that problematic anger comorbid with PTSD in military populations can be targeted directly via a primary intervention for anger. Such an intervention appears to not only significantly reduce anger levels but also PTSD symptoms. Participants were currently serving military members with military-related PTSD, who had comorbid psychiatric conditions, had experienced multiple service related traumatic events, and had significant ongoing life stressors, including the impact of their PTSD and anger on their current and future employment status. The study findings are particularly promising for the military population where, for some, balancing the role of anger as a perceived adaptive coping and motivational mechanism. However, the potential for problematic anger to be a significant barrier to treatment efficacy is an ongoing challenge. All of those who took part in the therapy completed all of the therapy sessions. While the incidence of aggression was not directly measured, the very large effect size reductions in the DAR-5 item focusing on interpersonal aggressive intent when angry, suggests the intervention may be important in reducing aggression and violence in those troubled by trauma-related anger. A strength of this study is its use of a manualized treatment and standardized assessment tools. However, it is limited by a small sample size, gender, and lack of a control group. Follow-up assessments would have significantly strengthened the study findings. Future research should follow up on these case series findings and test the effectiveness of the intervention under randomized controlled conditions and further explore the impact of the treatment on direct indicators of aggression and violence. Funding This trial was funded by the Australian Department of Defence. The study sponsor had no role in the study design, data collection, analysis, interpretation, or writing of this report. 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Journal

Military Medicine – Oxford University Press

Published: Sep 1, 2018

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