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

MILITARY MEDICINE, 183, 9/10:e286, 2018 Effectiveness of an Anger Intervention for Military Members with PTSD: A Clinical Case Series Richard Cash*; Tracey Varker, PhD*; Tony McHugh, PhD†; Olivia Metcalf, PhD*; Alexandra Howard*; Delyth Lloyd*; Jacqueline Costello‡; David Said, PhD‡; David Forbes, PhD* 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 militaryrelated trauma.5 While anger plays a critical role in the development and maintenance of PTSD across a range of *Department of Psychiatry, Phoenix Australia – Centre for Posttraumatic Mental Health, University of Melbourne, Carlton, Victoria 3053, Australia †Department of Psychiatry, University of Melbourne, Carlton, Victoria 3053, Australia ‡Australian Defence Force Centre for Mental Health, HMAS Penguin, Mosman, New South Wales 2088, Australia doi: 10.1093/milmed/usx115 © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: . e286 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. PTSD and anger are highly correlated and there is a potential association between anger and aggression, and violence. Anger limits PTSD treatment effectiveness, therefore MILITARY MEDICINE, Vol. 183, September/October 2018 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. Effectiveness of an Anger Intervention for Military Members with PTSD 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. METHOD 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. 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 (...truncated)