Comorbidity in the prediction of Cognitive Processing Therapy treatment outcomes for combat-related posttraumatic stress disorder

Racial, Ethnic, and Sex Disparities in Mental Health Among US Service Members and Veterans: Findings From the Millennium Cohort Study

Although disparities in mental health occur within racially, ethnically, and sex-diverse civilian populations, it is unclear whether these disparities persist within US military populations. Using cross-sectional data from the Millennium Cohort Study (2014-2016; n = 103,184; 70.3% male; 75.7% non-Hispanic White), a series of logistic regression analyses were conducted to examine whether racial, ethnic, and/or sex disparities were found in mental health outcomes (posttraumatic stress disorder (PTSD), depression, anxiety, and problematic anger), hierarchically adjusting for sociodemographic, military, health-related, and social support factors. Compared with non-Hispanic White individuals, those who identified as American Indian/Alaska Native, non-Hispanic Black, Hispanic/Latino, or multiracial showed greater risk of PTSD, depression, anxiety, and problematic anger in unadjusted models. Racial and ethnic disparities in mental health were partially explained by health-related and social support factors. Women showed greater risk of depression and anxiety and lower risk of PTSD than men. Evidence of intersectionality emerged for problematic anger among Hispanic/Latino and Asian or Pacific Islander women. Overall, racial, ethnic, and sex disparities in mental health persisted among service members and veterans. Future research and interventions are recommended to reduce these disparities and improve the health and well-being of diverse service members and veterans.

Anger Among UK Ex-Service Military Personnel During the COVID-19 Pandemic

ABSTRACT

Military service and ex-service personnel commonly experience difficulties with anger. The COVID-19 pandemic had several negative consequences upon social, economic, and health factors that influence anger. This study aimed to explore 1) levels of anger in an ex-serving military cohort during the COVID-19 pandemic; 2) self-reported changes in anger compared with prepandemic levels; and 3) identify sociodemographic characteristics, military characteristics, COVID-19 experiences, and COVID-19 stressors associated with anger. UK ex-service personnel ( n = 1499) completed the Dimensions of Anger Reactions 5-item measure within an existing cohort study. Overall, 14.4% reported significant difficulties with anger, and 24.8% reported their anger worsened during the pandemic. Anger was associated with factors such as financial difficulties, extra/new caring responsibilities, and COVID-19 bereavement. Endorsing more COVID-19 stressors was associated with higher odds of anger difficulties. This study highlights the impact of the pandemic on ex-service personnel, including a strain on family/social relationships and financial hardship, which affected anger.

Influence of comorbid social anxiety disorder in PTSD treatment outcomes for Prolonged Exposure in female military sexual trauma survivors with PTSD

OBJECTIVE

Posttraumatic stress disorder (PTSD) is a common psychiatric disorder that frequently presents alongside other comorbid diagnoses. Although several evidence-based psychotherapies have been well-studied for PTSD, limited research has focused on the influence of diagnostic comorbidity on their outcomes. The present study sought to investigate the influence of comorbid social anxiety disorder on treatment outcomes in patients with PTSD.

METHODS

One hundred and twelve treatment-seeking female veteran participants with PTSD completed baseline assessments and received 12-15 sessions of Prolonged Exposure. Symptom measures were completed biweekly as well as at immediate posttreatment, 3-month, and 6-month follow-ups.

RESULTS

Thirty (26.8%) participants seeking PTSD treatment also met diagnostic criteria for social anxiety disorder. Multilevel modeling was used to examine effects of social anxiety disorder diagnosis on post-intervention symptoms and revealed significantly worse outcomes for symptoms of PTSD and depression in participants with comorbid PTSD and social anxiety disorder.

CONCLUSION

Consistent with previous studies of co-occurring PTSD and depression, present findings suggest that comorbid diagnoses may adversely affect disorder-specific treatment outcomes. As such, the presence of diagnostic comorbidity may merit further consideration and potential adaptions to the traditional, disorder-specific assessment and treatment practices for PTSD.

Is Fear Extinction Impairment Central to Psychopathology?

As discussed in this chapter, there have been enormous advances in our understanding of how anxiety disorders develop, are maintained, and can be treated. Many of these advances have been the result of translational studies using fear conditioning and extinction models. Despite these successes, we recognize, as a field, that there are important limitations in the extent to which extinction can explain how anxiety disorders and behaviors remit. Clinically speaking, the outstanding challenge for treatment of anxiety disorders is to improve the current suboptimal success rates. Over the past 30 years, we have not improved our treatment success rates despite employing many pharmacological and pharmacological strategies. While extinction and related fear circuitry mechanisms most certainly appear to play a role in treatment of anxiety disorders, they are also apparently insufficient to fully accommodate the varied responses individuals exhibit with this treatment approach. Increasingly diverse and innovative approaches are needed that accommodate the multitude of change mechanisms involved in treating anxiety. However, this is not to suggest ignoring the key role that extinction and memory updating processes play in overcoming anxiety.

Problematic Anger in the Military: Focusing on the Forgotten Emotion

PURPOSE OF REVIEW

Problematic anger is common in veteran and military populations, yet understudied relative to other mental health difficulties. However, in recent years, more clinical and research attention has been turned to problematic anger. This paper highlights important new findings in the epidemiology, course, and neurobiology of anger, the associations of anger with other mental health problems and risk, and next steps for research and practice.

RECENT FINDINGS

In longitudinal research, findings show that problematic anger changes over the life course of military members and veterans, and that deployment increases the likelihood of problematic levels of anger. Problematic anger is related to a range of mental health issues, most perniciously aggression and suicidality. Promising new assessment and treatment approaches are emerging, including innovations that leverage digital technology. Key areas of research include advancing assessment of problematic anger to identify patterns of heterogeneity, as well as advancing the evidence base for anger treatments. Recommended progress in clinical practice include conducting routine assessment of problematic anger in veteran and military populations, developing prevention and early intervention for at risk individuals, and optimizing the timing of interventions throughout the military lifecycle.

Four profiles of symptom change in residential Cognitive Processing Therapy

A significant portion of veterans do not respond to evidence-based treatments for PTSD. Therefore, researchers have sought to predict who will respond well to trauma-focused treatment. The present study examined pre- and posttreatment symptom profiles, session-by-session change, as well as demographic and additional diagnostic information to better understand PTSD treatment response. Participants included 332 veterans undergoing residential Cognitive Processing Therapy. Latent profile analyses were computed, and four meaningful profiles emerged: Fast Responders, Steady Responders, Partial Responders, and Minimal Responders. Each profile demonstrated symptom reduction at approximately the same rate in the first half of treatment. Two specific profiles, Steady Responders and Minimal Responders, showed key clinically important differences. Both profiles demonstrated severe pretreatment PTSD symptom severity; however, in the second half of treatment, Steady Responders saw the steepest decrease in symptoms of any of the profiles while Minimal Responders saw less symptom reduction compared to all other profiles. Via a thorough examination, membership in Steady Responders compared to Minimal Responders was not associated with demographic or health variables. Results suggest that pretreatment symptom severity does not necessarily determine a client's posttreatment symptom severity. Pretreatment symptom severity did not determine outcome, though some veterans (Minimal Responders) did not experience the same symptom change and treatment effectiveness. Further identifying the factors that lead to the separation of these groups will add important information for determining treatment selection and potential obstacles to effectiveness.

Association of Problematic Anger With Long-term Adjustment Following the Military-to-Civilian Transition

Importance

Few studies have examined the role of problematic anger in long-term adjustment of service members transitioning out of the military.

Objective

To determine the prevalence of problematic anger during the military-to-civilian transition period and the association of problematic anger with adjustment to civilian life.

Design, Setting, and Participants

This cohort study used 2 waves of survey data administered approximately 5 years apart (time 1 [T1; September 26, 2014, to August 25, 2016] and time 2 [T2; October 23, 2019, to August 31, 2021]) from the Millennium Cohort Study, a population-based military study. Participants were US active-duty service members within 24 months of separating from military service at T1. Statistical analysis was performed from September 2021 to May 2022.

Exposures

Problematic anger was operationalized as scoring at least 12 points on the 5-item Dimensions of Anger Reactions scale at T1.

Main Outcomes and Measures

Behavioral and functional health (depression, posttraumatic stress disorder, problem drinking, functional limitations), relationship health (relationship quality, coping with parental demands, social support), and economic health (major financial problems, financial insecurity, homelessness, employment status) were assessed at T2. Covariates, assessed at T1, included demographics, military characteristics, mental health, problem drinking, and physical health.

Results

Of the 3448 participants, 2625 (76.1%) were male, 217 (6.3%) were Hispanic, 293 (8.5%) were non-Hispanic Black, and 2690 (78.0%) were non-Hispanic White; the mean (SD) age was 40.1 (8.5) years; 826 (24.0%) met criteria for problematic anger. Prevalence of problematic anger was 15.9% (95% CI, 12.2%-19.7%) 24 months prior to military separation and 31.2% (95% CI, 26.2%-36.2%) 24 months following separation. After adjusting for covariates, problematic anger was associated with greater likelihood of behavioral and functional health outcomes (eg, posttraumatic stress disorder: adjusted odds ratio, 1.55, 95% CI, 1.23-1.96), relationship health difficulties (eg, low social support: aOR, 1.66; 95% CI, 1.23-2.24), and economic difficulties (eg, substantial financial insecurity: aOR, 1.64; 95% CI, 1.13-2.39) at T2.

Conclusions and Relevance

This cohort study found an association between prevalence of problematic anger during the military-to-civilian transition and problematic anger with subsequent adjustment difficulties among US service members. These findings suggest the need to equip service members proactively with skills to identify and manage anger as a way to support them before and during this period of transition.

Predictors of response to cognitive-behavioral therapy in patients with posttraumatic stress disorder: a systematic review

ABSTRACT Objective Posttraumatic stress disorder (PTSD) is a highly prevalent and disabling disorder. Even when treated with the first-line intervention, cognitive-behavioral therapy (CBT), 45% of the patients continue suffering from this disorder. Therefore, knowing the factors that could foresee who will respond to CBT would be of great value to the treatment of these patients. Thus, we have systematically reviewed the literature to identify the variables that could predict response to CBT in patients suffering from PTSD. Methods Following the PRISMA 2020 guidelines, we searched the electronic databases ISI Web of Science, Scopus, PsycINFO, MEDLINE, and PTSDpubs until November 2021. Two authors have independently conducted study selection and data extraction. Studies that examined possible predictors of response to therapy on a sample of adults (18-65 years), both genders, with and without comorbidities were considered eligible. The characteristics of the studies were synthesized in a table. The risk of bias was assessed by the Cochrane risk of bias quality assessment tool. Results Twenty-eight studies comprising 15 variables were selected. Among those, eight showed a low risk of bias, 19 showed some concerns, and one showed a high potential risk of bias. The therapeutic relationship was the only variable considered to be a predictor of a good response to therapy. All other variables showed conflicting results. Conclusions The most promising variable, although scientifically weak, is the therapeutic relationship. Additional randomized clinical trials should be conducted to clarify the role of this variable as a predictor of response to CBT in patients with PTSD.

Treatment of anger problems in previously deployed post-911 veterans: A randomized controlled trial

BACKGROUND

Problems with anger and aggression affect many veterans who have deployed to a warzone, resulting in serious impairment in multiple aspects of functioning. Controlled studies are needed to improve treatment options for these veterans. This randomized controlled trial compared an individually delivered cognitive behavioral therapy adapted from Novaco's Anger Control Therapy to a manualized supportive therapy to control for common therapeutic factors.

METHODS

Ninety-two post-911 veterans deployed during Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), or Operation New Dawn (OND) with moderate to severe anger problems were randomized to receive the cognitive behavioral intervention (CBI) or the supportive intervention (SI). Anger, aggression, multiple areas of functioning and quality of life were assessed at multiple time points inclu\ding 3- and 6-month follow-up.

RESULTS

Hierarchical linear modeling (HLM) analyses showed significant treatment effects favoring CBI for anger severity, social and interpersonal functioning, and quality of life. The presence of a PTSD diagnosis did not affect outcomes.

CONCLUSIONS

CBI is an effective treatment for OEF/OIF/OND veterans with anger problems following deployment, regardless of PTSD diagnosis.

Problematic anger and economic difficulties: Findings from the Millennium Cohort Study

BACKGROUND

The role of problematic anger in relation to economic difficulties is not well understood. This study examined the association of problematic anger with 4 elements of economic difficulties among service members and veterans.

METHODS

Study participants (n = 95,895) were from the Millennium Cohort Study, and included U.S. service members and veterans; analyses were restricted to a Reserve/National Guard and/or veteran sample as appropriate. Key measures included the Dimensions of Anger Reactions scale and self-reported economic variables (involuntary job loss, financial problems, unemployment and homelessness). Covariates included demographics, military characteristics, disabling injury or illness, problem drinking, posttraumatic stress disorder, and major depressive disorder. The study design was cross-sectional.

RESULTS

Among all participants, 17.4% screened positive for problematic anger, 29.7% reported involuntary job loss, and 6.4% reported financial problems. After adjustment for covariates, problematic anger was associated with involuntary job loss (AOR=1.28; 95% CI: 1.22, 1.33) and financial problems (AOR=1.46; 95% CI: 1.36, 1.57). Among veterans, 12.1% reported being unemployed; among Reserve/National Guard and veterans, 2.3% reported homelessness. Problematic anger was associated with unemployment (AOR=1.28, 95% CI: 1.18, 1.37) and homelessness (AOR=1.33; 95% CI: 1.16, 1.52) after adjusting for covariates.

LIMITATIONS

The study relied on self-report data and directionality could not be established.

CONCLUSIONS

Problematic anger was significantly associated with involuntary job loss, financial problems, unemployment and homelessness, even after adjusting for relevant covariates. These findings have clinical relevance in demonstrating the potential for targeting problematic anger in service members and veterans.

The nature of posttraumatic stress disorder in treatment-seeking first responders

BACKGROUND

Approximately 10% of first responders report posttraumatic stress disorder (PTSD). Although reports within first responders suggest that they have distinct symptom presentations, there is a need to understand how the clinical profiles of first responders may differ from others seeking treatment for PTSD.

OBJECTIVE

This study compared the PTSD symptom profiles of first responder and civilians seeking treatment for PTSD.

METHOD

Participants self-referred to the Traumatic Stress Clinic (University of New South Wales, Sydney) for enrolment in out-patient treatment trials for PTSD. Participants comprised people of mean age 41.72 years (SD = 10.71) who met DSM-IV criteria for PTSD. The sample was composed of 128 first responders and 182 civilians. Clinician-administered interviews of PTSD (Clinician-Administered PTSD Scale) and depression were conducted, as well as measures of self-report measures of depression, alcohol use, posttraumatic appraisals, and anger.

RESULTS

First responders reported greater rates of dysphoric cluster of symptoms, including diminished interest, emotional numbing, and social detachment, and less psychological reactivity and avoidance of situations, than civilians with PTSD. Beyond PTSD symptoms, first responders also reported more severe levels of depression and suppressed anger.

CONCLUSIONS

These findings indicate that treatment-seeking first responders present with a distinct clinical profile that is characterized by dysphoric symptoms. These symptoms can predict poor treatment response and require specific attention in treating PTSD in first responders.

The Role of Anger in Traumatic Harm and Recovery for Sexual Violence Survivors

Sexual violence is a strong predictor of posttraumatic stress disorder (PTSD). Sexual violence survivors presenting for PTSD treatment may experience and express a range of distressing emotions. An extensive body of research guides clinical conceptualization and targeting of fear responses in PTSD treatment. Models to guide clinicians in working with posttraumatic anger, in contrast, are scarce. To address this gap, we: 1) provide a review of the theoretical and empirical literature on sexual violence, anger, and trauma recovery among sexual violence survivors; 2) integrate this literature with social functionalist theories of anger; and 3) discuss implications of this integration for adaptively leveraging anger in psychological treatment.

Anger and predictors of drop-out from PTSD treatment of veterans and first responders

BACKGROUND

Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders.

AIMS

The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD.

METHOD

Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance.

RESULTS

Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme.

CONCLUSION

These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.

Distinguishing the Effects of Life Threat, Killing Enemy Combatants, and Unjust War Events in U.S. Service Members

Although previous studies have identified behavioral health risks associated with combat exposure, it is unclear which types of combat events are associated with these risks, particularly regarding contrasts among the risks associated with life-threatening experiences, killing combatants, and exposure to unjust war events, such as killing a noncombatant or being unable to help civilian women and children. In the present study, we examined surveys from 402 soldiers following deployment (i.e., baseline) and again 13 months later (i.e., Year 1). Regression analyses were conducted across a range of behavioral health (e.g., posttraumatic stress disorder, depression, suicide ideation, anxiety, somatic, insomnia, aggression) and benefit-finding measures, each controlling for two combat event categories while assessing the predictive utility of a third. The results suggested that life-threatening events were associated with poor behavioral health at baseline, relative risk (RR) = 10.00, but not at Year 1, RR = 2.67. At both baseline and Year 1, killing enemy combatants was not associated with behavioral health, RRs = 1.67-3.33, but was positively associated with benefit-finding, RRs = 26.67-40.00. Exposure to unjust war events was associated with a transdiagnostic pattern of behavioral health symptoms at baseline, RR = 40.00, and Year 1, RR = 23.33. Overall, the results suggest unjust war event exposure is particularly injurious, above and beyond exposure to other combat-related events. Future research can build on these findings to develop clearer descriptions of the combat events that might place service members at risk for moral injury and inform the development of assessment and treatment options.

Comorbid posttraumatic stress disorder and major depressive disorder: The usefulness of a sequential treatment approach within a randomised design

Cognitive Processing Therapy (CPT) and Behavioural Activation Therapy (BA) were used to treat individuals with comorbid posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Fifty-two individuals (48 women, 4 men) were randomized to CPT alone (n = 18), CPT then BA for MDD (n = 17), or BA then CPT (n = 17). Presenting trauma was primarily interpersonal (87 %). Participants were assessed at pre-, posttreatment, and 6-month follow-up. PTSD and MDD symptoms were the main outcome of interest; trauma cognitions, rumination, and emotional numbing were secondary outcomes. All groups showed sizeable reductions in PTSD and depression (effect sizes at follow-up ranging between 1.02-2.54). A pattern of findings indicated CPT/BA showed better outcomes in terms of larger effect sizes and loss of diagnoses relative to CPT alone and BA/CPT. At follow-up greater numbers of the CPT/BA group were estimated to have achieved good end-state for remission of both PTSD and depression (49 %, CI₉₅ [.26, .73]) relative to CPT alone (18 %, CI₉₅ [.03, .38]) and BA/CPT (11 %, CI₉₅ [.01, .29]). Although tempered by the modest sample size, the findings suggest that individuals with comorbid PTSD and MDD may benefit from having PTSD targeted first before remaining MDD symptoms are addressed.

Magnitude of problematic anger and its predictors in the Millennium Cohort

Background

Problematic anger is intense anger associated with elevated generalized distress and that interferes with functioning. It also confers a heightened risk for the development of mental health problems. In military personnel and veterans, previous studies examining problematic anger have been constrained by sample size, cross-sectional data, and measurement limitations.

Methods

The current study used Millennium Cohort survey data (N = 90,266) from two time points (2013 and 2016 surveys) to assess the association of baseline demographics, military factors, mental health, positive perspective, and self-mastery, with subsequent problematic anger.

Results

Overall, 17.3% of respondents reported problematic anger. In the fully adjusted logistic regression model, greater risk of problematic anger was predicted by certain demographic characteristics as well as childhood trauma and financial problems. Service members who were in the Army or Marines, active duty (vs. reserves/national guard), and previously deployed with high levels of combat had increased risk for problematic anger. Veterans were also more likely to report problematic anger than currently serving personnel. Mental health predictors included posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and comorbid PTSD/MDD. Higher levels of positive perspective and self-mastery were associated with decreased risk of problematic anger.

Conclusion

Not only did 1 in 6 respondents report problematic anger, but risk factors were significant even after adjusting for PTSD and MDD, suggesting that problematic anger is more than an expression of these mental health problems. Results identify potential targets of early intervention and clinical treatment for addressing problematic anger in the military and veteran context.

Predicting and Managing Treatment Non-Response in Posttraumatic Stress Disorder

PURPOSE OF REVIEW

This review aims to synthesize existing research regarding the definition of treatment resistance in posttraumatic stress disorder (PTSD), predictors of treatment non-response to first-line interventions, and emerging second-line PTSD treatment options into an accessible resource for the practicing clinician.

RECENT FINDINGS

The concept of treatment resistance in PTSD is currently poorly defined and operationalized. There are no well-established predictors of treatment non-response utilized in routine clinical care, but existing research identifies several potential candidate markers, including male gender, low social support, chronic and early life trauma exposure, comorbid psychiatric disorders, severe PTSD symptoms, and poor physical health. The most promising available treatment options for PTSD patients non-responsive to first-line psychotherapies and antidepressants include transcranial magnetic stimulation and ketamine infusion. Methylenedioxymethamphetamine-assisted psychotherapy also appears promising but is only available in a research context. These options require careful consideration of risks and benefits for a particular patient.

SUMMARY

More research is required to develop a robust, clinically-useful definition of treatment resistance in PTSD; identify reliable, readily assessable, and generalizable predictors of PTSD treatment non-response; and implement measurement and prediction in clinical settings to identify individuals unlikely to respond to first-line treatments and direct them to appropriate second-line treatments.

Development and Trial Implementation of a 30-Day Outpatient Program for Subthreshold PTSD

INTRODUCTION

Posttraumatic stress disorder (PTSD) negatively impacts service members at high rates, causing considerable physical and psychological consequences. Additionally, many service members experience subthreshold PTSD (i.e., experiencing PTSD symptoms that do not meet full diagnostic criteria), which has also been shown to cause significant functional impairment and can be a precursor to the development of full PTSD. Typically, treatment for PTSD at Walter Reed National Military Center facility includes weekly outpatient individual therapy over a three-month period or referral to an intensive outpatient program (IOP), which emphasizes group treatment. Inclusion in these programs is dependent on the severity of symptoms. Service members with subthreshold symptoms do not typically qualify for an IOP, and weekly outpatient therapy does not meet the needs of some service members or their commands.

METHODS

As a result, we developed an alternative program with the intention of allowing service members with subthreshold PTSD to receive treatment and return to full-duty status more rapidly. The program emphasized bi-weekly evidenced-based PTSD therapies treatment adjusted to meet the needs of each service member along with the option of adjunct individual and group treatments.

RESULTS

While this program is ongoing and we have not yet conducted outcome data analyses, the structure and pace of this program have the potential to produce quicker functional improvements, prevent the development of full PTSD symptoms, and reduce long-term or recurring healthcare utilization.

CONCLUSION

Although more research is needed, there exists preliminary empirical evidence of efficacy for an accelerated protocol of biweekly evidence-based therapy for service members with subthreshold PTSD.

DISCLAIMER

The opinions expressed in this abstract are those of the authors and do not necessarily represent the opinions of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States Government. Additionally, the authors have no conflicts of interests to report.

Posttraumatic anger: a confirmatory factor analysis of the Dimensions of Anger Reactions Scale-5 (DAR-5) - French adaptation

Background: Research has shown that posttraumatic anger is common after a traumatic experience, represents a risk factor for post-trauma psychopathology, and can be screened for using the Dimensions of Anger Reactions Scale-5 (DAR-5), a concise five-item measure. However, a French version of the DAR-5 is not yet available. Objective: We aimed to provide a French adaptation (DAR-5-F) and to replicate, in a French community sample, the psychometric properties of the original DAR-5. Method: After translation using transcultural psychometric principles, the DAR-5-F was presented to 822 fluent French speakers alongside validated scales of anger (State-Trait Anger Expression Inventory-2), anxiety and depression (Hospital Anxiety and Depression Scale), alcohol misuse (Alcohol Use Disorders Identification Test-Consumption), and trauma exposure (Life Events Checklist-5). Results: Confirmatory factor analyses confirmed that DAR-5-F scores fit a single-factor model as described with the English version of the scale. The scale showed noteworthy internal consistency and robust convergent validity with trait anger. The screening DAR-5-F cut-off of ≥12 successfully differentiated high from low scores of STAXI-2, anxiety, depression, and traumatic exposure. Conclusions: The DAR-5 is a robust, psychometrically strong brief scale of anger useful for post-trauma screening, with the DAR-5-F now available for use in French-speaking populations. Future research that examines relationships between the DAR-5-F and variables such as trauma severity and posttraumatic stress symptoms will further improve our understanding of these phenomena.

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

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.

Symptom severity in PTSD and comorbid psychopathology: A latent profile analysis among traumatized veterans

Individuals diagnosed with posttraumatic stress disorder (PTSD) show remarkably different symptom presentations. Identification of diagnostic profiles of PTSD may contribute to knowledge about treatment modifications to enhance treatment effectiveness. The present study aimed to identify symptom severity classes among 236 Dutch veterans based on a broad range of psychopathology outcomes, including PTSD, using Latent Profile Analysis (LPA). Moreover, multinomial logistic regression was used to test whether class membership could be predicted by the number and characteristics of traumatic event types, coping and personality dimensions. LPA identified three classes of individuals, defined as average, severe, and highly severe symptom severity classes, respectively. No qualitative differences in the symptom dimensions emerged between classes. Veterans with higher amounts of traumatic experiences and specifically with regard to lack of basic human needs, as well as those using more avoidant and problem-focused coping strategies and with more dysfunctional personality characteristics regarding neuroticism and agreeableness were significantly more often in the severe and/or highly severe symptom classes. In conclusion, general symptom severity was found to be an important diagnostic characteristic in this population. Integrated treatments targeting the broad spectrum of mental health problems may be of importance in treating patients that show low therapeutic recovery.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Using Explicit Case Formulation to Improve Cognitive Processing Therapy for PTSD

We investigated the utility of explicit case formulation (CF) within Cognitive Processing Therapy (CPT) for individuals with posttraumatic stress disorder (PTSD). An uncontrolled pre-posttreatment design was used. Participants attended 12-16 weekly sessions of CPT with explicit CF, where CF guided treatment length and treatment components. Treatment was completed by 19 of the 23 participants who started therapy. Results revealed significant reductions in PTSD and depression severity as well as unhelpful PTSD-related beliefs from pre- to posttreatment (ds between 1.10 - 1.92) and treatment gains were maintained at 3-month follow-up. Of the participants available at posttreatment for assessment, 69% (n = 11/16) met good end-state functioning for PTSD and 62% (n = 8/13) did so at follow-up. Finally, 72% (n = 13/18) of those interviewed at posttreatment no longer met criteria for PTSD and this was found for 93% of those assessed at follow-up (n = 14/15). Treatment, and CF in particular, was found to be acceptable by participants. Explicit case formulation did not interfere with positive outcomes of Cognitive Processing Therapy for PTSD. Further clinical implications and future directions for research are discussed.

Predictors of change in cognitive processing therapy for veterans in a residential PTSD treatment program

OBJECTIVE

Cognitive processing therapy is an evidence-based treatment for posttraumatic stress disorder (PTSD); however, questions remain regarding variability in treatment response.

METHOD

A total of 123 veterans participated in group-based cognitive processing therapy (CPT) in residential PTSD treatment. Change over time in PTSD symptoms was modeled as a function of selected demographic and clinical variables.

RESULTS

PTSD checklist (PCL) scores decreased by an average of 1 point per session (standard deviation [SD] = 0.1). Initial PCL scores were predicted by the Beck Depression Inventory-II (γ₀₁ = 0.25; standard error [SE] = 0.08), Insomnia Severity Index (γ₀₂ = 0.53; SE = 0.15), and Infrequency (F) scale of the Minnesota Multiphasic Personality Inventory-2 (γ₀₃ = 0.09; SE = 0.04). Rate of change was predicted by the Somatic Complaints (RC1) scale (γ₁₁ = -0.03; SE = 0.01) and the Antisocial Behavior (RC4) scale (γ₁₂ = 0.02; SE = 0.01).

CONCLUSIONS

These results provide insight into characteristics that may influence degree of benefit received from group-based CPT.

Characterizing anger-related affect in individuals with posttraumatic stress disorder using ecological momentary assessment

This study employed secondary analyses of existing ecological momentary assessment (EMA) data to characterize hostile and irritable affect in the day-to-day experience of 52 smokers with, and 65 smokers without, posttraumatic stress disorder (PTSD). EMA monitoring occurred over a mean of 8.2 days, and participants responded to an average of 2.8 random prompts/day. Analyses included Wilcoxon rank sum tests of group differences, and path analyses of cross-lagged multilevel models. Participants with PTSD endorsed a significantly higher proportion of total EMA entries indicating hostile affect and irritable affect than did individuals without PTSD. Cross-lagged analyses indicated that over a period of hours, PTSD symptoms significantly predicted subsequent hostile and irritable affect, but hostile and irritable affect did not predict subsequent PTSD symptoms. Findings suggest that day-to-day exposure to PTSD-related trauma cues may contribute to chronically elevated levels of anger-related affect. Such heightened affective arousal may, in turn, underlie an increased risk for verbal or physical aggression, as well as other health and quality-of-life related impairments associated with PTSD. Clinical implications include conceptualizing anger treatment in the broader context of trauma history and symptoms, and specifically targeting physiological arousal and maladaptive hostile cognitions triggered by trauma reminders in patients with PTSD.

The Effect of Sleep Disorders, Sedating Medications, and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis

Cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) is an effortful process requiring engagement in cognitive restructuring. Sleep disorders may lead to avoidance of effortful tasks and cognitive performance deficits. We explored whether sleep disorders, as assessed by polysomnography, were consistently associated with treatment response in combination with other factors. This study included 32 U.S. veterans who were examined both before and after CPT for combat-related PTSD. We employed a novel, case-comparative technique, fuzzy set qualitative comparative analysis (fsQCA), to identify combinations of fuzzy and crisp factors (recipes) that achieve a clinically significant outcome. Approximately one-quarter of cases experiencing clinically significant change were either (a) Vietnam era veterans without sedating medications, moderate sleep disordered breathing, and severe depression; or (b) non-Vietnam era veterans with sedating medications and without severe periodic limb movements (or significant periodic limb movement arousals). Recipes involving the absence of the relevant sleep disorder were associated with the highest coverage values. These results using fsQCA (a) provide valuable information about the heterogeneity of CPT response and (b) suggest that sleep disorders are important factors to consider in theoretical discussions of who responds to CPT for PTSD.

Can Anger Be Helpful?: Soldier Perceptions of the Utility of Anger

Studies have found that soldiers returning from combat deployment report elevated levels of anger and aggression. The present study examined the perception that anger was helpful in performing occupationally related duties and whether this perception was associated with mental health problems, somatic symptoms, and functioning. Soldiers (N = 627) completed a survey 4 months after their deployment to Afghanistan and again 3 months later. When examining anger over time, findings revealed four groups of different latent classes: low stable (resilient), high stable (chronic), decreasing over time (improved), and increasing over time (delayed problems). For two of the groups (chronic and delayed problems), perceiving anger as helpful was closely related to anger reactions. Perceiving anger as helpful was also associated with worse mental health symptoms. Further work in understanding how to mitigate this positive perception of anger in prevention initiatives may be useful in addressing anger reactions.

Growth mixture modeling of post-combat aggression: Application to soldiers deployed to Iraq

Prior research has found substantial heterogeneity in the course of key post-deployment outcomes, such as PTSD. The current paper employs growth mixture modeling to identify differential trajectories of change in the course of post-combat aggression. A Brigade Combat Team completed surveys within 72h of return from an Iraq deployment, 4 months later, and at 12 months after return. Based on model fit indices, analyses yielded four latent aggression trajectories: "low-stable", "delayed", "recovery", and "chronic". In addition, most individuals aligned with a "low-stable" trajectory indicative of minimal aggression in the first year following return from a combat deployment. A conditional model showed that lower posttraumatic stress and lower combat exposure characterized individuals aligned with the "low-stable" aggression trajectory relative to individuals aligned with "chronic" and "delayed" aggression trajectories. Implications for targeted intervention and future research are discussed.

Aggression in US soldiers post-deployment: Associations with combat exposure and PTSD and the moderating role of trait anger

Anger and aggression are among the most common issues reported by returning service members from combat deployments. However, the pathways between combat exposure and anger and aggression have not been comprehensively characterized. The present study aimed to characterize the relationship between trait anger, combat exposure, post-deployment PTSD, and aggression. U.S. Army soldiers (N = 2,420) were administered anonymous surveys assessing combat exposure, current PTSD symptoms and aggression, as well as trait anger items 3 months after returning from deployment to Afghanistan. PTSD symptom levels were related to aggression at higher levels of trait anger, but not evident among soldiers who had lower levels of trait anger. The pathway from combat exposure to PTSD, and then to aggression, was conditional upon levels of trait anger, such that the pathway was most evident at high levels of trait anger. This was the first study to our knowledge that concurrently modeled unconditional and conditional direct and indirect associations between combat exposure, PTSD, trait anger, and aggression. The findings can be helpful clinically and for developing screening protocols for combat exposed Soldiers. The results of this study suggest the importance of assessing and managing anger and aggression in soldiers returning from combat deployment. Anger is one of the most common complaints of returning soldiers and can have debilitating effects across all domains of functioning. It is imperative that future research efforts are directed toward understanding this phenomenon and developing and validating effective treatments for it.

The role of anger and ongoing stressors in mental health following a natural disaster

OBJECTIVE

Research has established the mental health sequelae following disaster, with studies now focused on understanding factors that mediate these outcomes. This study focused on anger, alcohol, subsequent life stressors and traumatic events as mediators in the development of mental health disorders following the 2009 Black Saturday Bushfires, Australia's worst natural disaster in over 100 years.

METHOD

This study examined data from 1017 (M = 404, F = 613) adult residents across 25 communities differentially affected by the fires and participating in the Beyond Bushfires research study. Data included measures of fire exposure, posttraumatic stress disorder, depression, alcohol abuse, anger and subsequent major life stressors and traumatic events. Structural equation modeling assessed the influence of factors mediating the effects of fire exposure on mental health outcomes.

RESULTS

Three mediation models were tested. The final model recorded excellent fit and observed a direct relationship between disaster exposure and mental health outcomes (b = .192, p < .001) and mediating relationships via Anger (b = .102, p < .001) and Major Life Stressors (b = .128, p < .001). Each gender was compared with multiple group analyses and while the mediation relationships were still significant for both genders, the direct relationship between exposure and outcome was no longer significant for men (p = .069), but remained significant (b = .234, p < .001) for women.

CONCLUSIONS

Importantly, anger and major life stressors mediate the relationship between disaster exposure and development of mental health problems. The findings have significant implications for the assessment of anger post disaster, the provision of targeted anger-focused interventions and delivery of government and community assistance and support in addressing ongoing stressors in the post-disaster context to minimize subsequent mental health consequences.

The efficacy of recommended treatments for veterans with PTSD: A metaregression analysis

Soldiers and veterans diagnosed with PTSD benefit less from psychotherapy than non-military populations. The current meta-analysis identified treatment predictors for traumatised soldiers and veterans, using data from studies examining guideline recommended interventions, namely: EMDR, exposure, cognitive, cognitive restructuring, cognitive processing, trauma-focused cognitive behavioural, and stress management therapies. A systematic search identified 57 eligible studies reporting on 69 treated samples. Exposure therapy and cognitive processing therapy were more effective than EMDR and stress management therapy. Group-only therapy formats performed worse compared with individual-only formats, or a combination of both formats. After controlling for study design variables, EMDR no longer negatively predicted treatment outcome. The number of trauma-focused sessions, unlike the total number of psychotherapy sessions, positively predicted treatment outcome. We found a relationship between PTSD pretreatment severity levels and treatment outcome, indicating lower treatment gains at low and high PTSD severity levels compared with moderate severity levels. Demographic variables did not influence treatment outcome. Consequently, soldiers and veterans are best served using exposure interventions to target PTSD. Our results did not support a group-only therapy format. Recommended interventions appear less effective at relatively low and high patient PTSD severity levels. Future high-quality studies are needed to determine the efficacy of EMDR.