The experience, expression, and control of anger following traumatic brain injury in a military sample

Involvement of physiological reactivity and interoception in emotional experience after a traumatic brain injury

OBJECTIVE

Emotional experience is based, among other factors, on physiological reactivity (PR) and the awareness of this reactivity corresponding to interoception. After a traumatic brain injury (TBI), patients exhibit reduced PR and interoception, raising questions about the integrity of their emotional experience.

METHOD

To examine this issue, 26 men with moderate to severe TBI (age: 37 ± 11) and 26 healthy male controls (age: 35 ± 14) watched emotional films (amusement, tenderness, anger, disgust). PR was measured via electrodermal activity (EDA) and heart rate variability (HRV). After each film, an emotional evaluation was completed using the Differential Emotional Scale (DES). Interoception was measured through a heartbeat counting (HBC) task and the Multidimensional Assessment of Interoceptive Awareness (MAIA) questionnaire.

RESULTS

Compared to controls, TBI participants scored lower on the MAIA Emotional Awareness and Noticing subscales, and exhibited lower EDA and HRV during the anger and tenderness films. However, emotional evaluations and HBC task scores were similar between groups. Positive correlations were found between emotional evaluation and the MAIA scale.

CONCLUSION

These results suggest a dissociation between emotional experience and PR after TBI and decreased interoceptive sensitivity. Since interoception links PR and emotional experience, exploring the impact of reduced interoception on this dissociation could improve our understanding of post-TBI emotional functioning.

Experiences of caregivers of patients with traumatic brain injury during hospitalization in western China: A qualitative study

Family members frequently provide both physical and emotional support to patients. Previous studies have focused primarily on the experiences of patients with traumatic brain injury (TBI) and their caregivers during home care and the transition from hospital care to the community, with less emphasis on their experiences during acute hospital care immediately after TBI. This study aimed to explore the experiences of caregivers of patients with TBI during acute hospitalizations. A qualitative descriptive study using individual semistructured interviews was conducted at the trauma center of a tertiary hospital in western China. A purposive sample of 21 caregivers of patients with TBI were recruited. The interviews were conducted face to face in the inpatient ward from July to September 2023. Conventional content analysis was used to conduct the framework analysis. The experiences of caregivers were identified within three key themes: TBI consequences in patients (physical impairments, psychological distress, and cognitive dysfunctions), challenges of caregivers (physiological/emotional/economic burdens, conflicts, and concerns regarding recovery), and needs of caregivers (health information, medical services, and recovery expectations). This study highlights the experiences of caregivers of patients with TBI during hospital stays in western China. The challenges faced by caregivers and the needs of caregivers are multidimensional. Appropriate support should be provided to alleviate the burden of caregiving.

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.

Putting the pieces together to understand anger in combat veterans and service members: Psychological and physical contributors

Dysregulated anger can result in devastating health and interpersonal consequences for individuals, families, and communities. Compared to civilians, combat veterans and service members (C-V/SM) report higher levels of anger and often have risk factors for anger including posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), pain, alcohol use, and impaired sleep. The current study examined the relative contributions of established variables associated with anger (e.g., combat exposure, current PTSD symptoms, history of TBI, pain interference, and hazardous alcohol use) in 1263 C-V/SM. Sleep impairments, represented by poor sleep quality and obstructive sleep apnea (OSA) risk, were also evaluated as potential mediators of the relationships between established risk factors and anger, and therefore potential modifiable treatment targets. Multiple regression model results revealed that PTSD symptoms (β = 0.517, p < .001), OSA risk (β = 0.057, p = .016), pain interference (β = 0.214, p < .001), and hazardous alcohol use (β = 0.054, p = .009) were significantly associated with anger. Results of the mediation models revealed that OSA risk accounted for the association between PTSD and anger, in addition to the association between pain interference and anger. The current study extends previous literature by simultaneously examining factors associated with anger using a multivariable model in a large sample of C-V/SM. Additionally, treating OSA may be a novel way to reduce anger in C-V/SM who have PTSD and/or pain interference.

Shades of Rage: Applying the Process Model of Emotion Regulation to Managing Anger After Brain Injury

Uncontrollable anger is common following an acquired brain injury (ABI), with impaired emotion regulation (ER) being one of the main contributors. Existing psychological interventions appear moderately effective, though studies typically include limitations such as small sample sizes, issues of long-term efficacy, and standardization of content. While ER has been a popular research field, the study of ER for anger management after ABI is less well investigated, and contains few interventions based on the widely used Process Model of ER. This review surveys the efficacy of ER strategies in individuals with ABI, and proposes a novel research design for future interventions. Recommendations are made about: strategy number and type, shared decision-making, approaches to data analysis, and mode of delivery.

Preliminary Evidence for a Relationship Between Anxiety, Anger, and Impulsivity in Collegiate Athletes With Sport-Related Concussion

This study used an exploratory mixed-method sequential design to examine anger, impulsivity, and anxiety following sport-related concussions (SRC). Ten college athletes (M = 20.10 years, SD = 2.92) completed four measures 1–10 days postconcussion (Visit 1) and 11–20 days postconcussion (Visit 2). At return to play or 30 days postconcussion, the athletes completed a semistructured interview (follow-up) to assess their lived experiences of the emotional sequelae of concussions. All participants indicated experiencing some level of anxiety at Visit 1, with half the participants scoring above the measure’s threshold for probable clinical diagnosis of anxiety. The results found a significant decrease in symptoms and anxiety at Visit 2. Inductive coding revealed frustration, irritability, impulsive behavior, and fear of the unknown as themes pertaining to athletes’ experiences. The findings highlight the need for sports medicine and sport psychology professionals to provide athletes with information to normalize their emotional responses during recovery.

Traumatic Brain Injury, Working Memory, and Violent Crime in a Sample of U.S. Service Members Involved in the Military Justice System

INTRODUCTION

This study examined working memory impairment following mild traumatic brain injury (mTBI) among active duty service members charged with criminal offenses. The prevalence of mTBI among service members involved in the military justice system is unknown. Impairments associated with mTBI may affect cognitive processes related to psycholegal capacities, and history of mTBI may have a persuasive appeal when explaining questions of culpability. The degree to which mTBI affects psycholegal abilities through cognitive impairment, however, is unknown.

MATERIALS AND METHODS

This was a retrospective study of U.S. service members who presented for forensic evaluation (n = 80). Completed forensic evaluations (eg, criminal responsibility, competence to stand trial, risk assessment) were the source of data. Working Memory Index (WMI) score of the Wechsler Adult Intelligence Scale, Fourth Edition was used as an index of sequelae after brain injury.

RESULTS

A history of mTBI was present in 20% of the sample. The mean time from mTBI diagnosis to presentation for forensic evaluation was 3.96 years. The mTBI-positive group had a mean WMI = 98 and the mTBI-negative group had a mean WMI = 103. The difference in WMI scores between groups was not statistically significant.

CONCLUSIONS

This study suggests that a history of mTBI is common among service members charged with criminal offenses. The findings that working memory scores were in the average range among service members with mTBI history may suggest that history of mTBI does not impair psycholegal relevant cognition. More research is needed to clarify how history of mTBI affects service member psycholegal capacities.

National Institutes of Health Toolbox Emotion Battery: Application of Summary Scores to Adults With Spinal Cord Injury, Traumatic Brain Injury, and Stroke

OBJECTIVE

To examine the validity of factor analytically based summary scores that were developed using the National Institutes of Health Toolbox Emotion Battery (NIHTB-EB); (ie, psychological well-being, social satisfaction, negative affect) normative sample in individuals with neurologic conditions.

DESIGN

Cross-sectional, observational cohort.

SETTING

Community.

PARTICIPANTS

A total of 1036 English-speaking adults from the National Institutes of Health Toolbox (NIHTB) normative project and 604 community-dwelling adults with neurologic conditions including spinal cord injury (SCI n=209), traumatic brain injury (TBI n=184), and stroke (cerebrovascular accident [CVA] n=211) (N=1640).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The NIHTB-EB.

RESULTS

A series of univariate analyses comparing summary scores across the 4 groups (SCI, TBI, CVA, normative group) were conducted to identify group differences. Base rates (defined as >1 SD toward the problematic direction) were also identified. The normative group demonstrated better emotional functioning characterized by greater social satisfaction and psychological well-being (normative group > SCI, TBI, CVA; P's <.0001), and less negative affect (normative group < SCI, P=.016; normative group < TBI, P<.001; normative group < CVA; P=.034) compared with each neurologic group. Using base rates to identify problematic emotions for the 3 summary scores, there were higher rates of problematic emotions on all 3 summary scores for the neurologic groups compared with the normative group.

CONCLUSIONS

The NIHTB-EB summary scores demonstrate an increased prevalence of problematic emotions among individuals with 3 neurologic conditions, and might be useful for identifying individuals with similar conditions and potentially in need of psychological support.

Elevated Aggression and Reduced White Matter Integrity in Mild Traumatic Brain Injury: A DTI Study

Mild traumatic brain injury (mTBI) remains the most commonly reported head injury in the United States, and is associated with a wide range of post-concussive symptoms including physical, cognitive and affective impairments. Elevated aggression has been documented in mTBI; however, the neural mechanisms associated with aggression at the chronic stage of recovery remain poorly understood. In the present study, we investigated the association between white matter integrity and aggression in mTBI using diffusion tensor imaging (DTI). Twenty-six age-matched adults participated in the study, including 16 healthy controls (HCs) and 10 individuals in the chronic stage of recovery (either 6-months or 12 months post-mTBI). Psychological measures of aggression included the Buss-Perry Aggression Questionnaire and the Personality Assessment Inventory (PAI). Axonal pathways implicated in affective processing were studied, including the corpus callosum, anterior thalamic radiation, cingulum and uncinate fasciculus, and measures of white matter integrity included fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD) and axial diffusivity (AD). We found that adults with mTBI in the chronic stage of recovery had higher levels aggression. Individuals with mTBI also had greater RD in the corpus callosum compared to HCs, indicating reduced fiber integrity. Furthermore, we observed a significant association between reduced white matter integrity in the corpus callosum and greater aggression. Our findings provide additional evidence for underlying neuroanatomical mechanisms of aggression, although future research will be necessary to characterize the specific relationship between aggression and the white matter pathways we identified.

Anger Self-Management Training for Chronic Moderate to Severe Traumatic Brain Injury: Results of a Randomized Controlled Trial

OBJECTIVE

To test efficacy of 8-session, 1:1 treatment, anger self-management training (ASMT), for chronic moderate to severe traumatic brain injury (TBI).

SETTING

Three US outpatient treatment facilities.

PARTICIPANTS

Ninety people with TBI and elevated self-reported anger; 76 significant others (SOs) provided collateral data.

DESIGN

Multicenter randomized controlled trial with 2:1 randomization to ASMT or structurally equivalent comparison treatment, personal readjustment and education (PRE). Primary outcome assessment 1 week posttreatment; 8-week follow-up.

PRIMARY OUTCOME

Response to treatment defined as 1 or more standard deviation change in self-reported anger.

SECONDARY OUTCOMES

SO-rated anger, emotional and behavioral status, satisfaction with life, timing of treatment response, participant and SO-rated global change, and treatment satisfaction.

MAIN MEASURES

State-Trait Anger Expression Inventory-Revised Trait Anger (TA) and Anger Expression-Out (AX-O) subscales; Brief Anger-Aggression Questionnaire (BAAQ); Likert-type ratings of treatment satisfaction, global changes in anger and well-being.

RESULTS

After treatment, ASMT response rate (68%) exceeded that of PRE (47%) on TA but not AX-O or BAAQ; this finding persisted at 8-week follow-up. No significant between-group differences in SO-reported response rates, emotional/behavioral status, or life satisfaction. ASMT participants were more satisfied with treatment and rated global change in anger as significantly better; SO ratings of global change in both anger and well-being were superior for ASMT.

CONCLUSION

ASMT was efficacious and persistent for some aspects of problematic anger. More research is needed to determine optimal dose and essential ingredients of behavioral treatment for anger after TBI.

Effect of Aerobic Exercise Training on Mood in People With Traumatic Brain Injury: A Pilot Study

BACKGROUND

Exercise training is associated with elevations in mood in patients with various chronic illnesses and disabilities. However, little is known regarding the effect of exercise training on short and long-term mood changes in those with traumatic brain injury (TBI).

OBJECTIVE

The purpose of this study was to examine the time course of mood alterations in response to a vigorous, 12-week aerobic exercise training regimen in ambulatory individuals with chronic TBI (>6 months postinjury).

METHODS

Short and long-term mood changes were measured using the Profile of Mood States-Short Form, before and after specific aerobic exercise bouts performed during the 12-week training regimen.

RESULTS

Ten subjects with nonpenetrating TBI (6.6 ± 6.8 years after injury) completed the training regimen. A significant improvement in overall mood was observed following 12 weeks of aerobic exercise training (P = .04), with moderate to large effect sizes observed for short-term mood improvements following individual bouts of exercise.

CONCLUSIONS

Specific improvements in long-term mood state and short-term mood responses following individual exercise sessions were observed in these individuals with TBI. The largest improvement in overall mood was observed at 12 weeks of exercise training, with improvements emerging as early as 4 weeks into the training regimen.

Mild traumatic brain injury and suicide risk among a clinical sample of deployed military personnel: Evidence for a serial mediation model of anger and depression

Research has demonstrated a robust link between traumatic brain injuries (TBIs) and suicide risk. Yet, few studies have investigated factors that account for this link. Utilizing a clinical sample of deployed military personnel, this study aimed to examine a serial meditation model of anger and depression in the association of mild TBI and suicide risk. A total of 149 military service members referred for evaluation/treatment of a suspected head injury at a military hospital participated in the present study (92.6% male; M_age = 27.9y). Self-report measures included the Suicidal Behaviors Questionnaire-Revised (SBQ-R), Automated Neuropsychological Assessment Metrics (ANAM) anger and depression subscales, and Behavioral Health Measure-20 depression subscale. A current mild TBI diagnosis was confirmed by a licensed clinical psychologist/physician. Overall, 84.6% (126/149) of participants met diagnostic criteria for a current mild TBI. Bootstrapped serial mediation analyses indicated that the association of mild TBI and suicide risk is serially mediated by anger and depression symptoms (bias-corrected 95% confidence interval [CI] for the indirect effect = 0.044, 0.576). An alternate serial mediation model in which depression symptoms precede anger was not statistically significant (bias-corrected 95% CI for the indirect effect = -0.405, 0.050). Among a clinical sample of military personnel, increased anger and depression statistically mediated the association of mild TBI and suicide risk, and anger appears to precede depression in this pathway. Findings suggest that therapeutically targeting anger may serve to thwart the trajectory to suicide risk among military personnel who experience a mild TBI. Future research should investigate this conjecture within a prospective design to establish temporality.