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Marmuse A, Billaud JB, Jacob S, Vigier C, Ramdani C, Trousselard M. 'Hidden' anger as a risk factor for operational health: An exploratory approach among French military personnel. MILITARY PSYCHOLOGY 2025; 37:148-158. [PMID: 38436979 PMCID: PMC11849923 DOI: 10.1080/08995605.2024.2324645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 02/20/2024] [Indexed: 03/05/2024]
Abstract
Military personnel are repeatedly exposed to multiple stressors, and are sometimes characterized by high levels of anger. Evidence suggests that this anger can become dysfunctional, and impact the health status of populations chronically exposed to stress. In particular, rumination (understood as perseverative thoughts about a past event), provides a theoretical framework for investigating how anger may impact stress regulation abilities in military personnel declared fit for deployment. This exploratory study aimed therefore to examine the impact of the anger profile on psychological suffering in terms of burnout and post-traumatic stress disorder (PTSD), along with the reactivity of the autonomic nervous system, measured as cardiac variability. One hundred and seventeen French soldiers were tested before deployment to Operation BARKHANE. Anger rumination, burnout, and PTSD symptoms were assessed using questionnaires, and cardiac variability was measured as the questionnaires were completed. The results revealed two profiles related to anger trait and anger rumination. Burnout and PTSD scores were higher among military personnel with high levels of anger trait and rumination, and this group also had lower parasympathetic activity and flexibility after completing the questionnaires. These results suggest that there may be a link between an angry profile and psychological suffering, notably burnout and PTSD. Rumination could be involved in this link, as it is associated with poor adaptation to stress in a military context. Prospective researches including post-deployment will establish whether this ruminative response can account for the relationship between problematic anger, stress regulatory capacities and psychological health in military populations.
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Affiliation(s)
- Anaïs Marmuse
- 9th Army Medical Center, Army Health Service, Draguignan, France
- INSPIIRE, University of Lorraine, Metz Cedex, France
| | - Jean-Baptiste Billaud
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Sandrine Jacob
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Cécile Vigier
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Céline Ramdani
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Marion Trousselard
- INSPIIRE, University of Lorraine, Metz Cedex, France
- Stress Neurophysiology Unit, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
- French Military Health Service Academy, Paris, France
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Wells SY, Knopp K, Wachsman TR, Dillon KH, Walker HE, Sippel L, Morland L, Glassman LH. Examining the impact of brief couples-based posttraumatic stress disorder treatments on anger and psychological aggression in veterans and their partners. J Trauma Stress 2025; 38:165-173. [PMID: 39318041 PMCID: PMC11794020 DOI: 10.1002/jts.23099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 09/26/2024]
Abstract
Anger can adversely impact functioning in veterans. Psychological aggression, which is related to but distinct from anger, is particularly detrimental to veterans' mental health. Research examining anger and psychological aggression following individual therapy for posttraumatic stress disorder (PTSD) has demonstrated small effect sizes. Treatments that directly target conflict management and interpersonal functioning, both regarding content and delivery to veterans and their loved ones (e.g., couples-based PTSD treatments), may be more effective in alleviating anger symptoms. This study examined whether larger reductions in anger and psychological aggression would be observed in a couples-based intervention compared to an active comparator at posttreatment and follow-up. Data were derived from a randomized trial comparing brief cognitive-behavioral conjoint therapy for PTSD (bCBCT) and PTSD family education (PFE). Participants were 137 veterans and their intimate partners (bCBCT: n = 92, PFE: n = 45). We observed within-condition significant reductions in angry temperament, d = -0.47, p < .001, and angry reaction, d = -0.26, p = .004, among veterans in bCBCT but not PFE, |d|s = 0.13-0.17, ps = .166-.268. Veterans and partners in both conditions reported reductions in psychological aggression, |d|s = 1.09-1.46, ps < .001. There were no significant differences between the treatment conditions on any outcome, ps = .103-.443, and there were no significant changes in anger between posttreatment and follow-up, |d|s = 0.07-0.24, ps = .052-.582. Couples-based interventions for PTSD, including bCBCT and PFE, can be effective in improving aspects of anger among veterans and their intimate partners.
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Affiliation(s)
- Stephanie Y Wells
- Durham VA Health Care System, Durham, North Carolina, USA
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
| | - Kayla Knopp
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Tamara R Wachsman
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Kirsten H Dillon
- Durham VA Health Care System, Durham, North Carolina, USA
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Lauren Sippel
- Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut, USA
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Evaluation Division, Department of Veterans Affairs National Center for PTSD, West Haven, Connecticut, USA
| | - Leslie Morland
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
- Women's Health Sciences Division, Department of Veterans Affairs National Center for PTSD, Boston, Massachusetts, USA
| | - Lisa H Glassman
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
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Plummer Lee C, Mersky JP, Liu X. Postpartum anger among low-income women with high rates of trauma exposure. J Trauma Stress 2025; 38:124-134. [PMID: 39432439 DOI: 10.1002/jts.23109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/26/2024] [Accepted: 09/09/2024] [Indexed: 10/23/2024]
Abstract
Few studies have examined anger concerns among postpartum women despite their risk of mood dysregulation. This study examined the performance of the Dimensions of Anger Reactions-5 (DAR-5) scale, a brief screen for problematic anger, in a sample of 1,383 postpartum women in Wisconsin who received perinatal home visiting services. We aimed to analyze the discriminant validity and measurement invariance of the DAR-5, the occurrence of problematic anger symptoms and their co-occurrence with mental health concerns, and the association between elevated anger levels and exposure to potentially traumatic events in childhood and adulthood. Descriptive statistics for anger symptoms and their associations with depression, anxiety, and PTSD were calculated. Psychometric properties of the DAR-5 were assessed via confirmatory factor analyses, and associations between trauma exposure and anger were evaluated as bivariate and partial correlations. Approximately 21% of the sample exhibited problematic anger based on an established DAR-5 cutoff score (≥ 12). Anger symptoms co-occurred with posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms, though the DAR-5 sufficiently distinguished anger from these correlated symptom profiles. The DAR-5 also demonstrated acceptable measurement invariance across levels of trauma exposure. Higher levels of trauma exposure in childhood and adulthood significantly increased the risk of problematic anger even after controlling for PTSD, anxiety, and depressive symptoms, partialγ ${{\bm \gamma }}$ pb range: .07-.16. The findings suggest the DAR-5 is a valid brief screen for anger in postpartum women. Increased attention should be paid to elevated anger and the co-occurrence of other mental health concerns following childbirth.
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Affiliation(s)
- ChienTi Plummer Lee
- Institute for Child and Family Well-Being, Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Joshua P Mersky
- Institute for Child and Family Well-Being, Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Xiyao Liu
- Institute for Child and Family Well-Being, Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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Metcalf O, Pham L, Lamb KE, Zaloumis S, O'Donnell ML, Qian T, Varker T, Cowlishaw S, Forbes D. A mixed-methods investigation of a digital mental health tool to manage posttrauma anger. J Trauma Stress 2025. [PMID: 39865623 DOI: 10.1002/jts.23126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 11/24/2024] [Accepted: 11/25/2024] [Indexed: 01/28/2025]
Abstract
Problematic anger affects up to 30% of individuals who have experienced trauma. Digital mental health approaches, such as ecological momentary assessment (EMA) delivered via smartphone and wearable devices (i.e., wearables), hold significant potential for the development of novel digital technology treatments. The objective of this cohort study was to examine the acceptability, feasibility, and outcomes from 10 days of usage of a digital mental health tool combining EMA and wearable use among trauma-exposed adults with problematic anger. We used mixed methods to examine feasibility and acceptability and explored quantitative changes in mental health symptoms among participants over the study period (N = 98, 80.4% women, Mage = 38 years). Quantitative and qualitative data revealed that regular EMA combined with a wearable was feasible and acceptable in the sample. We observed reductions in problem anger, p < .001, repeated-measures d (dRM) = -0.81, 95% CI [-1.04, -0.59]; and posttraumatic stress disorder symptoms, p = .025, dRM = -0.26, 95% CI [-0.55, -0.03], over the 10 days of monitoring. Qualitative findings suggest that by regularly "checking in" on anger symptoms, participants improved their self-awareness and ability to self-manage their mood. These findings provide valuable learnings for building future personalized digital mental health tools.
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Affiliation(s)
- Olivia Metcalf
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
- Centre for Digital Transformation of Health, University of Melbourne, Parkville, Australia
| | - Le Pham
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - Karen E Lamb
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
- Methods and Implementation Support for Clinical Health Research Hub, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
- Methods and Implementation Support for Clinical Health Research Hub, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Meaghan L O'Donnell
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - Tianchen Qian
- Department of Statistics, University of California Irvine, Irvine, California, USA
| | - Tracey Varker
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
| | - Sean Cowlishaw
- Turner Institute for Brain and Mental Health, Monash School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
| | - David Forbes
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Victoria, Australia
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Oltvolgyi CG, Meurk C, Heffernan E. Suicide and suicidality in Australian Defence Force veterans: A systematic scoping review. Aust N Z J Psychiatry 2024; 58:760-774. [PMID: 38650320 PMCID: PMC11370192 DOI: 10.1177/00048674241246443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Increased suicidality and suicide deaths among veterans of the Australian Defence Force have gained recent prominence. A systematic scoping review was conducted to identify, summarise and synthesise the existing literature relating to Australian veteran suicide and suicidality, with the objective of identifying future research priorities. METHODS We conducted a PRISMA-compliant systematic search on PubMed/MEDLINE, Embase and CINAHL databases for all manuscripts reporting primary data on suicide and suicidality in Australian veterans. The search was supplemented by grey literature and a search of reference lists. Manuscripts of any study type, published in the English language since the Vietnam era, were eligible for inclusion. RESULTS A total of 26 articles and reports, utilising a variety of mostly quantitative approaches, were included in the review. Findings, especially in larger and more recent studies, indicate increased suicidality in the veteran population. Suicide deaths appeared to increase with transition out of the military. Mental illness was identified as an important risk factor for suicide and suicidality. Current service was identified as a protective factor against suicide. There was mixed evidence regarding the impact of operational deployment on suicide and suicidality. CONCLUSIONS Gaps were identified in relation to the relative contributions to risk from transition, the various psychosocial correlates (for example, relationships, finances, employment), pre-service factors and the extent to which these are causal or mediating in nature. A better understanding of health service utilisation would also aid in targeting preventive efforts. Future research in these areas is warranted.
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Affiliation(s)
- Csongor G Oltvolgyi
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
| | - Carla Meurk
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
| | - Ed Heffernan
- School of Public Health, The University of Queensland, Herston, QLD, Australia
- Queensland Centre for Mental Health Research, Wacol, QLD, Australia
- Queensland Forensic Mental Health Service, Brisbane, QLD, Australia
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Potik D, Einat T, Idisis Y. Posttraumatic Stress Disorder Symptom Clusters, Exposure to Potentially Morally Injurious Events, and Aggression Among Army Veterans. Clin Psychol Psychother 2024; 31:e3056. [PMID: 39312899 DOI: 10.1002/cpp.3056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2024] [Revised: 09/01/2024] [Accepted: 09/02/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVE Very few studies have examined the association between posttraumatic stress disorder (PTSD) symptom clusters and aggression since the change in PTSD diagnosis criteria a decade ago. Furthermore, these studies have used measures based on PTSD criteria of the DSM-IV. The current study therefore examines the association between PTSD symptom clusters, exposure to potentially morally injurious events (PMIEs), and various types of aggression following the change in PTSD criteria and in accordance with the criteria of the DSM-5-TR. METHOD A sample of 167 Israeli combat veterans completed validated self-report questionnaires tapping PTSD symptoms, exposure to PMIEs, and aggression levels. RESULTS Our analysis revealed a significant positive relationship between the number of court-martials, betrayal-based PMIEs, all PTSD symptom clusters, and aggression. We also found that the arousal cluster, as well as the number of court-martials and age, predicted aggression, whereas the re-experiencing cluster predicted lower aggression levels. CONCLUSION Besides an updated understanding of the association between all PTSD symptom clusters and various forms of aggression, these findings emphasize the importance of targeting arousal symptoms and especially anger in treatment of veterans with PTSD symptoms and those who report experiences of betrayal. The findings also suggest clinicians to consider arousal symptoms, age, and history of court-martials when conducting either clinical or actuarial risk assessments of veterans.
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Affiliation(s)
- David Potik
- Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
- Dr. Miriam & Sheldon G. Adelson Clinic for Drug Abuse, Treatment & Research, The Psychiatric Division, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tomer Einat
- Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
| | - Yael Idisis
- Department of Criminology, Bar-Ilan University, Ramat Gan, Israel
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Nordstrand AE, Anyan F, Bøe HJ, Hjemdal O, Noll LK, Reichelt JG, Forbes D, Adler AB. Problematic anger among military personnel after combat deployment: prevalence and risk factors. BMC Psychol 2024; 12:451. [PMID: 39180131 PMCID: PMC11344415 DOI: 10.1186/s40359-024-01955-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 08/16/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Problematic anger, characterized by excessive frequency, intensity, and duration of anger which causes substantial emotional distress and functional interference, poses a marked challenge in military populations. Despite its importance, research on this topic is limited. This study contributes to the literature by exploring problematic anger in a large sample of Norwegian military personnel who served in NATO missions in Afghanistan. METHODS All Norwegian military personnel who deployed to Afghanistan between 2001 and 2020 were sent a link to a cross-sectional web-based survey by the Joint Medical Services of the Norwegian Armed Forces in 2020. A total of 6205 individuals (response rate: 67.7%) participated. The cross-sectional survey assessed problematic anger, mental and physical health, war zone stressor exposure, and quality of life. RESULTS Overall, 8.4% of participants reported problematic anger. Mental health disorders, deployment-related shame and guilt, chronic pain, and challenges with the military-to-civilian transition were independently associated with problematic anger. Both staying in service and maintaining a part-time connection with the military as a reservist mitigated the risk of problematic anger after deployment, compared to complete separation from military service. CONCLUSION Findings demonstrate a sizeable prevalence of problematic anger among veterans of combat deployments. Given the associations between problematic anger and mental health disorders, chronic pain, and transition challenges, interventions designed to mitigate problematic anger need to be multi-faceted, including the possibility of maintaining an ongoing connection to military service. By reducing the risk of problematic anger, occupational, interpersonal and health outcomes may be improved for service members. Future research should examine the impact of problematic anger on adjustment over time, prevention strategies, and problematic anger in other high-risk occupations.
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Affiliation(s)
- Andreas Espetvedt Nordstrand
- Joint Medical Services, Institute of Military Psychiatry, Norwegian Armed Forces, Grev Wedels plass 2, Oslo, 0015, Norway.
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
- Department of Psychological Sciences, Northern Arizona University (NAU), Flagstaff, AZ, USA.
| | - Frederick Anyan
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Hans Jakob Bøe
- Joint Medical Services, Institute of Military Psychiatry, Norwegian Armed Forces, Grev Wedels plass 2, Oslo, 0015, Norway
- Department of Psychology, University of Oslo (UiO), Oslo, Norway
| | - Odin Hjemdal
- Department of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Laura Katherine Noll
- Department of Psychological Sciences, Northern Arizona University (NAU), Flagstaff, AZ, USA
| | - Jon Gerhard Reichelt
- Joint Medical Services, Institute of Military Psychiatry, Norwegian Armed Forces, Grev Wedels plass 2, Oslo, 0015, Norway
| | - David Forbes
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Amy B Adler
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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Williamson C, Croak B, Simms A, Fear NT, Sharp ML, Stevelink SAM. Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review. PLoS One 2024; 19:e0299239. [PMID: 38669252 PMCID: PMC11051630 DOI: 10.1371/journal.pone.0299239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/06/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force. METHODS A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach. RESULTS Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support. CONCLUSION Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.
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Affiliation(s)
- Charlotte Williamson
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Bethany Croak
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Amos Simms
- Academic Department of Military Mental Health, King’s College London, London, United Kingdom
- British Army, London, United Kingdom
| | - Nicola T. Fear
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
- Academic Department of Military Mental Health, King’s College London, London, United Kingdom
| | - Marie-Louise Sharp
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
| | - Sharon A. M. Stevelink
- King’s Centre for Military Health Research, King’s College London, London, United Kingdom
- Department of Psychological Medicine, King’s College London, London, United Kingdom
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Forbes D, LeardMann CA, Lawrence-Wood E, Villalobos J, Madden K, Gutierrez IA, Cowlishaw S, Baur J, Adler AB. Three-Item Dimensions of Anger Reactions Scale. JAMA Netw Open 2024; 7:e2354741. [PMID: 38315485 PMCID: PMC10844994 DOI: 10.1001/jamanetworkopen.2023.54741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/13/2023] [Indexed: 02/07/2024] Open
Abstract
Importance Problematic anger is prevalent and associated with adjustment difficulties in military populations. To facilitate measurement of problematic anger, a very brief valid measure is needed. Objective To reduce the Dimensions of Anger Reactions 5-item (DAR-5) scale to a very brief measure. Design, Setting, and Participants This cross-sectional study used survey data collected between 2014 and 2016 in the Australian Transition and Well-Being Research Programme and US Millennium Cohort Study. Participants were service members who were actively serving or had transitioned out of the military (separated). Statistical analyses were performed from September 2021 to June 2023. Main Outcomes and Measures The DAR-5 was reduced to the 3 experiential items: frequency, intensity, and duration (the DAR-3). Psychometrics for the DAR-3 and DAR-5 were compared in terms of standardized Cronbach α, positive screening result, mean, and SD. Analyses were stratified by Australian and US military service status cohorts (active duty and separated). Results A total of 71 010 participants were included from Australia and the US. Of 10 900 Australian participants (8145 active duty participants [74.7%]; 2755 separated participants [25.3%]), 5893 (55.2%) were aged 40 years or older and 8774 (80.5%) were male; of 60 110 US participants (24 706 active duty participants [41.1%]; 35 404 separated participants [58.9%]), 28 804 (47.9%) were aged 30 to 39 years and 43 475 (72.3%) were male. The DAR-3 demonstrated good internal consistency in the active duty (Australia: mean [SD] score, 4.97 [2.5]; α = 0.90; US: mean [SD] score, 5.04 [2.6]; α = 0.87) and separated (Australia: mean [SD] score, 6.53 [3.4]; α = 0.92; US: mean [SD] score, 6.05 [3.2]; α = 0.91) samples. The cutoff score of 8 or greater on the DAR-3 had optimal sensitivity and specificity across all samples. DAR-3 and DAR-5 were associated with posttraumatic stress disorder (PTSD), depression, aggression, and relationship conflict. While the scales did not significantly differ in their associations with PTSD, depression, and relationship conflict, the magnitude of association for aggression was significantly lower in US samples using the DAR-3 (eg, US active duty sample: DAR-5 OR, 9.96; 95% CI, 9.01-11.00; DAR-3 OR, 8.36; 95% CI, 7.58-9.22). Conclusions and Relevance In this cross-sectional study of a very brief measure of anger, each item contributed to the overall strength of the measure without losing psychometric strength compared with the DAR-5. The consistency of these findings across military and veteran samples in Australian and US populations demonstrated the psychometric robustness of the DAR-3.
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Affiliation(s)
- David Forbes
- Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia
| | - Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Ellie Lawrence-Wood
- Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia
| | - Javier Villalobos
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, San Diego, California
| | - Kelsey Madden
- Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia
| | - Ian A. Gutierrez
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Sean Cowlishaw
- Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia
| | - Jenelle Baur
- Phoenix Australia–Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, Australia
| | - Amy B. Adler
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
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Truhan TE, Armour C. Perceived friendships protect against the development of anger following childhood adversities in UK military veteran men residing in Northern Ireland. Eur J Psychotraumatol 2023; 14:2289286. [PMID: 38084998 PMCID: PMC10993811 DOI: 10.1080/20008066.2023.2289286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 11/18/2023] [Indexed: 12/18/2023] Open
Abstract
Background: Experience of childhood adversity is associated with greater anger as an adult, particularly in men. Soldiers and veterans report higher incidence of adverse childhood experiences, many of whom also experience elevated rates of PTSD and anger. However, little is known about factors which may protect against the development of anger after experiencing childhood adversity.Objective: This study aims to assess the potential protective aspects of perceived social support in military veterans.Methods: Data from the Northern Ireland Veterans' Health and Wellbeing Study (N = 590, Mage = 56) was utilised in regression models to examine perceived social support (family, friend, partner; MSPSS) as a moderator of the association between adverse childhood experiences (ACEQ-10) and anger (DAR-7). This sample comprised men who were UK Armed Forces veterans residing in Northern Ireland.Results: Significant interaction effects, visualised using interaction plots, were found between perceived friend support and both child abuse and household challenge. When men perceived high friend support, there was no association between child abuse or household challenge and anger. For veteran men who perceived the maximum amount of partner support, there was no association between child abuse and anger. Family support did not change the positive association between child abuse, child neglect or household challenge and future anger.Conclusions: This study indicates that it is especially important to foster supportive and empathetic friendships for men that have experienced adversity as a child, perhaps through programmes such as Men's Sheds, as these friendships may alleviate the negative influences of child abuse and household challenge on anger.
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Affiliation(s)
- Tayler E. Truhan
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
| | - Cherie Armour
- Stress Trauma and Related Conditions (STARC) Research Centre, School of Psychology, Queen’s University Belfast, Belfast, UK
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11
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Williamson C, Jones M, Palmer L, Dighton G, Burdett H, Sharp ML, Fear NT. Anger Among UK Ex-Service Military Personnel During the COVID-19 Pandemic. J Nerv Ment Dis 2023; 211:940-947. [PMID: 37428877 DOI: 10.1097/nmd.0000000000001681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
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.
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12
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Forbes D, Adler AB, Pedlar D, Asmundson GJG. Problematic anger in military and veteran populations with and without PTSD: The elephant in the room. J Anxiety Disord 2023; 96:102716. [PMID: 37163842 DOI: 10.1016/j.janxdis.2023.102716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Affiliation(s)
- David Forbes
- Phoenix, Australia: Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Australia.
| | - Amy B Adler
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - David Pedlar
- Canadian Institute for Military and Veteran Health Research, Queen's University, Kingston, ON, Canada
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13
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Metcalf O, Finlayson-Short L, Lamb KE, Zaloumis S, O’Donnell ML, Qian T, Varker T, Cowlishaw S, Brotman M, Forbes D. Ambulatory assessment to predict problem anger in trauma-affected adults: Study protocol. PLoS One 2022; 17:e0278926. [PMID: 36548307 PMCID: PMC9778625 DOI: 10.1371/journal.pone.0278926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Problem anger is common after experiencing a traumatic event. Current evidence-driven treatment options are limited, and problem anger negatively affects an individual's capacity to engage with traditional psychological treatments. Smartphone interventions hold significant potential in mental health because of their ability to deliver low-intensity, precision support for individuals at the time and place they need it most. While wearable technology has the capacity to augment smartphone-delivered interventions, there is a dearth of evidence relating to several key areas, including feasibility of compliance in mental health populations; validity of in vivo anger assessment; ability to predict future mood states; and delivery of timely and appropriate interventions. METHODS This protocol describes a cohort study that leverages 10 days of ambulatory assessment in the form of ecological momentary assessment and a wearable. Approximately 100 adults with problem anger will complete four-hourly in vivo mobile application-delivered micro-surveys on anger intensity, frequency, and verbal and physical aggression, as well as other self-reported mental health and wellbeing measures. Concurrently, a commercial wearable device will continuously record indicators of physiological arousal. The aims are to test the feasibility and acceptability of ambulatory assessment in a trauma-affected population, and determine whether a continuously measured physiological indicator of stress predicts self-reported anger intensity. DISCUSSION This study will contribute new data around the ability of physiological indicators to predict mood state in individuals with psychopathology. This will have important implications for the design of smartphone-delivered interventions for trauma-affected individuals, as well as for the digital mental health field more broadly.
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Affiliation(s)
- Olivia Metcalf
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
| | - Laura Finlayson-Short
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
| | - Karen E. Lamb
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Meaghan L. O’Donnell
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
| | - Tianchen Qian
- Department of Statistics, University of California, Irvine, Irvine, California, United States of America
| | - Tracey Varker
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
| | - Sean Cowlishaw
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
| | - Melissa Brotman
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, United States of America
| | - David Forbes
- Department of Psychiatry, Phoenix Australia, University of Melbourne, Carlton, Victoria, Australia
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14
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Forbes D, Metcalf O, Lawrence-Wood E, Adler AB. Problematic Anger in the Military: Focusing on the Forgotten Emotion. Curr Psychiatry Rep 2022; 24:789-797. [PMID: 36445637 DOI: 10.1007/s11920-022-01380-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- David Forbes
- Department of Psychiatry, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne, Parkville, Australia.
| | - Olivia Metcalf
- Department of Psychiatry, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne, Parkville, Australia
| | - Ellie Lawrence-Wood
- Department of Psychiatry, Phoenix Australia - Centre for Posttraumatic Mental Health, University of Melbourne, Parkville, Australia
| | - Amy B Adler
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
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15
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Adler AB, LeardMann CA, Villalobos J, Jacobson IG, Forbes D. Association of Problematic Anger With Long-term Adjustment Following the Military-to-Civilian Transition. JAMA Netw Open 2022; 5:e2223236. [PMID: 35862043 PMCID: PMC9305378 DOI: 10.1001/jamanetworkopen.2022.23236] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/05/2022] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Amy B. Adler
- Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, Maryland
| | - Cynthia A. LeardMann
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc, San Diego, California
| | - Javier Villalobos
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc, San Diego, California
| | - Isabel G. Jacobson
- Deployment Health Research Department, Naval Health Research Center, San Diego, California
- Leidos, Inc, San Diego, California
| | - David Forbes
- Phoenix Australia-Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Carlton, VIC, Australia
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