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

The influence of trauma symptoms on interpersonal attributions in daily life

There is well-documented evidence that trauma exposure can disrupt relationships. However, limited research has examined whether posttraumatic stress symptoms (PTSS) moderate interpersonal processes in daily life. To this end, undergraduates (N = 98) completed a measure of PTSS at baseline. They then completed smartphone-based surveys after every interpersonal interaction that lasted longer than 3 min. for 10 days. These surveys assessed perceptions of self and other agency and communion as well as feelings of rejection, neglect, abandonment, worthlessness, emptiness, guilt, and shame. Results of multilevel modeling suggest that interpersonal perception and PTSS predicted 10%-26% of the variance in outcomes. Regarding agency, more agentic participants reported higher levels of negative attributions, γs = .47-.56. Participants also reported higher rejection and guilt when they experienced their interaction partner as more agentic than usual, γs = .07, and PTSS did not moderate these associations. For communal perceptions, participants who experienced themselves and others as warmer than other participants reported fewer negative outcomes, γs = -.44--.58. Individuals also reported more negative outcomes when they experienced themselves and others as warmer than they usually did, γs = -.10--.28, and PTSS moderated these associations. The negative associations between self- and other communion ratings and feelings of neglect, abandonment, and shame were stronger in individuals with higher PTSS scores. Together, these findings support continued efforts to understand the ways in which trauma exposure and PTSS disrupt interpersonal dynamics in daily life.

The feasibility of using ecological momentary assessment to understand urinary and fecal incontinence experiences in adults with spina bifida: A 30-day study

In this paper, we evaluate the feasibility of using ecological momentary assessment (EMA) to understand urinary (UI) and fecal (FI) incontinence in adults with spina bifida (SB). As part of a larger 30-day prospective study to understand the incontinence in adults with SB (N = 89), participants completed end-of-day EMA diaries assessing the frequency and context of UI and FI. We used these data to assess the method feasibility across six dimensions: (a) compliance, or data entry which is consistent with study protocol and substantially complete; (b) reactivity, or behavior change attributed to study participation; (c) participant acceptability, or convenience and ease of method beneficial to compliance; (d) data capture, or the volume of incontinence behaviors collected; (e) the accuracy of incontinence reports; and f) participant-provided feedback for future studies. Participants were highly compliant with diary entry protocol and schedule: submitting 95.7% (2576/2700) of the expected total daily entries. The average completion time was two minutes. Neither the total number of submissions nor the completion time varied by demographic characteristics or health history. A sufficient volume of incontinence and affective outcomes were captured, with small downtrends in reporting of UI and affect over time. Exit survey recall was highly correlated with diary reports. Participants found the methodology to be acceptable, reported their experiences honestly, enjoyed and felt comfortable participating in the study and would engage in similar study in the future. Accurate information about the daily context of UI and FI is a key factor in the success of intervention or education programs relying on this information. Our findings demonstrate that EMA is a feasible way to describe UI and FI in adults with SB.

Sleep and day-to-day PTSD symptom variability: an ecological momentary assessment and actigraphy monitored study in trauma-exposed young adults

BACKGROUND

Disrupted sleep and post-traumatic stress disorder (PTSD) are bi-directionally linked and have been found to mutually reinforce each other on a day-to-day basis. However, most of the previous research has focused on subjective measures of sleep only.

OBJECTIVE

Here, we investigated the temporal relationship between sleep and PTSD symptoms using both subjective (sleep diary) and objective measures of sleep (actigraphy).

METHODS

Forty-one non-treatment seeking, trauma exposed young adults (age M = 24.68, SD = 8.15) with a range of PTSD symptom severities (PTSS, 0-53 on PCL-5) were recruited. Participants completed two surveys per day over four weeks to measure day-time PTSD symptoms (i.e. PTSS and number of intrusions) and night-time sleep subjectively, while wearing an actigraphy watch to measure sleep objectively.

RESULTS

Linear mixed models revealed that subjectively reported sleep disruptions were associated with elevated next-day PTSS and increasing number of intrusive memories both within and between participants. Similar results were found for daytime PTSD symptoms on night-time sleep. However, these associations were not found using objective sleep data. Exploratory moderator analyses including sex (male vs. female) found that these associations differed in strength between sexes but were generally in the same direction.

DISCUSSION

These results were in line with our hypothesis with regards to the sleep diary (subjective sleep), but not actigraphy (objective sleep). Several factors which have implications on both PTSD and sleep, such as the COVID-19 pandemic and/ or sleep-state misperception, may be potential reasons behind those discrepancies. However, this study had limited power and needs to be replicated in larger samples. Nonetheless, these results add to the current literature about the bi-directional relationship between sleep and PTSD and have clinical implications for treatment strategies.

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.

A Study on the Factors Affecting Anger in Patients With Post-traumatic Stress Disorder

OBJECTIVE

To identify the factors affecting anger in post-traumatic stress disorder (PTSD) patients who underwent Clinician-Administered PTSD Scale (CAPS) and Minnesota Multiphasic Personality Inventory-2 (MMPI-2).

METHODS

We retrospectively reviewed patients who underwent CAPS and MMPI-2 at Veteran Health Service Medical Center, Seoul, Korea. Based on the CAPS score, the patients were divided into the PTSD group (n=46) and the trauma exposed without PTSD group (n=29). After checking the correlation between anger, CAPS, and MMPI-2 scales, logistic regression analysis was performed to identify the risk factors for clinically relevant symptoms.

RESULTS

The PTSD group showed significant differences in schizophrenia-related symptoms, ideas of persecution, aggressiveness, psychoticism, and anger scales compared to the trauma-exposed without PTSD group. There was a significant correlation between anger, CAPS, and MMPI-2 except masculinity/femininity, disconstraint, and MacAndrew Alcoholism-Revised. In particular, anger has been shown to have a substantial connection with paranoia, schizophrenia-related symptoms, ideas of persecution, aberrant experiences, and psychoticism. Multiple regression analysis identified that the only significant risk factor for anger was the negative emotionality/neuroticism scale (odds ratio=1.152, p<0.001).

CONCLUSION

The PTSD group had increased anger compared to the trauma-exposed without PTSD group, and that negative emotions may be a risk factor for PTSD.

Using an ecological momentary assessment protocol to understand problem anger in veterans

BACKGROUND AND OBJECTIVES

Problem anger is highly destructive, and is one of the most commonly reported issues in military and veteran populations. The goal of this study was to use ecological momentary assessment (EMA) to explore and characterize moment-to-moment experiences of problem anger in a sample of Australian veterans.

METHODS

Sixty veterans with problem anger (measured on the Dimensions of Anger Reactions Scale) completed measures of anger and anger rumination, before and after a 10-day EMA period which assessed the frequency, intensity, and expression of momentary anger experiences.

RESULTS

Findings showed that 75% of respondents indicated some level of anger during EMA monitoring. In 25% of cases, anger was reported as severe. Moreover, anger was expressed verbally in 43% of cases, and expressed physically in 27% of cases. While anger fluctuated frequently during the day, more severe anger was more likely to be reported in the late afternoon/early evening. Problem anger symptoms decreased significantly over time, from pre-EMA to post EMA (p < .001).

LIMITATIONS

The generalizability of findings is limited to a predominantly male sample, with low levels of risk of harm or violence. The study was also limited in the selection of outcome variables assessed and the lack of a control group; other momentary factors could influence experience of problem anger and provide further explanation of study results.

CONCLUSIONS

EMA is a valuable assessment tool for individuals with problem anger, and the potential for EMA as an intervention needs to be explored further.

Multilevel analysis of sleep quality and anger in emergency medical service workers

OBJECTIVE

Poor sleep quality characterizes the emergency medical service (EMS) profession. Anger is particularly affected by sleep disturbance and may be related to sleep quality at both between- and within-person levels, yet this has never been examined. The current study performed a multilevel analysis of the relationship between sleep quality and anger among EMS workers.

DESIGN

Ecological momentary assessment PARTICIPANTS: Seventy-nine EMS workers employed at an emergency medical service provider in Central New York.

MEASUREMENTS

Participants completed 8 daily assessments that inquired about sleep quality and anger.

RESULTS

EMS workers who typically experienced poorer sleep quality reported greater anger levels; for instance, workers who routinely experienced poor sleep quality reported anger levels that were 18%-35% higher compared to workers receiving fair sleep quality. Regardless of their typical sleep quality, days when workers experienced poorer sleep than usual was characterized by higher levels of anger: on a day when a worker experienced poorer sleep quality than usual for them, their anger levels were 5% higher on that day regardless of their typical sleep quality.

CONCLUSIONS

EMS workers regularly experiencing poor sleep quality experience more anger. However, even workers who typically have better sleep quality experience anger elevations following poor sleep. These findings suggest that interventions targeting both between- and within-person factors impacting sleep may be important for addressing sleep quality's influence on anger in the EMS profession.

Neural correlates of anger expression in patients with PTSD

Anger is a common and debilitating symptom of post-traumatic stress disorder (PTSD). Although studies have identified brain circuits underlying anger experience and expression in healthy individuals, how these circuits interact with trauma remains unclear. Here, we performed the first study examining the neural correlates of anger in patients with PTSD. Using a data-driven approach with resting-state fMRI, we identified two prefrontal regions whose overall functional connectivity was inversely associated with anger: the left anterior middle frontal gyrus (aMFG) and the right orbitofrontal cortex (OFC). We then used concurrent TMS-EEG to target the left aMFG parcel previously identified through fMRI, measuring its cortical excitability and causal connectivity to downstream areas. We found that low-anger PTSD patients exhibited enhanced excitability in the left aMFG and enhanced causal connectivity between this region and visual areas. Together, our results suggest that left aMFG activity may confer protection against the development of anger, and therefore may be an intriguing target for circuit-based interventions for anger in PTSD.

Cannabis use disorder, anger, and violence in Iraq/Afghanistan-era veterans

An association has been found between cannabis use disorder (CUD) and violence in several clinical populations, including veterans with posttraumatic stress disorder (PTSD), and there is evidence that CUD has been increasing among veterans since September 11, 2001. There is also evidence that some veterans may be attempting to self-medicate psychological problems including PTSD and aggression with cannabis, despite the lack of safety and efficacy data supporting this use. To date, however, the association between CUD and aggression has yet to be examined in a large, non-clinic sample of veterans. The present study examined the association between cannabis use disorder, anger, aggressive urges, and difficulty controlling violence in a large sample of Iraq/Afghanistan-era veterans (N = 3028). Results of multivariate logistic regressions indicated that current CUD was significantly positively associated with difficulty managing anger (OR = 2.93, p < .05), aggressive impulses/urges (OR = 2.74, p < .05), and problems controlling violence in past 30 days (OR = 2.71, p < .05) even accounting for demographic variables, comorbid symptoms of depression and PTSD, and co-morbid alcohol and substance use disorders. Lifetime CUD was also uniquely associated with problems controlling violence in the past 30 days (OR = 1.64, p < .05), but was not significantly associated with difficulty managing anger or aggressive impulses/urges. Findings indicated that the association between CUD and aggression needs to be considered in treatment planning for both CUD and problems managing anger and aggressive urges, and point to a critical need to disentangle the mechanism of the association between CUD and violence in veterans.

Ecological momentary assessment of self-rated health, daily strategies and self-management app use among trauma-exposed adults

Background: The process whereby trauma-exposed people benefit from self-management apps to increase health is poorly understood. Objective: We investigated whether access to a self-management smartphone app for posttraumatic stress (PTSD Coach) improved momentary self-rated health (SRH) and if use of a self-management app or specific strategies related to SRH. Method: Participants were 179 adults in Sweden with trauma exposure in the past 2 years who were enrolled in a randomized trial of PTSD Coach versus waitlist. Ecological momentary assessments (EMA) were collected twice daily during 21 consecutive days from participants in both groups, with questions about momentary SRH as well as self-management app use and use of strategies (social support, distress management, monitoring of discomfort and seeking information) in the preceding 12 hours. Results: Overall, neither access to PTSD Coach nor reported use of an app in the preceding hours was related to SRH. Even so, people with access to PTSD Coach reported using more social support over time. Socializing and use of social support predicted greater SRH. Use of other strategies was associated with worse short-term SRH. Conclusions: Momentarily improved health relates to utilization of social support. However, the directionality of the day-to-day associations is unclear; uncertainty remains around the timing for assessing these relationships.

Anger mediates the relationship between posttraumatic stress disorder and suicidal ideation in veterans

BACKGROUND

Theoretical models and cross-sectional empirical studies of suicide indicate that anger is a factor that may help explain the association between posttraumatic stress disorder (PTSD) and suicide, but to date no longitudinal studies have examined this relationship. The current study used longitudinal data to examine whether changes in anger mediated the association between changes in PTSD symptomatology and suicidal ideation (SI).

METHODS

Post 9/11-era veterans (N = 298) were assessed at baseline, 6-months, and 12-month time points on PTSD symptoms, anger, and SI. Analyses covaried for age, sex, and depressive symptoms. Multilevel structural equation modeling was used to examine the three waves of data.

RESULTS

The effect of change in PTSD symptoms on SI was reduced from B = 0.02 (p = .008) to B = -0.01 (p = .67) when change in anger was added to the model. Moreover, the indirect effect of changes in PTSD symptoms on suicidal ideation via changes in anger was significant, B = 0.02, p = .034. The model explained 31.1% of the within-person variance in SI.

LIMITATIONS

Focus on predicting SI rather than suicidal behavior. Sample was primarily male.

CONCLUSIONS

Findings suggest that the association between PTSD and SI is accounted for, in part, by anger. This study further highlights the importance of anger as a risk factor for veteran suicide. Additional research on clinical interventions to reduce anger among veterans with PTSD may be useful in reducing suicide risk.

PTSD and anger: Evaluation of an indirect effect model in a civilian trauma sample

BACKGROUND AND OBJECTIVES

Theoretical models propose that PTSD symptoms and subjective anger are indirectly associated through hostile attribution bias, physiological reactivity, and aggressive psycho-motor scripts (Chemtob, Novaco, Hamada, Gross, & Smith, 1997). Originally developed to account for symptoms observed in military personnel, proposed anger mechanisms have received limited attention in civilian populations. The current study looked to evaluate the generalizability of Chemtob et al.'s model in trauma-exposed university students (N = 152).

METHODS

Trauma exposure and corresponding symptoms were assessed during an initial screening procedure. Hostile attributions and aggressive scripts were examined prior to a laboratory-based anger induction procedure. Physiological reactivity was monitored throughout the provocation task. Ratings of subjective anger and anger recovery were completed following the induction period. Relations of post-trauma symptoms with subjective anger through hypothesized anger processes were examined using bootstrapped estimates of indirect effects.

RESULTS

A significant indirect effect of PTSD severity on state-level anger was noted for hostile attribution bias (ab = 0.020, 95% CI [0.002, 0.041]) and a marginal effect through aggressive inclinations (ab = 0.015, 95% CI [-0.001, 0.039]). Data failed to provide evidence for physiological reactivity as an intervening variable. Trauma symptoms did not moderate anger recovery following the provocation task.

LIMITATIONS

Induction of anger in a sub-clinical sample may limit tests of hypothesized effects and the generalizability of the present findings.

CONCLUSIONS

Results indicate the proposed model may be applicable beyond combat trauma samples and suggest potential anger-related targets for PTSD treatment.

Examining the relationship between negative affect and posttraumatic stress disorder symptoms among smokers using ecological momentary assessment

BACKGROUND

Posttraumatic stress disorder (PTSD) and negative affect (e.g., anger, depression, anxiety), are highly co-occurring. It remains unclear whether changes in PTSD symptoms subsequently impact negative affect, or vice versa. This study assessed associations between moment-to-moment PTSD symptoms and negative affect in a sample of smokers with PTSD to determine directionality of this relationship.

METHODS

Participants (N = 125) enrolled in two smoking cessation studies with co-occurring PTSD and cigarette use completed measures of PTSD and negative affect. Ecological momentary assessment (EMA) methodology was used to record symptoms during a one-week baseline period, during which participants smoked ad lib. Cross-lagged path analyses assessed PTSD symptoms and negative affect for directionality of their relationship, controlling for whether an EMA reading was smoking or non-smoking. Path analyses examined the lagged associations between PTSD symptoms and negative affect.

RESULTS

Results found PTSD symptom severity at T-1 was significantly related to negative affect levels at time T, but negative affect at time T-1 was not associated with PTSD symptom severity at time T. Results indicated the model retaining the cross-lagged effect of PTSD symptom severity on negative affect provided better fit to the data than other models.

LIMITATIONS

Limitations included use of self-report data, brief measures of symptoms, participants already had PTSD and/or MDD, participants were recruited from a specific clinical population, and use of DSM-IV data.

CONCLUSIONS

Results suggest PTSD symptoms drive day-to-day fluctuations in negative affect, and highlight the importance of evaluating negative affect in the treatment of PTSD.

Smartphones and Wearables as a Method for Understanding Symptom Mechanisms

While psychological treatments have been shown to be effective in treating psychiatric disorders, the mechanism of their therapeutic effect is less well understood. An improved mechanistic understanding of psychiatric disorders and their treatments would enable refinement of existing interventions, and more targeted intervention and the development of new treatments. A major limitation in understanding the mechanism of effect in psychological treatments has been the challenge of capturing what happens outside of the clinical setting. The development of new digital technologies such as smartphones and wearables enables much more inter-session data to be collected. The rapid evolution of smartphones and wearable technologies, combined with the ubiquity of mobile networks means that is possible for patients to provide regular, longitudinal, and high-resolution data. This allows a previously inaccessible and untapped stream of a specific patient's behaviours, moods, activities, and thoughts to be quantified. Monitoring through such technologies may be of therapeutic value, improving self-awareness and promoting mentalization. Smartphones and wearable technologies can also be used to delivered therapies remotely. Digital technologies enable new insights to be gained into the lived experience of mental disorder enabling current treatments to be refined and personalised, as well as generating new targets for future treatment development. In this article we discuss how such technologies are improving our understanding of psychiatric disorder, informing psychological treatments before considering the future potential of such technologies. We will also consider the challenges and ethical concerns of such approaches.