The impact of trauma-focused psychotherapies on anger: A systematic review and meta-analysis

OBJECTIVE

Anger is one of the most prevalent concerns among individuals with posttraumatic stress disorder (PTSD) and is often a residual symptom following PTSD treatment. The purpose of this systematic review and meta-analysis was to determine how effective trauma-focused PTSD psychotherapies are in reducing anger.

METHOD

The study was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This study conducted a systematic review of studies that reported the effect of trauma-focused treatments on anger outcomes. Additionally, a meta-analysis was conducted with a subset of studies that used randomized controlled trials (RCTs) methodologies to compare trauma-focused PTSD treatments to nontrauma-focused and control conditions.

RESULTS

The systematic review included 16 studies with a total of 1,846 participants. In 11 of the studies, there was a significant decrease in an anger dimension following treatment. Eight studies with 417 total participants met inclusion criteria for the meta-analysis. The meta-analysis yielded a pooled effect size of PTSD treatment on anger of Hedges's g = 0.33.

CONCLUSION

Overall, trauma-focused treatments for PTSD significantly improve anger, but the magnitude of change is small-to-medium. Additional research is needed to determine how best to maximize anger outcomes following trauma-focused treatment or determine if and when targeted anger treatment is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Impact and efficiency of treatment across two PTSD clinical trials comparing in-person and telehealth service delivery formats

The intent of this study is to examine treatment impact and efficiency observed when cognitive behavioral treatments for posttraumatic stress disorder (PTSD) are delivered in-person or using telehealth. This study pooled data from 268 veterans enrolled in two PTSD clinical trials. In both trials, treatment was delivered using in-home telehealth (telehealth arm), in-home in-person (in-home arm), and in-office care, where patients traveled to the Department of Veterans Affairs for either office-based telehealth or office-based in-person care (office arm). Average age was 44 (SD = 12.57); 80.9% were males. The PTSD Checklist for DSM-5 (PCL-5) was used to assess symptom severity. Treatment impact was measured by (a) the proportion of participants who completed at least eight treatment sessions and (b) the proportion with a reliable change of ≥ 10 points on the PCL-5. Treatment efficiency was measured by the number of days required to reach the end point. The proportion of participants who attended at least eight sessions and achieved reliable change on the PCL-5 differed across treatment formats (ps < .05). Participants in the in-home (75.4%) format were most likely to attend at least eight treatment sessions, followed by those in the telehealth (58.3%) and office (44.0%) formats, the latter of which required patients to travel. Participants in the in-home (68.3%, p < .001) format were also more likely to achieve reliable change, followed by those in the telehealth (50.9%) and office (44.2%) formats. There were no significant differences in the amount of time to complete at least eight sessions. Delivery of therapy in-home results in a significantly greater likelihood of achieving both an adequate dose of therapy and a reliable decrease in PTSD symptoms compared to telehealth and office formats. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Examining the daily relationship between guilt, shame, and substance use among veterans with psychiatric disorders

Background

Shame and guilt are key emotions known to amplify trauma-related symptoms in veterans. Maintenance of symptoms is facilitated by avoidance behaviors, such as substance use. However, limited research has examined the associations between shame, guilt, and substance use in daily life.

Methods

The current study sought to examine the cross-lagged association between shame, guilt, and substance use. Forty veterans completed 28 days of experience sampling reporting on their current emotional experiences and use of substances.

Results

Results suggest a reciprocal relationship among shame and guilt and substance use, such that shame and guilt separately predicted subsequent substance use, and substance use predicted subsequent shame and guilt.

Conclusions

These results highlight the dynamic relationship among shame, guilt, and substance use and suggest the potential value of conceptualizing these clinical targets as mutually reinforcing to inform integrative intervention strategies that can interrupt the in-the-moment cascade of negative consequences.

Interpersonal stress and nonsuicidal self-injury disorder in veterans: An ecological momentary assessment study

INTRO

Nonsuicidal self-injury (NSSI) is associated with marked functional impairment and is a robust predictor of suicide attempts. Prevalence rates of NSSI, and self-directed violence more broadly, are elevated among military veterans. Despite the inclusion of interpersonal difficulty in the diagnostic criteria for NSSI disorder, the relationship between interpersonal risk factors and NSSI is not well-characterized, especially among veterans. This ecological momentary assessment (EMA) study investigated the hypothesis that interpersonal stressors and associated distress would precede and predict NSSI urge and engagement-but not vice versa-via cross-lagged multilevel modeling.

METHOD

Forty veterans with NSSI disorder completed a 28-day EMA protocol with three daily prompts assessing NSSI urges, NSSI engagement, the occurrence of interpersonal stressors, and associated subjective interpersonal distress.

RESULTS

Interpersonal stressors preceded and predicted subsequent NSSI urges, but not NSSI engagement, whereas subjective interpersonal distress preceded and predicted both NSSI urges and NSSI engagement.

CONCLUSION

Results identified interpersonal stressors as a risk factor for NSSI urges, and interpersonal distress as a risk factor for both NSSI urges and NSSI engagement. Findings highlight the importance of temporally assessing interpersonal factors related to NSSI and suggest that interpersonal distress may be a modifiable risk factor for NSSI.

Enjoying the violence of war: Association with posttraumatic symptomatology in U.S. combat veterans

OBJECTIVE

Engaging in war-related violence can have a devastating impact on military personnel, with research suggesting that injuring or killing others can contribute to posttraumatic stress disorder (PTSD), depression, and moral injury. However, there is also evidence that perpetrating violence in war can become pleasurable to a substantial number of combatants and that developing this "appetitive" form of aggression can diminish PTSD severity. Secondary analyses were conducted on data from a study of moral injury in U.S., Iraq, and Afghanistan combat veterans, to examine the impact of recognizing that one enjoyed war-related violence on outcomes of PTSD, depression, and trauma-related guilt.

METHOD

Three multiple regression models evaluated the impact of endorsing the item, "I came to realize during the war that I enjoyed violence" on PTSD, depression, and trauma-related guilt, after controlling for age, gender, and combat exposure.

RESULTS

Results indicated that enjoying violence was positively associated with PTSD, β (SE) = 15.86 (3.02), p < .001, depression, β (SE) = 5.41 (0.98), p < .001, and guilt, β (SE) = 0.20 (0.08), p < .05. Enjoying violence moderated the relationship between combat exposure and PTSD symptoms, β (SE) = -0.28 (0.15), p < .05, such that there was a decrease in the strength of the relationship between combat exposure and PTSD in the presence of endorsing having enjoyed violence.

CONCLUSIONS

Implications for understanding the impact of combat experiences on postdeployment adjustment, and for applying this understanding to effectively treating posttraumatic symptomatology, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and refinement of the mobile anger reduction intervention for veterans with posttraumatic stress disorder

OBJECTIVE

Problematic anger is commonly reported among veterans with posttraumatic stress disorder (PTSD) and is associated with numerous psychosocial impairments. There is a clear need to develop innovative and effective anger interventions. One of the cognitive mechanisms associated with anger is the hostile interpretation bias, which is the tendency to interpret ambiguous interpersonal situations as hostile. The current study presents a successive cohort design methodology to develop and refine a mobile treatment application, entitled Mobile Anger Reduction Intervention (MARI), which uses interpretation bias modification techniques to modify hostile interpretation bias.

METHOD

Two cohorts (total N = 13) of veterans with PTSD and problematic anger used the MARI application for 4 weeks. After each cohort, qualitative and quantitative data were used to modify the MARI application. The intervention is described, as well as the qualitative and quantitative findings and subsequent changes made to the mobile application based on participant feedback.

RESULTS

Treatment adherence was high (90% of participants completed all sessions). Participants reported that they found the treatment helpful and easy to use and experienced improvements in hostile interpretation bias and problematic anger.

CONCLUSIONS

This study demonstrates the utility of a successive cohort treatment design for the development of mobile interventions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Examination of PTSD symptom networks over the course of cognitive processing therapy

OBJECTIVES

Cognitive processing therapy (CPT) is an evidence-based psychotherapy for posttraumatic stress disorder (PTSD); however, little is known about how interrelationships between PTSD symptoms change over the course of treatment. The current study examined baseline, midtreatment, and posttreatment PTSD symptom networks during CPT for PTSD.

METHOD

Adults with PTSD (n = 107) received 12 sessions of CPT as part of a randomized trial. Self-reported PTSD symptoms were assessed at pretreatment, midtreatment, and posttreatment, and network analysis was used to examine the interrelationships between symptoms at these three timepoints. Linear regression was conducted to examine whether any baseline symptoms or midpoint symptoms predicted overall treatment change.

RESULTS

In the baseline PTSD network, feelings of detachment and feeling upset at reminders of the trauma were central to the symptom network. These symptoms were no longer central at midtreatment, possibly suggesting that CPT quickly reduces the importance of these symptoms. These findings were consistent with regression results that, after accounting for multiple comparisons, high baseline scores of feeling upset at trauma reminders predicted later treatment change. At the conclusion of treatment, strong negative emotions were the most central symptom and may be most important in maintaining or lowering other PTSD symptoms at the conclusion of treatment.

CONCLUSIONS

Though replication is necessary, these findings offer insights into identifying which symptoms may be most predictive of treatment outcomes and the course by which CPT reduces PTSD symptoms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Correlates of Incarceration History Among Military Veterans

Veterans with histories of incarceration are at greater risk for poor physical and mental health outcomes, yet prior research in this population has focused on specific subsets of veterans or a narrow range of predictors. We utilized the Bronfenbrenner Socioecological Model as the framework to evaluate correlates of incarceration history in a large sample of Iraq and Afghanistan-era veterans at four levels: demographic, historical, clinical, and contextual. Participants were 2,904 veterans (76.9% male; 49.5% White and 46.5% Black; mean age 38.08, SD = 10.33), 700 of whom reported a history of incarceration. Four logistic regression models predicting history of incarceration were tested, adding demographic, historical, clinical, and contextual variables hierarchically. In the final model, younger age (OR=0.99, 95% CI=0.98-1.00), male gender (OR of being female =0.28, 95% CI=0.21-0.38), belonging to a historically marginalized group (OR of being White =0.69, 95% CI=0.56-0.84), family history of incarceration (OR=1.47, 95% CI=1.10-1.94), adult interpersonal trauma (OR=1.39, 95% CI=1.28-1.51), problematic alcohol use (OR=1.03, 95% CI=1.02-1.05), drug abuse (OR=1.15, 95% CI=1.11-1.19), and unemployment (OR for being employed=0.76, 95% CI=0.62-0.92) were significantly associated with a history of incarceration. Implications of these findings for developing interventions and supporting systems to effectively target this high-risk population of veterans are discussed.

Affective states and nonsuicidal self-injury (NSSI): Results from an ecological momentary assessment study of veterans with NSSI disorder

BACKGROUND

The affective states most strongly associated with nonsuicidal self-injury (NSSI) remain poorly understood, particularly among veterans. This study used ecological momentary assessment (EMA) to examine relationships between affect ratings and NSSI urges and behaviors among veterans with NSSI disorder.

METHODS

Participants (N = 40) completed EMA entries via mobile phone for 28 days (3722 total entries). Entries included intensity ratings for five basic affective states, as well as NSSI urges and behaviors, during the past 4 hours.

RESULTS

Bivariate analyses indicated that each affect variable was significantly associated with both NSSI urges and behaviors. Angry/hostile and sad were most strongly associated with both NSSI urges and behaviors. A multivariate regression revealed that angry/hostile, disgusted with self, and happy (inversely related) were contemporaneously (within the same period) associated with NSSI behaviors, whereas all five basic affective states were contemporaneously associated with NSSI urges. In a lagged model, angry/hostile and sad were associated with subsequent NSSI urges but not behaviors.

CONCLUSIONS

Findings highlight the relevance of particular affective states to NSSI and the potential utility of targeting anger in treatments for NSSI among veterans. There is a need for future EMA research study to further investigate temporal relationships between these variables.

Anger, impulsivity and wall/object punching in a sample of U.S. veterans with psychiatric disorders

Nonsuicidal self-injury (NSSI) has been identified as one of the strongest predictors of suicide attempts. Wall/object punching is a particularly prevalent form of NSSI among male veterans that has been linked to both impulsivity and anger. The objective of the present study was to examine the indirect effect of impulsivity on wall/object punching via anger. Participants included 124 veterans (32 identified as women, 92 identified as men) with at least one psychiatric disorder. A third of the sample met criteria for NSSI disorder (33.1%) with nearly a half of the remaining sample endorsing NSSI. Almost half (41.94%) of the sample endorsed wall/object punching. Consistent with our hypothesis, impulsivity was significantly associated with anger, which was, in turn, significantly associated with wall/object punching. Impulsivity was found to be indirectly related to wall/object punching via anger. These findings underscore the significance of assessing and treating anger among veterans engaging in wall/object punching. Improving our knowledge of anger and impulsivity and their relationship with this particularly prevalent form of NSSI among veterans may lead to a better understanding of suicide risk among veterans and inform future treatments.

Psychosocial well-being among veterans with posttraumatic stress disorder and substance use disorder

OBJECTIVE

Concurrent posttraumatic stress disorder and substance use disorder (PTSD/SUD) in U.S. military veterans represents an urgent public health issue associated with significant clinical challenges. Although previous research has shown that veterans with PTSD/SUD endorse more psychosocial risk factors and fewer protective factors than veterans with neither or only one of these disorders, no study has applied a comprehensive framework to characterize the vocational, financial, and social well-being of veterans with PTSD/SUD. Furthermore, it is not fully known how well-being among veterans with PTSD/SUD compares to that of veterans with posttraumatic stress disorder (PTSD) only, substance use disorder (SUD) only, or neither disorder.

METHOD

This cross-sectional observational study analyzed data from the National Post-Deployment Adjustment Survey, which recruited a random national sample of U.S. veterans who served on/after September 11, 2001. Participants (weighted N = 1,102) self-reported sociodemographic, clinical, and military background information in addition to aspects of their vocational, financial, and social well-being.

RESULTS

Veterans with PTSD/SUD were particularly likely to report lifetime experiences of homelessness, violent behavior, suicidal ideation, and suicide attempts. Veterans with PTSD/SUD reported worse social well-being than the PTSD-only, SUD-only, and neither-disorder groups. They also reported worse vocational and financial well-being than veterans with SUD only or with neither disorder but did not significantly differ from the PTSD-only group on vocational or financial well-being.

CONCLUSIONS

The findings underscore the importance of assessing multiple aspects of well-being in veterans with PTSD and/or SUD. The findings also point to promising treatment targets to improve psychosocial functioning and overall quality of life among veterans with PTSD and/or SUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

In-office, in-home, and telehealth cognitive processing therapy for posttraumatic stress disorder in veterans: a randomized clinical trial

BACKGROUND

Trauma-focused psychotherapies for combat-related posttraumatic stress disorder (PTSD) in military veterans are efficacious, but there are many barriers to receiving treatment. The objective of this study was to determine if cognitive processing therapy (CPT) for PTSD among active duty military personnel and veterans would result in increased acceptability, fewer dropouts, and better outcomes when delivered In-Home or by Telehealth as compared to In-Office treatment.

METHODS

The trial used an equipoise-stratified randomization design in which participants (N = 120) could decline none or any 1 arm of the study and were then randomized equally to 1 of the remaining arms. Therapists delivered CPT in 12 sessions lasting 60-min each. Self-reported PTSD symptoms on the PTSD Checklist for DSM-5 (PCL-5) served as the primary outcome.

RESULTS

Over half of the participants (57%) declined 1 treatment arm. Telehealth was the most acceptable and least often refused delivery format (17%), followed by In-Office (29%), and In-Home (54%); these differences were significant (p = 0.0008). Significant reductions in PTSD symptoms occurred with all treatment formats (p < .0001). Improvement on the PCL-5 was about twice as large in the In-Home (d = 2.1) and Telehealth (d = 2.0) formats than In-Office (d = 1.3); those differences were statistically large and significant (d = 0.8, 0.7 and p = 0.009, 0.014, respectively). There were no significant differences between In-Home and Telehealth outcomes (p = 0.77, d = -.08). Dropout from treatment was numerically lowest when therapy was delivered In-Home (25%) compared to Telehealth (34%) and In-Office (43%), but these differences were not statistically significant.

CONCLUSIONS

CPT delivered by telehealth is an efficient and effective treatment modality for PTSD, especially considering in-person restrictions resulting from COVID-19.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT02290847 (Registered 13/08/2014; First Posted Date 14/11/2014).

The Impact of Hostility on Quality of Life, Functioning, and Suicidal Ideation Among Male Veterans with Posttraumatic Stress Disorder

Veterans with posttraumatic stress disorder (PTSD) often experience high levels of hostility. Although studies have found that PTSD is associated with poorer quality of life (QoL), increased functional impairment, lower levels of social support, and increased suicidal ideation, it is unclear if hostility impacts these domains in veterans with PTSD above and beyond the impact from PTSD and depressive symptoms. The present study aimed to examine whether hostility is related to several indices of poorer QoL and functioning after controlling for demographic characteristics, PTSD symptoms, and depressive symptoms. Participants (N = 641) were male U.S. veterans seeking PTSD treatment through a specialty clinic in the Veterans Affairs Healthcare System. Veterans completed the Davidson Trauma Scale for DSM-IV (DTS), Personality Assessment Inventory (PAI), Quality of Life Inventory, and the Sheehan Disability Scale. Hierarchical regressions were conducted to examine the impact of PAI measures of hostility on QoL, functioning, social support, and suicidal ideation beyond DTS, depression, race, and age. After covarying for DTS total score, depression symptoms, age, and race, higher levels of hostility were significantly associated with higher degrees of functional impairment and lower degrees of social support, ΔR² = .01 and ΔR² = .02, respectively. Higher levels of hostility were significantly related to diminished functioning and lower social support beyond PTSD and depressive symptoms in veterans seeking treatment for PTSD. These findings highlight the importance of assessing and treating hostility in veterans with PTSD.

A Comparison of Group Anger Management Treatments for Combat Veterans With PTSD: Results From a Quasi-Experimental Trial

Difficulty controlling anger is a significant concern among combat veterans with posttraumatic stress disorder (PTSD), yet few controlled studies have examined the efficacy of anger treatments for this population. This study examined the effects of a group cognitive behavioral therapy (CBT) intervention compared with a group present-centered therapy (PCT) control condition in male and female combat veterans with PTSD. Thirty-six combat veterans with PTSD and anger difficulties began group treatment (CBT, n = 19; PCT, n = 17). Separate multilevel models of self-rated anger, PTSD symptoms, and disability were conducted using data from baseline, each of 12 treatment sessions, posttreatment, and 3- and 6-month follow-up time points. Significant decreases in anger and PTSD symptoms were observed over time, but no significant differences between CBT and PCT were observed on these outcomes. A significant interaction of therapy by time favoring the PCT condition was observed on disability scores. Gender differences were observed in dropout rates (i.e., 100% of female participants dropped out of CBT). Findings suggest that both CBT and PCT group therapy may be effective in reducing anger in combat veterans with PTSD. Results also highlight potential gender differences in response to group anger treatment.

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.

A network analysis of risk factors for suicide in Iraq/Afghanistan-era veterans

Suicidal ideation (SI) is a prevalent issue in the veteran population. A number of factors have been identified as risk factors for suicidal ideation (SI) in veterans, including suicide attempts, depression, posttraumatic stress disorder (PTSD), and drug use. However, clinicians' ability to predict suicide is poor, particularly given the interplay between various factors such as previous suicide attempts. As such, there is a gap in our knowledge of which factors most saliently predict suicide risk and which should be targets for interventions designed to lower SI. Network analysis, a method allowing for an examination of how variables relate within the context of a network of factors, may bridge this gap by simultaneously evaluating the interrelationships between risk factors for suicide in veterans. Current study used network analysis and data from 2268 Iraq/Afghanistan-era military veterans to examine the relationships between suicidal ideation and several factors related to suicide risk, such as past suicide attempts, PTSD symptoms, depression, drug use, trauma exposure. Partial correlation network results showed suicidal ideation to be strongly related to depression, with smaller connections to past suicide attempts and anger. Additionally, past suicide attempts was strongly related to history of childhood trauma and weakly related to problematic drug use and PTSD symptoms. These results offer valuable information for both predicting suicide risk and differentiating targets for interventions lowering suicide risk in veterans.

Exploring the role of anger in nonsuicidal self-injury in veterans

Up to 14% of veterans engage in nonsuicidal self-injury (NSSI) in their lifetime and this behavior is a relatively strong predictor of suicidal behavior compared to other identified risk factors. Further, NSSI is a clinically relevant behavior in its own right; it is associated with more severe psychopathology as well as bodily harm that sometimes requires medical intervention. Therefore, a better understanding of NSSI may help inform suicide prevention efforts as well as mental healthcare strategies for veterans. Anger may be relevant to understanding NSSI in veterans. Over 60% of veterans report difficulties managing anger and this emotion is strongly associated with engagement in NSSI. However, no research has explored the extent to which anger is present prior to NSSI or whether anger is associated with specific NSSI methods or functions in veterans. The purpose of this study was to explore whether anger was associated with engagement in specific NSSI methods, and whether anger uniquely predicted any functions of NSSI while controlling for the presence of other basic negative emotions (fear and sadness). An existing dataset of 61 veterans who reported engaging in NSSI in the past year was analyzed. Results indicated anger was the most common emotional antecedent to NSSI. Further, anger was associated with several methods of NSSI including burning oneself with a cigarette, carving pictures, designs or other marks into skin, sticking sharp objects into skin, severely scratching oneself, head banging, punching oneself, and punching walls or objects. Finally, when controlling for the presence of other negative emotions, anger was associated with engaging in NSSI to relieve tension, stop feeling numb, communicate with others, feel alive, get help from others, and prove to oneself how bad things are. These results highlight the importance of assessing and treating dysregulated anger in veterans who engage in self-harming behavior.

Anger precedes and predicts nonsuicidal self-injury in veterans: Findings from an ecological momentary assessment study

Veterans have high rates of suicide, and nonsuicidal self-injury (NSSI) is one of the strongest predictors of suicide risk; however, there is presently little known about antecedents of NSSI that might inform intervention efforts. Accumulating research suggests that anger and hostility play an important role in NSSI, but whether these emotions precede and predict NSSI is currently unknown. The aim of the current study was to examine the temporal relationships between anger/hostility and NSSI urges and behavior among veterans diagnosed with NSSI disorder. Our hypothesis was that angry/hostile affect would predict subsequent NSSI urge and engagement, but not vice versa. Forty veterans with NSSI disorder completed a 28-day ecological momentary assessment study with three daily prompts to report on their affect and NSSI urges and engagement. Multilevel cross-lagged path modeling was used to determine the direction of effects between angry/hostile affect and NSSI urges and engagement over time. Consistent with our hypothesis, results indicated that the lagged effects of angry/hostile affect on subsequent NSSI urge and engagement were significant, whereas the lagged effects of NSSI urge and engagement on angry/hostile affect were not significant. Findings highlight the importance of assessing and treating anger among veterans who engage in NSSI.

Post-traumatic symptom severity mediates the association between combat exposure and suicidal ideation in veterans

OBJECTIVE

Previous studies of military veterans have produced mixed findings regarding whether combat exposure is directly related to suicidal ideation or is indirectly related to suicidal ideation via its influence on other factors. The present study used a longitudinal design to test the hypothesis that post-traumatic stress disorder (PTSD) symptom severity mediates the effect of combat exposure on suicidal ideation in veterans.

METHOD

Participants included 319 post-9/11 veterans (83.4% male; 42.1% White/52.1% Black; Mage  = 39.7) assessed at baseline, 6, and 12 months. Structural equation modeling and bootstrapped confidence intervals were employed to examine the direct and indirect relationships between combat exposure, suicidal ideation, and PTSD symptom severity.

RESULTS

Results from the mediation model, in which demographic variables and non-combat trauma were included as covariates, revealed that the indirect effect of combat exposure on suicidal ideation via PTSD symptom severity was statistically significant, accounting for 64.1% of the covariance between combat exposure and suicidal ideation.

CONCLUSIONS

This study provides longitudinal evidence that the effects of combat exposure on suicidal ideation are mediated by PTSD symptom severity, suggesting the importance of targeting such symptoms in treatment to mitigate suicide risk among veterans with combat exposure.

Development of the Response to Fearful Situations Scale

BACKGROUND

Most measures of anxious avoidance are limited to disorder-specific mechanisms and ignore the measurement of courage/approach responding in confronting fearful situations.

AIMS

The purpose of the present study was to construct and validate a self-report assessment of the tendency towards avoidant or approach responding in fearful situations, the Response to Fearful Situations Scale (RFSS).

METHOD AND RESULTS

In Study 1 (n = 241), exploratory factor analysis resulted in two factors, avoidance and approach. Study 2 (n = 423) replicated the two-factor structure and established test-re-test reliability. In Study 3 (n = 44), the RFSS demonstrated predictive validity on a behavioural avoidance task. In Studies 4 (n = 253) and 5 (n = 256), the RFSS was associated with clinical symptoms above existing measures of avoidance.

DISCUSSION

These results validate the use of the RFSS as a transdiagnostic measure of avoidance and approach.

Using Interpretation Bias Modification to Reduce Anger in Veterans with Posttraumatic Stress Disorder: A Pilot Study

Difficulty controlling anger is the most commonly reported reintegration concern among veterans with posttraumatic stress disorder (PTSD). One of the mechanisms associated with problematic anger is a tendency to interpret ambiguous interpersonal situations as hostile, known as the hostile interpretation bias (HIB). A computer-based interpretation bias modification (IBM) intervention has been shown to successfully reduce HIB and anger but has not been tested in veterans with PTSD. The current study was a pilot trial of this IBM intervention modified to address problematic anger among veterans with PTSD. Veterans with PTSD and a high level of anger (N = 7) completed eight sessions of IBM treatment over the course of 4 weeks. Participants completed self-report questionnaires at pre- and posttreatment assessment visits, as well as a treatment acceptability interview at posttreatment. Veterans experienced large reductions in hostile interpretation bias and anger from pre- to posttreatment, ds = 1.03-1.96, although these estimates may be unstable due to the small sample size. The feasibility for recruitment, retention, and treatment completion were high. Questionnaire and interview data demonstrated that most participants were satisfied with the treatment and found it helpful and easy to use. Overall, IBM for anger was feasible and acceptable to veterans with PTSD and was associated with reductions in hostile interpretations and self-reported anger outcomes. Further research examining this approach is warranted.

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.

Weekly Changes in Blame and PTSD Among Active-Duty Military Personnel Receiving Cognitive Processing Therapy

Both negative posttraumatic cognitions and posttraumatic stress disorder (PTSD) symptoms decrease over the course of cognitive-behavior therapy for PTSD; however, further research is needed to determine whether cognitive change precedes and predicts symptom change. The present study examined whether weekly changes in blame predicted subsequent changes in PTSD symptoms over the course of cognitive processing therapy (CPT). Participants consisted of 321 active duty U.S. Army soldiers with PTSD who received CPT in one of two clinical trials. Symptoms of PTSD and blame were assessed at baseline and weekly throughout treatment. Bivariate latent difference score modeling was used to examine temporal sequential dependencies between the constructs. Results indicated that changes in self-blame and PTSD symptoms were dynamically linked: When examining cross-construct predictors, changes in PTSD symptoms were predicted by prior changes in self-blame, but changes in self-blame were also predicted by both prior levels of and prior changes in PTSD. Changes in other-blame were predicted by prior levels of PTSD, but changes in other-blame did not predict changes in PTSD symptoms. Findings highlight the dynamic relationship between self-blame and PTSD symptoms during treatment in this active military sample.

Associations between anger and suicidal ideation and attempts: A prospective study using the National Epidemiologic Survey on Alcohol and Related Conditions

Suicide is among the leading causes of death in the United States, with rates having risen substantially over the past two decades. Anger is a common symptom of several disorders associated with suicide, and the little research that has been done in the area suggests that it may be an often overlooked transdiagnostic risk factor for both suicidal ideation and behavior. The current study used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) dataset to evaluate anger at Wave 1 as a risk factor for suicidal ideation and suicide attempt at Wave 2 (three years later) in a nationally representative sample of 34,653 participants. Chi-square analyses indicated that participants reporting problematic anger at Wave 1 were significantly more likely to endorse suicidal ideation (χ2 = 65.35, p < .001) and suicide attempt (χ2 = 24.86, p < .001) at Wave 2. Multivariate regression analyses confirmed that problematic anger significantly predicted suicidal ideation (OR = 1.48, 95% CI [1.21,1.82], p < .001) and attempt (OR = 1.53, 95% CI [1.07,2.19], p = .020) over the three year period, even after adjusting for psychiatric risk factors, and demographic and historical covariates. Findings suggests the potential benefit of integrating anger assessment and treatment into research and clinical programs focused on reducing suicide.

The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community

Military-affiliated individuals (i.e., active duty personnel and veterans) exhibit high rates of posttraumatic stress disorder (PTSD). Although existing evidence-based treatments for PTSD, such as cognitive processing therapy (CPT), have demonstrated effectiveness with military-affiliated patients, there is evidence to suggest these individuals do not benefit as much as civilians. However, few studies have directly compared the effects of PTSD treatment between civilian and military-affiliated participants. The current study compared treatment outcomes of military-affiliated and civilian patients receiving CPT. Participants with PTSD who were either civilians (n = 136) or military-affiliated (n = 63) received CPT from community-based providers in training for CPT. Results indicated that military-affiliated participants were equally likely to complete treatment, Log odds ratio (OR) = 0.14, p = .648. Although military-affiliated participants exhibited reductions in PTSD, B = -2.53, p < .001; and depression symptoms, B = -0.65, p < .001, they experienced smaller reductions in symptoms relative to civilians: B = 1.15, p = .015 for PTSD symptoms and B = 0.29, p = .029 for depression symptoms. Furthermore, variability estimates indicated there was more variability in providers' treatment of military-affiliated versus civilian participants (i.e., completion rates and symptom reduction). These findings suggest that military-affiliated patients can be successfully retained in trauma-focused treatment in the community at the same rate as civilian patients, and they significantly improve in PTSD and depression symptoms although not as much as civilians. These findings also highlight community providers' variability in treatment of military-affiliated patients, providing support for more military-cultural training.

Using a Learning Collaborative Model to Disseminate Cognitive Processing Therapy to Community-Based Agencies

Although effective treatments for posttraumatic stress disorder exist, their use in community settings is disappointingly low. Training alone does not necessarily lead to adoption. To address this problem, we trained community clinicians in cognitive processing therapy, an evidence-based treatment for posttraumatic stress disorder, using a Learning Collaborative, an intensive training methodology focused on both clinical training and developing sustainability. Sixty clinicians within 18 agencies began the year-long, team-based Learning Collaborative. Clinicians attended three in-person Learning Sessions, received weekly consultation, and submitted audio-recorded sessions to be rated for fidelity. Clinicians were rostered as approved treatment providers if they completed all training requirements. Additionally, we engaged leadership from each agency to build a sustainable practice. Clinicians trained through the Learning Collaborative demonstrated a high degree of fidelity to the treatment (average competence ratings "satisfactory" to "good"), and most (68%) were rostered as approved treatment providers. Patients treated by clinician trainees exhibited significant symptom reductions (d = 1.68 and 1.28 for posttraumatic stress and depression symptoms, respectively, among treatment completers). At a 6-month follow-up, 95% of rostered clinicians and 100% of agencies with rostered clinicians were still providing the treatment. These results suggest that the Learning Collaborative model is a promising approach for the dissemination and implementation of evidence-based treatments for adult posttraumatic stress disorder.

Design of a clinical effectiveness trial of in-home cognitive processing therapy for combat-related PTSD

Approximately 14% of military personnel and veterans who have deployed to the combat theater are at risk for combat-related posttraumatic stress disorder (PTSD). The treatment of combat-related PTSD in active duty service members and veterans is challenging. Combat trauma may involve multiple high levels of exposure to different types of traumatic events (e.g., human carnage after explosive blasts, life threat/injuries to self/others, etc.). Many service members and veterans are unable or unwilling to receive treatment in government facilities due to avoidance, scheduling difficulties, transportation or parking problems, concerns about career advancement, or stigma associated with seeking treatment. Innovative treatment-delivery approaches are needed to help overcome these barriers. The present study is a randomized clinical trial to evaluate three versions of Cognitive Processing Therapy (CPT; [54]) for the treatment of combat-related PTSD in active duty military service members and veterans: (1) standard In-Office CPT, (2) In-Home Telebehavioral Health CPT from the provider's office to the participant's home, and (3) In-Home CPT in which the provider delivers treatment in the participant's home. Use of an equipoise-stratified randomization design allows participants to decline one of the treatment arms. This research design partly overcomes the problems active duty military and veterans face when receiving PTSD treatment by allowing them to opt out of one inappropriate or unacceptable treatment modality and still permitting randomization to the two remaining treatment modalities. This manuscript provides an overview of the research design and methods for the study.

Examination of the indirect effects of combat exposure on suicidal behavior in veterans

BACKGROUND

Researchers have theorized that increased rates of suicide in the military are associated with combat exposure; however, this hypothesis has received inconsistent support in the literature, potentially because combat exposure may be indirectly related to suicide risk through its influence on posttraumatic stress disorder (PTSD) and depressive symptoms. The current study tested the hypothesis that combat exposure has a significant indirect effect on suicidal behavior among Iraq/Afghanistan-era veterans through its effects on PTSD-depressive symptomatology.

METHODS

Iraq/Afghanistan-era veterans (N = 3,238) participated in a cross-sectional, multi-site study of post-deployment mental health consisting of clinical interviews and self-report questionnaires. Structural equation modeling (SEM) was used to examine direct and indirect relationships between three latent variables: combat exposure, PTSD-depression, and suicidal behavior (past attempts and current ideation, intent, and preparation).

RESULTS

A partial mediation model was the best-fitting model for the data. Combat exposure was significantly associated with PTSD-depression (β = 0.50, p < .001), which was in turn associated with suicidal behavior (β = 0.62, p < .001). As expected, the indirect effect between combat exposure and suicidal behavior was statistically significant, β = 0.31, p < .001.

LIMITATIONS

Data were cross-sectional, and suicidal behavior was measured via self-report.

CONCLUSIONS

Results indicated that combat exposure was indirectly related to suicidal behavior via PTSD-depressive symptomatology. Findings lend support for a higher-order combined PTSD-depression latent factor and suggest that Iraq/Afghanistan-era veterans with high levels of PTSD-depressive symptoms are at increased risk for suicidal behavior.

Association of posttraumatic stress disorder and traumatic brain injury with aggressive driving in Iraq and Afghanistan combat veterans

PURPOSE

Aggressive driving contributes to the high rates of postdeployment motor vehicle-related injury and death observed among veterans, and veterans cite problems with anger, aggressive driving, and road rage as being among their most pressing driving-related concerns. Both posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) have been associated with driving-related deficits in treatment-seeking samples of veterans, but the relative contribution of each of these conditions to problems with aggressive driving in the broader population of combat veterans is unclear.

METHOD

χ2 and logistic regression analyses were used to examine the relative association of PTSD, TBI, and co-occurring PTSD and TBI to self-reported problems with road rage in a sample of 1,102 veterans living in the mid-Atlantic region of the United States who had served in Afghanistan or Iraq.

RESULTS

Results indicate that controlling for relevant demographic variables, PTSD without TBI (odds ratio = 3.44, p < .001), and PTSD with co-occurring TBI (odds ratio = 4.71, p < .001) were associated with an increased risk of road rage, but TBI without PTSD was not.

CONCLUSIONS

Our findings suggest that PTSD, with or without comorbid TBI, may be associated with an increased risk of aggressive driving in veterans. Clinical implications for treating problems with road rage are discussed, including use of interventions targeting hostile interpretation bias and training in emotional and physiological arousal regulation skills. (PsycINFO Database Record

Hostile interpretation training for individuals with alcohol use disorder and elevated trait anger: A controlled trial of a web-based intervention

High trait anger is associated with more severe alcohol use problems, and alcohol has been found to facilitate aggressive behavior among individuals with high trait anger. Treatments focused on a sample with alcohol use disorder with elevated anger could reduce alcohol use problems, as well as violence and aggression. We sought to examine the efficacy of interpretation bias modification for hostility (IBM-H) in a sample with high trait anger and alcohol use disorder (AUD). Fifty-eight individuals with AUD and elevated trait anger were randomly assigned to eight web-based sessions (two per week) of IBM-H or a healthy video control condition (HVC). Measures of interpretation bias, anger, and alcohol use were administered at pre- and post-treatment and at one-month follow-up. IBM-H led to greater improvements in interpretation bias compared to HVC at post and follow-up. IBM-H also led to greater reductions in trait anger than HVC, though this was an indirect effect mediated by changes in interpretation bias. Further, IBM-H led to lower anger expression than HVC; this was a direct (non-mediated) effect. Lastly, both conditions reported decreases in alcohol use and consequences following treatment, though there were no significant differences between them. These findings provide initial support for the utility of IBM-H as a brief non-confrontational intervention for AUD with elevated trait anger. Limitations and future research directions are discussed.

Hostile interpretation bias in depression

BACKGROUND

Research suggests an important relationship between interpretation bias, hostility and Major Depressive Disorder (MDD). Extant literature has yet to examine hostile interpretation bias in clinically depressed samples; the current studies sought to fill this gap.

METHOD

Study 1 participants included undergraduates who met criteria for MDD (n=36) or no anxiety or mood diagnosis (n=35). Each participant completed a structured clinical interview along with measures of depression, hostile interpretation bias, and trait hostility. In Study 2, a sample of treatment-seeking individuals with elevated trait anger completed measures of depression, hostile interpretation bias, and trait anger.

RESULTS

Study 1 demonstrated that, relative to the non-depressed group, individuals with depression displayed greater hostile interpretation bias but comparable levels of trait hostility. In Study 2, greater hostile interpretation bias was associated with greater depressive symptoms, and this relationship was independent of co-occurring trait anger.

LIMITATIONS

The correlational nature of these studies precludes interpretation of causal relationships between constructs. Additionally, replication of these results should be sought in a larger, more diverse sample.

CONCLUSION

Overall, the findings suggest hostile interpretation bias may play a unique role in depression and could be a treatable feature of interpersonal mechanisms maintaining MDD.

Six In Vivo Assessments of Compulsive Behavior: A Validation Study Using the Obsessive-Compulsive Inventory-Revised

Due to the complex and heterogeneous nature of obsessive-compulsive disorder (OCD), movement toward multimodal assessment has become necessary to more precisely understand the nature of the disorder and interrelations between symptom clusters. Thus, the present study utilized large undergraduate samples (total N = 800) to test the validity of six in vivo assessments of OC symptoms (i.e., one ordering/arranging task, two contamination fear/washing tasks, and three checking tasks). Associations between task-specific variables and self-reported symptom scores (as measured by the Obsessive-Compulsive Inventory-Revised [OCI-R]) were examined. The majority of the in vivo task variables (those presented in Studies 1-4) exhibited significant relationships with the corresponding OCI-R symptom subscale (i.e., ordering, washing, checking). However, many of the task variables demonstrated relationships with other OCI-R symptom subscales, as well. Some evidence for discriminant validity was found, as task variables were generally unrelated to past-week symptoms of depression or anxiety. While continued research is necessary to further establish the validity and utility of the tasks discussed in the current article, findings have implications for improving future empirical examination of OC symptoms.

Is worst-event trauma type related to PTSD symptom presentation and associated features?

Posttraumatic stress disorder (PTSD) is generally assessed with reference to a "worst-event" (index) trauma, though little research has examined whether symptom presentation and comorbidity differ across worst-events. Data from individuals meeting lifetime PTSD criteria in the National Comorbidity Survey-Replication (N=398) were used to examine relations between PTSD presentation and comorbidity with the three most commonly reported "worst-event" trauma types: sexual trauma, non-sexual physical violence, and unexpected death of a loved one. Sexual trauma and non-sexual physical violence were associated with more symptomatic presentation of PTSD and lifetime trauma types compared to other worst-events. Non-sexual physical violence was associated with comorbid substance use disorder, and unexpected death of a loved one was associated with comorbid depression. Inclusion of number of lifetime trauma types as a covariate rendered most, but not all associations non-significant. These findings suggest worst-event trauma type is related to some important differences in PTSD presentation.

Measuring Hostile Interpretation Bias: The WSAP-Hostility Scale

Hostile interpretation biases are central to the development and maintenance of anger, yet have been inconsistently assessed. The Word Sentence Association Paradigm (WSAP) was used to develop a new measure of hostile interpretation biases, the WSAP-Hostility. Study 1 examined the factor structure and internal consistency of the WSAP-Hostility, as well as its relationship with trait anger. Study 2 provided convergent and divergent validity data by examining its associations with trait anger, aggression, depression, and anxiety. Study 3 examined the relationship between WSAP-Hostility and another measure of hostile interpretation biases, as well as another word sentence association measure, in a sample of community participants. Study 4 also used a sample of community participants to offer further evidence of convergent validity. Across the studies, the WSAP-Hostility demonstrated convergent and divergent validity and internal consistency, supporting its use as a measure of hostile interpretation biases.