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A randomized pilot study of anger treatment for Iraq and Afghanistan veterans

https://doi.org/10.1016/j.brat.2013.05.013Get rights and content

Highlights

  • A randomized pilot study compared a cognitive-behavioral treatment for anger problems in veterans to an active control.

  • Significant differences were found for anger and interpersonal functioning at post-treatment.

  • Improvement was maintained at 3 months post-treatment.

  • There were no differences found for PTSD symptoms.

  • A larger clinical trial is needed to provide a definitive test of the intervention.

Abstract

Objective

Anger and aggression are serious problems for a significant proportion of veterans who have served in combat. While prior research has suggested that cognitive behavioral treatments may be effective for anger problems, there are few controlled studies of anger treatment in veterans and no studies of anger treatment focusing exclusively on veterans from the Iraq and Afghanistan wars. This randomized pilot study compared an adapted cognitive behavioral intervention (CBI) to a supportive intervention (SI) control condition for the treatment of anger problems in veterans returning from deployment in Iraq or Afghanistan.

Methods

25 veterans with warzone trauma, problems with anger, and one or more additional hyperarousal symptoms were randomized and 23 started treatment (CBI, n = 12; SI, n = 11). Outcome measures were administered at pre- and post- treatment and at 3 months post-treatment.

Results

CBI was associated with significantly more improvement than SI on measures of anger and interpersonal functioning. Gains were maintained at follow-up.

Conclusions

Findings suggest that CBI may be more effective than an active control providing psychoeducation, relaxation, and supportive therapy for treating anger problems in returning veterans. The findings need to be replicated in an adequately powered and more diverse sample.

Introduction

Poorly controlled anger is a common problem with often devastating effects in veterans who have served in a warzone. As early as World War II, anger and aggression were identified as common responses to combat stress (e.g. Grinker and Spiegel, 1945, Kardiner and Spiegel, 1947), and the association between combat experience and symptoms of anger and hostility has been demonstrated repeatedly in empirical research (e.g. Boulanger, 1986, Kulka et al., 1990). Findings from the National Vietnam Veterans Readjustment Survey (NVVRS; Kulka et al., 1990) showed that Vietnam veterans exposed to high levels of war stress expressed higher levels of hostility and committed more violent acts compared to Vietnam era (non theatre) veterans, civilians, and theatre veterans exposed to lower levels of war stress. Higher levels of anger increased risk for divorce, domestic violence, job loss and instability, and other serious impairments in family, social, and occupational functioning (Kulka et al., 1990). Anger has also been shown to predict poorer response to treatment among veterans with PTSD (Forbes et al., 2003, Forbes et al., 2008).

More recent findings show that anger and aggression are problems for a significant proportion of veterans of Iraq (Operation Iraqi Freedom, OIF; Operation New Dawn, OND) and Afghanistan (Operation Enduring Freedom, OEF). For example, anger was the most frequently reported problem among 754 OEF/OIF combat veterans receiving VA medical care, with 57% reporting increased problems controlling anger (Sayer et al., 2010), and 39% of 117 OEF and OIF combat veterans presenting to a VA Deployment Health Clinic reported at least one act of aggression within the past four months (Jakupcak et al., 2007). There is some evidence to suggest that OEF/OIF veterans manifest more violent behavior than those of previous war eras (Fonatana & Rosenheck, 2008).

Why are problems with anger so prominent in veterans who have served in war zones? Evidence suggests that hyperarousal symptoms of PTSD play a prominent role in post-war aggression (Lasko et al., 1994, McFall et al., 1999). Also, military training focuses on responding to threat with aggression, which is further associated with the powerful reinforcement of survival in combat experiences. Novaco and Chemtob (2002) proposed a model for the relationship between anger and trauma that incorporates the adaptive value of anger and aggression in life threatening situations. They describe a “survival mode” of functioning involving over-activation of cognitive structures that facilitate a response to life threatening situations. Once triggered, the “survival mode” preempts all other cognitive processing, increases more rapid reactions requiring less evidence of threat, and decreases capacity to regulate arousal level (Chemtob, Novaco, Hamada, & Gross, 1997, Chemtob, Novaco, Hamada, Gross & Smith, 1997). Persistence of the “survival mode” of cognitive processing beyond the warzone results in the chronic inability to adaptively regulate behavioral responses to threat, and excessive anger and aggression in response to situations perceived as threatening even where there is no real threat. Thus, a response that is highly adaptive during combat becomes maladaptive with the loss of the ability to regulate the intensity and expression of anger appropriate to the current social and environmental conditions (Novaco & Chemtob, 2002).

Although there is evidence that cognitive-behavioral treatment (CBT) can be effective in treating anger problems in non-veteran samples (e.g. Del Vecchio and O’Leary, 2004, DiGiuseppe and Tafrate, 2003), research on anger treatment in military personnel or veterans following exposure to war zone stress is surprisingly limited (Morland, Love, Greene & Rosen, 2012). Despite encouraging findings from a handful of studies (Chemtob, Novaco, Hamada, & Gross, 1997, Gerlock, 1994, Linkh and Sonnek, 2003, Morland et al., 2010), no studies have focused specifically on OEF/OIF veterans, and the absence of a control group in three of the studies (Gerlock, 1994, Linkh and Sonnek, 2003, Morland et al., 2010) limits conclusions regarding the efficacy of the cognitive behavioral treatment per se, distinct from the benefits of common factors such as therapeutic relationship and support and mobilization of hope.

In practice, treatment of anger problems in veterans has largely occurred after anger has negatively impacted relationships, jobs, and health. The potential advantages of early intervention, before the secondary consequences of anger problems are established, highlight the importance of available effective interventions for military personnel and veterans showing early signs of anger problems following return from deployment. The objective of the current paper is to report findings from a randomized controlled pilot study of a cognitive behavioral intervention that was adapted for the specific needs of military personnel returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).

Section snippets

Overview

The study protocol was approved by Human Subjects Boards at Brown University, the Department of Defense, and the Providence Veterans Affairs Medical Center. All participants were fully informed of the nature and extent of study participation, and the consent form was reviewed in detail. All study participants provided written informed consent. Those meeting study criteria were randomized to either the cognitive behavioral intervention or a supportive intervention control condition using urn

Participant characteristics

Twenty-three participants began treatment, including twelve in CBI and eleven in SI (Fig. 1). The average age was 36.3 (SD = 10.2). Participants were all male, and the majority was Caucasian (91%), married (65%), and employed (96%). Forty-eight percent had some post high school education. In terms of current diagnoses, 30% had PTSD, 17% had anxiety disorders beside PTSD, 35% had Major Depressive Disorder, and 9% had a diagnosis of Depressive Disorder N.O.S. The mean scores on the Global

Discussion

The findings from this pilot study showed more improvement for CBI compared to SI on our primary measures of outcome and on most of the secondary measures. The use of an interview based measure of anger that was administered blind to treatment condition reduces the likelihood of potential bias in ratings, although a limitation is that inter-rater reliability on the OAS-M was not established for the current study interviewers. It is likely however that inadequate inter-rater reliability would

Acknowledgments

This research was supported by grant W81XWH-05-1-0171 from the US Army Medical Research and Materiel Command, Department of Defense. The authors thank Jocelyn Howard, Nancy Davis, Wendy Ossman, Abigail Mansfield, Zachary Walsh, and Brian Borsari for their role as study therapists; Elisa Bolton for providing supervision of therapists; and Elizabeth Sevin for overseeing assessments and assistance in study coordination.

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