Dominic Murphy1,2,*, B Parry1, W Busuttil1
1Combat Stress, Leatherhead, UK
2King’s Centre for Military Health Research, Department of Psychological Medicine, King’s College London, London, UK
*Corresponding author: Dominic Murphy, Combat Stress, Tyrwhitt House, Oaklawn Rd, Leatherhead, KT22 0BX, UK. Tel: +441372587017; Fax: +441372587017; Email: dominic.murphy@combatstress.org.uk
Received
Date: 15 June, 2017; Accepted
Date: 12 July, 2017; Published Date: 20 July, 2017
1. Abstract
1.1. Objective: This study
assessed the efficacy of a two-week residential treatment programme to support
anger difficulties in veterans diagnosed with PTSD.
1.2. Methods: 172
participants with a diagnosis of PTSD and co-morbid difficulties with anger
completed a standardised two-week residential treatment based upon cognitive
behaviour therapy and Dialectical Behaviour Therapy principles.The intervention
consisted of a mixture of group sessions and individual therapy.Participants
were asked to complete a range of health outcomes pre- and post-treatment and
three months later.85 participants (49.4%) were followed up three months after
treatment.Primary outcomes were measures of anger and aggression and secondary
outcomes included other mental health difficulties.
1.3. Results: No differences
in terms of baseline health outcomes and demographic characteristics were
evident between those followed up and participants lost to follow-up.Significant
reductions on the primary outcome measures of anger and aggressive behaviour
were observed post-treatment.Examination of mean scores on the DAR-5 suggested
anger difficulties was at sub-threshold levels following treatment.Significant,
but more modest reductions were observed for symptoms of PTSD, depression and
anxiety. Individuals who were unemployed, not in relationships or being defined
as being early service leavers from the military had poorer treatment outcomes.
In addition, higher rates of pre-treatment depression were associated with
lower treatment efficacy.
1.4. Conclusions: Whilst limitations exist, findings from the study suggest cautious optimism for the treatment of anger in veterans with co-morbid PTSD.
2.
Keywords: Aggression; Anger; Ex-service Personnel; Mental Health; Military; Veterans
1.
Introduction
2.1. Settings
This was a naturalistic study that exploited data collected from a national clinical service in the UK.This service is called Combat Stress (CS) and is the largest dedicated provider of mental health services to veterans in the UK. CS receives approximately 2,500 new referrals annually from veterans across the UK seeking support [26]. The most prevalent disorder that veterans seek support for is PTSD [9]. CS uses a phased treatment model as recommended by NICE to support individuals with PTSD [27,28]. The initial phase of treatment is stabilisation support and aims to provide individuals with adaptive strategies to manage emotional dysregulation [27]. The AMP fitted within this phase of treatment [29].
2.2. AMP description
Participants were recruited from a population of treatment seeking veterans that had been diagnosed with PTSD.Participants may also have been experiencing a range of other co-morbid mental health difficulties.Inclusion criteria for the AMP included being a veteran (in the UK this is defined as completing one day of paid service [30]), having a diagnosis of PTSD and evidence of significant difficultieswith anger.Exclusion criteria included uncontrolled substance misuse, current psychotic symptoms,a formal diagnosis of a personality disorder, or a brain injury with evidence of significant neurological impairment take would impact on their ability to engage with a psychological intervention. This did not exclude those with mild and moderate traumatic brain injuries.Those with current substance misuse or psychotic symptoms would be referred to specialist support and may have been referred to the AMP at a later date.
Age, sex,
educational achievement, relationship status, role in military (combat vs
non-combat), type of discharge from military (voluntary vs non-voluntary
redundancy), length of employment within the military and the date they left
military were collected at the start of treatment.In addition to these
measures, we constructed an additional measure titled 'Time to seek help' by
taking away the data of initial contact with Combat Stress with the date an
individual left the military.
3.
Results
Changes
in the primary and secondary health outcomes following treatment were reported
in (Table 3).Significant reductions in the two
primary health outcomes assessing anger or aggressive behaviours that were
maintained three months after treatment were observed.Changes in mean DAR-5
score between pre-treatment and three months follow up suggest that these
dropped from above the cut-off of 12 to sub-threshold level of anger (15.2
reducing to 10.8).A large effect size was observed for the DAR-5 (0.96) and a
medium effect size on the WR-4 (0.75).Whilst significant, more modest
reductions were found for the secondary health outcomes such as depression and
PTSD.No significant changes for alcohol were reported, though it should be
noted that the mean AUDIT scores at both pre-treatment and follow up, were
below the cut-off of eight which can be used to indicate the presence of
alcohol problems.
4. Discussion
In this study, we provided evidence for positive treatment responses in a sample of UK veterans diagnosed for PTSD and who had been treated for anger and aggression.The intervention they had received was a standardised two-week residential treatment programme that consisted of a mixture of groups and individual sessions structured around both DBT and CBT principles.Improvements in symptoms of anger and aggression were noted post-treatment and maintained three months later.On average, these reductions suggested that following treatment, participants' difficultieswith anger were at sub-threshold levels.Encouragingly, post-treatment reductions in both anger and aggressive behaviours were observed.
More modest improvements were observed for secondary outcomes such as PTSD, depression and anxiety.Reductions in the severity of PTSD scores post treatment are intriguing.The AMP was not designed to target PTSD per se, however, the overlap between anger and hyper-arousal symptoms of irritability common in PTSD may explain this reduction.Indeed, researchers have suggested that within military populations anger and aggression are defining features of PTSD [4].No changes in alcohol difficulties were observed.This is perhaps not unexpected given that the mean pre-treatment scores on the AUDIT were below clinical cut-offs suggesting that alcohol problems were not prevalent within this sample prior to them starting therapy.
A number of predictors of poorer treatment efficacy were identified. These included the severity of pre-treatment depression, not being in employment or being an early service leaver from the military.Previous research has identified that early service leavers report experiencing a greater number of adverse childhood experiences and suggested they are at greater risk of experiencing mental health difficulties and post-service social exclusion compared to their peers [42-45].The finding from the current study is worrying, as it also suggests they are also at risk of poorer treatment responses, possibly as a result of the previously listed vulnerability factors.Pre-treatment depression has previously been identified as a predictor of poorer treatment response in veterans with [8,12,46-48].An inclusion criterion for this study was that participants had received a PTSD diagnosis.As such, as we did within the current study, it could be expected to replicate the finding of an association between symptoms of depression and poorer treatment efficacy.This replicated finding is further evidence of the importance of treating mental health difficulties that are common co-morbidities with PTSD, such as depression, prior to trauma-related therapy.
5. Strengths and limitations
The study
profited from the use of a standardised intervention that had been manualised
to ensure good treatment fidelity.The sample was recruited from a national
charity providing mental health services to veterans meaning they were
representative of treatment-seeking veterans who had been diagnosed with PTSD
and co-morbid difficulties with anger and aggression.Indeed, a recent study
exploring the mental health profile of treatment seeking observed that PTSD was
the most prevalent disorder within this population and that it was most
frequently co-morbid with anger[49].This
increases confidence in the generalisability of the reported outcomes for other
treatment seeking veteran populations.
However,
there are a number of potential limitations that need to be considered when
interpreting the results presented.Firstly, we were only able to follow up
around 50% of the sample three months after treatment.We were able to
demonstrate there were no differences between those followed up or not in terms
of socio-demographic factors and pre-treatment health outcomes.However, these
two groups may have differed on unmeasured variables.For example, it could have
been that the most unwell were lost to follow-up, as being unwell may have
restricted their capacity to return the follow up measures. Alternatively, it
could be that the most unwell may have been more motivated to return measures
to alert the service to their need for additional support.Secondly, the current
study employed an observational design.We acknowledge the limitations that not
using randomisation entails.The rationale for this was that we had taken the
opportunity to evaluate an existing service offered by CS.It could be that
gains observed within the current study resulted from natural recovery from
PTSD.However, participants reported that on average they had left the military
18.7 years previously.We have used this time as a proxy measure for time since
experiencing mental health difficulties.As such, this provides evidence against
spontaneous recovery as participants had been experiencing anger related to
their diagnosis of PTSD for significant periods of time.Thirdly, the criteria
for the study may have inadvertently excluded groups of individuals that could
be hypothesised to have the most significant issues related to anger and
aggression.For example, individuals with uncontrolled substance misuse
difficulties.Given the brevity of the intervention, there is a clear clinical
rationale for this, though it is important to note that the target population
for this described intervention may be individuals with more moderate
difficulties with anger, rather than individuals with more severe
difficulties.That said, the mean pre-treatment score on the DAR-5 was 15.2 out
of a possible 20 which suggests that participants reported significant
difficulties with anger.
6. Conclusions
Overall, we have presented results that
demonstrated the efficacy of a two-week residential treatment programme for
veterans diagnosed with PTSD to target co-morbid difficulties with anger and
aggression.This programme contained a mixture of groups based upon principles
of DBT and CBT alongside individual therapy sessions.The effect sizes suggest
cautious optimism about such an approach.The results presented could propose a
number of relevant clinical implications.Our data suggests that anger associated
with PTSD can be treated prior to engaging in trauma-focused therapy.In turn,
this could mean that individuals are better prepared for when they do start
trauma therapy to directly address their symptoms of PTSD as co-morbid
psychological problems have been found to reduce the efficacy of PTSD
treatments [8].Further,
the treatment described could be categorised as a brief intervention that only
included five individual therapy sessions.As such, this may provide a
cost-effective method to support veterans.More research is needed to explore
the intervention described within the paper using a RCT design to overcome the
limitations discussed above.In addition, it would be advantageous to explore
whether support for anger and aggression can have a beneficial effect on
treatment outcomes for those then offered therapy targeted directly at their
symptoms of PTSD.
|
Full Sample |
Variable |
(N=172) |
Age group, n (%) |
|
<35 |
26 (15.1) |
35-44 |
49 (28.5) |
>45 |
97 (56.4) |
Sex, n (%) |
|
Male |
171 (99.4) |
Female |
1 (0.6) |
Education, n (%) |
|
Low (O Levels or none) |
109 (63.4) |
High (A Levels or above) |
63 (36.6) |
Relationship status, n (%) |
|
In a relationship |
120 (68.8) |
Single |
53 (30.2) |
Employment status, n (%) |
|
Working |
44 (26.5) |
Not working |
122 (73.5) |
Early Service Leaver, n (%) |
|
No |
153 (91.1) |
Yes |
15 (8.9) |
Military discharge, n (%) |
|
Voluntary |
109 (64.1) |
Non-voluntary |
61 (35.9) |
Years since left the military, n (%) |
|
01-Sep |
44 (26.3) |
Oct-19 |
43 (25.8) |
20-29 |
48 (28.8) |
30+ |
32 (19.1) |
1Numbers may not add up to 172 because of missing data |
Table 1: Demographic Characteristics.
|
Not followed up
|
Followed up |
Adjusted odds |
|
N (%) 87 (50.6%) |
N (%) 85 (49.4%) |
OR (95% CI) |
Age group |
|
|
|
<35 |
16 (18.4) |
10 (11.8) |
1.00 |
35-44 |
25 (28.7) |
24 (28.2) |
1.68 (0.49-5.77) |
>45 |
46 (52.9) |
51 (60.0) |
2.49 (0.69-9.30) |
Education |
|
|
|
Low |
31 (35.6) |
32 (37.7) |
1.00 |
High |
56 (64.4) |
53 (62.3) |
0.89 (0.41-1.95) |
Relationship status |
|
|
|
In a relationship |
56 (64.4) |
64 (75.3) |
1.00 |
Single |
31 (35.6) |
21 (24.7) |
0.67 (0.30-1.50) |
Employment status |
|
|
|
Working |
21 (25.0) |
23 (28.1) |
1.00 |
Not working |
63 (75.0 |
59 (71.9) |
0.74 (0.30-1.83) |
Early Service Leaver |
|
|
|
No |
77 (90.6) |
76 (91.6) |
1.00 |
Yes |
8 (9.4) |
7 (8.4) |
0.74 (0.21-2.61) |
Military discharge |
|
|
|
Voluntary |
52 (60.5) |
57 (67.9) |
1.00 |
Non-voluntary |
34 (39.5) |
27 (32.1) |
0.70 (0.33-1.51) |
Anger (DAR-5) |
|
|
|
Non-case |
1 (1.2) |
4 (4.7) |
1.00 |
Case |
86 (98.8) |
81 (95.3) |
0.20 (0.02-2.54) |
Depression (PHQ-9) |
|
|
|
Non-case |
6 (6.9) |
6 (7.1) |
1.00 |
Case |
81 (93.1) |
78 (92.9) |
1.27 (0.22-7.33) |
Anxiety (GAD-7) |
|
|
|
Non-case |
3 (3.5) |
4 (4.7) |
1.00 |
case |
84 (96.5) |
81 (95.3) |
0.70 (0.06-8.40) |
PTSD (IES-R) |
|
|
|
Non-case |
9 (10.7) |
7 (9.0) |
1.00 |
Case |
75 (89.3) |
71 (91.0) |
1.50 (0.27-8.44) |
Alcohol (AUDIT) |
|
|
|
Non-case |
50 (57.5) |
52 (61.9) |
1.00 |
Case |
37 (42.5) |
32 (38.1) |
0.91 (0.43-1.92) |
Table 2: Characteristics and admission health differences between participants who were successfully followed up or not at 3 months.
|
Admission Score Mean (SD)
|
3 Month Score Mean (SD) |
Unadjusted β (95% CI) |
Adjusted β1 (95% CI) |
Problem with anger |
|
|
|
|
DAR-5 |
15.2 (3.69) |
10.8 (5.07) |
-4.30 (-5.66 to -2.95) |
-4.26 (-5.65 to -2.86) |
Aggressive behaviours |
|
|
|
|
WR-4 |
7.78 (3.81) |
4.93 (3.74) |
-2.79 (-3.90 to -1.68) |
-2.85 (-3.99 to -1.70) |
Depression |
|
|
|
|
PHQ-9 |
16.8 (5.65) |
16.1 (6.04) |
-1.23 (-1.85 to -0.61) |
-1.24 (-1.98 to -0.61) |
Anxiety |
|
|
|
|
GAD-7 |
14.8 (4.42) |
14.0 (4.71) |
-1.26 (-1.84 to -0.68) |
-1.29 (-1.88 to – 0.70) |
PTSD |
|
|
|
|
IES-R |
54.9 (18.1) |
49.8 (21.2) |
-4.35 (-6.04 to -2.66) |
-4.54 (-6.28 to -2.80) |
Alcohol problems |
|
|
|
|
AUDIT |
7.26 (7.55) |
6.89 (6.99) |
-0.06 (-0.58 to 0.46) |
-0.04 (-0.56 to 0.47) |
1Model adjusted for age, relationship status and employment status. SD=Standard Deviation. Effect size for DAR-5: Cohen’s d=0.96.Effect size for WR-4: Cohen’s d=0.75 |
Table 3: Three-month post-treatment health outcomes.
|
DAR-5
|
WR-4 |
||
|
Model 1 |
Model 2 |
Model 1 |
Model 2 |
|
β (95% CI) |
β (95% CI) |
β (95% CI) |
β (95% CI) |
Depression (PHQ-9) |
0.49 (0.15 to 0.83)* |
0.52 (0.21 to 0.84)* |
0.01 (-0.29 to 0.30) |
0.03 (-0.23 to 0.28) |
Anxiety (GAD-7) |
-0.06 (-0.42 to 0.31) |
-0.25 (-6.1 to 0.10) |
0.10 (-0.20 to 0.41) |
-0.16 (-0.45 to 0.13) |
PTSD (IES-R) |
0.04 (-0.05 to 0.12) |
0.02 (-0.06 to 0.10) |
0.01 (-0.06 to 0.09) |
0.01 (-0.05 to 0.08) |
Alcohol (AUDIT) |
0.04 (-0.13 to 0.21) |
0.01 (-1.48 to 0.16) |
-0.03 (-0.14 to 0.14) |
-0.08 (-0.20 to 0.05) |
Education (high group) |
-0.07 (-2.40 to 2.26) |
-0.31 (-2.47 to 1.84) |
1.84 (-0.10 to 3.77) |
0.98 (-0.75 to 2.72) |
Relationship (single) |
1.00 (-1.43 to 3.45) |
0.58 (-2.70 to 2.85) |
-1.11 (-3.17 to 0.96) |
-0.62 (-2.43 to 1.20) |
Employment (not working) |
3.30 (0.76 to 5.85)* |
3.77 (1.40 to 6.13)* |
0.74 (-1.40 to 2.88) |
1.28 (-0.60 to 3.16) |
Early Service Leaver (yes) |
3.99 (0.01 to 7.98)* |
3.92 (0.23 to 7.61)* |
-1.74 (-5.05 to 1.57) |
-1.31 (-4.20 to 1.59) |
Note. *=p≤.05. Model 1 β adjusted for the other health outcomes and demographic characteristics in table. Model 2 additionally adjusted for pre-treatment DAR-5 and WR-4 scores. |
Table 4: Baseline health and demographic predictors of three-month anger treatment outcomes.
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Citation: Murphy D, ParryB, Busuttil W (2017) Exploring the Efficacy of an Anger Management Programme for Veterans with Post-Traumatic Stress Disorder. J Psychiatry Cogn Behav: JPCB-117. DOI: 10.29011/2574-7762.000017