Staff Perspective: Practical Treatment Essentials for PTSD-Related Anger
June is national Post-Traumatic Stress Disorder awareness month. As behavioral health professionals raise awareness of PTSD and effective PTSD treatments, I would be remiss if I did not mention anger as it relates to PTSD. This post will briefly review a model of anger related to PTSD, provide recommendations for measuring anger in clinical populations and practical information for clinical intervention with military populations experiencing anger and PTSD. At the end of the post, I have included additional resources on anger management and PTSD. Please feel free to contribute your thoughts on what has been helpful in your clinical practice.
Veterans of OIF/OEF who meet diagnostic criteria for PTSD often report issues with anger management, hostility or aggression. Although “irritability and angry outbursts” is one of the diagnostic criteria for the hyperarousal symptom cluster, this particular symptom may have an extraordinary impact on daily functioning in the lives of Service members. Problems with anger significantly impact interpersonal relationships and may notably interfere with occupational functioning, social functioning, PTSD treatment as well as limit social support. On some occasions, Service members and Veterans may also have legal consequences, due in part to dysregulated anger.
First, let’s assume that anger is often adaptive in combat. The ability to respond quickly and intensely, (often with aggression) is likely to help the Service member survive the situation as well as suppress any feelings of helplessness. This response is appropriately intense, as the individual is facing a life-or-death stressor. However, the context changes once the Service member returns stateside.
Second, let’s assume that anger and aggression are related, but distinct. We can describe anger as a function of (a) cognitions or appraisals of a situation (b) physiological arousal and (c) behaviors which may include verbal aggression or physical confrontation.
Chemtob et al (1997) put forth a model which helps behavioral health providers better understand the relationship between PTSD and anger. They propose that combat veterans may be triggered into survival mode functioning in situations outside of combat. Once they are in survival mode, this supercedes other cognitive processing. Survival mode is characterized by quick responses, increased vigilance and a threat-confirmation bias, thus becoming self-confirming. As people with PTSD are readily (perhaps too quickly) able to identify threat, they may be triggered into survival mode inappropriately. In short, some combat veterans with PTSD may perceive threat more frequently, triggering them into survival mode, leading to anger and aggression in situations when the level of threat should not activate survival mode information processing.
Anger assessment tools
Aggression Questionnaire AQ – This measure allows quick screening of aggression for adults. It has been widely used and is quick to administer and score. It is available for cost at http://www.wpspublish.com/store/p/2661/aggression-questionnaire-aq
State-Trait Anger Expression inventory – 2 STAXI-2. This measure is designed to measure the experience, expression and control of anger in adults. It is quick to administer and score and is available for purchase at http://www4.parinc.com/Products/Product.aspx?ProductID=STAXI-2
Dimensions of Anger Reactions- DAR. This brief assessment tool measures anger directed towards others. This tool has been used specifically with military populations and is sensitive to therapeutic change associated with PTSD interventions. It is available for purchase and veterans may take this online assessment measure at http://afterdeployment.t2.health.mil/topics-anger
Anger treatment overview
Remember that anger has its place in combat and many Service members and Veterans will be unwilling to let go of all of their anger. I recommend that you focus treatment goals on finding ways to better manage anger in daily interactions with friends, family and others without removing the emotion entirely. Also, be mindful that anger often interferes with therapy via weakened therapeutic alliance, reduced client engagement and avoidance. You should employ motivational interviewing strategies which help combat veterans to weigh the pros and cons of anger as they self-determine the benefits of behavioral change.
At this point, no singular treatment has clearly emerged as the gold standard of treatment for anger, but that may be because there are different types of dysregulated anger as well as multiple manifestations of anger. A review of the extant literature suggests that anger treatment based on a cognitive-behavioral model is most likely to be effective. Treatment should begin with an assessment of anger, consideration of motivation to change and contemplation of the benefits of healthy anger management to interpersonal relationships. Clinicians should also carefully consider co-morbid conditions during treatment planning. For example, a Service member with chronic pain or insomnia has good reasons to be irritable so effective treatment planning may go a long way towards affect regulation.
Good anger management training should include:
- Psychoeducation on anger and affect intensity
- Guidance on anger triggers and skills to identify their personal anger triggers
- Psychoeducation for SM and family on PTSD and common trauma reactions
- Remind SMs that anger is much easier to manage at lower levels than at higher levels
- Instruction on healthy assertive behaviors and healthy communication skills so that alternative behaviors are available
- Numerous skills to increase relaxation and manage anger before it becomes elevated
- Consultation with a prescribing provider to consider pharmacotherapy
Resources for managing anger related to PTSD
Make the Connection - http://maketheconnection.net/symptoms/anger-irritability - This resource features veterans sharing their struggles with anger and irritability. It includes helpful tips for managing anger on a daily basis and resources for getting help. Information is included for male and female veterans as well as family members.
Afterdeployment.org - http://afterdeployment.t2.health.mil/topics-anger
This resource features an online anger assessment and a brief anger management workshop. You must be registered and logged into your account in order to take the workshop. Additional information about anger, videos of veterans discussing anger and tips on how to manage anger are included along with links to online forums.
National Center for PTSD - http://www.ptsd.va.gov/professional/continuing_ed/anger_aggression.asp
This helpful resource includes information specifically for behavioral health professionals working with veterans. The featured online course provides one hour of CEUs for VA providers. The podcast is also available for clinical providers outside of the VA system. Please note that this course is designed to be a multimedia presentation and is most helpful via the online format.
Additional PTSD Education Resources
CDP online courses on PTSD
The CDP has two excellent online courses for behavioral health providers which specifically address PTSD in military populations.
Epidemiology of PTSD in Military Personnel and Veterans: Working with Service Members and Veterans with PTSD - http://www.deploymentpsych.org/online-courses/ptsd
This highly recommended course is 90 minutes in duration. It reviews types of trauma exposure and emotional reactions typical among OIF/OEF veterans. It enumerates PTSD assessment tools and treatment recommendations. It also recognizes barriers to treatment often faced by veterans. This course may be taken for free OR behavioral health professionals may pay a small fee to earn CEUs.
The impact of Stress and Trauma Related to Military Deployment - http://www.deploymentpsych.org/content/stress-and-trauma-related-militar...
This intermediate level course was created in collaboration with the American Psychological Association. This course reviews the unique stressors of military personnel and their families before, during and after deployment. It may be taken for CEUs for a small fee.
DoD/VA guidelines for PTSD - http://www.healthquality.va.gov/guidelines/MH/ptsd/
The DoD/VA guidelines for the management of PTSD were updated in 2010. This is an excellent resource for providers managing PTSD treatment that is reviews the gold standards PTSD treatment in military populations. This PDF is available online via the link above
Do you have suggestions on how to manage PTSD-related anger?
Holly N. O’Reilly, Ph.D., is a clinical psychologist and Lead on Traumatic Stress and Sexual Assault at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
June is national Post-Traumatic Stress Disorder awareness month. As behavioral health professionals raise awareness of PTSD and effective PTSD treatments, I would be remiss if I did not mention anger as it relates to PTSD. This post will briefly review a model of anger related to PTSD, provide recommendations for measuring anger in clinical populations and practical information for clinical intervention with military populations experiencing anger and PTSD. At the end of the post, I have included additional resources on anger management and PTSD. Please feel free to contribute your thoughts on what has been helpful in your clinical practice.
Veterans of OIF/OEF who meet diagnostic criteria for PTSD often report issues with anger management, hostility or aggression. Although “irritability and angry outbursts” is one of the diagnostic criteria for the hyperarousal symptom cluster, this particular symptom may have an extraordinary impact on daily functioning in the lives of Service members. Problems with anger significantly impact interpersonal relationships and may notably interfere with occupational functioning, social functioning, PTSD treatment as well as limit social support. On some occasions, Service members and Veterans may also have legal consequences, due in part to dysregulated anger.
First, let’s assume that anger is often adaptive in combat. The ability to respond quickly and intensely, (often with aggression) is likely to help the Service member survive the situation as well as suppress any feelings of helplessness. This response is appropriately intense, as the individual is facing a life-or-death stressor. However, the context changes once the Service member returns stateside.
Second, let’s assume that anger and aggression are related, but distinct. We can describe anger as a function of (a) cognitions or appraisals of a situation (b) physiological arousal and (c) behaviors which may include verbal aggression or physical confrontation.
Chemtob et al (1997) put forth a model which helps behavioral health providers better understand the relationship between PTSD and anger. They propose that combat veterans may be triggered into survival mode functioning in situations outside of combat. Once they are in survival mode, this supercedes other cognitive processing. Survival mode is characterized by quick responses, increased vigilance and a threat-confirmation bias, thus becoming self-confirming. As people with PTSD are readily (perhaps too quickly) able to identify threat, they may be triggered into survival mode inappropriately. In short, some combat veterans with PTSD may perceive threat more frequently, triggering them into survival mode, leading to anger and aggression in situations when the level of threat should not activate survival mode information processing.
Anger assessment tools
Aggression Questionnaire AQ – This measure allows quick screening of aggression for adults. It has been widely used and is quick to administer and score. It is available for cost at http://www.wpspublish.com/store/p/2661/aggression-questionnaire-aq
State-Trait Anger Expression inventory – 2 STAXI-2. This measure is designed to measure the experience, expression and control of anger in adults. It is quick to administer and score and is available for purchase at http://www4.parinc.com/Products/Product.aspx?ProductID=STAXI-2
Dimensions of Anger Reactions- DAR. This brief assessment tool measures anger directed towards others. This tool has been used specifically with military populations and is sensitive to therapeutic change associated with PTSD interventions. It is available for purchase and veterans may take this online assessment measure at http://afterdeployment.t2.health.mil/topics-anger
Anger treatment overview
Remember that anger has its place in combat and many Service members and Veterans will be unwilling to let go of all of their anger. I recommend that you focus treatment goals on finding ways to better manage anger in daily interactions with friends, family and others without removing the emotion entirely. Also, be mindful that anger often interferes with therapy via weakened therapeutic alliance, reduced client engagement and avoidance. You should employ motivational interviewing strategies which help combat veterans to weigh the pros and cons of anger as they self-determine the benefits of behavioral change.
At this point, no singular treatment has clearly emerged as the gold standard of treatment for anger, but that may be because there are different types of dysregulated anger as well as multiple manifestations of anger. A review of the extant literature suggests that anger treatment based on a cognitive-behavioral model is most likely to be effective. Treatment should begin with an assessment of anger, consideration of motivation to change and contemplation of the benefits of healthy anger management to interpersonal relationships. Clinicians should also carefully consider co-morbid conditions during treatment planning. For example, a Service member with chronic pain or insomnia has good reasons to be irritable so effective treatment planning may go a long way towards affect regulation.
Good anger management training should include:
- Psychoeducation on anger and affect intensity
- Guidance on anger triggers and skills to identify their personal anger triggers
- Psychoeducation for SM and family on PTSD and common trauma reactions
- Remind SMs that anger is much easier to manage at lower levels than at higher levels
- Instruction on healthy assertive behaviors and healthy communication skills so that alternative behaviors are available
- Numerous skills to increase relaxation and manage anger before it becomes elevated
- Consultation with a prescribing provider to consider pharmacotherapy
Resources for managing anger related to PTSD
Make the Connection - http://maketheconnection.net/symptoms/anger-irritability - This resource features veterans sharing their struggles with anger and irritability. It includes helpful tips for managing anger on a daily basis and resources for getting help. Information is included for male and female veterans as well as family members.
Afterdeployment.org - http://afterdeployment.t2.health.mil/topics-anger
This resource features an online anger assessment and a brief anger management workshop. You must be registered and logged into your account in order to take the workshop. Additional information about anger, videos of veterans discussing anger and tips on how to manage anger are included along with links to online forums.
National Center for PTSD - http://www.ptsd.va.gov/professional/continuing_ed/anger_aggression.asp
This helpful resource includes information specifically for behavioral health professionals working with veterans. The featured online course provides one hour of CEUs for VA providers. The podcast is also available for clinical providers outside of the VA system. Please note that this course is designed to be a multimedia presentation and is most helpful via the online format.
Additional PTSD Education Resources
CDP online courses on PTSD
The CDP has two excellent online courses for behavioral health providers which specifically address PTSD in military populations.
Epidemiology of PTSD in Military Personnel and Veterans: Working with Service Members and Veterans with PTSD - http://www.deploymentpsych.org/online-courses/ptsd
This highly recommended course is 90 minutes in duration. It reviews types of trauma exposure and emotional reactions typical among OIF/OEF veterans. It enumerates PTSD assessment tools and treatment recommendations. It also recognizes barriers to treatment often faced by veterans. This course may be taken for free OR behavioral health professionals may pay a small fee to earn CEUs.
The impact of Stress and Trauma Related to Military Deployment - http://www.deploymentpsych.org/content/stress-and-trauma-related-militar...
This intermediate level course was created in collaboration with the American Psychological Association. This course reviews the unique stressors of military personnel and their families before, during and after deployment. It may be taken for CEUs for a small fee.
DoD/VA guidelines for PTSD - http://www.healthquality.va.gov/guidelines/MH/ptsd/
The DoD/VA guidelines for the management of PTSD were updated in 2010. This is an excellent resource for providers managing PTSD treatment that is reviews the gold standards PTSD treatment in military populations. This PDF is available online via the link above
Do you have suggestions on how to manage PTSD-related anger?
Holly N. O’Reilly, Ph.D., is a clinical psychologist and Lead on Traumatic Stress and Sexual Assault at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.