Background: Troops on hazardous deployments may face a variety of traumatic stressors that could result in long-term psychiatric difficulties, including chronic posttraumatic stress disorder (PTSD). For example, among male veterans of the Vietnam War, an estimated 31% developed PTSD, with half of these having a chronic course. Among female Vietnam veterans, the incidence of PTSD is an estimated 27%. Following the 1991 Persian Gulf War, rates of PTSD were estimated at about 9% of veterans assessed shortly after returning home from the 1991, and at 7% of men and 16% of women approximately 2 years later, suggesting that even relatively brief warzone exposure can contribute to the onset of PTSD.

Anger is one of a range of symptoms that may be experienced by individuals who develop PTSD following exposure to trauma, but for many may be the most impairing. As early as World War II, anger and aggression were identified as common responses to combat stress. It has since become clear that anger is a very salient symptom of postwar adjustment. Intense anger may interfere with emotional recovery in the aftermath of trauma, and it has been found to predict later PTSD diagnosis. It also is highly correlated with PTSD severity, is associated with poorer treatment outcomes for individuals with PTSD, and plays a significant role in the negative sequelae associated with chronic PTSD, including impaired social and occupational functioning, increased health problems, and high health care utilization.

Anger has been relatively neglected as a target for intervention following traumatic events despite the established association between trauma and anger and the wide range of negative consequences. Most interventions occur after anger has negatively impacted relationships, jobs, or health. Earlier interventions may be particularly important for military personnel who experience high rates of exposure to traumatic events and who are trained to respond with aggression. Uncontrolled anger in this population may be especially lethal as evidenced by a series of well-publicized domestic homicides that occurred at Fort Bragg in 2002. These and a number of subsequent incidents involved active duty servicemen who had recently returned from hazardous deployments. Given the association between trauma and anger, including evidence of increased rates of domestic violence among veterans with PTSD (vs. those without), it is likely that some of the servicemen involved in these incidents were experiencing symptoms of PTSD, particularly the hyperarousal symptoms of anger and irritability, secondary to their combat experiences. It is crucial that programs be developed to address the mental health needs of these veterans to prevent the myriad of complications associated with chronic PTSD and associated anger.

Objective/Hypothesis: The objective of the proposed study is to adapt and pilot test the efficacy and benefits of an existing evidenced-based cognitive-behavioral anger intervention for the secondary prevention of PTSD-related anger problems, including the escalating effects of poor anger control (domestic violence, unemployment, etc.) in military personnel returning from hazardous deployments. It is hypothesized that individuals receiving the anger intervention will exhibit less anger and aggression, less severe PTSD symptoms, better overall functioning, and higher quality of life than those receiving a control treatment of supportive therapy.

Specific Aims: (1) To adapt an existing cognitive-behavioral anger intervention for the specific needs of military personnel returning from hazardous deployments with PTSD-related anger problems. (2) To gather preliminary efficacy data of the adapted treatment to determine whether a larger-scale study is warranted.

Study Design: The period of study will involve two phases. In Phase 1, the cognitive behavioral intervention will be administered to eight individuals, and a supportive (control) intervention to two individuals, with clinically significant anger problems and meeting PTSD hyperarousal criteria. The interventions will be modified based upon the experience and feedback from this first phase. The second phase will involve a small-scale controlled study comparing the adapted cognitive-behavioral anger intervention to the supportive control intervention. Individuals who consent to participate in the study will be randomly assigned to receive twelve 75-minute individual therapy sessions of either the cognitive behavioral intervention or the supportive intervention. Assessments will be completed at pretreatment, termination, and 3 months after completion of treatment. Participants will include a total of 50 male and female military personnel who have recently served in Iraq or other hazardous deployments.

Relevance: There is an urgent need for early effective interventions for troops returning from hazardous deployments. Many of these individuals have been exposed to a variety of traumatic stressors. Without treatment, a significant proportion will develop long-term psychological complications. PTSD is one of most common, debilitating, and chronic psychological disorders diagnosed among veterans, and among the symptoms of PTSD, anger arguably plays the greatest role in the highly negative outcomes. The question of whether early treatment might prevent or reduce the chronic suffering and impairment associated with PTSD and related anger is of critical importance for this new cohort of veterans returning from hazardous deployments.