Suzannah K. Creech

Assessment and treatment of posttraumatic anger and aggression: a review.

The Department of Veterans Affairs (VA) and Department of Defenses (DOD) recently published and updated Department of Veterans Affairs/Department of Defense VA/ DOD Clinical Practice Guideline for Management of PostTraumatic Stress includes irritability, severe agitation, and anger as specific symptoms that frequently co-occur with PTSD. For the first time, the guideline includes nine specific recommendations for the assessment and treatment of PTSD-related anger, irritability, and agitation. This article will review the literature on PTSD and its association with anger and aggression. We highlight explanatory models for these associations, factors that contribute to the occurrence of anger and aggression in PTSD, assessment of anger and aggression, and effective anger management interventions and strategies.

Alcohol use, military sexual trauma, expectancies, and coping skills in women veterans presenting to primary care

BACKGROUND Little is known regarding alcohol use and its correlates in women veterans. An understanding of these variables is of utility to providers in primary care at Veterans Affairs (VA) hospitals, who are among the first to identify and intervene for problem drinking. OBJECTIVE The objective of this study was to describe and explore the associations between posttraumatic stress disorder symptoms, experience of military sexual trauma (MST), expectancies for alcohol use, and coping skills in predicting drinking behavior. DESIGN Each month all women veterans attending appointments in primary care were mailed a letter alerting them to the study. Women then received a call asking them to participate, and many were directly recruited at their primary care appointment. Participants then completed a survey of current alcohol use and related variables in a private room. PARTICIPANTS Participants were 93 women veterans seeking care at VA. MAIN MEASURES Measures included the Alcohol Use Disorders Identification Test, a modified version of the VA MST screen, the Davidson Trauma Scale; the Coping Inventory for Stressful Situations, and the Brief Comprehensive Effects of Alcohol Questionnaire. KEY RESULTS Positive expectancies and evaluations emerged as significant correlates of AUDIT scores, while PTSD symptoms were not related to AUDIT scores. A hierarchical regression revealed a significant positive interaction between avoidance coping and positive evaluations. Depression, positive evaluations and avoidance coping were significant independent predictors of AUDIT scores in the final model, but MST was not. CONCLUSIONS Findings highlight the importance of considering of the function of alcohol use when delivering clinical interventions and the need for further research on the association between MST and drinking in women veterans.

A Randomized Controlled Clinical Trial of the Strength at Home Men’s Program for Partner Violence in Military Veterans

OBJECTIVE We evaluated the efficacy of the Strength at Home Mens Program (SAH-M), a trauma-informed group intervention based on a social information processing model to end intimate partner violence (IPV) use in a sample of veterans/service members and their partners. To date, no randomized controlled trial has supported the efficacy of an IPV intervention in this population. METHOD Participants included 135 male veterans/service members and 111 female partners. Recruitment was conducted from February 2010 through August 2013, and participation occurred within 2 Department of Veterans Affairs hospitals. Male participants completed an initial assessment that included diagnostic interviews and measures of physical and psychological IPV using the Revised Conflict Tactics Scales and were randomly assigned to an enhanced treatment as usual (ETAU) condition or SAH-M. Those randomized to SAH-M were enrolled in this 12-week group immediately after baseline. Those randomized to ETAU received clinical referrals and resources for mental health treatment and IPV services. All male participants were reassessed 3 and 6 months after baseline. Female partners completed phone assessments at the same intervals that were focused both on IPV and on the provision of safety information and clinical referrals. RESULTS Primary analyses using hierarchical linear modeling indicated significant time-by-condition effects such that SAH-M participants compared with ETAU participants evidenced greater reductions in physical and psychological IPV use (β = -0.135 [SE = 0.061], P = .029; β = -0.304 [SE = 0.135], P = .026; respectively). Additional analyses of a measure that disaggregated forms of psychological IPV showed that SAH-M, relative to ETAU, reduced controlling behaviors involving isolation and monitoring of the partner (β = -0.072 [SE = 0.027], P = .010). CONCLUSIONS Results provide support for the efficacy of SAH-M in reducing and ending IPV in male veterans and service members. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01435512.

Predicting the Completion of an Integrative and Intensive Outpatient Chronic Pain Treatment With the Personality Assessment Inventory

The effects of intensive, integrative treatments for chronic pain are affected by patient compliance, and in many cases, selecting noncompliant individuals adversely impacts the cost-effectiveness of such programs. The pretreatment identification of individuals who are at risk for dropout could assist clinicians in augmenting treatments with motivational enhancement strategies for high-risk patients or using such information to select individuals who are most likely to complete a given intervention program. In this study, we tested the ability of indicators from the Personality Assessment Inventory (PAI; Morey, 1991), administered prior to treatment, to identify individuals who dropped out of a 20-day chronic pain program. Results replicate findings from outpatient psychotherapy research in finding that PAI Mean Clinical Elevation and Treatment Process Index significantly differentiated dropouts from graduates, particularly when the Treatment Rejection scale suggested patients were motivated for treatment. We discuss these results and offer recommendations for the prediction of treatment dropout in pain settings.

Impact of Coping Style and PTSD on Family Functioning After Deployment in Operation Desert Shield/Storm Returnees

The relationship between military combat and postdeployment family functioning difficulties has been frequently investigated in the literature, as has the relationship between types of coping and posttraumatic stress disorder (PTSD). Few studies, however, have examined these variables together, and no studies of which we are aware have examined the effect of coping on family functioning after combat exposure. This study examined coping style measured immediately after return from deployment, and PTSD symptoms and family functioning 18-24 months after return from deployment in a sample of Operation Desert Shield/Storm veterans (N = 2,949). Structural equation models suggested that the relationships between distinct coping styles on family functioning were differentially mediated by postdeployment PTSD symptoms. Results are consistent with full mediation for avoidant coping (βdirect = -.09, p = .07; βindirect = -.17, p < .001) and partial mediation for approach coping (βdirect = .16, p < .001; βindirect = .09, p < .001). Results suggest that the strategies used to cope with a combat stress event may impact both PTSD and family functioning outcomes, and highlight the potential utility of pre- and postdeployment coping skills training.

Written Emotional Disclosure of Trauma and Trauma History Alter Pain Sensitivity

UNLABELLED The present study investigated whether written emotional disclosure of trauma and trauma history alters sensitivity to experimental pain in healthy women. We examined the immediate affective and physiological effects of written emotional disclosure and evaluated the pain modulatory effects of this personally relevant method of affect induction in women with and without trauma history. Participants wrote for 20 minutes about a traumatic or neutral topic prior to the thermal pain threshold and the ischemic pain tolerance tests. Written disclosure of trauma increased negative affect and skin conductance, which resulted in increased pain sensitivity on heat threshold tests. Trauma history was associated with lower basal ischemic pain tolerance under the neutral writing condition; however, this effect was reversed by disclosure of trauma, suggesting that preexisting differences in pain sensitivity and pain modulation may be related to lifetime history of trauma. PERSPECTIVE These findings indicate that written emotional disclosure provides an effective method for inducing personally relevant affect that is sufficient to modulate pain. History of trauma was related to reduced pain tolerance and enhanced stress-induced hypoalgesia, which underscores the need for further research to examine the extent to which prior history of trauma alters pain processing.

Targeting Relational Aggression in Veterans: The Strength at Home Friends and Family Intervention

OBJECTIVE We evaluated the effectiveness of Strength at Home Friends and Families (SAH-F), a dyadic group intervention to prevent relational aggression and its negative consequences, in a community-based sample of service members/veterans and significant others who reported relational difficulties. METHOD Participants included 70 veterans and their loved ones. Recruitment was conducted from October 2010 through March 2012. Participants completed an initial assessment that included measures of relational aggression and functioning, depressive symptoms, and posttraumatic stress disorder (PTSD) symptoms. Participants were enrolled in the 10-week SAH-F targeting social information-processing mechanisms hypothesized to underlie the relationship between trauma and aggression and were reassessed at program completion and 3 months after intervention. RESULTS Significant reductions in psychological aggression were seen both at program completion and at 3-month follow-up for both veterans (standardized mean gain effect size [ESsg] = -0.45, P < .05) and significant others (ESsg = -0.30, P < .05). Perpetration of physical aggression remained low after pretreatment and did not increase. Relationship adjustment reported by significant others, but not veterans, indicated a significant improvement from pretreatment to program completion (ESsg = 0.33, P < .05). Significant (P < .05) decreases in depressive symptoms were observed from pretreatment to program completion for veterans (ESsg = -0.30, P < .05) and significant others (ESsg = -0.55, P < .05), and significant decreases in PTSD symptoms were observed from pretreatment to follow-up for veterans and significant others (ESsg = -0.52, P < .05). CONCLUSIONS Results provide support for the effectiveness of SAH-F in reducing relational aggression in military member/significant other dyads and enhancing relationship quality and mental health.

College women's perceived risk to experience sexual victimization: a prospective analysis.

This study implemented a prospective design to explore college women’s perceived risk to experience sexual victimization over a 2-month interim (N = 143). Compared to women without such histories, women with a history of unwanted sexual contact via arguments/pressure, or a history of unwanted sexual intercourse via administration of alcohol/drugs reported higher perceived risk to subsequently experience these forms of victimization. Compared to women who were not victimized, women who subsequently experienced unwanted sexual intercourse via administration of alcohol/drugs or arguments/pressure reported higher levels of risk to experience these forms of victimization. Controlling for victimization history, higher levels of risk to experience sexual intercourse over the interim via arguments predicted this form of victimization over the follow-up. Implications are discussed.

Predicting utilization of healthcare services in the veterans health administration by returning women veterans: The role of trauma exposure and symptoms of posttraumatic stress.

Combat exposure and military sexual trauma (MST) are prevalent among returning women veterans and are associated with increased alcohol use and psychological distress. However, it remains unclear the extent to which combat exposure and MST are associated with utilization of health care in the Veterans Health Administration (VHA). The current study explored the relationships among alcohol use and distress in women who deployed in support of Operations Enduring Freedom, Iraqi Freedom, and New Dawn. It was hypothesized that increased posttraumatic stress disorder (PTSD) and depression symptomatology and trauma exposure would be related to greater VHA utilization, whereas alcohol misuse would predict lower VHA use. Participants (N = 133) completed an Internet-based survey of deployment experiences, substance use, mental health, and utilization of VHA services. In this sample, 33% endorsed MST exposure, 64% endorsed combat exposure, and 78% indicated exposure to the aftermath of battle. Multiple regression models found combat exposure-but not MST or aftermath-to be significantly associated with alcohol use and symptoms of PTSD and depression. Only 37% of participants reported use of VHA services, and logistic regression models indicated that PTSD symptomatology was the only unique predictor of VHA use. Findings suggest potential barriers for women who endured sexually based trauma in a military setting in seeking treatment at the VHA.

The Convergence and Predictive Validity of the Multidimensional Pain Inventory and the Personality Assessment Inventory Among Individuals with Chronic Pain

Objective: To explore the convergence, redundancy, and validity of the Multidimensional Pain Inventory (MPI) and the Personality Assessment Inventory (PAI) in a chronic pain treatment setting. Participants: Data from intake (N 235) and follow-up (N 187) for individuals with an average of 9 years of chronic pain who participated in a 20-day integrative treatment program were analyzed. Outcome Measures: Oswestry Disability Index, Beck Depression and Anxiety inventories, Rand Short-Form Health Survey, and clinician-rated ability to stand and carry. Results: Conjoint factor analyses suggested that the MPI and PAI combine to tap five orthogonal factors: Negative Affect, Support, Externalizing, Physical Dysfunction, and Impulsivity. MPI and PAI scales significantly related to various aspects of client functioning, although these scales were more limited in predicting clinician-rated markers and change during treatment. Conclusion: Results support the combined use of the MPI and PAI to understand patient heterogeneity and predict treatment outcome in chronic pain samples.