Veterans with Combat-PTSD and Individuals with High Trait Anger

171 Pages·2014·2.04 MB·English

by  Lucas Rigby

An Investigation of Anger Regulation in Two Clinical Groups:
Veterans with Combat-PTSD and Individuals with
High Trait Anger

Carmen L. Germain
BPsych (Hons)

Submitted for the degree of Doctor of Psychology (Clinical)
Centre for Emotional Health
Department of Psychology, Macquarie University
December 2013

i
Table of Contents

List of Tables v
List of Figures vi
General Summary vii
Certification ix
Acknowledgements x

Chapter 1: General Introduction 1
Introduction 2
Anger and Its Causes 4
Anger as a Multidimensional Construct 5
Cognitive Processes in Anger 6
Problematic Anger 9
Anger as a Feature of PTSD 12
Models of PTSD Emphasising “Hard-Wired” Associative Processes 14
Models of PTSD Emphasising Appraisal-Driven Processes 15
Anger Regulation Variables in PTSD 18
Approaches to Anger Treatment 20
Control- Versus Acceptance-Based Approaches to Emotion Regulation:
Evidence from Experimental Research 21
Trait Emotion Regulation Style 26
Effects of Trauma Exposure on Emotion Regulation Strategies:
Implications for Anger Regulation 28
Summary and Overview of the Current Program of Research 28
References 31
Chapter 2: Study 1 – The Role of Trauma-Related Cognitive
Processes in the Relationship between Combat-Related PTSD
Symptom Severity and Maladaptive Anger Expression and Control 48
Abstract 49
Introduction 50
Method 54
Participants and Procedure 54
Self Report Measures 55
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Statistics 57
Results 58
Sample Characteristics 58
PTSD Severity and Anger 59
Trauma-Related Appraisals and Anger Expression 60
Mediating Role of Trauma-Related Cognitive Processes 63
Discussion 65
References 71
Chapter 3: Acceptance Versus Control-Based Approaches to Anger 76
Regulation
References 80
Chapter 4: Study 2 - Trait Anger and Emotion Regulation: The Effectiveness
of Reappraisal, Acceptance and Suppression Strategies in Regulating Anger 82
Abstract 83
Introduction 84
The Current Study 91
Method 93
Participants 93
Self-Report Measures 93
Procedure 97
Data Analysis 101
Results 101
Sample Characteristics 101
Manipulation Check 103
Effects of ER Strategy on State Anger 103
Effects of ER Strategy on Systolic Blood Pressure 105
Anger Intrusions and Interference 107
24-hour Follow-up: Event-related Anger, Event-related Intrusions 108
Moderation of Trait ER Style 110
Moderation of PTSD 111
Discussion 112
Effects on State Anger and Physiological Arousal 112
Impact of Anger Intrusions and Interference on a Behavioural Task 115
Moderation of Trait ER Style 116
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Study Limitations 118
References 123
Chapter 5: General Discussion 133
Clinical Implications 142
Limitations and Future Research 144
Conclusion 148
References 149
Appendix: Ethics Committee Approval Letters 156

iv
List of Tables

Chapter 2
Table 1: Means, Standard Deviations, and Intercorrelations of Outcome Measures 62
Table 2: Model Fit Indices for Hypothesised and Nested Alternative Models 63

Chapter 4
Table 1: Means, Comparisons between ER Conditions on Demographic, Emotional
Well-being, and Baseline Measures 104
Table 2: Experimental Manipulation Check Based on Item Averages of
Manipulation Check Scales 106
Table 3: Summary of Means and Standard Deviations for Dependent Variables
Across Reappraisal, Acceptance, and Suppression Conditions 109

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List of Figures

Chapter 2
Figure 1: Model 1 – Testing Mediating Role of Trauma Appraisals in PTSD and
Anger Regulation Variables 61
Figure 2: Model 7 – Final Parsimonious Model 65

Chapter 4
Figure 1: State Anger Scores at Baseline, Post-Anger Provocation, and Post-
Instructed ER condition 105
Figure 2: Systolic Blood Pressure at Baseline, Post-Anger Provocation, and Post-
Instructed ER condition 107
Figure 3: IES-Intrusion Scores at Baseline, and at 24-hour Follow-up 108

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General Summary
Two studies were conducted to investigate anger regulation in two clinical groups well
documented to experience anger-related problems: trauma-exposed combat veterans, and
adult individuals with high levels of trait-anger. The first study was a path-analysis
investigation of the effect of trauma-related cognitive factors (negative trauma appraisals,
trauma rumination and suppression) on the association between combat-PTSD symptom
severity and anger regulation domains of suppression, aggressive expression and control.
Negative trauma appraisals about self and the world were found to partially mediate the
relationship between PTSD and anger regulation domains, while trauma rumination and
suppression did not. A direct relationship was found between combat-PTSD and aggressive
anger expression. Implications for the theoretical conceptualisation and treatment of anger
dysregulation in combat-PTSD were discussed.
While cognitive-behavioural therapy is the most empirically supported treatment for
dysregulated anger to date, acceptance-based approaches have recently been proposed.
However, few studies have examined the relative effectiveness of cognitive reappraisal and
acceptance approaches to anger. The second study was an experimental investigation of the
effectiveness of instructed cognitive reappraisal, acceptance and emotional suppression on
state-anger in response to provocation, amongst individuals with high trait-anger. This study
examined trait-emotion regulation style and elevated PTSD symptoms as moderators of the
effect of instructed ER. Immediate and delayed adaptive effects on subjective state-anger,
physiological arousal, and anger intrusions were found for all three emotion regulation
instructions. Trait-concealing was found to augment the adaptive effects of suppression on
physiological arousal, while trait-tolerance enhanced the effect of cognitive reappraisal. PTSD
status was not found to be a significant moderator.
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This research highlighted the importance of targeted assessment and interventions for
negative trauma appraisals in the context of anger treatment for combat veterans, and
generated support for cognitive reappraisal, acceptance and emotional suppression as
effective short-term strategies for coping with provoked state anger amongst individuals with
high trait anger.

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Certification
I certify that this thesis is entirely my own work except where otherwise acknowledged, and
has not been submitted for a higher degree to any other university or institution. Macquarie
University Ethics Committee (Human Ethics) approval was obtained, HE27JUN2008-D05934
(Study 1) and 5201100755 (Study 2).

Carmen L. Germain
Date:

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Acknowledgements
This doctoral research was completed with the support and guidance of a number of people in
my academic and personal life, for which I extend my heart-felt thanks. I would firstly like to
thank my principal supervisor Dr Maria Kangas, for her expert guidance, honest and timely
feedback, patience, and encouragement throughout all stages of the research and thesis
preparation process. During challenging periods, her wry sense of humour and kindness
during supervision was greatly appreciated. I would also like to express my gratitude for the
expertise of my adjunct supervisor Associate Professor David Forbes (University of
Melbourne) for his valuable input in the preparation of the manuscript for Study 1. Special
thanks also goes to Dr Alan Taylor for his invaluable assistance with statistics throughout all
stages of the research. I would like to extend my sincere gratitude to Dr Graham Altman,
Northside Cremorne Clinic, for his generous assistance with participant recruitment and
screening, and to the many veterans who saw the value in my research and generously gave
their time to participate.
To my mother Elsa, my father Graham, my stepfather Paul, my stepmother Jan, and
my sister Daniella, I thank you all for your love, support and unwavering faith that I would
achieve this degree. To my wonderful husband Peter and my amazing children Lucas and
Daniel, your love has kept me afloat through the challenging phases of this journey, and for
that I can’t thank you enough.
This thesis is dedicated to the memory of my dear late friend, Alison Rumbelow.

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