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Anger and predictors of drop-out from PTSD treatment of veterans and first responders

Published online by Cambridge University Press:  27 September 2021

Emily Hinton
Affiliation:
Discipline of Clinical Psychology, University of Technology Sydney, Ultimo, Australia
Zachary Steel
Affiliation:
School of Psychiatry, University of New South Wales, Sydney, Australia St John of God Health Care, Richmond Hospital, Australia Black Dog Institute, Randwick, Australia
Dominic Hilbrink
Affiliation:
St John of God Health Care, Richmond Hospital, Australia
David Berle*
Affiliation:
Discipline of Clinical Psychology, University of Technology Sydney, Ultimo, Australia School of Psychiatry, University of New South Wales, Sydney, Australia
*
*Corresponding author. Email: [email protected]

Abstract

Background:

Drop-out is an important barrier in treating post-traumatic stress disorder (PTSD) with consequences that negatively impact clients, clinicians and mental health services as a whole. Anger is a common experience in people with PTSD and is more prevalent in military veterans. To date, no research has examined if anger may predict drop-out in military veterans or first responders.

Aims:

The present study aimed to determine the variables that predict drop-out among individuals receiving residential treatment for PTSD.

Method:

Ninety-five military veterans and first responders completed pre-treatment measures of PTSD symptom severity, depression, anxiety, anger, and demographic variables. Logistic regression analyses were used to determine if these variables predicted drop-out from treatment or patterns of attendance.

Results:

Female gender was predictive of drop-out. However, when analysed by occupation female gender was predictive of drop-out among first responders and younger age was predictive of drop-out in military participants. Anger, depression, anxiety and PTSD symptom severity were not predictive of drop-out in any of the analyses. No variables were found to predict attendance patterns (consistent or inconsistent) or early versus late drop-out from the programme.

Conclusion:

These results suggest that although anger is a relevant issue for treating PTSD, other factors may be more pertinent to drop-out, particularly in this sample. In contrast with other findings, female gender was predictive of drop-out in this study. This may indicate that in this sample, there are unique characteristics and possible interacting variables that warrant exploration in future research.

Type
Main
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the British Association for Behavioural and Cognitive Psychotherapies

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References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th edn). Arlington, VA, USA.Google Scholar
Baekeland, F., & Lundwall, L. (1975). Dropping out of treatment: a critical review. Psychological Bulletin, 82, 738783. doi: 10.1037/h0077132 CrossRefGoogle ScholarPubMed
Barrett, M. S., Chua, W.-J., Crits-Christoph, P., Gibbons, M. B., & Thompson, D. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training, 45, 247267. doi: 10.1037/0033-3204.45.2.247 CrossRefGoogle ScholarPubMed
Bedard-Gilligan, M., Garcia, N., Zoellner, L. A., & Feeny, N. C. (2018). Alcohol, cannabis, and other drug use: engagement and outcome in PTSD treatment. Psychology of Addictive Behaviors, 32, 277288. doi: 10.1037/adb0000355 CrossRefGoogle ScholarPubMed
Beidel, D. C., Frueh, B. C., Neer, S. M., & Lejuez, C. W. (2017). The efficacy of trauma management therapy: a controlled pilot investigation of a three-week intensive outpatient program for combat-related PTSD. Journal of Anxiety Disorders, 50, 2332. doi: 10.1016/j.janxdis.2017.05.001 CrossRefGoogle ScholarPubMed
Berke, D. S., Kline, N. K., Wachen, J. S., McLeand, C. P., Yarvis, J. S., Mintz, J., … & Litz, B. T. (2019). Predictors of attendance and dropout in three randomized controlled trials of PTSD treatment for active duty service members. Behaviour Research and Therapy, 118, 717. doi: 10.1016/j.brat.2019.03.003 CrossRefGoogle ScholarPubMed
Bhardwaj, V., Angkaw, A. C., Franceschetti, M., Rao, R., & Baker, D. G. (2018). Direct and indirect relationships among posttrauamtic stress disorder, depression, hostility, anger, and verbal and physical aggression in returning veterans. Aggressive Behavior, 45, 417426. doi: 10.1002/ab.21827 CrossRefGoogle Scholar
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The validity of the Hospital Anxiety and Depression Scale: an updated literature review. Journal of Psychosomatic Research, 52, 6977. doi: 10.1016/S0022-3999(01)00296-3 CrossRefGoogle Scholar
Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. Journal of Traumatic Stress, 28, 489498. doi: 10.1002/jts.22059 CrossRefGoogle ScholarPubMed
Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–fifth ddition (PCL-5) in veterans. Psychological Assessment, 28, 13791391. doi: 10.1037/pas0000254 CrossRefGoogle Scholar
Cash, R., Varker, T., McHugh, T., Metcalf, O., Howard, A., Lloyd, D., … & Forbes, D. (2018). Effectiveness of an anger intervention for military members with PTSD: a clinical case series. Military Medicine, 183, e286e290. doi: 10.1093/milmed/usx115 CrossRefGoogle ScholarPubMed
Chemtob, C. M., Novaco, R. W., Hamada, R. S., Gross, D. M., & Smith, G. (1997). Anger regulation deficits in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 10, 1736. doi: 10.1002/jts.2490100104 CrossRefGoogle ScholarPubMed
Clifton, E. G., Feeny, N. C., & Zoellner, L. A. (2017). Anger and guilt in treatment for chronic posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 54, 916. doi: 10.1016/j.jbtep.2016.05.003 CrossRefGoogle ScholarPubMed
Clinical Data Interchange Standards Consortium (CDISC) (2011). CDISC Clinical Research Glossary. Retrieved from: https://www.cdisc.org/system/files/all/standard_category/application/pdf/act1211_011_043_gr_glossary.pdf Google Scholar
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155159. doi: 10.1037/0033-2909.112.1.155 CrossRefGoogle ScholarPubMed
DeViva, J. C. (2014). Treatment utilization among OEF/OIF veterans referred for psychotherapy for PTSD. Psychological Services, 11, 179184. doi: 10.1037/a0035077 CrossRefGoogle ScholarPubMed
Ditlevesen, D. N., & Elklit, A. (2012). Gender, trauma type, and PTSD prevalence: a re-analysis of 18 nordic convenience samples. Annals of General Psychiatry, 11, 26. doi: 10.1186/1744-859X-11-26 CrossRefGoogle Scholar
Doran, J. M., & DeViva, J. (2018). A naturalistic evaluation of evidence-based treatment for veterans with PTSD. Traumatology, 24, 157167. doi: 10.1037/trm0000140 CrossRefGoogle Scholar
Doran, J. M., Pietrzak, R. H., Hoff, R., & Harpaz-Rotem, I. (2017). Psychotherapy utilization and retention in a national sample of veterans with PTSD. Journal of Clinical Psychology, 73, 12591279. doi: 10.1002/jclp.22445 CrossRefGoogle Scholar
Foa, E. B., Riggs, D. S., Massie, E. D., & Yarczower, M. (1995). The impact of fear activation and anger on the efficacy of exposure treatment for posttraumatic stress disorder. Behavior Therapy, 26, 487499. doi: 10.1016/S0005-7894(05)80096 CrossRefGoogle Scholar
Forbes, D., Creamer, M., Hawthorne, G., Allen, N., & McHugh, T. (2003). Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder. Journal of Nervous and Mental Disease, 191, 9399. doi: 10.1097/01.NMD.0000051903.60517.98 CrossRefGoogle ScholarPubMed
Forbes, D., Parslow, R., Creamer, M., Allen, N., McHugh, T., & Hopwood, M. (2008). Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 21, 142149. doi: 10.1002/jts.20315 CrossRefGoogle ScholarPubMed
Garcia, H. A., Kelley, L. P., Rentz, T. O., & Lee, S. (2011). Pretreatment predictors of dropout from cognitive behavioral therapy for PTSD in Iraq and Afghanistan war veterans. Psychological Services, 8, 111. doi: 10.1037/a0022705 CrossRefGoogle Scholar
Goetter, E. M., Bui, E., Ojserkis, R. A., Zakarian, R. J., Brendel, R. W., & Simon, N. M. (2015). A systematic review of dropout from psychotherapy for Posttraumatic Stress Disorder among Iraq and Afghanistan combat veterans. Journal of Traumatic Stress, 28, 401409. doi: 10.1002/jts.22038 CrossRefGoogle ScholarPubMed
Graham, J. (2012). Cognitive behavioural therapy for occupational trauma: a systematic literature review exploring the effects of occupational trauma and the existing CBT support pathways and interventions for staff working within mental healthcare including allied. Cognitive Behaviour Therapist, 5, 2445. doi: 10.1017/S1754470X12000025 CrossRefGoogle Scholar
Gros, D. F., Yoder, M., Tuerk, P. W., Lozano, B. E., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome and comparison to treatment delivered in person. Behavior Therapy, 42, 276283. doi: 10.1016/j.beth.2010.07.005 CrossRefGoogle ScholarPubMed
Hatchett, G. T., Han, K., & Cooker, P. G. (2002). Predicting premature termination from counseling using the Butcher Treatment Planning Inventory. Assessment, 9, 156163. doi: 10.1177/10791102009002006 CrossRefGoogle ScholarPubMed
Hatchett, G. T., & Park, H. L. (2003). Comparison of four operational definitions of premature termination. Psychotherapy: Theory, Research, Practice, Training, 40, 226231. doi: 10.1037/0033-3204.40.3.226 CrossRefGoogle Scholar
Holder, N., Holliday, R., Wiblin, J., LePage, J. P., & Surís, A. (2019). Predictors of dropout from a randomized clinical trial of cognitive processing therapy for female veterans with military sexual trauma-related PTSD. Psychiatry Research, 276, 8793. doi: 10.1016/j.psychres.2019.04.022 CrossRefGoogle ScholarPubMed
Hundt, N. E., Ecker, A. H., Thompson, K., Helm, A., Smith, T. L., Stanley, M. A., & Cully, J. A. (2018). ‘It didn’t fit for me’: a qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans. Psychological Services. doi: 10.1037/ser0000316 Google Scholar
Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 394404. doi: 10.1037/a0031474 CrossRefGoogle ScholarPubMed
Jeffreys, M. D., Reinfeld, C., Nair, P. V., Garcia, H. A., Mata-Galan, E., & Rentz, T. O. (2014). Evaluating treatment of posttraumatic stress disorder with cognitive processing therapy and prolonged exposure therapy in a VHA specialty clinic. Journal of Anxiety Disorders, 28, 108114. doi: 10.1016/j.janxdis.2013.04.010 CrossRefGoogle Scholar
Klimley, K. E., Van Hasselt, V. B., & Stripling, A. M. (2018). Posttraumatic stress disorder in police, firefighters, and emergency dispatchers. Aggression and Violent Behavior, 43, 3344. doi: 10.1016/j.avb.2018.08.005 CrossRefGoogle Scholar
Lange, A., van de Ven, J.-P., Schrieken, B., & Emmelkamp, P. M. G. (2001). Interapy. Treatment of posttraumatic stress through the internet: a controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 32, 7390. doi: 10.1016/S0005-7916(01)00023-4 CrossRefGoogle ScholarPubMed
Lawson, K. J., Rodwell, J. J., & Noblet, A. J. (2012). Mental health of a police force: estimating prevalence of work-related depression in Australia without a direct national measure. Psychological Reports, 110, 743752. doi: 10.2466/01.02.13.17.PR0.110.3.743-752 CrossRefGoogle ScholarPubMed
Lewis, C., Roberts, N. P., Gibson, S., & Bisson, J. I. (2020). Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: systematic review and meta-analysis. European Journal of Psychotraumatology, 11, 1709709. doi: 10.1080/20008198.2019.1709709 CrossRefGoogle ScholarPubMed
Lievaart, M., Franken, I. H. A., & Hovens, J. E. (2016). Anger assessment in clinical and nonclinical populations: further validation of the State-Trait Anger Expression Inventory-2. Journal of Clinical Psychology, 72, 263278. doi: 10.1002/jclp.22253 CrossRefGoogle ScholarPubMed
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clinical Psychology Review, 29, 695706. doi: 10.1016/j.cpr.2009.07.003 CrossRefGoogle ScholarPubMed
Lloyd, D., Nixon, R. D. V., Varker, T., Elliott, P., Perry, D., Bryant, R. A., … & Forbes, D. (2014). Comorbidity in the prediction of cognitive processing therapy treatment outcomes for combat-related posttraumatic stress disorder. Journal of Anxiety Disorders, 28, 237240. doi: 10.1016/j.janxdis.2013.12.002 CrossRefGoogle ScholarPubMed
Marchand, A., Nadeau, C., Beaulieu-Prévost, D., Boyer, R., & Martin, M. (2015). Predictors of posttraumatic stress disorder among police officers: a prospective study. Psychological Trauma: Theory, Research, Practice and Policy, 7, 212221. doi: 10.1037/a003878010.1037/a0038780.supp CrossRefGoogle ScholarPubMed
Novaco, R. (1975). Dimensions of Anger Reactions. Irvine, CA, USA: University of California.Google Scholar
Novaco, R. W., Swanson, R. D., Gonzalez, O. I., Gahm, G. A., & Reger, M. D. (2012). Anger and postcombat mental health: validation of a brief anger measure with U.S. soldiers postdeployed from Iraq and Afghanistan. Psychological Assessment, 24, 661675. doi: 10.1037/a0026636 CrossRefGoogle ScholarPubMed
Orth, U., & Wieland, E. (2006). Anger, hostility, and posttraumatic stress disorder in trauma-exposed adults: a meta-analysis. Journal of Consulting and Clinical Psychology, 74, 698706. doi: 10.1037/0022-006X.74.4.698 CrossRefGoogle ScholarPubMed
Owens, G. P., Chard, K. M., & Cox, T. A. (2008). The relationship between maladaptive cognitions, anger expression and posttraumatic stress disorder among veterans in residential treatment. Journal of Aggression, Maltreatment and Trauma, 17, 439452. doi: 10.1080/10926770802473908 CrossRefGoogle Scholar
Renshaw, K. D., & Kiddie, N. S. (2012). Internal anger and external expressions of aggression in OEF/OIF veterans. Military Psychology, 24, 221235. doi: 10.1080/08995605.2012.678197 CrossRefGoogle Scholar
Rizvi, S. L., Vogt, D. S., & Resick, P. A. (2009). Cognitive and affective predictors of treatment outcome in cognitive processing therapy and prolonged exposure for posttraumatic stress disorder. Behaviour Research and Therapy, 47, 737743. doi: 10.1016/j.brat.2009.06.003 CrossRefGoogle ScholarPubMed
Rosen, C., Adler, E., & Tiet, Q. (2013). Presenting concerns of veterans entering treatment for posttraumatic stress disorder. Journal of Traumatic Stress, 26, 640643. doi: 10.1002/jts.21841 CrossRefGoogle ScholarPubMed
Salkind, N. J. (2010). Encyclopedia of Research Deisgn (vols 1–10). Thousand Oaks, CA, USA: Sage. doi: 10.4135/9781412961288 CrossRefGoogle Scholar
Scamardo, M., Bobele, M., & Biever, J. L. (2004). A new perspective on client dropouts. Journal of Systemic Therapies, 23, 2738. doi: 10.1521/jsyt.23.2.27.36639 CrossRefGoogle Scholar
Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V. E., de Vries, M. H., & Gersons, B. P. R. (2007). Treatment of acute posttraumatic stress disorder with brief cognitive behavioral therapy: a randomized controlled trial. American Journal of Psychiatry, 164, 8290. doi: 10.1176/ajp.2007.164.1.82 CrossRefGoogle ScholarPubMed
Silove, D., Mohsin, M., Tay, A. K., Steel, Z., Tam, N., Savio, E., … & Rees, S. (2017). Six-year longitudinal study of pathways leading to explosive anger involving the traumas of recurrent conflict and the cumulative sense of injustice in Timor-Leste. Social Psychiatry and Psychiatric Epidemiology: The International Journal for Research in Social and Genetic Epidemiology and Mental Health Services, 52, 12811294. doi: 10.1007/s00127-017-1428-3 CrossRefGoogle ScholarPubMed
Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-2. Lutz, FL, USA: Psychological Assessment Resources.Google Scholar
Spinhoven, P., Penninx, B. W., van Hemert, A. M., de Rooij, M., & Elzinga, B. M. (2014). Comorbidity of PTSD in anxiety and depressive disorders: prevalence and shared risk factors. Child Abuse & Neglect, 38, 13201330. doi: 10.1016/j.chiabu.2014.01.017 CrossRefGoogle ScholarPubMed
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: a meta-analysis. Journal of Consulting and Clinical Psychology, 80, 547559. doi: 10.1037/a0028226 CrossRefGoogle ScholarPubMed
Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24, 193207. doi: 10.1037/a0037512 CrossRefGoogle Scholar
Szafranski, D. D., Smith, B. N., Gros, D. F., & Resick, P. A. (2017). High rates of PTSD treatment dropout: a possible red herring? Journal of Anxiety Disorders, 47, 9198. doi: 10.1016/j.janxdis.2017.01.002 CrossRefGoogle ScholarPubMed
Taft, C. T., Creech, S. K., & Murphy, C. M. (2017). Anger and aggression in PTSD. Current Opinion in Psychology, 14, 6771. doi: 10.1016/j.copsyc.2016.11.008 CrossRefGoogle ScholarPubMed
Taft, C. T., Street, A. E., Marshall, A. D., Dowdall, D. J., & Riggs, D. S. (2007). Posttraumatic stress disorder, anger, and partner abuse among Vietnam combat veterans. Journal of Family Psychology, 21, 270277. doi: 10.1037/0893-3200.21.2.270 CrossRefGoogle ScholarPubMed
van Minnen, A., Arntz, A., & Keijsers, G. P. J. (2002). Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout. Behaviour Research and Therapy, 40, 439457. doi: 10.1016/S0005-7967(01)00024-9 CrossRefGoogle ScholarPubMed
Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS One, 10.CrossRefGoogle Scholar
Zalta, A. K., Held, P., Smith, D. L., Klassen, B. J., Lofgreen Nomand, P. S., Brennan, M. B., Rydberg, T. S., Boley, R. A., Pollack, M. H., & Karnik, N. S. (2018). Evaluating patterns and predictors of symptoms change during a three-week intensive outpatient treatment for veterans with PTSD. BMC Psychaitry, 18, 242. doi: 10.1186/s12888-018-1816-6 CrossRefGoogle ScholarPubMed
Zandberg, L. J., Rosenfield, D., Alpert, E., McLean, C. P., & Foa, E. B. (2016). Predictors of dropout in concurrent treatment of posttraumatic stress disorder and alcohol dependence: rate of improvement matters. Behaviour Research and Therapy, 80, 19. doi: 10.1016/j.brat.2016.02.005 CrossRefGoogle ScholarPubMed
Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361370. doi: 10.1111/j.1600-0447.1983.tb09716.x CrossRefGoogle ScholarPubMed
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