Anger Dimensions and PTSD Treatment
June 11, 2014
In this episode, Dr. Tara Galovski discusses her research on the dimensions of anger and how they relate to change in Posttraumatic Stress Disorder (PTSD).
Tara Galovski, PhD, is an associate professor at the Center for Trauma Recovery of the University of Missouri–St. Louis. She is primarily interested in treatment outcome research with a current focus on the development and testing of Cognitive Processing Therapy within survivors of interpersonal assault suffering from Posttraumatic Stress Disorder (PTSD). In addition, Dr. Galovski investigates the impact of gender differences, chronicity of trauma, type of trauma and the presence of comorbid psychiatric disorders on the development and maintenance of PTSD as well as its resolution.
Psychological Trauma: Theory, Research, Practice, and Policy publishes empirical research on the psychological effects of trauma. The journal is intended to be a forum for an interdisciplinary discussion on trauma, blending science, theory, practice, and policy.
Visit the Psychological Trauma website.
Marla Bonner: Hello, I'm Marla Bonner. Welcome to APA Journals Dialogue, a podcast featuring research from the Journals program of the American Psychological Association. In this episode, we look at a study from Psychological Trauma: Theory, Research, Practice, and Policy, the official journal of APA Division 56 (Trauma Psychology).
Dr. Tara Galovski is an associate professor at the Center for Trauma Recovery of the University of Missouri-St. Louis. Dr. Galovski's research interests include treatment outcome research and the impact of multiple factors on the development and maintenance of PTSD.
In their recent study, "Changes in Anger in Relationship to Responsivity to PTSD Treatment", Dr. Galovski and her colleagues examined the dimensions of anger and how they relate to change in PTSD.
Here with us to discuss her research is Dr. Galovski. Welcome. Thank you for joining us.
Dr. Tara Galovski: You're welcome, thanks for having me.
Marla Bonner: In your article, you define the different presentations of anger, such as state anger and trait anger. Could you please describe the differences between the two?
Dr. Galovski: Sure. Anger is a large general construct, and oftentimes we can break that down into a number of subtypes, for lack of a better word. The two of the broader subtypes certainly would include state anger and trait anger. So we think about state anger specifically as describing the amount of anger that any given individual is currently experiencing, right now, in this moment, whereas trait anger would reflect a bit more of an overall tendency to respond to different situations or stimuli with anger.
Marla Bonner: And you mention in your article that previous studies have shown a unique relationship between anger and PTSD. Could you describe in more detail what this unique relationship is as presented in previous research?
Dr. Galovski: We reviewed in the paper a number of metaanalytic studies that combined individual anger studies and really showed that anger, in addition to hostility, have been related to PTSD. So anger really seems to occur alongside PTSD, at a rate that you would consider to be higher than what we would normally see in a non-PTSD population, including other anxiety disorder populations.
So when you look specifically at anger, as we were talking about a minute ago, it can be broken down into these subtypes, and it appears that most specifically, anger directed inward, directing anger at oneself, and one's ability to control their anger, were really specifically important in driving this relationship between PTSD and anger. So in other words, this anger directed inward and the amount of control that one has over the anger is particularly problematic for individuals suffering from PTSD — with anger directed outward also being important.
Marla Bonner: Really interesting. So, I understand that you've done a fair amount of work in this area of trauma, but what were your particular goals for this study that we're discussing today?
Dr. Galovski: Well, we were particularly interested in the role of anger in general in a PTSD population. Anger is clearly present, in many clinical presentations, with folks coming into our offices with post-traumatic stress disorder. Although PTSD really has been, historically perhaps, considered more of fear-based disorder, but anger really has an important role, so based on these types of metaanalytic studies, suggesting that anger and PTSD have this unique relationship, we decided to really examine the patterns of change in different types of anger across a therapy for PTSD.
So specifically, we wanted to ask the question, how does this change in anger depend on a change of PTSD symptoms? Or maybe the reverse is happening, is it the PTSD treatment content that's directly influencing anger symptoms, even if the PTSD isn't getting better? We wanted to look at this specifically across these types of anger that are showing to be really important to PTSD populations.
Marla Bonner: And looking at the methodology of your study, I see that the sample consisted of female survivors of interpersonal violence. Why focus on this audience?
Dr. Galovski: Yeah, great question. We focused primarily on our female survivors, because the anger and the change in anger has really been less studied in women, particularly with respect to treatment outcome and particularly with respect to these subtypes of anger that we've seen to be most related to PTSD, this anger-in, anger control, and anger-out. So even less attention has been paid to the patterns or rates of change, so we thought that this was a very understudied population, and would be a contribution to the general literature.
Marla Bonner: And what were some of the limitations of this sample? Were there any that were surprising to you?
Dr. Galovski: Yeah, well the limitations of the sample is kind of the flipside of the other answer. When you look at a very specific population, you lose some ability to generalize those results beyond the individual types that were looked at in the sample. That being said, though, looking at anger in this way with this sample is a contribution because we have a larger literature already that predominantly focuses on the male combat veterans, for example where we see a lot of anger within males.
We did publish a subsequent paper with a different sample of male and female interpersonal assault survivors, and we did find that men and women recover similarly, so we extended this current study that we are talking about, but it would be really interesting to combine men and women and trauma types to one study, and really partial out the influence of sex differences in terms of anger and also recovery from anger in PTSD and exposure to different types of trauma.
Marla Bonner: So is this an area of study that our audience can look forward to receiving from you and your colleagues? Are you presently working on that?
Dr. Galovski: Yes, definitely. We recently published a couple of sex differences papers where we included anger and we are hoping to start a study soon looking at prison populations with individuals suffering from PTSD and so we anticipate seeing elevated types of anger there as well.
Marla Bonner: Certainly looking forward to that research from you and your colleagues. So, were any of your observations consistent to previous findings as it relates to PTSD and anger, and if so, what were some of those unique conclusions?
Dr. Galovski: So we saw some similar patterns emerge. We certainly saw that anger and its anger control state and trait anger were elevated with our PTSD folks.
One difference was that we saw not quite as strong of a relationship between anger directed outwards and PTSD, and we hypothesized that this might be because of a lack of males in our sample, but perhaps most interesting we found that individuals who received our PTSD treatment, which was cognitive processing therapy or prolonged exposure, improved similarly on state anger and anger-in, even if they didn't improve on the PTSD symptoms, so this suggests that the PTSD interventions are really targeting anger symptoms specifically and even independently from relief from the PTSD improvement, but anger control seems to be much more dependent on change in PTSD symptoms with respect to the individuals who respond well to treatment and lost that PTSD diagnosis, those PTSD responders seem to show more overall change on anger control, which was interesting.
Marla Bonner: What bearing do your results have on other populations, specifically, those who are predisposed to PTSD and who have also experienced interpersonal assault and violence, I'm thinking specifically of survivors of child abuse and neglect?
Dr. Galovski: Yes, absolutely, and it is interesting that of the 139 women who participated in this particular trial, most of them had significant histories of child abuse and neglect as well as adult exposure to violence as well, so we're talking about this sample really did include lifelong abuse history, the results are most likely quite generalizable to folks who experienced trauma at really any developmental point.
Marla Bonner: That's very interesting. So as you know, trauma not only has psychological effects, but physiological ones as well, and so, in your opinion, how do other traumas like neglect and deprivation alter brain circuitry, and could this provide some insight into the lack of engagement of dropouts in your study?
Dr. Galovski: Absolutely. It's a great question and we didn't measure it specifically, but we certainly know from the larger literature that neglected deprivation can certainly be demonstrated to alter brain circuitry especially in early stages of development and in critical stages of development.
In addition in our sample, many women suffered significant domestic violence or other types of violent assault, which can result in blows to the head, and we often see traumatic brain injuries and so forth, so any type of physiological disruption and injury can certainly influence the extent to which you are able to engage in the treatment and also to benefit from the treatment.
That being said, conducting these types of trials in the center with respect to treatment dropout, it's been much more the experience that individuals drop out of treatment due to other reasons such as moving out of town, or having a medical problem, or difficulties with transportation, or because that they get better so they don't complete treatment.
So in those kinds of cases with respect to engagement in treatment, I don't know if it's as much of a physical limitation that's preventing that engagement or causing dropout, as more of a logistical one, so we would introduce something like motivational interviewing or something like that to increase someone's readiness to change and get back to the trauma work.
Marla Bonner: So would you say that motivational interviewing for example is an alternative treatment option for dropouts? Are there other treatment options that may be provided at your institution?
Dr. Galovski: We will use the best evidence-based intervention at our institution, and those have really been demonstrated to be cognitive processing therapy and prolonged exposure and so those are the primary treatments that we'll offer, so with respect to dropouts, if someone's at a risk of dropout, then we will use interventions such as motivational interviewing to increase their readiness to get back to the trauma work, but there are certainly other interventions that have shown empirical support, like MDR, and there's some support for yoga, and other types of alternative interventions, that we would certainly be happy to try, we've just had pretty significant success with CBT or PE.
Marla Bonner: Sure, and in your estimation, what impact does your study have or do you hope that it will have on the way anger is defined, assessed, and treated clinically?
Dr. Galovski: I think the important take home points from our study include the assessment and maybe real consideration of the different subtypes of anger as you're starting to formulate your treatment plan. So we have a substantial literature that shows that anger can certainly get in the way of goals, sticking with treatment, engaging in treatment, and also certainly benefiting from treatment.
So our data really show that as clinicians we fully expect to see individuals realize benefits and their problematic anger during the course of these interventions for PTSD. So elevated anger at the beginning of therapy really should not be a reason to exclude or delay someone from getting treatment for PTSD. Of course, if there's a priority like the anger potentiating harm to oneself or to others, or possibly resulting in the loss of a job or incarceration, then those are treatment priorities, but overall our data really, I think, contribute to the larger literature suggesting that anger will commonly occur in the context of PTSD and it's quite reasonable to expect that will significantly change for the better over the course of the therapy.
Marla Bonner: Well thank you so much, this was a great conversation and we certainly appreciate you taking the time to speak with us today.
Dr. Galovski: Oh I'm happy to do so. Thank you.
Marla Bonner: To read this article and others from Psychological Trauma, please visit our website at: www.apa.org/pubs/journals/tra/.
Thank you for joining us. I'm Marla Bonner, with APA Journals Dialogue.
Episode 1: Anger Dimensions and PTSD Treatment
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