Evaluation of the Dimensions of Anger Reactions-5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder
Introduction
In recent years there has been an increased focus on anger as a common mental health sequelae in people exposed to a potentially traumatic event such as sexual and physical assault (Feeny et al., 2000, Feeny et al., 2002, Zoellner et al., 2000), motor vehicle accidents (Mayou, Ehlers, & Bryant, 2002), torture (Ekblad, Prochazka, & Roth, 2002), and exposure to human rights violations (Silove et al., 2009). Difficulties with anger have also been observed in refugees (Hinton, Rasmussen, Nou, Pollack, & Good, 2009) and in 9/11 disaster relief workers (Jayasinghe, Giosan, Evans, Spielman, & Difede, 2008). The prominence of anger as an outcome following traumatic events has been particularly evident in combat veterans, where anger has also been associated with aggression and interpersonal violence (Elbogen et al., 2008, McManus et al., 2008). Anger and anger-related cognitions also appear to play a significant role in the development and maintenance of key posttraumatic mental health disorders such as posttraumatic stress disorder (PTSD) (Jayasinghe et al., 2008, Koenen et al., 2003) with evidence of it attenuating gains in PTSD treatment, most notably in combat veterans (Forbes et al., 2003, Forbes et al., 2008).
In this context, it is critical to consider screening for anger as part of routine mental health assessment following exposure to potentially traumatic events. Routine assessment of anger requires brief psychometrically robust measures that can be easily inserted into screening batteries and included in longitudinal tracking and surveillance of mental health outcomes following trauma exposure, guiding targeted intervention where appropriate. Major psychometrically established measures of anger, such as the State-Trait Anger Expression Inventory (STAXI: Spielberger, 1996) and the Novaco Anger Scale (Novaco, 2003), both extensively validated with clinical populations, are too long to include in routine screening and assessment batteries. To address the need for a brief anger screening tool, the Dimensions of Anger Reactions (DAR) scale, developed by Novaco (1975), was validated by Forbes et al. (2004) against the STAXI in a combat veteran sample. Novaco, Swanson, Gonzalez, Gahm, and Reger (2012) demonstrated its concurrent, discriminant, and incremental validity with behavioral health data for 3528 treatment-seeking soldiers who had been in combat in Iraq and Afghanistan. Forbes et al. (2004) found that the DAR was able to demonstrate sensitivity to change in anger as an outcome of PTSD treatment and that two of its seven items could be removed without compromising psychometric properties. Further, the measure's 9-point response scale was considered excessive, and a burden for respondents’ decision-making (Hawthorne, Mouthaan, Forbes, & Novaco, 2006). Using the five items identifed by Forbes et al. (2004), Hawthorne et al. (2006) reduced the number of response categories from nine to five and reported improved psychometric strength of the modified measure. The shortened scale was referred to as the DAR-5 (5 items and 5 response categories).
Forbes et al. (2014) recently validated the DAR-5 in a sample of 486 college students with and without a history of trauma exposure. In this study the DAR-5 demonstrated strong internal reliability and convergent validity with the STAXI-2. Confirmatory factor analysis supported a single factor model of the DAR-5 for the trauma-exposed and non-trauma exposed subsamples. Discriminant validity was evident with depression symptom scores. In order to target the use of the DAR-5 as a screening measure, a screening cut-point score was developed against the STAXI as a marker of anger likely to interfere with function. A screening cut-point of 12 on the DAR-5 successfully differentiated high and low scorers on STAXI-2 Trait Anger and PCL posttraumatic stress scores (Forbes et al., 2014).
Results of Forbes et al. (2014) provide support for the use of the DAR-5 in screening for anger when a short and effective scale is required. However given the study tested the DAR-5 in college students, validation of the DAR-5 is needed in a trauma-affected clinical sample to ensure its applicability to patients with psychiatric disorders. Given the prominence of anger associated with PTSD, particularly combat-related PTSD, this study sought to examine the psychometric properties of the DAR-5 in a sample of combat veterans with a lifetime history of PTSD who presented for care at a veterans’ clinical service.
Section snippets
Participants
Participants were 163 male veterans who had participated in a hospital based treatment program for combat-related PTSD. Veterans currently engaged in PTSD treatment programs were excluded to avoid response resistance as they were already completing evaluation protocols. Respondents’ ages ranged from 25 to 81 years (M = 59.9; SD = 5.7). Seventy-six percent of the sample was married or in a de-facto relationship, 4% were employed, 11% were retired with the remaining 85% receiving a full incapacity
Results
The means and standard deviations for the DAR-5 and the STAXI subscales have been provided in Table 2.
Discussion
Previous work has provided evidence that the DAR-5 is a reliable and valid measure of anger in college students, including those exposed to trauma. The present findings provide further evidence to support the utility of the DAR-5 by demonstrating its strong psychometric properties when used with a clinical population, here being combat veterans with PTSD. In this study, the DAR-5 recorded high levels of reliability and appropriate levels of convergent, concurrent and discriminant validity. In
References (43)
- et al.
A causal model of post-traumatic stress disorder: disentangling predisposed from acquired neural abnormalities
Trends in Cognitive Sciences
(2013) - et al.
One-year prospective follow-up of motor vehicle accident victims
Behaviour Research and Therapy
(1996) - et al.
The validity of the PTSD checklist as a measure of symptomatic change in combat-related PTSD
Behaviour Research and Therapy
(2001) - et al.
Population norms and meaningful differences for the Assessment of Quality of Life (AQoL) measure
Australian and New Zealand Journal of Public Health
(2005) - et al.
Posttraumatic stress disorder after motor vehicle accidents: 3-year follow-up of a prospective longitudinal study
Behaviour Research and Therapy
(2002) - et al.
The diagnostic accuracy of the PTSD checklist: a critical review
Clinical Psychology Review
(2010) - et al.
Anger in PTSD: is there a need for a concept of PTSD-related posttraumatic anger?
Clinical Psychology Review
(2012) - et al.
Explosive anger as a response to human rights violations in post-conflict Timor-Leste
Social Science & Medicine
(2009) - et al.
The Alcohol Use Disorders Identification Test: guidelines for use in primary care
(2001) - et al.
Clinician-Administered PTSD Scale for DSM-IV
(1998)
Confirmatory factor analysis for applied research
Statistical power analysis for the behavioral sciences
Psychological impact of torture: a 3-month follow-up of mass-evacuated Kosovan adults in Sweden. Lessons learnt for prevention
Acta Psychiatrica Scandinavica
Assessing risk of violent behavior among veterans with severe mental illness
Journal of Traumatic Stress
Anger, dissociation, and posttraumatic stress disorder among female assault victims
Journal of Traumatic Stress
Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: a preliminary examination
Journal of Personality Disorders
Factor analysis in the development and refinement of clinical assessment instruments
Psychological Assessment
Utility of the Dimensions of Anger Reactions-5 (DAR-5) Scale as a brief anger measure
Depression and Anxiety
Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder
Journal of Nervous and Mental Disease
A concise measure of anger in combat-related posttraumatic stress disorder
Journal of Traumatic Stress
Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder
Journal of Traumatic Stress
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