Evaluation of the Dimensions of Anger Reactions-5 (DAR-5) Scale in combat veterans with posttraumatic stress disorder

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Abstract

After a traumatic event many people experience problems with anger which not only results in significant distress, but can also impede recovery. As such, there is value to include the assessment of anger in routine post-trauma screening procedures. The Dimensions of Anger Reactions-5 (DAR-5), as a concise measure of anger, was designed to meet such a need, its brevity minimizing the burden on client and practitioner. This study examined the psychometric properties of the DAR-5 with a sample of 163 male veterans diagnosed with Posttraumatic Stress Disorder. The DAR-5 demonstrated internal reliability (α = .86), along with convergent, concurrent and discriminant validity against a variety of established measures (e.g. HADS, PCL, STAXI). Support for the clinical cut-point score of 12 suggested by Forbes et al. (2014, Utility of the dimensions of anger reactions-5 (DAR-5) scale as a brief anger measure. Depression and Anxiety, 31, 166–173) was observed. The results support considering the DAR-5 as a preferred screening and assessment measure of problematic anger.

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)

  • T.A. Brown

    Confirmatory factor analysis for applied research

    (2006)
  • J. Cohen

    Statistical power analysis for the behavioral sciences

    (1988)
  • S. Ekblad et al.

    Psychological impact of torture: a 3-month follow-up of mass-evacuated Kosovan adults in Sweden. Lessons learnt for prevention

    Acta Psychiatrica Scandinavica

    (2002)
  • E.B. Elbogen et al.

    Assessing risk of violent behavior among veterans with severe mental illness

    Journal of Traumatic Stress

    (2008)
  • N.C. Feeny et al.

    Anger, dissociation, and posttraumatic stress disorder among female assault victims

    Journal of Traumatic Stress

    (2000)
  • N.C. Feeny et al.

    Treatment outcome for chronic PTSD among female assault victims with borderline personality characteristics: a preliminary examination

    Journal of Personality Disorders

    (2002)
  • F.J. Floyd et al.

    Factor analysis in the development and refinement of clinical assessment instruments

    Psychological Assessment

    (1995)
  • D. Forbes et al.

    Utility of the Dimensions of Anger Reactions-5 (DAR-5) Scale as a brief anger measure

    Depression and Anxiety

    (2014)
  • D. Forbes et al.

    Comorbidity as a predictor of symptom change after treatment in combat-related posttraumatic stress disorder

    Journal of Nervous and Mental Disease

    (2003)
  • D. Forbes et al.

    A concise measure of anger in combat-related posttraumatic stress disorder

    Journal of Traumatic Stress

    (2004)
  • D. Forbes et al.

    Mechanisms of anger and treatment outcome in combat veterans with posttraumatic stress disorder

    Journal of Traumatic Stress

    (2008)
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