Relations between anger and DSM-5 posttraumatic stress disorder symptoms

Highlights

• Three competing PTSD models were compared and validated against anger.

• Results indicated PTSD's dysphoric arousal model fit the data best.

• Anger demonstrated significant relations with NAMC, dysphoric arousal and anxious arousal.

• Anger was most related to dysphoric arousal.

Abstract

The present study investigated the relationship between posttraumatic stress disorder (PTSD) and anger. Anger co-occurring with PTSD is found to have a severe effect across a wide range of traumatic experiences, making this an important relationship to examine. The present study utilized data regarding dimensions of PTSD symptoms and anger collected from a non-clinical sample of 247 trauma-exposed participants. Confirmatory factor analysis (CFA) was used to determine the underlying factor structure of both PTSD and anger by examining anger in the context of three models of PTSD. Results indicate that a five-factor representation of PTSD and one-factor representation of anger fit the data best. Additionally, anger demonstrated a strong relationship with the dysphoric arousal and negative alterations in cognitions and mood (NACM) factors; and dysphoric arousal was differentially related to anger. Clinical implications include potential need to reevaluate PTSD's diagnostic symptom structure and highlight the potential need to target and treat comorbid anger in individuals with PTSD. In regard to research, these results support the heterogeneity of PTSD.

Introduction

Posttraumatic stress disorder (PTSD) is comorbid with many psychological disorders; most commonly PTSD is comorbid with substance use disorders with rates as high as 51.9% in men (Kessler et al., 1995). Research has demonstrated that in approximately 43.6% of women and 59.0% of men with a PTSD diagnosis are likely to have three or more diagnoses (Kessler et al., 1995). Another construct that is highly prevalent across many trauma-exposed populations is anger (Olatunji et al., 2010). Anger's impact on PTSD is more complicated than anger simply being a symptom of the disorder (McHugh et al., 2012). Clinically speaking, anger co-occurring in individuals with a wide variety of traumas leads to negative outcomes such as negative patient-therapist relationships (Chemtob et al., 1997) and poor treatment efficacy and greater symptom severity (McHugh et al., 2012). Also detrimental to functioning is a proposed externalizing subtype of PTSD that includes anger/aggression reactions and is highly comorbid with more severe psychopathology such as substance use disorders and antisocial personality disorder (Miller et al., 2003). The severe consequences of this co-occurrence illustrate the importance for examining PTSD and anger.

One theoretical explanation for the relationship between PTSD and anger is the fear avoidance theory (Foa et al., 1995). This theory posits that fear-related emotions are activated via reexperiencing symptoms in trauma-exposed individuals. Secondary to this fear activation, individuals are hypothesized to use avoidance strategies as a means of coping with reexperiencing symptoms and trauma/fear-related emotions. Specifically, anger is conceptualized as a potential means to avoid fear-related emotions. As such, anger can be perceived as a maladaptive coping strategy for individuals with PTSD. Considering the assumption that avoidance maintains PTSD, this theory demonstrates the ineffectiveness and severity of using anger to cope with PTSD.

Relations between PTSD and anger have been empirically evaluated in various ways. In one study, anger significantly predicted PTSD's hyperarousal and avoidance/numbing symptom cluster severity (Kulkarni et al., 2012), although that study did not utilize latent factors to measure PTSD, as is our focus. Similarly in another study, a strong relationship persisted even when anger-related PTSD items were removed from instruments measuring anger (Novaco and Chemtob, 2002), implying that there is more to this relationship than mere overlapping symptoms. Additionally, there is a proposed externalizing subtype of PTSD (Miller et al., 2003) and prior research demonstrates that anger/aggression seem to be a key component of this subtype (Castillo et al., 2014, Miller and Resick, 2007).

As far as the effects of comorbid PTSD and anger behaviors are concerned, this co-occurrence seems to produce enduring and detrimental subsequent emotional responses to traumatic events above and beyond what is already covered in the PTSD diagnostic criteria. According to a meta-analysis, the co-occurrence of PTSD and anger holds true across a wide array of traumatic experiences (Olatunji et al., 2010). Although trauma-exposed veterans commonly report anger symptoms (Calhoun et al., 2012, Hellmuth et al., 2012, Kulkarni et al., 2012, Orth and Wieland, 2006, Quimette et al., 2004, Raab et al., 2013), anger has also been reported by individuals experiencing posttraumatic stress after motor vehicle accidents (Chibnall and Duckro, 1994, Ehlers et al., 1998), disaster relief working (Evans et al., 2006), sexual assault (Feeny et al., 2000, Riggs et al., 1992) and in trauma-exposed undergraduates (Jakupcak and Tull, 2005).

Anger and PTSD are both conceptualized in various ways in the extant literature. We used a unidimensional representation of anger derived from the Dimensions of Anger Reactions (DAR-5; Forbes et al., 2014, Forbes et al., 2004). The DAR-5 is a relatively new, 5-item measure of anger. According to a recent factor analysis, the DAR-5 involves a one-factor solution (Forbes et al., 2014) and no competing models for the DAR-5 have been reported to date.

PTSD's factor structure is widely debated among PTSD researchers. Based on empiricism suggesting a poorly identified DSM-IV three-factor model, the newly released DSM-5 has altered the diagnostic structure (Friedman, 2013) such that the avoidance/numbing cluster is now separated into two discrete clusters of avoidance and negative alterations in cognitions and mood (NACM; American Psychiatric Association, 2013). Furthermore, two new symptoms were added (distorted blame, persistent negative emotional state) located in the NACM factor and a symptom of recklessness into the alterations in arousal and reactivity (AAR) symptom cluster (American Psychiatric Association, 2013).

The underlying structure of DSM-5 PTSD is based on the emotional numbing model proposed by King and colleagues (King et al., 1998) suggesting that avoidance and numbing symptoms are better conceptualized distinctly; extensive research supports this model (reviewed in Elhai and Palmieri, 2011). Although most research was conducted prior to the release of the DSM-5 nosology, a few recent investigations of the DSM-5 emotional numbing model have revealed that it fits well in a number of trauma samples (Biehn et al., 2013, Contractor et al., 2014, Elhai et al., 2012, Liu et al., 2014a, Miller et al., 2013).

A further alteration of PTSD's conceptualization is the dysphoria model proposed by Simms et al. (2002). Adjusted for DSM-5, a dysphoria factor is proposed that consists of the entire NACM symptom cluster in addition to three distress-related AAR symptoms. This is based on theory suggesting that dysphoria/distress underlies mood and anxiety disorders (Watson, 2005, Watson, 2009) and is supported empirically (Biehn et al., 2013, Contractor et al., 2014, Grant et al., 2008). The dysphoria model has demonstrated good fit using DSM-5 data (Biehn et al., 2013, Contractor et al., 2014, Liu et al., 2014a, Miller et al., 2013).

Most recently, evidence has emerged to suggest a five-factor conceptualization of PTSD (Elhai et al., 2011). The five-factor dysphoric arousal model divides the AAR symptom cluster to distinguish dysphoric arousal from anxious arousal (Elhai et al., 2011). This model was developed because the dysphoria and emotional-numbing models do not always demonstrate excellent fit (Elhai et al., 2011) and some symptoms (i.e., difficulty sleeping, irritability, difficulty concentrating) do not fit well into the numbing or dysphoria factors. The authors argue that the aforementioned symptoms better represent a somewhat agitated form of dysphoria rather than a general dysphoria and that being overly alert and easily startled is truly representative of a type of anxious arousal found in most fear-based disorders (Elhai et al., 2011, Watson, 2005).

The five-factor PTSD dysphoric arousal model consistently demonstrates superior fit to the four-factor models in trauma-exposed samples of veterans (Armour et al., 2012, Harpaz-Rotem et al., 2014, Pietrzak et al., 2012a), victims of natural disasters (Armour et al., 2013a, Pietrzak et al., 2012b, Wang et al., 2011a, Wang et al., 2011c), youth (Bennett et al., 2014, Elhai et al., 2013), and adult inpatients in an academic hospital (Reddy et al., 2013). More recently, six (Liu et al., 2014b, Tsai et al., 2015) and seven (Armour et al., 2014) factor models have been introduced into the extant literature. See Armour et al. (2014) for complete PTSD model comparisons.

The purpose of the present study was to explore the latent factor structure of PTSD and more specifically to assess the relationship between PTSD's factors and a unidimensional anger factor. Prior research has conceptualized anger multi-dimensional, despite the dimensions of anger being highly intercorrelated. The present study is novel in that we treated anger unidimensionally. Exploring PTSD's latent factor structure could hopefully help in our understanding of PTSD symptom presentations, given the discrepancy in the extant literature regarding which is the best fitting model of PTSD. Additionally, given the high comorbidity between PTSD and anger, and the severity and complications surrounding PTSD and anger, this topic is quite important. Several specific hypotheses were proposed. First, we hypothesized that the dysphoric arousal model would fit better than alternative models. This is based on prior research indicating the dysphoric arousal model best represents PTSD.

In regard to the dysphoric arousal factors, we hypothesized that anger would be more related to PTSD's avoidance, NACM, dysphoric arousal and anxious arousal symptom clusters than to re-experiencing, because reexperiencing has not demonstrated to be differentially related to anger in the extant literature. Anger has shown relations with PTSD's numbing and arousal factors in the extant literature (Kulkarni, 2012) and the fear-avoidance theory suggests that anger may be used as an avoidant coping strategy for individuals with PTSD (Foa et al., 1995) thus relating anger and PTSD's avoidance factor. We also hypothesized that anger would be more related to dysphoric arousal than NACM and anxious arousal given that broad anger/irritability is subsumed within the dysphoric arousal factor (Elhai et al., 2011).