(PS2-D92) Examining Changes in Anger Following Couples-based PTSD Treatments

Background: Anger is a primary reason Veterans seek treatment for posttraumatic stress disorder (PTSD; Rosen et al., 2013), and predicts greater PTSD severity (Koenen et al., 2003). Further, social support is a protective factor against PTSD, but anger negatively impacts social functioning and relationships (Ray & Vanstone, 2009). Unfortunately, prior studies have generally found PTSD treatments to result in small decreases in anger, and anger has been found to be a residual symptom following treatment. Fewer studies have examined if couples-based PTSD treatments (e.g., cognitive behavioral conjoint therapy; CBCT) result in significant increases in anger following treatment. This study aimed to 1) test the impact of CBCT relative to an active control on improving anger outcomes, and 2) Identify mediators of improvements in anger following treatment.

Method: This study is a secondary analysis that includes 137 Veterans and their partners from a parent randomized clinical trial comparing CBCT delivered in-person and via home-based telehealth to PTSD Family Education (PFE) in-person (blinded for review). The Trait anger subscales of the STAXI-2 (angry temperament and angry reaction) and the psychological aggression subscale from the Conflict Tactics Scale-2 were administered at pretreatment, mid-treatment, post-treatment, and at 3 and 6 months follow-up. Additionally, Veterans completed the posttraumatic cognitions inventory-9 (PTCI-9), the Experiences in Close Relationships Revised scale (ECR-R), and the PTSD Checklist for DSM-5 (PCL-5). These measures were used to examine if changes in posttraumatic cognitions, hyperarousal symptoms (using the PCL-5 hyperarousal symptom cluster), and attachment style influenced changes in anger following treatment. Analyses of outcomes were linear mixed effects models, and analyses of mediation used structural equation modeling.

Results: Veterans receiving CBCT demonstrated significant improvements in both trait angry temperament and trait angry reaction (ps < .002); change for the PFE group was nonsignificant during treatment (ps > .09), but showed significant decline during follow-up (ps < .043). Partners in the CBCT group only showed a significant improvement in trait angry reaction (p = .005). Both veterans and partners in both treatment groups reported significant reductions in psychological aggression (ps < .001). None of the mediators examined showed significant mediation of the treatment effects on improvement in anger.

Conclusions: These findings suggest that CBCT is more effective than PFE at reducing Veterans’ angry temperament and angry reactions, and their partners’ angry reactions. However, both treatments effectively reduced psychological aggression for both partners. We did not find evidence of mediation among the candidate variables we tested, suggesting more research is needed to understand the underlying mechanisms of changes in anger in CBCT, such as improved communication, that were not examined in this study.