CBT for Aggression in Veterans

Posttraumatic stress disorder (PTSD) robustly predicts anger and aggression (Olatunji,
Ciesielski, & Tolin, 2010), and U.S. Iraq/Afghanistan-era Veterans report that controlling
anger and aggressive urges are primary readjustment concerns (Sayer et al, 2010).
Trauma-related anger and aggression are associated with functional impairments that
significantly limit community reintegration (Rodriguez, Holowka, & Marx, 2012) and that may
persist for decades (Koenen et al, 2003). As more troops return from multiple deployments to
Iraq and Afghanistan, there is an urgent and growing need for the development and testing of
psychosocial treatment for anger and aggression in combat Veterans with PTSD. VA clinicians
are doing their best to be responsive to Veteran's needs by offering anger management
treatment to Veterans: A survey of clinical practices within the VA found that 35-65% of VA
PTSD specialists report providing anger management to their patients (Rosen et al., 2004).
Yet to date only one randomized clinical trial (RCT), published in 1997, has investigated the
efficacy of treatment of anger and aggression in Veterans with PTSD (Chemtob et al., 1997).

A recent review noted that most researchers who have examined the effects of anger management
interventions have not done so as part of a systematic program of research (DiGiuseppe and
Tafrate, 2003). The proposed CDA-2 application outlines Training and Mentoring Plans that
will provide the applicant with the foundation to establish a career systematically
developing, testing, and refining treatments for PTSD-related anger and aggression in
Veterans. The following specific Training Goals have been formulated: 1) To acquire the
advanced skills in the development and evaluation of clinical interventions necessary to
begin an independent research career within the VA; 2) To develop greater expertise in
delivery of behavioral interventions to improve functional outcomes and community
reintegration in Veterans with PTSD, anger problems, and aggression; 3) To acquire expertise
in the development and evaluation of treatment innovations to help Veterans generalize
treatment gains beyond the therapy setting; 4) To increase understanding of rehabilitation
theory and methods in treatment practices and research; and 5) To achieve critical
professional development milestones, including submission of a Merit Review proposal based on
the pilot data generated from the CDA-2 project.

The Research Plan proposes a pilot feasibility trial for an RCT of Cognitive-Behavioral
Therapy for Anger and Aggression in Combat Veterans with PTSD (CBT-A). CBT-A is a 12-week
manualized group treatment protocol that has been designed to address the specific needs of
combat Veterans whose PTSD-related anger and aggression interfere with effective community
reintegration. The group was implemented with 4 male Vietnam Veterans with severe
combat-related PTSD who were referred for anger management treatment, and preliminary data
were promising. The active comparison treatment for the pilot RCT will be group
Present-Centered Therapy (PCT), a manualized treatment for PTSD that controls for treatment
time, social support, and instillation of hope. The proposed research project will address
the following Specific Aims: Aim 1: Characterize the differential effects of group CBT-A and
group PCT on anger, aggression, and anger/aggression-related limitations to psychosocial
functioning and community reintegration in combat Veterans with PTSD; and Aim 2: Evaluate
study feasibility and treatment delivery procedures of an RCT comparing CBT-A to a PCT
comparison condition. The results generated will guide the design of a full RCT to be funded
by the end of the CDA-2 funding period. The research, training, and mentoring plans outlined
here will provide the foundation for the PI's independent research career developing a
systematic program of research in the treatment of anger and aggression among combat Veterans
with PTSD. The availability of empirically-supported anger treatment would benefit the many
Veterans with PTSD who return from combat reporting problems with anger and aggression.

Inclusion Criteria:

A Veteran will meet criteria for inclusion if he/she meets all of the following criteria:

- Current PTSD based on the CAPS;

- served in combat (regardless of era or country of combat service);

- can speak and write fluent conversational English;

- at least 18 years of age;

- report problems with irritability, anger, or aggression within the past month.
Problems with anger and aggression will be defined via the "rule of 4": Inclusion in
the study will require a CAPS-V score > 2 on item 15 (E1), "irritable or angry and
showed it in your behavior" item within the past month.

Exclusion Criteria:

A Veteran will be excluded from participation if he/she:

- is expected to be unstable on his/her medication regimen during the study;

- currently meets criteria for Bipolar I Disorder or a primary psychotic disorder as
determined by the Structured Clinical Interview for the DSM (most current version
available) (SCID);

- is receiving (or plan to) other anger-management psychotherapy during the course of
the study;

- will be undergoing empirically supported psychotherapy for PTSD during the treatment
component of the study;

- meets criteria for substance dependence (other than nicotine) within the past month as
determined by the SCID; or

- is determined to have moderate or severe impairment related to traumatic brain injury
as measured by the Brief Traumatic Brain Injury Screen and consultation with the
Veteran's provider.