Research roundup: PTSD beyond the DSM-IV criteria

Emotions not addressed in the diagnostic manual that can help inform PTSD treatment are explored in this issue

By Practice Research and Policy staff

Sept. 13, 2012—Posttraumatic stress disorder (PTSD) as defined by the DSM-IV is an anxiety disorder that can occur when an individual has witnessed or experienced a traumatic event. In order to meet the criteria for a diagnosis of PTSD, one must experience a traumatic stressor, accompanied by re-experiencing, numbing/avoidance and hyper-arousal symptoms.

Factors including anger, aggression and a desire for revenge are not captured in current diagnostic criteria for PTSD, yet researchers and clinicians alike have noted their prevalence. The research covered in this article addresses these emotions and may help inform treatment beyond use of the DSM-IV. 

Ciesielski, B. G., Olatunji, B. O., & Tolin, D. F. (2010). Fear and loathing: A meta-analytic review of the specificity of anger in PTSD. Behavior Therapy, 41(1) 93-105. Doi: 10.1016/j.beth.2009.01.004


Summary
The authors conducted a meta-analysis of the current literature on anger, PTSD, and anxiety disorders to examine the degree to which anger is more likely to be specifically associated with PTSD than with other anxiety disorders. The analysis found that patients with anxiety disorders had significantly higher levels of anger than controls, with the exception of individuals with social and specific phobia.

Since contemporary models often view anger as a multidimensional construct, the analysis also compared patients with anxiety disorders to control samples for differences in specific anger domains such as the tendency to suppress feelings of anger (anger in), the tendency to outwardly express anger toward individuals or objects with verbal or physical aggression (anger out), or the inability to overcome angry feelings (anger control). Also considered were the differences between experiencing present angry feelings linked to a specific situation (state anger) and angry feelings that last over time and are linked to various situations (trait anger). PTSD and non-PTSD anxiety disorder patients had more difficulties with anger control, anger in, and anger out than controls, but did not significantly differ on state and trait anger.

Practical Implications
Certain anger domains appear to be uniquely associated with PTSD. Anger in PTSD may contribute to greater interpersonal difficulties, greater risk of substance abuse and physical health problems, all of which may require specific intervention in order to enhance treatment outcome. Better clinical understanding of the patient’s unique anger pattern may facilitate more targeted interventions.

Lancaster, S., Melka, S., & Rodriguez, B. (2011). Emotional predictors of PTSD symptoms. Psychological Trauma: Theory, Research, and Policy, 3(4) 313-317. Doi: 10.1037/a0022751


Summary
One of four criteria required by the DSM-IV for a diagnosis of PTSD is the experience of a traumatic stressor that is accompanied at the time of the event by the emotions of fear, helplessness, or horror. The workgroup report that led to the current DSM-IV PTSD diagnostic criteria noted that other emotional reactions such as guilt, dysphoria and sadness were also more commonly present in those developing PTSD after a traumatic stressor than in those who did not develop PTSD. However, the DSM-IV included only fear, helplessness and horror in the stressor criteria. Subsequent research has examined whether these three emotions are uniquely predictive of PTSD development. The goal of this study was to examine a broader range of emotional predictors of PTSD.

An initial pool of 771 undergraduate students in an introduction to psychology course completed a demographics form and the Brief Trauma Questionnaire (BTQ). The results from the administration of this 10-item self-report measure yielded a final sample of 341 participants who had experienced a potentially traumatic event. These participants then completed the PTSD Checklist-Specific (PCL-S), a Likert-style scale of 17 questions designed to measure symptoms of PTSD.

The authors found that only anger, guilt, sadness, and disgust were predictive of PTSD. Across all groups who participated in the study, there was a significant relationship between the level of anger experienced and the severity of PTSD symptoms.

In both men and women, anger was a strong predictor of PTSD. Experience of other emotions varied by gender; men demonstrated guilt as a unique predictor and women expressed emotions of disgust and sadness at the time of trauma.

European-American and African-American participant's emotions varied somewhat from European-American students’ emotions of guilt, helplessness, and disgust, in addition to anger, predicting PTSD, while African-American students’ level of PTSD was predicted only by anger.

Practical Implications
Both the DSM and the International Classification of Diseases (ICD) are currently undergoing revision and additional emotional reactions may be included in the revised criteria. Additional research is likely needed but, in the meantime, clinicians will want to explore a wide range of emotions beyond fear, helplessness and horror in order to understand clients’ response to the trauma they have experienced.

McHugh, T., Forbes, D., Bates, G., Hopwood, M., & Creamer, M. (2012). Anger in PTSD: Is there a need for a concept of PTSD-related posttraumatic anger? Clinical Psychology Review, 32(1) 93-104. Doi: 10.1016/j.cpr.2011.07.013


Summary
Two decades of research consistently demonstrated that anger is a critical predictor of PTSD severity and treatment efficacy. In addition, the co-occurrence of anger with PTSD is present across a wide range of populations, including the military, emergency and disaster relief workers, crime victims, and accident survivors. PTSD, particularly when chronic, can be difficult to treat and anger has been shown to reduce the effectiveness of treatment. In this analysis, the authors reviewed studies on visual imagery in the areas of neuropsychology, psychopathology, anger and PTSD and propose that visual imagery is a significant factor in causing and sustaining anger in PTSD.

One aim of this review was to investigate whether visual imagery may be the distinct aspect that sets anger in PTSD apart from other types of anger. Research in neuropsychology provides evidence that there is a high level of overlap in areas of the brain that are stimulated during the experience and production of both visual imagery and the emotion of anger. Evidence from research in psychopathology demonstrates that repetitive intrusive visual imagery produces negative emotions in various psychological disorders. The inability to manage negative visual imagery leads to greater mental distress. Studies on anger and PTSD evidence the strength of the relationship to visual imagery, with visual intrusions being described as a core symptom and risk factor of the disorder. The symptoms of physiological arousal that accompany anger cause intrusions and the intrusions yield a higher level of physiological arousal. Visual imagery and anger are intimately and complexly connected.

Practical Implications
The authors suggest numerous directions for future research about the role visual imagery plays in anger in PTSD. For one, they suggest conducting studies into visual imagery capacity, which may be influenced by factors such as age, gender, culture, and developmental experiences. Another potential avenue for research would be to identify trauma-related factors that may moderate the effect of visual imagery on anger in PTSD. For example, non-trauma related moderators such as the individual’s personality or temperament might affect the role visual imagery plays in their PTSD.

Currently, there is no satisfactory model that can define the complex relationship between anger and PTSD. The authors believe inquiry into the role of visual imagery in anger in PTSD could significantly improve our understanding of this anxiety disorder and contribute to more effective treatments that focus on the role visual imagery plays in responses to trauma and assist patients with learning new ways to manage intrusive thoughts.

Makin-Byrd, K.N., Bonn-Miller, M., Drescher, K., & Timko, C. (2012). Posttraumatic stress disorder symptom severity predicts aggression after treatment. Journal of Anxiety Disorders, 26(2), 337-342. doi:10.1016/j.janxdis.2011.11.012


Summary
While consistent evidence from numerous studies links posttraumatic stress disorder (PTSD) symptoms with aggression, little information exists regarding the relationship between PTSD severity and aggression after the completion of PTSD treatment. This study examined the association between PTSD and aggression by using a longitudinal data set derived from patients whose PTSD severity and aggression were reported before, immediately after and four months after intensive PTSD treatment.

A sample of 175 male patients admitted between 2000 and 2007 to a Veterans Affairs (VA) residential PTSD treatment program consented to participate in this study. A self-report measure using the 17 PTSD symptoms included in the DSM-IV was administered to the veterans. The questions represented three subscales that corresponded to symptom clusters of re-experiencing, avoidance/numbing and hyperarousal.

The patients also completed an assessment to measure aggression pre-treatment, post-treatment and at a four-month follow-up. There was a significant correlation between aggression and PTSD severity both pre-treatment and post-treatment. Of particular interest was the strong correlation between the hyperarousal symptom cluster and aggression before and after treatment.

Practical Implications
Monitoring the symptoms of PTSD and aggression during the course of treatment is crucial. Furthermore, aggression may need to be a focus during PTSD treatment. While more evidence with larger, younger patient samples and different traumas is necessary, this study suggests that assessing aggression in the context of PTSD may lead to important information regarding post-treatment functioning. Additional studies to examine the impact of treating aggression on outcome of PTSD care will be important to better understand effective treatment and longer term patient functioning.

Kunst, M. J. J. (2011). PTSD symptom clusters, feelings of revenge, and perceptions of perpetrator punishment severity in victims of interpersonal violence. International Journal of Law and Psychiatry, 34(1) 362-367. Doi: 10.1016/j.ijlp.2011.08.003


Summary
Many studies have focused on PTSD among victims of violent trauma. A variety of normal emotions are associated with symptoms of PTSD. These include self-oriented emotions such as shame, guilt, self-blame and other-oriented emotions such as the desire for revenge. Feelings of revenge often follow trauma that involves intentional and personal infliction of harm to an individual.

Two hundred and thirty-five victims of violent crime were given a three-item revenge scale to measure their feelings of revenge over the previous four weeks. Using the PTSD Symptom Scale, Self-Report (PSS-SR), PTSD symptoms resulting from violent acts were assessed. An additional scale was employed to evaluate the victims’ views on perpetrator punishment severity. Finally, regression analysis was used to determine if the three PTSD symptom clusters – re-experiencing/intrusion, avoidance and/or hyperarousal – might predict feelings of revenge.

Of the 235 participants who took the PSS-SR, 139 experienced re-experiencing/intrusion, 107 experienced feelings of avoidance, and 160 experienced feelings of hyperarousal. The re-experiencing/intrusion symptom cluster was the only predictor of a desire for revenge. A possible explanation for the correlation between symptoms of re-experiencing/intrusion and revenge is their shared ruminative character. Repeated, negative thoughts are predictive of both PTSD and revenge. The study failed to find a significant correlation between perceived punishment of the perpetrator and the victim’s feelings of revenge.

Practical Implications
Given the finding of this study that the re-experiencing/intrusion symptom cluster positively correlates with feelings of revenge, when treating patients with a strong desire for revenge, it may be important to focus on strategies that minimize or control intrusive thoughts or assist the patient in managing re-experiencing symptoms. The authors also suggest investigating whether sensory stimuli that remind patients of their emotional and behavioral responses during the traumatic event may trigger or contribute to the intrusions.

Ending Notes


Posttraumatic stress disorder is a prevalent and debilitating disorder. Further research into the relationship between PTSD and emotions such as anger, aggression and an inclination for revenge is needed to better understand patients’ reactions to the trauma they have experienced and enhance treatment.