By Marija Kelber, Ph.D.
Feb. 7, 2024

U.S. Army photo by T. Anthony Bell

Anger has been identified as an important emotion that affects the functioning of many service members and veterans. Despite its importance, anger gets very little attention. Lack of guidelines on managing anger may leave providers wondering how to differentiate “normative” anger from problematic anger and how to help patients with anger-related problems.

Anger is an unpleasant emotion we may experience when we are faced with obstacles or perceived threat or injustice. Imagine you’re driving on a busy highway, and someone cuts you off; or you’re standing in a long line, and someone brazenly gets in front of you. These circumstances may make you feel angry. Like other emotions, anger is thought of as adaptive. It can help us achieve goals, solve problems, or change an unfair situation. Sometimes anger can become problematic, such that the angry response is out of proportion to the threat. In this case, anger becomes a routine way of responding to the world or angry feelings may be slow to dissipate. Problematic anger interferes with everyday life or interpersonal relationships. In some circumstances, anger can lead to aggressive behavior, like yelling or physical altercations.

Problematic anger is common in military service members. This is not surprising considering that anger can be perceived as helpful in performing military-related duties.¹ In one study of U.S. active duty service members, prevalence of problematic anger was 15.9% in the 24 months prior to separating from the military and 31.2% in the 24 months after separation.² Substantial rates of problematic anger have also been documented in Australian service members and veterans.³ Problematic anger has been found to predict posttraumatic stress disorder and other adverse outcomes.² In U.S. Army soldiers, anger attacks (e.g., losing control and breaking something, or hurting or threatening someone) that interfere with personal life have been associated with the onset of generalized anxiety disorder and suicidal ideation even after taking into account baseline psychiatric comorbidity.⁴

The Diagnostic and Statistical Manual of Mental Disorders lists anger and aggression as symptoms of PTSD.⁵ Individuals with PTSD experience heightened arousal, negative thoughts and mood, increased vigilance for threat, and they may have comorbid alcohol and substance use. All these factors can increase the likelihood of aggressive behavior in response to a perceived provocation. Individuals with PTSD may experience difficulties controlling anger; they may be more likely to engage in violent behavior, such as intimate partner violence, and they are more likely to be arrested for violent crimes.^{6, 7, 8}

Despite the high prevalence of problematic anger in service members and adverse outcomes associated with it, evidence on prevention and treatment of problematic anger is lacking. In veterans with PTSD, anger has been found to attenuate effectiveness of PTSD treatments. While PTSD treatments are effective for reducing the PTSD symptoms, they are less effective for anger. Though this evidence suggests that anger-focused treatments are necessary, there are very few studies on anger-focused treatments in military populations.

In one recent randomized controlled trial with 92 veterans, researchers compared a cognitive behavioral intervention that was developed specifically for the treatment of anger to an adapted present-centered therapy.⁹ The results showed that the cognitive behavioral intervention was more effective in reducing anger and improving social functioning and quality of life than was the control group. These findings supporting the use of anger-focused treatments are encouraging. Though more research is needed, this study offers an alternative for treating patients with PTSD and problematic anger.

More research on anger in service members and veterans is underway. With greater attention given to this important topic, we may be able to better understand how to detect, prevent, and treat problematic anger in service members and veterans.

References

1. Adler, A. B., Brossart, D. F., & Toblin, R. L. (2017). Can anger be helpful?: Soldier perceptions of the utility of anger. The Journal of Nervous and Mental Disease, 205, 692-698. doi: 10.1097/NMD.0000000000000712
2. Adler, A. B., LeardMann, C. A., Villalobos, J., Jacobson, I. G., Forbes, D., & Millennium Cohort Study Team. (2022). Association of problematic anger with long-term adjustment following the military-to-civilian transition. JAMA Network Open, 5(7), e2223236-e2223236. doi: 10.1001/jamanetworkopen.2022.23236
3. Varker, T., Cowlishaw, S., Baur, J., McFarlane, A. C., Lawrence-Wood, E., Metcalf, O., Van Hoof, M., Sadler, N., O’Donnell, M. L., Hodson, S., Benassi, H. & Forbes, D. (2022). Problem anger in veterans and military personnel: Prevalence, predictors, and associated harms of suicide and violence. Journal of Psychiatric Research, 151, 57-64. doi: 10.1016/j.jpsychires.2022.04.004
4. Smith, D. M., Meruelo, A., Campbell-Sills, L., Sun, X., Kessler, R. C., Ursano, R. J., Jain, S., Stein, M. B., & Army STARRS Team. (2021). Pre-enlistment anger attacks and postenlistment mental disorders and suicidality among US Army soldiers. JAMA Network Open, 4, e2126626-e2126626. doi: 10.1001/jamanetworkopen.2021.26626
5. American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders, fifth edition, text revision. Washington, DC: American Psychiatric Association.
6. Olatunji, B. O., Ciesielski, B. G., & Tolin, D. F. (2010). Fear and loathing: A meta-analytic review of the specificity of anger in PTSD. Behavior Therapy, 41, 93-105. doi: 10.1016/j.beth.2009.01.004
7. Taft, C. T., Weatherill, R. P., Scott, J. P., Thomas, S. A., Kang, H. K., & Eckhardt, C. I. (2015). Social information processing in anger expression and partner violence in returning US Veterans. Journal of Traumatic Stress, 28, 314-321. doi: DOI: 10.1002/jts.22017
8. Taylor, E. N., Timko, C., Nash, A., Owens, M. D., Harris, A. H., & Finlay, A. K. (2020). Posttraumatic stress disorder and justice involvement among military veterans: A systematic review and meta‐analysis. Journal of Traumatic Stress, 33, 804-812. doi: 10.1002/jts.22526
9. Shea, M. T., Stout, R. L., Reddy, M. K., Sevin, E., Presseau, C., Lambert, J., & Cameron, A. (2022). Treatment of anger problems in previously deployed post‐911 veterans: A randomized controlled trial. Depression and Anxiety, 39, 274-285. doi: 10.1002/da.23230

Dr. Marija Kelber is a research psychologist and a team lead for Evidence Synthesis and Dissemination at the Psychological Health Center of Excellence.