Anger treatment via CBAT delivered remotely: Outcomes on psychometric and self-monitored measures of anger.

Studies of anger treatment have often reported on reappraisal and relaxation techniques delivered in person to forensic and psychiatric samples. The present study evaluated an integrative programme of cognitive-behavioural affective therapy (CBAT) delivered remotely to chronic pain sufferers with comorbid anger. Volunteers (N = 54) were randomly assigned to either CBAT or an Emotional Education (EE) group, both receiving hour-long videorecorded sessions twice a week for 4 weeks plus weekly calls by telephone. At 1-month post-treatment, follow-up was conducted. Outcomes were measured using the Anger Parameters Scale (APS) and its five subscales (frequency, duration, intensity, latency and threshold) as well as daily self-monitored anger logs. As hypothesized, pre- to post-treatment decline in APS total scores was significant for CBAT, Hedges' g = 0.65, 95% CI [0.14, 1.16] but nonsignificant and small for EE, g = 0.17, CI [-0.41, 0.75]. At the primary endpoint (post-treatment), APS total scores were significantly lower for CBAT than for EE. Treatment gains were maintained till follow-up. On all five APS subscales, pre-post effect sizes were medium-sized for CBAT and generally small for EE. This picture was mirrored in the self-monitored frequency, duration and intensity of anger. Findings support the efficacy of CBAT over time, its comparative efficacy over EE and its ecological generalizability. Future research could expand sample size, reduce sample imbalance, extend follow-up and strengthen treatment potency with more sessions. The present study renews enthusiasm for teletherapy and is the first to demonstrate CBAT efficacy in treating maladaptive anger in the chronic pain population.

Live psychotherapy by video versus in-person: A meta-analysis of efficacy and its relationship to types and targets of treatment.

In-person psychotherapy (IPP) has a long and storied past, but technology advances have ushered in a new era of video-delivered psychotherapy (VDP). In this meta-analysis, pre-post changes within VDP were evaluated as were outcome differences between VDP versus IPP or other comparison groups. A literature search identified k = 56 within-group studies (N = 1681 participants) and 47 between-group studies (N = 3564). The pre-post effect size of VDP was large and highly significant, g = +0.99 95% CI [0.67-0.31]. VDP was significantly better in outcome than wait list controls (g = 0.77) but negligible in difference from IPP. Within-groups heterogeneity of effect sizes was reduced after subgrouping studies by treatment target, of which anxiety, depression, and posttraumatic stress disorder (PTSD) (each with k > 5) had effect sizes nearing 1.00. Disaggregating within-groups studies by therapy type, the effect size was 1.34 for CBT and 0.66 for non-CBT. Adjusted for possible publication bias, the overall effect size of VDP within groups was g = 0.54. In conclusion, substantial and significant improvement occurs from pre- to post-phases of VDP, this in turn differing negligibly from IPP treatment outcome. The VDP improvement is most pronounced when CBT is used, and when anxiety, depression, or PTSD are targeted, and it remains strong though attenuated by publication bias. Clinically, therapy is no less efficacious when delivered via videoconferencing than in-person, with efficacy being most pronounced in CBT for affective disorders. Live psychotherapy by video emerges not only as a popular and convenient choice but also one that is now upheld by meta-analytic evidence.

Social Desirability Bias Against Admitting Anger: Bias in the Test-Taker or Bias in the Test?

The veracity of self-report is often questioned, especially in anger, which is particularly susceptible to social desirability bias (SDB). However, could tests of SDB be themselves susceptible to bias? This study aimed to replicate the inverse correlation between a common test of SDB and a test of anger, to deconstruct this relationship according to anger-related versus non-anger-related items, and to reevaluate factor structure and reliability of the SDB test. More than 200 students were administered the Marlowe-Crowne Social Desirability Scale Short Version [M-C1(10)] and the Anger Parameters Scale (APS). Results confirmed that anger and SDB scores were significantly and inversely correlated. This intercorrelation became nonsignificant when the 4 anger-related items were omitted from the M-C1(10). Confirmatory factor analyses showed excellent fit for a model comprising anger items of the M-C1(10) but not for models of the entire instrument or nonanger items. The first model also attained high internal consistency. Thus, the significant negative correlation between anger and SDB is attributable to 4 M-C1(10) anger items, for which low ratings are automatically scored as high SDB; this stems from a tenuous assumption that low anger reports are invariably biased. The SDB test risks false positives of faking good and should be used with caution.

21st Century Cognitive Behavioural Therapy for Anger: A Systematic Review of Research Design, Methodology and Outcome.

BACKGROUND: Past reviews of cognitive behavioural therapy (CBT) for anger have focused on outcome in specific subpopulations, with few questions posed about research design and methodology. Since the turn of the century, there has been a surge of methodologically varied studies awaiting systematic review. AIMS: The basic aim was to review this recent literature in terms of trends and patterns in research design, operationalization of anger, and covariates such as social desirability bias (SDB). Also of interest was clinical outcome. METHOD: After successive culling, 42 relevant studies were retained. These were subjected to a rapid evidence assessment (REA) with special attention to design (ranked on the Scientific Methods Scale) measurement methodology (self-monitored behaviour, anger questionnaires, and others' ratings), SDB assessment, and statistical versus clinical significance. RESULTS: The randomized controlled trial characterized 60% of the studies, and the State Trait Anger Expression Inventory was the dominant measure of anger. All but one of the studies reported statistically significant outcome, and all but one of the 21 studies evaluating clinical significance laid claim to it. The one study with neither statistical nor clinical significance was the only one that had assessed and corrected for SDB. CONCLUSIONS: Measures remain relatively narrow in scope, but study designs have improved, and the outcomes suggest efficacy and clinical effectiveness. In conjunction with previous findings of an inverse relationship between anger and SDB, the results raise the possibility that the favourable picture of CBT for anger may need closer scrutiny with SDB and other methodological details in mind.

Anger parameters in parolees undergoing psychoeducation: Temporal stability, social desirability bias, and comparison with non-offenders.

BACKGROUND: Anger is commonly measured as if it were a single, simple construct. This may be particularly unhelpful if the main purpose of a measure is to determine change and responsiveness to interventions. AIMS: Our primary aim was to assess five anger parameters in parolees - frequency, duration, intensity, latency, and threshold - and to test for effects of psychoeducation and social desirability bias on parolees' scores. Average anger scores for the offender sample were compared with those in a non-offender sample. METHODS: The offender sample was drawn from male parolees in San Antonio. Age-matched volunteers recruited at public libraries were engaged for baseline comparisons. The Anger Parameters Scale and the Marlow-Crowne Scale were used to assess anger and social desirability, respectively. Parole officers delivered a psychoeducation course to parolees over 12 weeks, and anger and social desirability measures were taken before and afterwards. RESULTS: At baseline, parolees were angry more often, stayed angry longer, and reached higher levels of anger than the non-offenders, confirming their eligibility for the programme. Mean anger scores were not significantly different after psychoeducation than before it. Parolees' reported anger was significantly and negatively correlated with social desirability scores. CONCLUSIONS: Only three of the five anger parameters were prominent among these offenders: frequency, duration, and intensity of their outbursts. Psychoeducation did not produce improvement, possibly because it was instructional rather than therapeutic, but also because group means may mask useful individual differences. Concurrent assessment of social desirability is likely to assist in interpretation of anger measures. Copyright © 2017 John Wiley & Sons, Ltd.

Parameters of anger as related to sensory-affective components of pain.

OBJECTIVES: Comorbid with chronic pain are negative emotions, anger being particularly salient. To evaluate specific relationships between pain and anger, the present study deconstructed anger into five parameters and dichotomized pain into sensory vs. affective components. Hypotheses were (i) anger parameters would be significantly and positively correlated with affective pain more so than with sensory pain, and (ii) individual parameters would be differentially related to pain components. METHODS: The Anger Parameters Scale (APS) was used to rate five parameters of anger: frequency, duration, intensity, latency, and threshold. Also rated was the physical sensation of pain and the degree of distress from pain. The volunteer sample comprised n=51 chronic pain patients, varying in ethnicity/race and educational level. RESULTS: Descriptive statistics revealed: APS total M=71.52, SD=16.68, Sensory pain M=6.27, SD=2.15, Affective pain M=5.76, SD=2.28. Sensory and affective pain were highly correlated, r=0.70. APS total was significantly associated with affective pain (r=+0.28) but hardly with sensory pain (r=0.12). Two anger parameters significantly correlated with affective pain: anger frequency (r=+0.30, p<0.05) and anger threshold (r=+0.33, p<0.05). Secondarily, certain educational levels (but not gender and ethnicity/race) were associated with significantly higher APS total scores. CONCLUSIONS: Scores for all variables were in the mid-range. As hypothesized, anger was more strongly correlated with distress/suffering of pain than with physical sensation of pain, though both pain components were closely coupled. Specific findings regarding frequency and threshold imply that being angry often and being oversensitive to provocation are associated with greater distress in this context. In deconstructing anger and dichotomizing pain, the present study extends previous research by elaborating on what aspects of anger are most related to which components of pain. Moreover, certain educational levels with higher levels of anger may need special attention. Further research could examine if treatment of anger might lead to corresponding changes in chronic pain.

Sensory Versus Affective Pain Descriptors Predicting Functional Versus Psychosocial Disability.

In the lexical assessment of pain, an offshoot of the McGill Pain Questionnaire is the Pain Descriptor System (PDS) which assesses sensory, affective, and overall intensity of pain. To determine if sensory versus affective pain components might be selectively related to different aspects of disability, PDS scores were examined in relation to functional status and psychosocial impairment on the Pain Disability Questionnaire (PDQ). A sample of 629 chronic pain patients rated the degree to which each of 36 PDS words described their pain and also rated 15 items of the PDQ. Three regression models (including Group Lasso) were applied to the data. Results showed that as hypothesized, PDS sensory scores significantly predicted PDQ functional status, accounting for about 13% of the variance; PDS affective scores significantly predicted PDQ psychosocial impairment, accounting for 17% of the variance; PDS total scores significantly predicted PDQ total scores, accounting for approximately 24% of the variance. This supports the overall predictive validity of pain descriptors, while confirming more specific links between components of pain and facets of disability. Clinically, the patient's description of pain sensation may hold valuable clues to physical impairment, whereas the communication of affect/suffering is more likely to connote psychosocial difficulties in functioning. PERSPECTIVE: Regression models (including Group Lasso) were applied to data on pain and disability from 629 patients. Findings support the Pain Descriptor System in assessing pain but further suggest that sensory descriptors are predictive of physical impairment from chronic pain, whereas affective descriptors are more predictive of psychologically-related disability.

Development of a brief online intervention to address aggression in the context of emotion-related impulsivity: Evidence from a wait-list controlled trial.

Trait-like tendencies to respond impulsively to emotion, labelled emotion-related impulsivity, are robustly related to aggression. We developed and tested an online intervention to address emotion-related impulsivity and aggression. The 6-session intervention focused on behavioral techniques shown to decrease arousal and aggression, supplemented with implementation intentions and smartphone prompts to facilitate skills transfer into daily life. First, we piloted the intervention in-person with 4 people. Then, 235 participants were randomly assigned to take the online intervention immediately or after a wait-list period; those in the waitlist were then invited to take part in the intervention. Participants completed the self-rated Feelings Trigger Action Scale to assess emotion-related impulsivity, the interview-based Modified Overt Aggression Scale and the self-rated Buss Perry Aggression Questionnaire. Participants who took part in the treatment completed daily anger logs. Attrition, as with other online programs, was high; however, treatment completers reported high satisfaction, and outcomes changed more rapidly during treatment than waitlist across all key outcome indices. In analyses including all participants who took part in the treatment (immediate or delayed), we observed moderate-to-large treatment gains, which were maintained as of the 3-month follow-up assessment. This work supports the usefulness of an intervention for addressing emotion-related impulsivity and aggression.

A brief online intervention to address aggression in the context of emotion-related impulsivity for those treated for bipolar disorder: Feasibility, acceptability and pilot outcome data.

Although aggression is related to manic symptoms among those with bipolar disorder, new work suggests that some continue to experience elevations of aggression after remission. This aggression post-remission appears related to a more general tendency to respond impulsively to states of emotion, labelled emotion-related impulsivity. We recently developed the first intervention designed to address aggression in the context of emotion-related impulsivity. Here, we describe feasibility, acceptability, and pilot data on outcomes for 21 persons who received treatment for bipolar disorder and endorsed high levels of aggression and emotion-related impulsivity. As with other interventions for aggression or bipolar disorder, attrition levels were high. Those who completed the intervention showed large changes in aggression using the interview-based Modified Overt Aggression Scale that were sustained through three months and not observed during wait list control. Although they also showed declines in the self-rated Buss-Perry Aggression Questionnaire and in self-rated emotion-related impulsivity as assessed with the Feelings Trigger Action Scale, these self-ratings also declined during the waitlist control. t Despite the limitations, the findings provide the first evidence that a brief, easily disseminated intervention could have promise for reducing aggression among those with bipolar disorder.

Anger treatment in chemically-dependent inpatients: evaluation of phase effects and gender.

BACKGROUND: There is a growing quest for anger management techniques especially in underserved populations. Patients with a substance abuse history often have untreated anger problems. AIMS: To test a new comprehensive program for prevention, intervention, and remediation of anger in chemically-dependent patients. A secondary aim was to explore any anger differences between males versus females. METHOD: Twenty-six participants (13 male, 13 female) completed three phases of treatment plus follow-up. Dependent measures were six subscales of the (STAXI) questionnaire and self-monitored frequency, duration, and intensity of anger. RESULTS: A significant multivariate effect of phase of study accounted for 42% of the variance in STAXI scores. Univariate F-tests confirmed significant changes on all STAXI subscales. Most of these were between pre and post phases of the study, the effect sizes = +0.8 for state anger and +0.99 for trait anger. For self-monitored variables, significant reductions emerged between treatment phases, the average pre-post effect size = +1.02. Gender did not affect STAXI scores although females had more self-monitored anger, particularly anger episodes. CONCLUSIONS: Findings suggest cumulative efficacy of the anger treatment program. That trait anger declined more than state anger may indicate characterological change in addition to situational change; anger frequency and duration declined more than intensity in keeping with other reports that intensity peaks suddenly and is less modifiable. That males and females were generally similar in anger is worth noting in relation to other studies. Finally, participant attrition is discussed as a problem and a possible index of treatment outcome.

Association of anxiety and depression with reported disease severity in patients undergoing evaluation for chronic rhinosinusitis.

OBJECTIVES: We sought to determine the impact of psychiatric comorbidity on symptom density and resource utilization in chronic rhinosinusitis (CRS). METHODS: A prospective cohort of patients who sought evaluation of CRS was studied with the Rhinosinusitis Symptom Inventory and the Hospital Anxiety and Depression Scale. Data concerning symptom scores, symptom domains, and psychiatric comorbidity were analyzed to determine the interactions among psychiatric comorbidity, symptom reporting, and resource utilization in CRS. RESULTS: We studied 143 patients (mean age, 43.4 years). Low, moderate, and high levels of anxiety were reported by 48.3%, 25.9%, and 25.9% of patients, respectively. Low, moderate, and high levels of depression were reported by 76.2%, 9.1%, and 14.7%. For the combined psychopathology group, 43.3%, 25.9%, and 30% had low, moderate, and high levels. Patients with high anxiety levels reported significant elevations of oropharyngeal symptoms (p = .013) and total symptoms (p = .030) in comparison with the low group. Patients with high depression levels reported higher oropharyngeal (p = .003), systemic (p = .001), and total symptom (p = .003) scores than did the low group. High combined psychopathology scores were associated with elevated facial, oropharyngeal, and systemic scores (p < .05). Regarding medical utilization, high anxiety levels or high combined psychopathology scores were associated with more frequent physician visits (p < .05). A high level of depression was associated with increased antibiotic use, missed workdays, and physician visits (p < .05). CONCLUSIONS: High levels of anxiety and depression are common in patients who undergo evaluation for CRS. Psychiatric comorbidity is associated with increased symptoms in CRS and increased health-care utilization. Anxiety and depression should be identified in these patients to structure appropriate treatment.

Anger in psychological disorders: Prevalence, presentation, etiology and prognostic implications.

Anger is present as a key criterion in five diagnoses within DSM-5: Intermittent Explosive Disorder, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Borderline Personality Disorder and Bipolar Disorder. This review amasses scientific literature demonstrating that within each of these disorders, anger is a central clinical feature that is highly prevalent and predictive of important outcomes. For each disorder, we also discuss the phenomenology and etiology of anger. Although models of anger have been quite distinct across these disorders, few empirical studies have truly tested whether anger stems from different etiological factors across these different conditions. We end with a discussion of transdiagnostic research that draws from cognitive psychology, affective science, and the neuroscience of anger, and that also fits with integrative approaches to treatment.

Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators.

UNLABELLED: In this era of insistence on evidence-based treatments, cognitive behavioral therapy (CBT) has emerged as a highly preferred choice for a spectrum of psychological disorders. Yet, it is by no means immune to some of the vagaries of client participation. Special concerns arise when clients drop out from treatment. OBJECTIVE: The aim of this study was to answer questions about the rate and timing of dropout from CBT, with specific reference to pretreatment versus during treatment phases. Also explored were several moderators of dropout. METHOD: A meta-analysis was performed on dropout data from 115 primary empirical studies involving 20,995 participants receiving CBT for a range of mental health disorders. RESULTS: Average weighted dropout rate was 15.9% at pretreatment, and 26.2% during treatment. Dropout was significantly associated with (a) diagnosis, with depression having the highest attrition rate; (b) format of treatment delivery, with e-therapy having the highest rates; (c) treatment setting, with fewer inpatient than outpatient dropouts; and (d) number of sessions, with treatment starters showing significantly reduced dropout as number of sessions increased. Dropout was not significantly associated with client type (adults or adolescents), therapist licensure status, study design (randomized control trial [RCT] vs. non-RCT), or publication recency. CONCLUSIONS: Findings are interpreted with reference to other reviews. Possible clinical applications include careful choice and supplementing of treatment setting/delivery according to the diagnosis, and use of preparatory strategies. Suggestions for future research include standardization of operational definitions of dropout, specification of timing of dropout, and exploration of additional moderator variables.

A classification system of cognitive coping strategies for pain.

Cognitive strategies have received considerable interest in pain management, alongside the traditional approaches of physical intervention and behavior modification. However, the literature on these strategies is ridden with inconsistencies of terminology that present major difficulties in the conceptualization and evaluation of different strategies. A new classification scheme is hence proposed in which these strategies are grouped into 3 broad categories: imagery, self-statements and attention-diversion--which are further divided into a total of 10 subcategories. Examples are drawn from the literature to illustrate the use of each strategy. The new classification system offers a comprehensive nomenclature for the identification of cognitive coping strategies for pain and provides a basis for guiding research on the relative efficacy of different cognitive strategies in pain management.

A parsimonious set of verbal descriptors of pain sensation derived from the McGill Pain Questionnaire.

In view of some recent disagreements about the vocabulary of pain as suggested in the McGill Pain Questionnaire (MPQ), the present study re-examined all MPQ pain descriptors with regard to their appropriateness as descriptors of pain sensation. A sample of 70 undergraduate students (whose first language was English) assigned descriptors to individual sensory subcategories and then rated them in terms of implied intensity of pain. Data were evaluated using three criteria related to the absolute frequency, relative frequency, and unimodality of word assignments to each subcategory. Results revealed that about 40% of the supposed MPQ sensory descriptors could not be classified within any of the sensory subcategories because of incomprehension, underuse, or ambiguity of usage. The majority of the words, however, were classified in the same subcategories and given similar intensity ratings as in the MPQ. These words constitute a parsimonious subset of MPQ descriptors of pain sensation. Such words promise more diagnostic specificity in the assessment of pain. Further research could serve to replicate these findings as part of the ongoing refinement of the MPQ.

The scope and significance of anger in the experience of chronic pain.

This paper is divided into 3 sections. The first provides the conceptual framework by introducing definitions of anger and related constructs and highlighting pertinent aspects of the concept of pain. The second section examines the evidence for anger as a feature of chronic pain. The available research indicates that chronic pain patients experience anger but this may be underestimated because of denial. In fact, anger stands out as one of the most salient emotional correlates of pain, even though past research has been largely confined to the study of depression and anxiety. the third section explores the significance of anger in chronic pain, in terms of its compounding effects on pain, depression and psychosocial functioning, as well as its consequences for physical health and health habits. The impact of anger among chronic pain patients for treatment outcome is discussed. Finally, the information from these sections is integrated into a model depicting the antecedents and consequences of anger as specifically associated with the chronic pain experience.

Affective and evaluative descriptors of pain in the McGill pain questionnaire: reduction and reorganization.

Recent reports indicate that several descriptors of pain sensations in the McGill Pain Questionnaire (MPQ) are difficult to classify within MPQ sensory subcategories because of incomprehension, underuse, or ambiguity of usage. Adopting the same methodology of recent studies, the rule revealed that only 6 to 18 words met criteria for the affective category and 5 of 11 words met criteria for the evaluative category, thus warranting a reduced list of words in these categories. This classification, the intensity ratings of the retained words correlated very highly with those originally reported for the MPQ. In conclusion, although the intensity ratings of MPQ affective and evaluative descriptors need no revision, selective reduction and reorganization of these descriptors can enhance the efficiency of this approach to pain assessment.

Coping style influences compliance with multidisciplinary pain management.

The treatment of chronic pain disorders has become multifaceted in recognition of the complexities of chronic pain. However, few models have emerged to predict patients' response to treatment. This study examined a path model of pain treatment outcome, incorporating the variables of coping style and treatment compliance. Results indicated that the suppression of negative emotion was associated with greater treatment compliance, whereas amplification of negative emotion was found to be associated with poorer treatment compliance. An aggressive coping style was found to be associated with poor treatment compliance. In turn, poor compliance predicted poor pre-/post-treatment functional capacity. Moreover, a path model incorporating compliance as a mediator between coping styles and functional impairment revealed an excellent model fit when compared to a path model with no mediators.

Male circumcision: pain, trauma and psychosexual sequelae.

Infant male circumcision continues despite growing questions about its medical justification. As usually performed without analgesia or anaesthetic, circumcision is observably painful. It is likely that genital cutting has physical, sexual and psychological consequences too. Some studies link involuntary male circumcision with a range of negative emotions and even post-traumatic stress disorder (PTSD). Some circumcised men have described their current feelings in the language of violation, torture, mutilation and sexual assault. In view of the acute as well as long-term risks from circumcision and the legal liabilities that might arise, it is timely for health professionals and scientists to re-examine the evidence on this issue and participate in the debate about the advisability of this surgical procedure on unconsenting minors.

Descriptors of pain sensation: a dual hierarchical model of latent structure.

UNLABELLED: Recently, the lexicon of pain was refined into a parsimonious set of words making up the Pain Descriptor System (PDS). The present study investigated the latent structure of the sensory category of the PDS with its 24 descriptors distributed equally across 8 subcategories. A sample of 629 chronic pain patients rated the degree to which each of these words described their pain. It was found that coldness-related words were rarely used and shared high covariance with other descriptors, thus warranting their removal as a subcategory. Confirmatory factor analysis of a previously theorized single higher-order model of 7 latent factors (each with 3 observed variables) resulted in poor fit, x(2)(181) = 377.72, P < .05; comparative fit index (CFI) = .915; root mean square error of approximation (RMSEA) = .04. This model was replaced with a dual higher-order model retaining the same 7 latent factors plus 2 higher-order factors corresponding to deep pain versus superficial pain. This model provided a good representation of the data, x(2)(181) = 301.07, P < .05; CFI = .948; RMSEA = .032. Therefore, descriptors of pain sensation differentiate sensory quality while also reflecting a fundamental dichotomy supported by neurophysiological research. Thus, the lexicon can illuminate pathophysiology, thereby clarifying pain diagnoses. PERSPECTIVE: Confirmatory factor analysis was performed on pain sensation descriptors used by 629 patients. This supported a hierarchical model with 7 lower-order factors plus 2 higher-order factors corresponding to deep pain versus superficial pain. By reflecting neurophysiology, this lexicon of pain can offer diagnostic clues.