Relationship between Scores on Anger Measures

and PTSD Symptomatology, Employment, and

Compensation-Seeking Status in Combat Veterans
Ä

B. Christopher Frueh
Medical University of South Carolina
and Ralph H. Johnson VAMC, Charleston, SC
Ä

Kris R. Henning and Karen L. Pellegrin

Medical University of South Carolina
Ä

Keith Chobot
Medical University of South Carolina
and Ralph H. Johnson VAMC, Charleston, SC

The interrelationship between the theoretically related constructs of anger

and posttraumatic stress disorder (PTSD) symptoms was examined in a
group of 42 combat veterans with PTSD using a multimeasure assess-
ment strategy. Scores on several anger measures were found to be quite
high in this sample and were significantly correlated with PTSD symptom-
atology. Furthermore, anger measures were found to be related to employ-
ment status independent of PTSD severity, but were not related to disability
compensation-seeking status. Clinicians are advised to be aware of the
potential implications for physical health and interpersonal functioning,
and to incorporate anger management strategies into treatment plans for
this population. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53: 871–
878, 1997

Address correspondence to B. Christopher Frueh, Mental Health Service (116), Ralph H. Johnson Veterans Affairs
Medical Center, 109 Bee Street, Charleston, SC, 29401-5799.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 53(8), 871–878 (1997)

© 1997 John Wiley & Sons, Inc. CCC 0021-9762/97/080871-08
872 Journal of Clinical Psychology, December 1997

Although anger and associated behavioral problems are listed as symptoms of posttraumatic
stress disorder (PTSD) in DSM-IV (APA, 1994) and there is a persistent stereotype of veterans
with PTSD being hostile and violent, the empirical evidence of an interrelationship between
PTSD and anger is limited. There are several epidemiological (e.g., Boulanger, 1986; Kulka
et al., 1990; Laufer, Yager, Frey–Wouters, & Donnellan, 1981) and clinical (e.g., Blum, Kelly,
Meyer, Carlson, & Hodson, 1984; Riley, Treiber & Woods, 1989; Silver & Iacono, 1984)
reports describing the prominence of anger symptoms in combat veterans with PTSD; however,
only a handful of psychometric studies have examined this construct in veterans with combat-
related PTSD using standardized measures (Chemtob, Hamada, Roitblat, & Muraoka, 1994;
Kubany, Gino, Denny, & Torigoe, 1994; Kulka et al., 1990). These few studies provide tenta-
tive empirical support for the theoretical relationship between anger and PTSD.
The National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990) reported
that veterans with PTSD scored higher on the PERI Active Expression of Hostility Scale (Dohren-
wend, Shrout, Egri, & Mendelsohn, 1980) and reported more violent behaviors than did veter-
ans without PTSD. Chemtob et al. (1994) found that 24 Vietnam veterans with PTSD scored
significantly higher on anger measures (i.e., Buss Durkee Hostility Index, Anger Expression
Scale) than 23 Vietnam veterans without PTSD and a group of 12 noncombat Vietnam era
veterans with other psychiatric diagnoses. Another study found that the Cook–Medley hostility
subscale of the MMPI was significantly correlated with the MMPI-PTSD supplementary scale
in a sample of Vietnam veterans, and that the Cook–Medley subscale was significantly higher
for a group of Vietnam veterans with PTSD disability ratings than for a group of Vietnam era
veterans without PTSD disability (Kubany et al., 1994).
These studies indicate that high levels of hostility and anger exist in veterans with combat-
related PTSD even after accounting for combat exposure and concurrent psychiatric disorders.
It is likely that this anger contributes to the interpersonal difficulties, including violent behav-
ior, that are so widely noted in this population (e.g., Jordan et al., 1992; Roberts et al., 1982).
Understanding the nature and extent of the experiences and expression of anger among veter-
ans with PTSD is also important for its potential relevance to physical health. Both cross
sectional and prospective studies have shown that anger, hostility, and cynicism are closely
associated with heart disease and other serious health problems (e.g., Smith, 1992; Spielberger
et al., 1991). Therefore, a better understanding of the relationship between anger and PTSD has
widespread implications for the quality of combat veterans’ lives.
Only one study has examined the correlation between anger and PTSD symptoms (Kubany
et al., 1994), and that study used only one measure of anger and one measure of PTSD. There-
fore, the present study was designed to further examine, via several psychometric instruments,
the interrelationship between anger and PTSD symptoms in a group of combat veterans diag-
nosed with PTSD, and to evaluate the role of employment and compensation-seeking status on
anger scores. Towards this end, we used a multimeasure assessment strategy where three reli-
able and valid instruments for measuring anger and hostility were correlated with two widely
used self-report measures of PTSD. It was expected that veterans’ scores on anger measures
would be significantly correlated with their endorsement of PTSD symptomatology, but that
employment and compensation-seeking status would account for part of the variance on anger
measures.

METHOD
Subjects
Subjects were 42 consecutive combat veterans referred for evaluation at a VAMC PTSD out-
patient clinic and diagnosed with PTSD. Clinical diagnoses of PTSD, based on Diagnostic and
 Anger and PTSD 873

Statistical Manual, Third Edition-Revised (DSM-III-R; American Psychiatric Association, 1987)

criteria, were made by the staff after a thorough evaluation, which included a chart review, a
psychosocial history interview, a military history interview and review of Form DD214, and
the Clinician-Administered PTSD Scale (CAPS-1; Weathers & Litz, 1994). The average age of
patients was 48.74 years (SD 5 7.75); 22 (51%) were African-American, 19 (44%) were Cau-
casian, and 2 (5%) were classified as other; 36 (84%) served in the Vietnam War, 3 (7%) served
in WWII, 2 (5%) served in the Korean War, and 2 (5%) served in the Persian Gulf War; 16
(40%) were employed full or part time. Additionally, all patients were asked about their
compensation-seeking status. Patients were classified as compensation-seeking if they reported
intention to file for a PTSD disability rating or an increase in an existing PTSD disability
rating, or were already in the process of doing so. Twenty six (68%) of the patients in this
sample were classified as compensation-seeking.

Materials
For assessment purposes, psychological self-report inventories were administered to patients
prior to treatment, including the following:

Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Graham, 1993). The MMPI-2 is a

567 true/false item scale that functions as a measure of general psychopathology and person-
ality features, and is frequently used with combat veterans being evaluated for PTSD. For
purposes of this study we used the adjusted t scores of two specific subscales. The Keane PTSD
supplementary scale (MMPI-2-PK; Keane, Malloy, & Fairbank, 1984) was developed to iden-
tify PTSD symptomatology and it has been shown to possess adequate psychometric proper-
ties. The internal consistency coefficients for males in the normative sample was .85, while
test-retest reliability .86. The Anger content scale (MMPI-2-Ang) was developed to identify
individuals who feel angry and hostile much of the time and who are likely to lose control of
their anger. These scales have 46 and 16 items respectively and have an overlap of two items
(see Graham, 1993, for a more comprehensive description and review of both subscales).

Mississippi Scale for Combat-Related PTSD (M-PTSD; Keane, Caddell, & Taylor, 1988). The
Mississippi Scale is a 35 Likert-item scale designed to measure PTSD symptomatology related
to traumatic combat experiences. It has been found to be correlated with the SCID-R and to be
sensitive to the degree of combat exposure (McFall, Smith, Roszell, Tarver, & Malas, 1990).
Keane et al. (1988) found a cut-off score of 107 to be indicative of PTSD, and the average score
for combat veterans with PTSD to be 130. They also found the scale to have robust psycho-
metric properties, with a sensitivity of .93, a specificity of .89, an overall hit rate of .90, and to
be a good continuous measure of symptom severity.

Buss Durkee Hostility Index (BDHI; Buss & Durkee, 1957). The BDHI is one of the oldest, and
therefore perhaps the most well known and widely used measure of hostility to date. It consists
of 66 true/false items and provides seven subscale scores and an overall hostility score, along
with a guilt subscale. The total score has consistently evidenced good reliability and concurrent
validity, although the reliability and validity of the subscales is currently a matter of some
debate (Moreno, Fuhriman, & Selby, 1993). Therefore, for purposes of the present study, only
the total hostility score was used.

Anger Expression Scale (Ax/Ex; Spielberger et al., 1985). This 24-item 4-point scale was
designed to assess the methods people use to express feelings of anger. It produces a total score
874 Journal of Clinical Psychology, December 1997

(Ax/Ex) and three subscales: Anger-In (suppressed hostility), Anger-Out (hostility manifested
in aggressive behavior), and Anger-Control (appropriate modulation of hostility). The internal
consistency a for the subscales range from .75 to .82, and the two anger expression scales
(Anger-In and -Out) appear to be factorially orthogonal.

RESULTS

Descriptive statistics, including means, standard deviations, range, and distribution skewness
were calculated for the entire sample on each of the self-report anger measures used. These data
and the correlations of these variables to the two PTSD self-report indices are presented in
Table 1. All measures were found to be normally distributed and means and standard deviations
for the PTSD measures are as follows: M-PTSD 5 122.60 (SD 5 18.30); MMPI-2-PK 5 87.03
(adjusted t score; SD 5 13.31). All of the anger scales but the MMPI-2-Ang subscale correlated
significantly with the M-PTSD, and all but the Ax-Out subscale correlated significantly with
the MMPI-2-PK.
Two independent MANOVAs were used to evaluate the effect of employment status and
compensation seeking status on the five anger measures (Ax-In, Ax-Out, Ax-Control, BDHI,
MMPI-2-Anger; the total Ax/Ex scale score was excluded in these analyses because it is derived
directly from the three subscales). The combination of anger measures was found to vary
reliably as a function of employment status, Wilks’ approximate F(5,34) 5 3.0, p , .02, but not
compensation seeking status. Univariate analyses revealed that veterans who were currently
employed had significantly lower scores on Ax-Out, F(1,38) 5 11.30, p , .002, BDHI,
F(1,38) 5 6.49, p , .02, and higher scores on Ax-Control, F(1,38), p , .002. Table 2 provides
the means and standard deviations of anger measures as a function of employment status.
Although the preceding analyses suggest that unemployed veterans are at greater risk for
anger problems, the results might be attributable to a higher level of PTSD in this group.
Therefore, three simultaneous multiple regression analyses were used to evaluate the effect of
employment status on anger independent of PTSD severity. The M-PTSD was used as a con-
tinuous measure of PTSD severity in these analyses. Table 3 provides the results of these three
regressions. The overall model for each of the dependent variables was significant, with the two
predictors explaining 25% of the variance in Ax-Out, F(2,38) 5 6.44, p , .004, 20% of the
variance in Ax-Control, F(2,38) 5 4.9, p , .01, and 29% of the variance in the BDHI,
F(2,38) 5 7.72, p , .002. Employment status predicted unique variance on the Ax-Out (sr 2 5
.14, p , .01) and the Ax-Control (sr 2 5 .09, p , .05), but not on the BDHI.

Table 1. Descriptive Statistics for Anger Measures and their Correlations with PTSD Indices

Descriptive Statistics Correlations

M SD Min Max SK KU M-PTSD MMPI-2-PK

Ax/Ex 33.66 9.96 9 55 −0.174 0.104 .52*** .48**

Ax-In 19.95 3.92 12 30 0.150 −0.031 .51*** .37*
Ax-Out 17.54 4.46 9 26 −0.113 −0.770 .34* .30
Ax-Control 19.83 4.73 11 32 0.654 −0.209 −.34* −.42**
BDHI 38.75 11.50 13 58 −0.521 −0.631 .51*** .65***
MMPI-2-Ang 67.70 12.41 36 86 −0.601 −0.289 .28 .47**

Note.—*p < .05. **p < .01. ***p < .001.

 Anger and PTSD 875

Table 2. Means and Standard Deviations of Anger Measures

as a Function of Employment Status

Employed Unemployed

M SD M SD

Ax-In 19.56 3.74 20.33 4.12

Ax-Out 14.94 4.63 19.29** 3.56
Ax-Control 22.19 4.89 17.88** 3.44
BDHI 33.44 12.50 42.29* 9.47
MMPI-2-Ang 63.88 14.46 70.67 11.06

Note.—*p < .05. **p < .01.

DISCUSSION
This study provides further empirical support for the notion that anger and combat-related
PTSD symptomatology are closely associated. Combat veterans with PTSD were found to be
an angry group of men who are likely to demonstrate difficulty modulating their expression of
that anger. These findings are consistent with the results of Chemtob et al. (1994), in which the
mean scores and standard deviations on the BDHI and the Anger Expression Scale were similar
to the present results. The data are also consistent with the findings of Kubany et al. (1994) in
that measures of anger and PTSD were significantly correlated with one another, indicating a
direct interrelationship between anger and PTSD severity.
The data also showed that anger varied as a function of employment status, but not
compensation-seeking status. Unemployed veterans evidenced greater anger problems (e.g.,
higher general anger and externalized anger, and lower anger control). Furthermore, employ-
ment predicted unique variance (from PTSD symptom severity) on two of the anger measures
(Ax-Out, Ax-Control). Thus, the anger problems noted in this sample may be explained not
only by severity of PTSD symptomatology, but also by factors related to unemployment. Al-
though it is somewhat surprising that anger, unlike other acute indicators of psychopathology
in veteran populations (e.g., Frueh, Smith, & Barker, in press), did not vary as a function of
compensation-seeking status, the finding with regard to employment status is consistent with
the chronic pain literature which shows that chronic pain patients who are working experience
less subjective pain than unemployed pain patients (e.g., Tait, Chibnall, & Richardson).

Table 3. Simultaneous Multiple Regressions Predicting Anger from Employment Status

and PTSD Symptom Severity (n = 40)

Ax-Out Ax-Control BDHI

b sr 2 b sr 2 b sr 2

Employment Status −.40** .14 .32* .09 −.21 .04

M-PTSD .19 .03 −.22 .04 .42** .15

R2 .25** .20** .29**

Adj R 2 .21 .16 .26

Note.—*p < .05. **p < .01.

876 Journal of Clinical Psychology, December 1997

One implication of these findings is that, based on the established link between anger and
heart disease (e.g., Smith, 1992; Spielberger et al., 1991), veterans with PTSD may be at
increased risk for cardiac difficulties. Thus, these data supports previous suggestions (e.g.,
Kubany et al., 1994) that high levels of anger may lead not only to potential difficulties with
interpersonal functioning, but also to physical health problems in veterans with PTSD. Cer-
tainly this is a population who have demonstrated dramatic levels of health problems in recent
years (e.g., Kulka et al., 1990; Litz, Keane, Fisher, Marx, & Monaco, 1992), and hostility may
be one of several factors to account for this. The extent to which anger plays a role in these
health problems should be examined systematically in future studies.
Conclusions about the association between anger and PTSD in this study must remain
equivocal at this point. It is possible that the significant correlations between the two constructs
may be the result of a tendency on the part of combat veterans to elevate all measures of
distress. In other words, self-report questionnaires may measure a single “distress” factor in
this population, as indicated by the diffuse elevations noted across psychological inventories in
other studies (e.g., Fairbank, Keane, & Malloy, 1983; Frueh, Smith, & Libet, 1996; Hyer,
Fallon, Harrison, & Boudewyns, 1987). In fact, this negative response bias may be partially
linked to employment status, although it is somewhat puzzling that it was not associated with
compensation-seeking status. Further research is necessary to clarify this issue with regard to
anger and PTSD symptomatology.
In conclusion, the implications for clinical practice with this population are potentially
significant. Specifically, clinicians should be aware of the importance of assessing anger and
should consider incorporating anger management strategies (such as those used by Frueh, Turner,
Beidel, Mirabella, & Jones, 1996) into the treatment plans of veterans with combat-related
PTSD. Interventions designed to help veterans better manage and express their anger may help
them not only cope more effectively and have stronger interpersonal relationships, but may also
help reduce their risk of heart disease and other associated health problems. Furthermore, the
potentially therapeutic role of increased employment should be considered in some cases where
veterans are not currently working.

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