An Analysis of the State-Trait Anger Expression Inventory Ratings of Traumatized Children and Adolescents Relative to Non-traumatized Controls Nicole K. Elliott Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy under the Executive Committee of the Graduate School of Arts and Sciences COLUMBIA UNIVERSITY 2012 © 2012 Nicole K. Elliott All rights reserved ABSTRACT An Analysis of the State-Trait Anger Expression Inventory Ratings of Traumatized Children and Adolescents Relative to Non-traumatized Controls Nicole K. Elliott This study compared the anger ratings of traumatized youth with and without PTSD relative to the anger ratings of a non-traumatized control group. Participants consisted of youth aged 7-18 years who were previously evaluated for a study at Bellevue Hospital Center in New York City. In order to potentially increase the external validity of the study, youth with comorbid major depressive disorder and substance dependence were included in the sample. Diagnostic measures identified 31 youth with PTSD, 59 traumatized youth without PTSD, and 39 non- traumatized controls. Participants completed the State-Trait Anger Expression Inventory, a self- report inventory that measures anger experience, anger expression, and anger control. Data analyses indicated significant group differences on the State Anger, Trait Anger, Angry Temperament, and Angry Reaction scales and subscales. Specifically, the PTSD group and traumatized PTSD negative group had significantly higher State Anger scores than the control group. State Anger scores for the PTSD and traumatized PTSD negative groups did not significantly differ. Regarding Trait Anger, the PTSD group had significantly higher scores than both the traumatized PTSD negative and control groups. Trait Anger scores for the traumatized PTSD negative group and the controls did not significantly differ. Angry Temperament scores of the PTSD group were significantly higher than scores of the traumatized PTSD negative and control groups. Angry Temperament scores of the traumatized PTSD negative and control groups did not differ. Angry Reaction scores of the PTSD group significantly exceeded scores of the control group only. Angry Reaction scores for the PTSD and traumatized PTSD negative groups did not differ, and the traumatized PTSD negative and control group scores also did not differ. Statistical analyses failed to identify significant group differences for the remaining scales (Anger Expression, Anger In, Anger Out, and Anger Control). Overall findings of this study indicate that the relationship between PTSD and anger varied depending on the anger domain that was examined, as significantly higher anger scores were not consistently related to diagnostic status. A discussion of the results including theoretical and clinical significance is presented. Finally, limitations of the study and possible directions for future research are addressed. Table of Contents Chapter 1: Post-Traumatic Stress Disorder (PTSD)…………………………………. 1 History of Post-Traumatic Stress Disorder…………………………………... 1 Diagnostic Classification of Stress Reactions……………………………….. 6 Summary……………………………………………………………………… 23 Chapter 2: Epidemiology of Child-Adolescent Post-Traumatic Stress Disorder…….. 24 Prevalence of Trauma Exposure……………………………………………… 24 Community Based PTSD Prevalence Investigations………………… 31 Criminal Victimization Studies………………………………………. 37 War Studies…………………………………………………………... 42 Accidents/Disaster Studies………………………………………...…. 50 Comorbidity………………………………………………………………….. 55 Summary and Risk Factors…………………………………………………… 56 Chapter 3: Methodology……………………………………………………………… 60 Background Information and Statement of the Problem……………………... 60 Purpose of the Study…………………………………………………………. 63 Need for the Study…………………………………………………………… 63 Research Design……………………………………………………………… 65 Rationale and Hypotheses……………………………………………………. 66 Method……………………………………………………………………….. 70 Sample Selection……………………………………………………... 70 PTSD Group………………………………………………….. 71 i Traumatized PTSD Negative Group…………………………. 71 Non-Traumatized Control Group…………………………….. 72 Exclusion Criteria…………………………………………….. 72 Diagnostic Measures…………………………………………………………. 73 Children’s PTSD Inventory…………………………………………... 73 Diagnostic Interview for Children and Adolescents – Revised………. 74 Clinical Interviews……………………………………………………. 74 Dependent Variable…………………………………………………………... 75 State-Trait Anger Expression Inventory……………………………… 75 Socioeconomic Index………………………………………………………… 76 The Hollingshead Four Factor Index of Social Status………………... 76 Chapter 4: Results…………………………………………………………………….. 78 Preliminary Data Analysis……………………………………………………. 78 Demographic Characteristics…………………………………………. 78 Types of Trauma……………………………………………………… 81 Primary Data Analysis………………………………………………………... 83 Multivariate and Univariate Analyses………………………………... 83 Post-hoc Analyses……………………………………………………. 86 Analyses of Possible Confounds……………………………………... 89 Chapter 5: Discussion………………………………………………………………… 92 Summary……………………………………………………………………… 92 Significance…………………………………………………………………... 98 ii Limitations and Future Directions……………………………………………. 101 References…………………………………………………………………………….. 106 Appendix: APA Permission for Citation……………………………………………... 128 iii List of Tables Table 1.1: Diagnostic Criteria for PTSD…………………………………………….. 16 Table 2.1: Prevalence of Trauma Exposure………………………………………….. 30 Table 2.2: Community Based PTSD Prevalence Studies……………………………. 36 Table 2.3: Criminal Victimization Studies…………………………………………... 41 Table 2.4: War Studies………………………………………………………………. 49 Table 2.5: Accidents / Disasters Studies…………………………………………….. 54 Table 4.1: Demographic Variables…………………………………………………... 80 Table 4.2: Types of Trauma Reported by Male and Female Participants between Groups………………………………………………………………………………... 82 Table 4.3: Number of Traumas Reported by Group…………………………………. 82 Table 4.4: Means, Standard Deviations, and Univariate Results……………………. 85 Table 4.5: Results of Post-hoc Analyses…………………………………………….. 88 Table 4.6: STAXI Correlations with SES and Age………………………………….. 89 Table 4.7: Two-Factor Analyses (Gender and PTSD Status)………………………... 91 List of Figures Figure 1: Schematic Representation of the Research Design………………………... 65 Figure 2: Means and Standard Deviations for STAXI Scales……………………….. 86 iv Acknowledgements As I near the end of the dissertation process, I would like to thank those who have helped me along the way. I am deeply grateful for the unwavering support that Dr. Philip Saigh has provided me since I began my graduate studies under his guidance. Dr. Saigh, thank you for your advice, dedication, and perseverance throughout this entire process. I am so appreciative to have had the opportunity to work with you. I have learned so much. Thank you to Dr. Stephen Peverly, for the guidance you have provided throughout my years in the doctoral program, and for the insights you provided as a part of my dissertation committee. In addition, I would like to thank the remaining members of my dissertation committee: Dr. Linda Hickson, Dr. Lisa Miller and Dr. Anastasia Yasik. Thank you for your support in the dissertation process and the invaluable feedback you have given along the way. To my mother and father: Thank you for always believing in me, for your steadfast support in my academic and career goals, and for instilling in me the belief that anything is possible with some hard work. I could not have done this without you. And to my husband, Mark: Thank you for your love and support, and for the encouragement you have given me in finishing this project. v 1 Chapter 1 History of Posttraumatic Stress Disorder For nearly 4,000 years, the emotional effects of exposure to extreme stressors have been recorded in historic accounts, clinical records, and in western literature (Figley, 1993). While the body of scholarly and clinical literature concerning posttraumatic stress reactions sharply increased in the nineteenth century, the inclusion of posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980) accelerated the empirical, systematic research of victims of warfare, natural and human- made disaster, and civilian violence (Eth & Pynoos, 1985). From an early historical perspective, Lucretius' De Rerum Natura, written in 50 BC indicated that, “The minds of mortals … often in sleep will do and dare the same . . . Kings take the towns by storm, succumb to capture, battle on the field, raise a wild cry as if their throats were cut even then and there. And many wrestle on and groan with pains, and fill all regions round with mighty cries and wild, as if then gnawed by fangs of panthor of lion fierce” (as cited in Crocq & Crocq, 2000, p. 48). In a similar vein, accounts of post-trauma psychological symptoms can be found in the Gísli Súrsson Saga, an Icelandic account of warfare written between 1270-1320 A.D. This account describes a war hero who “dreams so frequently of battle scenes that he dreads obscurity and cannot stay alone at night” (as cited in Figley, 1993, p. xvii). Accounts of soldiers waking from nightmares of war are common in literature, as depicted by Shakespeare through Mercutio’s account of Queen Mab in Romeo and Juliet: