Military Operational Medicine (JPC-5)
Decreasing Aggression in Veterans with PTSD
Posted November 17, 2020
Shannon R. Miles, Ph.D., James A. Haley Veterans’ Hospital
Dr. Shannon R. Miles
Impulsive aggression (IA) is common among Veterans with posttraumatic stress disorder (PTSD), and PTSD is one of the most prevalent post-deployment mental health conditions affecting Afghanistan and Iraq war Veterans. Emotion dysregulation is an underlying mechanism of IA. Dr. Shannon Miles of the James A. Haley Veterans’ Hospital received a Fiscal Year 2016 Consortium to Alleviate PTSD Award through the Psychological Health and Traumatic Brain Injury Research Program to design and pilot an emotion regulation training. After reviewing theoretical and empirical findings related to regulation of emotions from past studies, Dr. Miles’ team developed an emotion regulation training called Manage Emotions to Reduce Aggression (MERA). MERA is a novel, three-session emotion regulation training specifically developed for combat Veterans with PTSD. MERA was designed to teach Veterans skills in a condensed time frame, as younger Veterans are difficult to engage and are less likely to complete standard PTSD treatments.1 While most emotion regulation treatments are designed for civilians, MERA was specifically designed to incorporate examples relevant to the emotion regulation skills that are often used while on deployment.
Dr. Miles conducted this pilot study with 20 Veterans who had PTSD and IA but had not received evidence-based psychotherapies for PTSD. All Veterans who met the inclusion criteria received the treatment. Dr. Miles examined the preliminary effectiveness of MERA by measuring the pre- to post-training changes in aggression and emotion regulation and the rate at which participants subsequently initiated evidence-based psychotherapy for PTSD. She hypothesized that Veterans with IA and PTSD would be responsive to emotion regulation training if it were provided in a compressed time and that MERA participants would initiate and complete the emotional training program at an acceptable rate.
First, Dr. Miles tested the acceptability and feasibility of the MERA training, which was delivered in an outpatient PTSD clinic to Veterans who had PTSD and had experienced at least three episodes of IA in the last month, and who had not initiated evidence-based psychotherapies for PTSD. Outcomes focused on Veterans’ judgment of the MERA format; success in reaching goals for MERA recruitment, enrollment, and completion; and participants’ initiation of evidence-based PTSD treatment after completion of MERA.2 Ninety-two percent of patients willing to initiate treatment completed all three sessions. Additionally, 20 of the 24 Veterans who began MERA attended the 4-week post-treatment assessment, a follow-up rate of 83%. On the Exit Interview, most Veterans reported that MERA was at least somewhat helpful, and only one (5%) said MERA was “not helpful.” Veterans also reported that they were using many emotion regulation skills at the post-treatment assessment and that the skills were helpful. Most participants (85%) reported using controlled breathing, and the majority (70%) found it helpful. Other higher-rated emotion regulation skills used and considered helpful included remembering values, grounding, and realistic thoughts. Next, Dr. Miles evaluated MERA’s effectiveness by measuring the pre- to 1-month post-training changes in aggression and emotion regulation. Results from the mixed-effects regression model showed significant decreases in aggression over the course of training, with a moderate effect size. Aggression significantly decreased between the second and third sessions. The Difficulties in Emotion Regulation Scale showed similar results, as participants exhibited a significant decrease in scores from baseline to post-treatment that was moderate in size. Finally, the rate of PTSD evidence-based psychotherapy initiation for Veterans 6 months post-MERA was examined. Eighty-five percent of the participants who completed MERA stated that they felt more ready to participate in trauma-focused work after MERA at the exit interview. Forty percent of participants began an evidence-based psychotherapy for PTSD after completing MERA. An additional 30% engaged in supportive psychotherapy or symptom management groups that focus on current stressors, such as job and relationship stress.
Veterans are identifying anger and aggression as major reintegration concerns, and innovative methods to assist them are desperately needed.3 A Department of Veterans Affairs-funded, multi-center, randomized clinical trial is underway to test the efficacy of MERA. If psychotherapies can be condensed, Veterans can learn the most salient skills without having to commit to 12 sessions of treatment. Enhancing Veterans’ abilities to cope with trauma-related emotions can decrease IA and potentially lead to recovery from PTSD.
 Miles SR and Thompson KE. 2016. Childhood trauma and posttraumatic stress disorder in a “real world” Veterans Affairs clinic: Examining treatment preferences and dropout. Psychological Trauma: Theory, Research, Practice, and Policy 8:464-467.
 Miles, S. R., Kent, T. A., Stanley, M., Thompson, K. E., Sharp, C., Niles, B. L., Young-McCaughan, S., Mintz, J., Roache, J. D., Litz, B. T., Hale, W. J., Stanford, M. S, Keane, T. M., & Peterson, A. L., for the Consortium to Alleviate PTSD. (2020). Manage Emotions to Reduce Aggression: A pilot study of a brief treatment to help veterans reduce impulsive aggression. Journal of Nervous and Mental Disease, 208(11), 897-903.
 Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely A, and Murdoch M. 2010. Reintegration problems and treatment interests among Iraq and Afghanistan combat Veterans receiving VA medical care. Psychiatric Services 61(6):589-597.
Last updated Tuesday, November 17, 2020