The present study addresses problematic anger and irritability in community dwelling persons with traumatic brain injury (TBI). It is designed to test the worth of a novel treatment approach called Anger Self-Management Training (ASMT), compared to a treatment offering supportive therapy focused on personal readjustment and education, the PRE (Personal Readjustment and Education). The project is a 3-center randomized controlled trial employing equivalent therapist time and therapeutic structure in the delivery of treatment options. The overall aim is to evaluate the relative response rate and correlates of treatment response for the ASMT as compared to the PRE.

Problematic anger/ irritability is common, persistent, and difficult to treat after TBI, and has a broad impact on community and social function. Anger following TBI is related, in part, to deficits in executive function including impaired problem-solving and impaired self-monitoring. In this 2-group, 3-center clinical trial with masked outcome assessment, we will explore feasibility and efficacy of a manualized, 8-session individual treatment, Anger Self-Management Training (ASMT), compared to a treatment using non-specific ingredients of therapist attention, education, and psychological support (PRE).

The ASMT was designed to decrease subjective and objective anger and irritability following traumatic brain injury (TBI), using theoretically motivated "active ingredients." The ASMT focuses on 2 executive deficits implicated in anger post TBI, (1) self-awareness and self-monitoring and (2) problem-solving. Participants will be randomly assigned in 2:1 proportion to ASMT or PRE. The PRE treatment is manualized to the same degree as the ASMT, but focuses on educational and personal readjustment to injury rather than anger-specific strategy training.

The overall goals are to examine the effects of the ASMT compared to PRE on self-reported problematic anger, both 1 week and 2 months after treatment, and to assess the time course of treatment response during the treatment phase.

Specific Aims

1. To examine the efficacy of ASMT compared to a control treatment (PRE) as measured by improvement from baseline to post-treatment on the State-Trait Anger Expression Inventory-Revised (STAXI-2) Trait Anger; STAXI-2 Anger Expression-Out; or the Brief Anger-Aggression Questionnaire (BAAQ) (primary outcome).
2. To examine the trajectory of treatment response within the treatment phase of ASMT/ PRE as shown by a change on 1 or more of the target scales halfway through the treatment (i.e., after 4 of 8 sessions) for those participants who exhibited a positive response post treatment (as defined above).
3. To examine the persistence of treatment effects 2 months after the end of the treatment phase.

Inclusion Criteria:

• Age ≥ 16 at the time of injury

• ages 18 to 65 at the time of enrollment

• TBI (closed or penetrating) occurring a minimum of 6 months prior to enrollment

• TBI documented as complicated mild, moderate, or severe TBI by any one or more of the following indices:

  • post-resuscitation score on Glasgow Coma Scale (GCS) < 13 or GCS Motor < 6;
  • loss of consciousness, unresponsiveness or coma attributable to the TBI and persisting ≥ 1 hour;
  • post-traumatic amnesia, or disorientation (O x 0, 1 or 2) attributable to the TBI and persisting ≥ 24 hours; or
  • neuro-imaging study positive for TBI-related findings such as contusion, hematoma, hemorrhage, diffuse axonal injury, shear injury, and/ or depressed skull fracture

• Able to travel independently in the community (to maximize the probability that participants will be cognitively and physically able to engage in the treatment)

• Indication from self or other report that participant has problematic anger/ irritability that is new since the injury or worse than before the injury

• Self-report of anger ≥ 1 standard deviation above the mean for age and gender on the Trait Anger or Anger Expression-Out (AX-O) subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2), or a score of ≥ 7 on the Brief Anger-Aggression Questionnaire (BAAQ)

• Able to speak and understand English sufficiently to complete the screening and outcome measures and to participate in a verbally based treatment program, which thus far exists only in English

• Informed consent given by participant or legally authorized representative.

Exclusion Criteria:

• History of schizophrenia or schizo-affective disorder, as documented in medical records or by self-report that a medical professional has given the diagnosis
• Current psychosis, major depression, or suicidal ideation; or history of manic or hypomanic episode as determined by the Mini-International Neuropsychiatric Interview for DSM-IV (MINI) Current alcohol-l dependence, as determined by the MINI.
• Self-reported use of cocaine or amphetamines "daily" or "almost daily" using the relevant questions from the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)
• TBI requiring hospitalization that has occurred within 6 months prior to enrollment
• Involvement in one-to-one counseling or psychotherapy targeted to emotional health issues
• Involvement in another treatment trial that may affect participation or outcomes
• Evidence of severe, intractable anger as indicated by history of violence-related crimes, e.g., charges for assault.

Adverse event data were monitored from the first treatment session to the final outcome evaluation. This consisted of a monitoring period of 4 months per study participant. Adverse events (AE) and serious adverse events (SAE) were queried with a checklist at each data collection episode and each therapy session through study completion (4 months altogether). If endorsed, events were evaluated as to seriousness, duration, resolution date if any, and possible relationship to study procedures.

For SAEs, we adhered to a standard definition used in medical trials: any event for which the outcome is death, hospitalization, life-threatening (i.e., person is at risk of death at the time of the event) or the event leads to disability and/or incapacity, or requires intervention to prevent those outcomes. We defined AEs as self-reported emergency care visits, arrests, episodes of violence, thoughts of harming self or others and withdrawal from therapy sessions and/or from the study at large.

All participants had self-reported problems with anger and were excluded for serious limitations in communication. Thus, the study cannot be generalized to those with very severe cognitive or communication deficits or who deny anger problems.