Treatment of posttraumatic anger: A study into the feasibility and acceptability of a research protocol investigating an EMDR-based intervention directed at reducing trauma related anger symptoms in forensic outpatients*

Eye Movement Desensitization and Reprocessing (EMDR) and Cognitive Behavioral
Treatment (CBT) are recommended in various guidelines for the treatment of Post
Traumatic Stress Disorder (PTSD) symptoms since they are the most effective in
reducing anxiety-complaints. However, a subgroup of PTSD-patients does not
profit from standard EMDR and CBT. Research suggests that this subgroup suffers
from PTSD-related anger symptoms instead of PTSD-related anxiety symptoms. Yet,
there is no know treatment available that focuses on PTSD related anger
symptoms. Research suggests that anger symptoms negatively impact PTSD
treatment outcome, pointing towards the need for a treatment targeting these
anger symptoms.

Objective: The Directed Anger Protocol (DAP) is an EMDR-based treatment for
anger symptoms and revenge urges. Although professionals working with the DAP
express positive results in lowering anger symptoms and revenge urges, no
quantitative research has been done to support this. The objective of this
study is to investigate the feasibility and acceptability of a research
protocol using the DAP to reduce PTSD-related anger symptoms in adult forensic
patients.

Study design: A DAP protocol will be performed by a trained therapists
(hereafter named DAP-therapist) at one of ten locations of de Waag, centre for
forensic outpatient psychiatric care. Included are adult outpatients diagnosed
with PTSD and suffering from PTSD-related anger symptoms, as assessed with
several questionnaires. Exclusion criteria are an IQ below average and/or a
psychotic disorder or autism spectrum disorder. After being diagnosed with
PTSD, the research assistant will refer outpatients to one of the DAP-trained
therapists based on availability, at the location of their initial referral.
After written informed consent has been obtained and inclusion criteria met,
patients will then be subjected to a maximum of five DAP-sessions, depending on
the number of targets identified for the DAP and anger symptom severity. After
the DAP-treatment, outpatients will either start or continue treatment as
usual. Changes in levels of anger symptoms are measured with the STAXI-II (pre-
and post-trial) and the DIRAQ (each session, during the treatment phase).
During the DAP-treatment, the severity of overall PTSD symptoms is measured
with the PCL-5 (each session). If ratings on DIRAQ or PCL-5 increase, a
consultation with the patient and regular therapist will be scheduled before
the next trial session, to determine whether the trial needs to be aborted.
Upon completion of the trial, a semi-structured interview will be administered
to gain insight in the experiences of the patient and therapist regarding
participation in the trial.
Preliminaryresults of the study into the feasibility and plausibility of the
Anger Revenge Resentment Protocol (WWWP) showed that this treatment
intervention may be less suitable for part of the target group. Patients who
suppress their impulsiveness, seem to be unable to fully access their emotions
and/or patients who are more suspicious of the therapist seem to benefit less
from the treatment. Based on this, there is the impression that personality
traits might play a role. To investigate this further, it is important to
gather more information about the test subjects'personality traits.A
questionnaire will be added to the study to map relevant personality
dimensions.

The DAP is an EMDR based treatment and targets anger symptoms (anger
rumination, revenge fantasies, arousal, and perceived harm) towards individuals
responsible for harming the patient in the past. Patients are asked to create
an imaginary film scenario in which the harm doer is confronted and the
patient*s fantasies are acted upon, while simultaneously taxing the working
memory trough bilateral stimulation (i.e., eye movements, hearing clicks trough
headphones, or other memory tasks) as in regular EMDR treatment. Each harm doer
is addressed as a separate target in one or (incidentally) more DAP sessions.

Patients are expected to experience heightened levels of arousal during the
DAP-sessions, as this arousal is a necessary treatment component. To ensure
outpatient*s safety, outpatients included in the DAP-treatment exercise a
technique called *The Brake* to lower arousal levels. While preparing for DAP,
the therapist will assess the actual desire to act upon the revenge urges. If
this is the case, the DAP will not be administered.