If you would like further information on the trial or have any questions please contact Luke O’Shea.

SAInT – Self-help for Anger Internet Trial

The anger self-help trial is a collaborative project between The University of Exeter and Help for Heroes. The Mood Disorders Centre, University of Exeter is running this internet randomised controlled trial.

The background

Anger is an important and understudied emotion [1]. Symptoms of anger are frequently reported by individuals seeking mental health treatment [2]. However, maladaptive anger has received little focus compared to other emotional disorders [3], with anger not recognised as a mental disorder in the Diagnostic and Statistical Manual of mental disorders [4].

In addition to the psychological impact of anger, high trait anger is also associated with physiological risks such as stroke and coronary events [5]. Intense and frequent negative emotions, such as anger, in response to stress, can contribute to and maintain emotional disorders [1]. Further research trialling interventions for anger may offer both psychological and physiological benefits to individuals experiencing symptoms of anger.

The intervention is based on the hypothesis that pathological anger can often be a habitual response [6], that is, an automatic behaviour triggered in response to cueing contexts [7]. Habitual anger may lead to individuals expressing their anger in a range of situations, whereby their automatic response is to become angry [6]. The anger-as-a-habit intervention aims to break into the habitual anger cycle and address the maladaptive habitual anger response by (i) helping participants to identify the cues and triggers to their anger; (ii) where possible to remove or replace environmental or behavioural triggers, and (iii) practising the use of an incompatible more functional response to the triggers, such as taking a time out, relaxation, assertiveness, and problem-solving. The intervention does this by promoting and encouraging the development and application of implementation interventions in the form of ‘IF-THEN’ plans, which have been found to be an effective means to promote behaviour change [8]. There is evidence to support the idea that spotting warning signs and practising alternative responses can be helpful for reducing depression [9] and this approach has been adapted for anger.

Internet interventions allow for tailored, interactive material to be efficiently delivered to service users and are a major component to health care [10]. Internet interventions offer a promising new way to deliver psychological treatment [11]. Previous research has shown internet-based cognitive behavioural therapy (CBT) focussed interventions are beneficial in the treatment of emotional disorders [12]. In addition to this computerised CBT, particularly internet-based treatment, has been found to be both acceptable and effective in the treatment of emotional disorders in individuals who might otherwise remain untreated [13].

The trial

The aim of the current study is to assess the feasibility, efficacy and acceptability of an internet-based intervention for the treatment of anger in armed forces veterans. A randomised-controlled trial will be conducted, with participants being randomised to one of two arms: unguided anger intervention or wait list control condition. The study aims to answer the following research questions:

Research questions

  1. Feasibility: What is the feasibility of an anger intervention for armed forces veterans and/or members of the general public? Questions used to assess feasibility will include: How effective are the different recruitment strategies (e.g. via Help for Heroes website and Facebook pages, via the Hidden Wounds service, via other online sources)? How many participants were recruited and at what rate? What percentage of those screened met the inclusion/exclusion criteria? Of those, how many consented to participate? What percentage of participants dropped out? Did dropout rate vary by condition? At what stage of the trial did the dropouts occur?
  2. Acceptability: Is an internet-based anger intervention acceptable to an English speaking, adult population using a behavioural index of modules completed and time spent online? The questions will include; how many modules do participants complete? How long do participants spend logged into the system? Are there any modules that are completed more easily or frequently than others?
  3. Estimation of effect size to aid planning for a fully powered phase III trial, with respect to levels of symptoms across treatment arms (descriptives and confidence intervals).

Secondary outcomes

A secondary outcome of interest will be treatment effect. Can the intervention reduce symptoms of anger relative to a wait list control and will this be maintained at the three month follow up?

Who is taking part?

Participants will be adults aged 18+ who are experiencing elevated levels of anger and do not have posttraumatic stress disorder (PTSD) or moderate-severe depression. As the anger self-help is unguided we will have to exclude individuals who present with elevated levels of depression or risk and elevated symptoms of PTSD.

To see if you are eligible please click here: https://survey.ex.ac.uk/index.php/814385?lang=en

Where is the study taking place?

The study is an internet trial and can therefore be accessed from any device with an internet connection.

When is it starting?

The study is due to begin in the Autumn 2017, with an aim to recruit a minimum of 30 individuals. We are particularly interested in recruiting armed forces veterans, for each participant the study will last up to 12 weeks.

Funding

Funding for this research is part of the Doctoral research training fellowship awarded to Luke O’Shea, funded as part of the Hidden Wounds Programme, funded by the Libor Fund to the Help for Heroes charity in partnership with the University of Exeter.

Contact

The Chief Investigator for the trial is Luke O’Shea at the Mood Disorders Centre, University of Exeter. If you would like further information on the trial or have any questions please contact Luke O’Shea.

References

  1. Cassiello-Robbins, C., & Barlow, D.H. Anger: The unrecognised emotion in emotional disorders. Clinical Psychology Science and Practice, 2016; 23(1), 66-85. DOI: 10.1111/cpsp.12139
  2. Okuda, M., Picazo, J., Olfson, M., Hasin, D.S., Liu, S.M., & Bernardi, S et al. Prevalence and correlates of anger in the community: Results from a national survey. CNS Spectrums, 2015;20(2), 130-139.
  3. Saini, M. A meta-analysis of the psychological treatment of anger: Developing guidelines for evidenced based practice. Journal of the American Academy of Psychiatry and the Law, 2009; 37(4), 473-488.
  4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5thed.). 2013.
  5. Player, M.S., King, D.E., Mainous, A.G., & Geesey, M.E. Psychosocial factors and progression from prehypertension to hypertension or coronary heart disease. Annals of Family Medicine, 2007; 5(5), 403-411. doi: 10.1370/afm.738
  6. Gentry, W.D., Chesney, A.P., Kennedy, C.D., Hall, R.P., Gary Jn., H.E., & Harburg, E. The relation of demographic attributes and habitual anger-coping styles. The Journal of Social Psychology, 1983; 121, 45-50.
  7. Orbell, S., & Verplanken, V. The automatic component of habit in health behaviour: Habit as cue-contingent automaticity. Health Psychology, 2010; 29(4), 374-383
  8. Webb, T.L., Sheeran, P., & Luszczynska, A. Planning to break unwanted habits: Habit strength moderates implementation intention effects on behaviour change. British Journal of Social Psychology, 2009; 48, 507-523.
  9. Watkins, E.R., Taylor, R.S., Byng, R., Baeyens, C., Read, R., & Pearson et al. Guided self-help concreteness training as an intervention for major depression in primary care: A phase II randomised controlled trial. Psychological Medicine, 2012; 42(7), 1359-1371.
  10. Ritterband, L.E., Thorndike, F.P., Cox, D.J., Kovatchev, B.P., & Gonder-Frederick, L.A. A behaviour change model for internet interventions. Annals of Behavioural Medicine. 2009; 38(18). DOI: 10.1007/s12160-009-9133-4
  11. Andersson, G. The promise and pitfalls of the internet for cognitive behavioural therapy. BMC Medicine, 2010; 8:82. DOI:10.1186/1741-7015-8-82
  12. Spek, V., Cuijpers, P., Nyklicek, I., Riper, H., Keyzer, J., & Pop, V. Internet-based cognitive behavioural therapy for symptoms of depression and anxiety: a meta-analysis. Psychological Medicine, 2007; 37(3), 319-328.
  13. Andrews, G., Cuijpers, P., Craske, M.G., McEvoy, P., & Titov, N. Computer therapy for anxiety and the depressive disorders is effective, acceptable and practical health care: A meta-analysis. PloS One, 2010; 13. doi: 10.1371/journal.pone.0013196.