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Anger and Violence Among Individuals with Substance Use

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Anger and Violence Among Individuals with Substance Use Hurt people who hurt people: Anger and violence among individuals with substance use disorder and post traumatic stress disorder Emma L. Barrett B.Psych (Hons), M.Psych (Forensic) A thesis submitted in accordance with the requirements for admission to the degree of Doctor of Philosophy National Drug and Alcohol Research Centre School of Public Health and Community Medicine Faculty of Medicine University of New South Wales Sydney, Australia December, 2011 ORIGINALITY STATEMENT ‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged’. Emma Barrett December 2011 ii COPYRIGHT STATEMENT ‘I hereby grant the University of New South Wales or its agents the right to archive and to make available my thesis or dissertation in whole or part in the University libraries in all forms of media, now or here after known, subject to the provisions of the Copyright Act 1968. I retain all proprietary rights, such as patent rights. I also retain the right to use in future works (such as articles or books) all or part of this thesis or dissertation. I also authorise University Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International. I have either used no substantial portions of copyright material in my thesis or I have obtained permission to use copyright material; where permission has not been granted I have applied/will apply for a partial restriction of the digital copy of my thesis or dissertation’. Emma Barrett December 2011 AUTHENTICITY STATEMENT ‘I certify that the Library deposit digital copy is a direct equivalent of the final officially approved version of my thesis. No emendation of content has occurred and if there are any minor variations in formatting, they are the result of the conversion to digital format’. Emma Barrett December 2011 iii DEDICATION In the cherished memory of my dad, who bestowed not only the importance of working hard but also the value of enjoying life’s pleasures to the fullest. iv ACKNOWLEDGEMENTS Firstly I would like to thank my supervisor and mentor, Dr Katherine Mills, for her unwavering support and encouragement throughout my candidature. It has been an enormous privilege to work with someone with such patience, generosity, commitment, and such a huge knowledge of research. I would also like to thank my co-supervisor, Professor Maree Teesson, for her invaluable support. My supervisors created an extremely enjoyable work environment and provided me with amazing opportunities to further my research career. I give special thanks to the team on the COPE project: Dr Sabine Merz, Ms Julia Rosenfeld, and Mrs Philippa Ewer for their friendship and their efforts on the project. This research also would not have been possible without the participation of the treatment agencies and the men and women who were willing to share their personal histories. I extend my sincerest gratitude to these participants. I would also like to acknowledge my fellow colleagues at NDARC and Professor Shane Darke for their ongoing support and friendship. In particular, I would like to thank Dr Tim Slade and Ms Barbara Toson for their valuable statistical advice. Lastly, many thanks to all my wonderful friends including Nicola Newton, Katie Smythe and Penny Gribble who kept me on track by helping me keep a sense of balance and perspective. Most importantly, I would like to thank my mum, my two brothers and Tristan for their patience and their love, and for learning very early on not to ask. v ABSTRACT Substance use disorder (SUD) and post traumatic stress disorder (PTSD) are chronic disabling disorders that frequently co-occur. This comorbidity (SUD+PTSD) has been associated with a range of harms, however, little research has examined the association between these disorders, anger and violence; outcomes with devastating effects for the individual and for society. This thesis aims to address this gap in literature by investigating the relationship between, anger, violence and SUD+PTSD. Study 1 involved an examination of data collected as part of the 2007 National Survey of Mental Health and Wellbeing. It is the first epidemiological investigation of the mental health correlates of anger in the Australian general population. Diagnoses of SUD and PTSD were among the only disorders to demonstrate a consistent and independent association with anger after controlling for demographics and mental health comorbidity. Study 2 examined correlates of anger and violence among individuals entering SUD treatment. Comorbid anxiety and trait anger were independently associated with recent anger, whereas childhood trauma and trait physical aggression were uniquely associated with violence perpetration. This study is the first to identify correlates of both anger and violence in one SUD sample while controlling for trait aggression, depression and anxiety. Studies 3 and 4 are the first to investigate violence perpetration in a heterogeneous sample of individuals with SUD+PTSD. Cross-sectional and longitudinal analyses were conducted to examine factors specific to SUD and PTSD that may place individuals with this comorbidity at increased risk of violence. Self-report and court record data revealed high rates of violence perpetration among those with SUD+PTSD. After controlling for demographics, substance use and other comorbidity, PTSD hyperarousal symptoms and trait physical aggression were found to be independent predictors of violence in both the cross-sectional and longitudinal analysis. It is concluded that PTSD hyperarousal symptoms specifically need to be addressed by interventions aimed at reducing violence in this population. vi These four novel empirical studies provide crucial information for clinicians identifying those most prone to anger and violence and developing targeted intervention programs designed to reduce these adverse outcomes. Such interventions have the potential to break the destructive cycle of trauma, substance use and violence. vii TABLE OF CONTENTS Originality Statement ............................................................................................................ ii Copyright Statement ............................................................................................................ iii Authenticity Statement ........................................................................................................ iii Dedication ............................................................................................................................ iv Acknowledgements ............................................................................................................... v Abstract ............................................................................................................................... vi List of Tables .........................................................................................................................xi List of Abbreviations............................................................................................................. xii 1 Introduction .................................................................................................................. 1 1.1 Substance use disorders .......................................................................................... 4 1.2 Post traumatic stress disorder ................................................................................. 6 1.3 PTSD among individuals with SUD ........................................................................... 8 1.4 Anger and violence ............................................................................................... 14 1.5 Anger among individuals with SUD ........................................................................ 19 1.6 Violence among individuals with SUD ................................................................... 23 1.7 Theories for the associations between SUD, anger and violence ........................... 34 1.8 Anger among individuals with PTSD ...................................................................... 41 1.9 Violence among individuals with PTSD .................................................................. 45 1.10 Theories for the associations between PTSD, anger and violence ...................... 49 1.11 Anger and violence among individuals with comorbid SUD+PTSD ...................... 54 1.12 Summary and aims of the present thesis ........................................................... 62 2 Correlates of anger in a nationally representative sample ......................................... 65 2.1 Introduction .......................................................................................................... 65 2.2 Method ................................................................................................................. 75 viii 2.3 Results .................................................................................................................
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