For Afghanistan veterans, anger, not PTSD, is the biggest problem

From 2001 to 2021, approximately 9,200 Norwegian soldiers served in Afghanistan. The vast majority of them have done well in the years since. However, a significant number of veterans are struggling with mental health problems, according to a new study conducted by the Joint Medical Services of the Norwegian Armed Forces.

“All Norwegian veterans who served in Afghanistan were invited to participate in a large health study in 2020,” says associate professor Andreas Espetvedt Nordstrand at the Department of Psychology at NTNU. He is also a senior researcher and lieutenant commander in the Norwegian Armed Forces.

Veterans are generally very disciplined people, so it is no surprise that the response rate was so high, with 6,205, or 68%, participating in the survey. This means that the results are credible and likely representative of the entire veteran population.

“One topic in this study was ‘problematic anger,’” says associate professor Nordstrand.

The results are published in the diary BMC Psychology.

More anger than PTSD

Only in recent years has “problematic anger” become a major component of veteran and trauma research, with researchers often choosing to focus on Posttraumatic Stress Disorder (PTSD).

“Over the years, we’ve come to realize that PTSD is just one of many possible trauma-related mental disorders,” Nordstrand said.

PTSD is a so-called ‘anxiety disorder’. It is often a result of exposure to life-threatening events.

“In recent years, we have seen that factors other than fear often contribute to health problems in veterans. These factors include witnessing the suffering or death of others, or exposure to serious moral transgressions. Trauma-related disorders can manifest in a variety of ways besides anxiety dysregulation. For example, they can cause alcohol problems, depression, or insomnia,” says Nordstrand.

Studying anger for the first time

Trauma research has rarely examined the connection between trauma exposure and anger problems. Nordstand believes the reason for this is likely that researchers have focused on anxiety dysregulation instead.

“No one has studied anger among Nordic veterans before. Anger among veterans has also received little attention internationally, with leading military psychology researchers going so far as to call anger “the forgotten emotion” in veteran research.

“Anger problems, also called ‘problematic anger,’ occur when someone becomes angry so frequently, intensely and persistently that it significantly disrupts their functioning, social life and quality of life. So this is a problem that we need to take seriously,” Nordstrand said.

High numbers

The researchers used a standard instrument for measuring anger, the Dimensions of Anger Reactions Scale (DAR-5). They consider it a useful tool for identifying clinical anger problems, that is, problems that are severe enough that individuals require treatment.

Some of the many findings include the following:

• 8.4% of Norwegian Afghanistan veterans have clinical anger problems, i.e. problematic anger. This makes anger by far the biggest mental health problem among these veterans.
• Anger problems are about three times more common than classic PTSD, which affects 2.9% of veterans.
• The second most common mental health problem is insomnia, affecting 5.1% of veterans.

These findings clearly show that mental health problems are common among veterans.

“If we add up all types of mental health conditions, 10.4 percent of all Afghan veterans suffer from mental health problems. We don’t include problematic anger. This means that we may have underestimated how many veterans struggle with mental health problems after their service in Afghanistan,” Nordstrand said.

In other words, anger problems are incidental.

“Veterans who struggle with problematic anger often also suffer from other mental health issues,” Nordstrand adds.

Some of the most resilient people to start with

These numbers are particularly high when we consider that these veterans were specifically chosen to serve in Afghanistan because they can endure more than most people.

“We must not forget that all Afghanistan veterans have undergone several rounds of medical and psychological selection. Therefore, they are considered to be the healthiest segment of the Norwegian population,” Nordstrand emphasizes.

In other words, it takes a lot for these people to get into trouble. Although they are generally more resilient than the average person, many still struggle because the pressure becomes so overwhelming.

“Problematic anger is closely related to feelings of guilt and shame about things you saw or did while serving,” says Nordstrand.

Problematic anger is also closely associated with chronic pain complaints after service in Afghanistan.

“This means that we probably need to take a more holistic approach to treating veterans who are struggling than we have in the past. Anger and chronic pain can quickly lead to a vicious cycle where these two problems mutually exacerbate each other,” says Nordstrand.

People who leave the military fight the most

“We also see that people who leave the armed forces after serving in Afghanistan are much more likely to develop anger problems than people who continue to serve,” Nordstrand said.

However, it does seem to help to keep in touch with your former employer.

“For people leaving the military, maintaining a connection with the armed forces, for example by serving in the Home Guard, offers much the same degree of protection against tantrums as continuing active service.

“We have to be very careful about assuming cause and effect here, but previous research among veterans shows that the transition from military to civilian life is a vulnerable phase for veterans.

“As civilians, veterans lose the social identity of a soldier or officer, and this identity often provides significant protection in dealing with military trauma. In addition, many veterans feel alienated from civilians as they attempt to reintegrate into civilian life,” says Nordstrand.

The Norwegian Armed Forces need veterans

This is often a bigger problem for people who have had many difficult experiences during their service abroad.

“Our findings should be interpreted in the context of this knowledge and applied to suggest possible ways to prevent anger problems. Perhaps it is a good idea to remain in the military for a while after completing overseas service. If they do not have the opportunity to do so, the new findings suggest that service in the Home Guard may be a good option.

“The Norwegian Armed Forces always needs experienced people for the Home Guard, so this could be a win-win situation,” says Nordstrand.

The researchers added that more research is needed on problematic anger over time, ways to prevent such problems from escalating, and problematic anger in other high-risk occupations.