**4. A guideline for the evidence based psychological treatment of anger in PTSD**

Treatments for PTSD with a high level of supporting evidence (i.e., randomised controlled trials with substantial sample sizes, systematic reviews and meta-analysis) are listed in **Table 3**. These treatments comprise: trauma-focused cognitive therapy, prolonged exposure, eye movement desensitisation and reprocessing and cognitive processing therapy. Collectively, the interventions fall under the rubric of traumafocused cognitive-behavioural therapy, meaning they directly focus on recollections, cues and triggers of the PTE and its associated cognitions and emotions [139]**.**

All these interventions require practitioners to pay deliberate, detailed attention to the provision of psychoeducation to assist clients to develop and maintain a personal model of recovery. They also require clinicians to help clients to develop skills to manage the maladaptive cognitions and affects which arise in the context of PTSD. Ultimately, they necessitate clinicians assisting clients to reprocess memories of causal traumatising events that they most likely, will have been avoiding. Finally, treatment aids the (re) development of functional abilities relating to everyday events based on the restoration of homeostatic mechanisms, habituation to emotion and new learning [88].

As well as exposure, imagery underpins various PTSD treatment interventions, including imagery rescripting and reprocessing therapy [140] and the treatment of post-traumatic nightmares via imagery rehearsal [141]. Imaginal exposure is,

however, by far the most researched of these intervention techniques and its efficacy has been demonstrated across a broad sweep of trauma-exposed populations. Over 50 randomised controlled trials with substantial sample sizes [142, 143], multiple metaanalyses [144] and systematic reviews [145] support the use of imaginal exposure. It has deep historical roots in the treatment of pathological anxiety and has demonstrated treatment superiority across the range of anxiety disorders. It considered the most important advance in the psychological treatment of anxious distress in the last 70 years [146].

The utility of exposure in the treatment of PTSD characterised by fear, of course, does not explain whether, how or why it will ameliorate anger in PTSD. Effectively treating anger in PTSD, requires understanding of its aetiology and maintaining factors and its best practice treatment. This review has detailed the former; the latter is, however, yet to be established. To begin to address this gap the following prototypical guidelines are suggested for the effective application of evidence-supported imagery interventions to PTSD where anger is the predominant emotion.
