**4.2 Recognise the influence of individual differences and circumstances on imagery**

To be effective, exposure must be applied while cognisant of individual differences in the capacity to image in a person-appropriate manner. Group characteristics, such

as ethnicity influence the capacity to experience imagery. Notably, imagery is greater among the peoples of East Asia [161] and indigenous cultures, like those of Australia, which utilise imagery in practical day-to-day tasks [162]. There are also gender differences in the capacity to utilise imagery [163]. Women have a superior ability to generate and maintain images [164] and experience more vivid images than men [165, 166]. They also react more strongly to unpleasant affective images, while men react more strongly to pleasant affective images [167]. Finally, the experience of imagery reduces with age [164, 168–170] and there is unequivocal evidence that imagery capacity degrades with age [171, 172].

The efficacy of exposure is also influenced by innate differences in imagery capacity. There are various abilities or traits related to the capacity to image. These include absorption, thinness of reality-imagination boundaries and imagery vividness [173]. Some types of imagery are personality based [174]. The style of imagery-based information processing is also affected by cognitive style and appraisal tendencies. This involves the balance between reflective thinking and thought-based information processing, known as verbalising style [175, 176]. Individuals with a higher capacity for visual imagery experience more visual and other sensory details when remembering or imagining past and future events [177].

Many abilities and personality traits influence the capacity to image. Imagery vividness has been associated with angry personality-based obsessionality [178] and individuals with high trait anger have been shown to have greater reactivity to angry imagery in the absence of enhanced imagery ability [95]. Imagery absorption is another dispositional trait that is highly correlated with the tendency to image and the intensity of the imagery experience [179, 180]. Under conditions of significant stress, absorption can become an imagery-based coping mechanism.

Greater imagery control is associated with greater internal locus of control [181], while extraversion and introversion are associated with imagery fluency [182]. The latter is consistent with the long-standing interpretation that extraverts are verbalisers and introverts are imagers [175, 176]. Importantly, this appears to be mediated by stress levels and Stricklin and Penk [183] found that, among incarcerated female offenders, extroverts reported more vivid imagery than introverts under high-distress. In contrast, introverts reported more vivid imagery than extroverts under low-distress.

The suitability of imagery to the remediation of anger is PTSD is also likely to vary according to situational circumstances. This is well illustrated from workplace injuries, where compensation and treatment claims involving psychological injuries are more difficult to administer and likely to become complicated where their aftermath possesses certain characteristics. These include a workplace climate which fails to promote workplace health and wellbeing or where the risk of injury is poorly managed or increased by inappropriate work practices. It can also involve the failure of the insurer to promptly approve best practice treatment for the injuries and worker perception(s) that the employer and/or insurer do not adequately care for them or where the event is associated with the injury involved horror, disgust human malevolence or culpable negligence [147]. In such circumstances, a sense of injustice motivates angry psychological distress in workers. Anger is associated with what happened and who allowed it to happen and/or failed to respond to their needs after an injury they neither expected nor caused. This powerful sense of wrong and the restorative justice required to address can instigate blazing and righteous anger and consequent revenge fantasises in those who perceive themselves unduly treated in the workplace [128]. This can lead to the targeting of health service providers and compensatory health and legal systems by individuals with traumatic injuries [184].

#### *The Influence of Anger and Imagery on the Maintenance and Treatment of PTSD DOI: http://dx.doi.org/10.5772/intechopen.105083*

The Contextual Model of Anger (see **Table 1**) heavily emphasises the importance of the interaction of several contributing factors. First is the anger derived from situational factors involving the experience of perceived or objective disrespectful conduct, unfairness, injustice, being wronged, thwarting of goal attainment and annoying behaviour of others. The second anger causing factor relates to ambient factors. For example, those relating to the environment, such as noise odour and temperature. Over time, through repetitious exposure and associative tendencies these factors become compounded in a third, distal factor. This involves embeddedness (via issues that may be personal, familial or social), interrelatedness (with other emotions and past experiences) and transformationalism (from isolated instances of anger to chronic anger problems and severe acts of aggression).

Novaco proposes that anger involves regulatory deficits in three psychological domains These include a cognitive domain (justification, attentional focus, rumination, hostile attitude and suspicion); an arousal domain (intensity, duration, somatic activation and irritability) and a behavioural domain (impulsive reactions, verbal aggression, physical confrontation and indirect expression of anger). The more deficits, characteristics and domains activated the greater the anger. Thus, in a study of veterans with PTSD and high levels of anger in multi-year anger treatment trial, Chemtob and others [35] described individuals who displayed high intensity regulatory deficits in all three domains of anger as "ball of rage patients".

#### **4.3 Apply evidence-supported and anger-specific treatments to anger in PTSD**

There is strong evidence of the general effectiveness of anger treatment. Bushman and colleagues have written extensively about this and have emphasised the utility of anger regulation interventions, such as cognitive therapy (especially distancing, behavioural distancing and language moderation), skills training and relaxation training [185, 186]. Meta-analyses by Tafrate [187], Edmondson and Conger [188], Beck and Fernandez [189], DiGiuseppe and Tafrate [190], Del Vecchio and O'Leary [191] and Henwood and others [192] and Lee and DiGiuseppe [193] report effect sizes as measured by Cohen's d [194] ranging from 0.64 to 1.16. Notably, Glancy and Saini [195] in their systematic review of meta-analyses of psychological treatments of anger and aggression, observed there are strong effect sizes for "classical" CBT approaches (skills training and problem solving) but lesser effect sizes for "variants", like acceptance and commitment therapy. They found multi-component interventions to be most effective (d = .93), followed by skills training (d = .85) and cognitive interventions alone (d = .83). They reported a trend for manualised treatments to produce larger effects than non-manualised treatments (d = .85 v. 76) The number of sessions also has a positive and significant relationship to the magnitude of the effect size, although the modal number of sessions is 8.5 and range of sessions provided is from 3 to 40. They further noted that such outcomes been established for clients of diverse backgrounds. This included forensic clients, violent recidivists, batterers, adults with intellectual and learning disabilities or serious mental illness, aggressive drivers and military personnel and veterans.

In comparison to the treatment of anger per se, the development of treatment strategies for anger in PTSD is in its formative stages and few interventions for anger and aggression in PTSD have been elaborated [196]. The CBT approaches identified in these reviews and meta-analyses have implicit applicability to anger in PTSD, provided they are nuanced for the impact of traumatisation. Research on PTSD associated anger demonstrates that cognitive therapy and skills training are effective in treatment of dysfunctional anger. These appear most effective when delivered individually or by group and face-to-face or remotely (e.g., by teleconferencing) [197].

Two studies have examined treatment approaches with solid face validity with promising results. The first by Mackintosh and colleagues [22], investigated the roles of anger regulation skills (i.e., relaxation training) and therapeutic alliance in reducing anger symptoms in contemporary (*N* = 109) US veterans. It identified that gains in calming skills predicted significantly larger reductions in anger symptoms. This finding has intuitive merit, for it is not possible that, apart from situations involving Schadenfreude, an individual can be simultaneously calm and angry. It also fits well with the above-identified effectiveness literature on the treatment of anger.

The other study used self-instruction training (SIT) which is an intervention with intuitive validity in the treatment of anger in PTSD [13, 198]. The aim of SIT is to enhance coping in face of adverse events by the use of pre-rehearsed self-talk instruction. Cash and colleagues [199], in an Australian contemporary serving combat personnel population, established a cognitive skills training set centred around self-instruction training. They used SIT targeted at negating the operation of schema modes [200], and reported impressive anger and PTSD symptom reduction effects (they reported effect sizes of 1.6 as measured by Cohen's d) pre to post-treatment. This efficacy of SIT for anger in PTSD fits with the long-demonstrated history of the efficacy of SIT, including for individuals with overlapping comorbidities, like anxiety, mood and substance abuse disorders [13]. It is also supported by the reviews and metanalyses cited at the start of this sub-section of the review.

Although such studies do not explicitly argue in favour of the use of imagery, it is clearly possible for it be involved in their implementation. Imagery may also be utilised in other treatment strategies for anger regulation, such as cognitive therapy, and treatment methods, such distancing and behavioural rehearsal. The best practice use of imagery in treatments of anger and anger in PTSD is yet to be determined. For example, the style of SIT deployed by Cash and colleagues emphasised a coping approach that sought to tolerate challenging situations. Their approach stands in contrast to the imaginal reliving of hierarchically organised provocative situations and experiences in stress-related anger studies by Novaco on populations as diverse as incarcerated individuals with intellectual disabilities and police [201]. The relative merits of these approaches-with their competing emphases on coping versus habituation-for reducing or exacerbating anger in PTSD, require explication. This is also the case for other treatments of anger involving imagery. This may require existing anger treatments to be finessed for the impact of trauma when applying them to anger in PTSD.

### **4.4 Locate anger work within a phased PTSD treatment model**

All treatments for PTSD are recommended for delivery via a staged sequence. This has been agreed for some time among theoreticians and researchers and long argued from diverse theoretical paradigms, including eclectic, psychodynamic and integrative perspectives (see **Table 4**).

A stage intervention sequence requires clinicians to provide an explanatory model of posttraumatic stress and how it best treated. A treatment roadmap is also needed that outlines the shared and individual responsibilities of clinician and client. Such an approach, provides a psychologically reassuring treatment structure for clients and enables them to build a personal model of recovery. A comprehensive staged model of treatment has been articulated by Keane and Kaloupek [208]. It involves six stages of treatment: (1) emotional and behavioural stabilisation, (2) education and


#### **Table 4.**

*Staged treatment models and theoretical treatment orientations.*

information, (3) arousal management, (4) exposure treatment, (5), cognitive restructuring and (6) relapse prevention and maintenance. A space for exposure is provided in its fourth stage. This is preceded by an arousal management treatment stage, where any anger-focused work required may be given focus.

It has long been recognised that, where posttraumatic anger is intense, more treatment will typically be needed before the implementation of exposure treatment [209]. Anger is particularly associated with enduring PTSD resulting from events characterised by culpability, issues of existential meaning (or in its simple form, moral injury [210]. It is also associated with intense primary (e.g., shame and guilt) responsibility and/or repugnance-related (e.g., horror and disgust) emotions. In prolonged PTSD anger is further connected to strong overarching concerns with atonement or revenge that manifest as psychopathology [116]. This almost inevitably requires treatment of greater frequency and duration.
