**1. Introduction**

Interest in PTSD as a clinical phenomenon burgeoned following its formal introduction in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980 [1]. Today, the PTSD literature is vast and "internationalised" [2]. Based on available estimates [3] and publication trends [4] more than 20,000 articles on PTSD have thusfar been produced.

Post DSM-III, research has driven many advances in conceptualising how PTSD develops, how it is experienced, prolonged and effectively treated. That work has resulted in detailed explication of the disorder's phenomenology, extensive theorising about its aetiology and clinically important descriptive and explanatory models of PTSD associated with best practice treatment.

Despite this progress, there remain many uncertainties, controversies, prominent points of disagreement and critical knowledge gaps about PTSD. For example, there is ongoing debate over which experiences may be considered traumatic [5] and the nature of the stressor(s) required to meet diagnostic criteria. Moreover, DSM 5 [6] and ICD 11 [7] differ in how they derfine the construct of complex PTSD. There is also uncertainty about how to best treat PTSD. This is most evident when PTSD is complicated by psychiatric comorbidities such as anxiety, substance abuse and depressive disorders that require decisions to be made about treatment sequencing. Practitioners have expressed concern about sub-optimal implementation and translation of evidence-based psychological treatments for PTSD [8]. This has led to calls for further examination of transdiagnostic protocols [9] and personalised approaches for treating PTSD to enhance treatment outcome efficacy [10].

Another significant problem relates to the influence of dysfunctional anger in PTSD. Dysfunctional anger there is associated with increased morbidity and mortality. For example, through physical ill-health via conditions like cardio-vascular [11] and hypertensive disease, especially stroke [12]. The ruminative processes and negative self, other and world-appraisals associated with dysfunctional anger can impair the capacity to reason, and diminish problem-solving and goal-setting ability [13, 14]. Anger can also be a sign of unsuccessful attempts to deal with the experience of a traumatic event.

Sufferers of enduring PTSD often experience unrelenting, intense and distressing anger and significant impairment in interpersonal functioning. Those experiences are associated with degraded interpersonal relatedness [15], disparagement of others, and failure in relationship and family functioning [16]. When anger is extreme this can produce social alienation [17]. This leaves a trail of hurt and damage that most disconcertingly has a strong nexus to aggression [18, 19], violence [20] and suicidality [21].

Current and ex-serving military personnel are troublingly prone to experiencing problematic anger associated with their combat service and are considered the angriest veterans yet encountered [22, 23]. However, while dysfunctional anger is best documented in military personnel and veterans with PTSD [24, 25], it has been identified as a problem across a range of PTSD-affected populations. Such populations include those occupationally at risk for PTSD, like first responders [26], crime victims and perpetrators, those injured in workplace and road traffic accidents [27] and survivors of disasters [28], terrorism, atrocities, torture and political oppression [26, 29, 30].

PTSD has been characterised as a disorder of recovery requiring efficacious application of better psychological theories and treatments if better treatment outcomes are to be achieved [31, 32]. Highly pertinent to this objective, anger is not only strongly related to the maintenance of PTSD but plays a critical causal role. Upperend estimates suggest 40% of PTSD score variance can be attributed to anger [33] and that reductions in anger lead not only to reductions in PTSD symptoms but caseness [34, 35]. Anger is also associated with poorer prognosis, high treatment dropout and is, perhaps, the principal impediment to the successful treatment of PTSD. This has been recognised in comprehensive reviews of anger [9] and anger in PTSD [34] and treatment studies, such as those focused on combat veterans [35].

Anger has emerged as an important aspect of the experience of PTSD that warrants further attention. However, there remains a need for nuanced explanatory models which capture the psychological mechanisms underlying the relationship between anger and PTSD. Accordingly, this chapter seeks to make clear why and how

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

those phenomena are joined. Specifically, it seeks to elucidate the role of imagery as a psychological mechanism underlying the relationship of anger and PTSD in an integrated (visual-linguistic) cognitive model. These core objectives are pursued by reviewing the dominant theories of anger and anger in PTSD, and imagery. The limits of existing explanations of the influence of anger on PTSD and the role of imagery in that relationship are considered. A model of anger in PTSD is proposed that emphasises the role of imagery. This provides a platform for developing a fuller description and theoretical account of the aetiology and maintenance of PTSD. This platform permits identification of conditions required for better adapting imagery-based PTSD interventions to the treatment of anger-affected PTSD. It also suggests directions for future research on the role of anger and anger-Influenced imagery in PTSD.
