**4.1 Know and observe the limits of imagery-based interventions in the context of PTSD**

Whether in the psychological or physical treatment realm, no intervention is, or can be, effective without exception. Thus while exposure is the gold standard treatment for PTSD [147, 148] and the archetypal example of imagery-focused approach to PTSD treatment, not all PTSD presentations respond well to it. For example, a study of active US military personnel with PTSD (*N* = 326) randomly allocated to massed exposure (10 daily treatment sessions delivered over 2 weeks) or spaced exposure (10 treatment sessions delivered over 8 weeks) treatments identified classes of responders. These classes comprised rapid responders, steep linear responders, gradual responders, non-responders and symptom exacerbation [88]. Similar responder typologies emerged in a study of individuals with PTSD associated with multiple interpersonal traumata and previous attempts at treatment (*N* = 73) [149]. Participants received an intensive phase of treatment (12 daily 90-minute sessions over 4 days) followed by a booster phase (4 weekly 90-minute booster sessions). While 71% were classed as treatment responders, cluster analysis demonstrated four treatment response trajectories. These were: fast responders (13%), slow responders (26%), partial responders (32%), and non-responders (29%).

The reasons for variations in treatment response to exposure have been ongoingly reviewed. Research has identified the impact on response to exposure treatment of symptom profiles. For example, those associated with PTSD's numbing symptom cluster [150], residual sleep problems [151] and emotional dysregulation [152] and ruminative and absorption processes [34]. Other studies have demonstrated that specific brain regions are involved in a differential response to or discriminated between responders and non-responders to exposure treatment. These include the bilateral superior frontal gyrus and pre-supplementary motor area [153] and pre-treatment hippocampal volumes [154]—and pre-treatment hormone levels, as measured in cortisol [155].

Importantly, a variety of imagery-related characteristics can mediate or moderate the efficacy of exposure in the treatment of PTSD. Although PTSD, anger and imagery share a connection, exposure and other imagery-based treatments may be unsuited to the certain presentations of anger in PTSD due to the appraisals and the presence of other negative affects [4]. This is because of the effect of the event types

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

and the associated appraisals. To illustrate, PTSD-related anxiety classically revolves around issues of danger and risk. In contrast, in PTSD-associated anger (as noted in section 2, page 4), those appraisals, their underlying assumptions and the emotions that arise extend well beyond issues of danger and risk. As depicted in **Table 3**, those issues relate to wrong and injustice, diminishment, annoyance around expectations, disgust, guilt and shame and other non-anxiety-based affects. Such issues and associated anger are highly likely to be present in the face of horrific, macabre or morallyquestionable behaviours associated with PTEs.

Given this, it is possible that the application of exposure, to problematic anger may not produce image decay and emotional habituation—the active mechanism involved in the remediation of the anxiety associated with PTSD. Instead, this may induce or exacerbate the frequency, intensity and duration of angry affect. This is because anger control is not about habituation and holding an angry image in the mind's eye until it decays. Rather, it is related to image control. Importantly, PTSD sufferers with high imagery control are known to have fewer intrusions and less anger than those with low imagery control [99]. While what constitutes imagery control in anger is opaque, imagery elimination and suppression are unviable alternatives to the unmitigated experience of imagery. Arguably, imagery control is characterised by the ability to down-regulate, disconnect from or relinquish imagery.

At different times, imagery may have little effect on anger in PTSD or have a large, singular and direct effect on anger. Arguably, any such effect may also be indirect and multiply determined in its interaction with other cognitive mechanisms, like thoughtbased appraisals. Furthermore, the motivations for angry responding may also possess a utilitarian social value (e.g., in relation to social justice and protection of the weak). Consequently, activating/invoking angry mentation via imaginal exposure may not produce the sought-after reduction in angry affect. This is greatest in PTSD, where anger interferes with the development of the treatment alliance that is so important in the successful treatment of PTSD [156] and, is perhaps, the principal impediment to the successful treatment of PTSD. Comprehensive reviews [9, 34] and treatment studies [35] having recognised its impact and metanalyses demonstrate its interference in exposure tasks [39]. Anger's impact on treatment is particularly notable in combat veterans [157], but is also likely to affect populations subject to malevolent interpersonal trauma (e.g., childhood and pernicious adult sexual assault [158]).

As Meichenbaum [13] incisively observed, intense anger is not easy to work with and clients with angry presentations may become more so during treatment and direct anger and aggression toward clinicians. He further noted that such angry clients are often highly impatient, easily frustrated, unrealistic about treatment goals, typically noncompliant with treatment and treatment resistant. In the face of such anger, clinician effectiveness is subject to significant challenge. Consequently, in worst case scenarios, clinicians are liable to be rendered impassive in the face of significant client anger. This may partially account for the all-too-often failure of clinicians to follow evidence based practice [8, 159] and to divert from protocols when faced with difficult-to-treat anger [160]. This is of concern as it is likely to produce sub-optimal implementation and translation of evidence-based psychological treatments of PTSD.
