**3. Anger in PTSD and the role of imagery: Insights, theories and models**

Imagery has emerged as a fundamental cognitive process which is intimately involved in all emotional responses and an important feature of the experience of many forms of psychopathology [58]. It is also integral to interventions aimed at ameliorating negative emotional states and appears to be an important mechanism where anger is associated with PTSD [34].

## **3.1 Imagery in the stress and trauma literature**

Mental imagery is the quasi-perceptual, subjectively-influenced, cognitive representation and recollection of perceptual experience in working memory in the absence of the originating stimulus [59, 60]. Although all five senses can generate imagery, its predominant form is visual [61]. Importantly, while all senses can be involved, the visual domain is most typically engaged in the application of imaginal treatments of PTSD. Referred to by a variety of names-including visual imagination [62], pictures in the mind [63] and seeing in the mind's eye [64]—visual imagery is less visually acute than perception. However, it preserves the perceptible properties of the stimulus and ultimately gives rise to the subjective experience of perception [60]. Henceforth, the term imagery refers to visual imagery. As imagery is more affectivelyvalenced than thought [58, 65], it imbues emotional memory with an intensity consistent with the original experience [66]. Thus mental images can be experienced as "realer than real" [62] and even influence the ability to experience emotion [67].

Imagery has an especially important relationship with negative emotion [68, 69] and psychopathology. Its role is well-documented in psychotic, dissociative, mood, substance-related, psychosomatic and anxiety disorders [58, 70, 71]. Imagery's strongest connection to negative, disordered emotion is however, among the anxiety disorders, notably specific phobia, social anxiety and stress disorders [72]. Imagery

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

is implicated in various forms of specific phobia, including the imagery of the feared stimuli central to snake, spider and vomiting phobias [73, 74]. It is also a key factor in social anxiety disorder [75] especially where it pertains to negative imagery of the self [76]. Its relationship to PTSD is axiomatic, intrusive imagery being accepted as a core symptom, risk factor and severity-moderator [77].

The role of imagery in PTSD has been investigated overwhelmingly by reference to the affect of fear. This dates to the late nineteenth century, when Pierre Janet proposed that posttraumatic syndromes driven by intrusive recollections were experienced as disordered anxiety [78, 79], An anxiety-based conception of trauma response is evident in the early posttraumatic stress case descriptions and constructs (e.g., nostalgia and railway spine). It is also emphasised in the early-to-mid twentieth century constructs of shell shock, combat exhaustion and compensation neuroses [80]. Subsequently, the diagnostic and classificatory systems of psychiatry—in ICD-9 [81] and DSM-III [1], formalised this anxiety-based definition of PTSD and ICD 10 [82], and DSM-IV [83] in turn, reiterated it. Highly effective, anxiety-focused treatments have, consequently, been designed and implemented consistent with this anxiety-based conceptualisation of PTSD. Those treatments are summarised and discussed shortly for their implications.

Notwithstanding the advances made in PTSDs treatment, the historical focus on fear as its primary emotion may have impeded a fuller understanding of the disorder [84]. This is demonstrated in the growing recognition that PTSD is associated with emotions other than anxiety [85]. Fifty percent or more of PTSD's affective experience is estimated to relate to anger directly or in conjunction with disgust, guilt and shame [31, 86].

The relocation of PTSD to the Trauma and Stressor Related Disorders section of DSM 5 [6] from its previous location in the Anxiety Disorders section of DSM-III [1] and V [83] indicates the disorder's ongoing conceptual evolution. There is, of course, no barrier to exploring PTSD as strongly-anger related because of an association with imagery: the worth of that will be proven by the data.

These classificatory changes, however, remain contentious [87]. Proponents of major theories of PTSD such as the emotional processing model of PTSD understand it as an anxiety disorder [80, 88, 89] and the view that PTSD is an anxiety disorder is tenacious [80]. Irrespective of this, the insistence that the distress of all who experience PTSD is, without exception, anxious, has obscured evidence that the distress of a substantial group of sufferers is not primarily anxious in nature.

Research of anger in PTSD related to imagery has received less attention than that focused on anxiety in PTSD. Nonetheless, various studies suggest imagery and anger share an important relationship in the presence of PTSD. Higher levels of anger are associated with greater responsivity to imagery, while visual intrusions not only compound, but elicit, anger [57, 90]. Two reviews have explored the underlying relationship between imagery and anger as an aspect of negative emotion or in its own right. The first, by Holmes and Mathews [58] identified three overarching explanatory themes for the impact of imagery on negative emotion (anger included). The first centred on imagery's direct effect on the brain's emotional systems (whereby, imagery stimulates and is stimulated by, emotional and physiological arousal). The second noted its similar impact to real events (imagining an act engages the same neurological motor and sensory programs involved in carrying it out). The final theme was the capacity of imagery to reactivate feeling states such that attempts to avoid or suppress imagery result in unwanted and unintentional increases in its frequency and intensity. The second review by McHugh and colleagues [34] identified neurological,

psychopathological and affective lines of evidence for the relationship of anger and imagery. They also formulated an imagery-informed model for better understanding the relationship of anger to PTSD, while detailing imagery's powerful effect on anger in PTSD.

Research has further identified imagery's role in eliciting angry mood and physiological reactivity [43]. Angry imagery has a particularly powerful effect on human physiological responses [91] and can generate responses greater than those derived from anger-provoking events themselves [92]. This link is evidenced by imagery's role in successful treatments for problematic anger across a range of populations [13, 93, 94].

Anger research shows that imagery impacts anger irrespective of imagery ability or repetition [95]. Consistent with this, high-intensity, emotional distress in PTSD promotes the experience of intrusions [59]. Posttraumatic intrusion repetition in turn increases imagery capacity [96] and vividness [97], in a circular affect-imagery relationship. Anger is not exempt from this and imagery's association with anger and anger in PTSD may not be dose-dependent. Thus, any level of imagery may be potent in its capacity to escalate anger. Finally, in PTSD, there is evidence that visual intrusions are both a cause and consequence of posttraumatic anger [57, 90, 98] and PTSD sufferers with high imagery control have fewer intrusions and less anger than those with low imagery control [99].

### **3.2 Theoretical models of anger and anger in PTSD**

Several theoretical perspectives on the aetiology and maintenance of anger are potentially applicable to better understanding anger in PTSD. These theories are detailed in **Table 1**.

Of these theories, many are foundational psychological theories. Among them, social learning theory [100] understands behavioural modelling as crucial to the development of learned anger through the propensity of individuals to imitate behaviour observed in significant others (e.g., parents). In this theory three regulatory systems control behaviour—contingencies, feedback loops and cognitive function. It is proposed that anger can exist as a means for dealing with distress and is more likely to occur during affective distress and when some contingency exists for anger alleviation. The result is a circular problem of aversion, distress and anger.

Social learning theory fits well with the conditioning model of PTSD proposed by Keane and colleagues [107]. A social-interactionist learning theory, it was derived from conditioning theories of pathological anxiety, such as classic Pavlovian fear conditioning and Mowrer's two factor model [31]. Consistent with such theories, it posits that unconditioned stimuli (e.g., traumatic events associated with military experiences) automatically evoke unconditioned emotional (fear) responses. The intensity of this response generates avoidant protective responses. Warzone and combat-situations are quintessential stress environments. In combat life and death contingencies motivate highly-charged anger and emotional information processing that can become distorted and predictive of later anger in PTSD [108]. These reactions are often facilitated by pre-combat military training that mobilises the supposed "strength" of anger to avoid the dysphoric "weakness" of anxiety. This training dehumanises enemy combatants and operationalises the military imperative to negate and eliminate their threat. This renders military personnel more likely to respond to (objective) stress and trauma with anger, thereby precluding or impeding the development of other salient emotions such as anxiety and remorse [107].


#### **Table 1.**

*Major explanatory theories of anger.*

The programmatic nature of pre-combat training makes anger in PTSD difficult to de-operationalise and anger can become associated with a multitude of seemingly trivial day-to-day occurrences. These are not directly associated with the original traumatic experience but are subjectively interpreted as if they were and are associated with extreme levels of distress. What is not as readily understood is the significant function anger can play in the avoidance of such affects. This is specifically accommodated in Greenberg and Paivio's [43] primary-secondary emotion taxonomy and Beck's model of anxiety [109] which both emphasise the tendency to replace incapacitating distress with anger's action-orientation. Anger thus becomes a costly camouflage for other primary emotions.

Two more anger theories with significant potential utility in explaining anger in PTSD, are the information processing theory of anger [101] and the appraisal theory of anger [103, 104]. The information processing theory asserts that the perception of potential cues to anger is critical in maintaining angry affect. It proposes that problem anger is associated with threat identification and unless corrective information is applied, misinterpretation ensues. It also proposes that past events, thoughts, feelings and behavioural responses and meanings, are all stored in a latent "memory

network" ready for activation. The appraisal theory of anger proposes event perception, and not the actual event, is the key determinant of anger, and that appraisals are not only necessary, but sufficient, causal factors for the experience of anger. This is particularly the case for perceptions of responsibility, culpability and entitlement [51, 110]. Neither of these theories have been explicitly investigated for their specific utility in explaining anger in PTSD populations. Nonetheless, they are consistent with established PTSD theories. Thus, the potential utility of the information processing theory of anger is suggested by both the information processing theory [111] and the conditioning model [107] of PTSD and the threat identification and misinterpretation they identify as occurring after exposure to military PTEs. The potential utility of the appraisal theory of anger is suggested by the warning signal hypothesis [112, 113] and the cognitive vulnerabilities model of PTSD [114]. Euphemistic of notions of neuroticism, the latter emphasises the impact of a negative attributional style for past and current-events and looming cognitive style for future-events on PTSD. This functions as a danger schema for predicting future threat and is strongly connected to perceptions about trauma and PTSD symptoms.

Two anger models have been explicitly investigated in relation to anger in PTSD. The first theory, the primary, secondary and instrumental emotion taxonomy developed by Greenberg and Paivio [43] holds that primary emotions, like fear and shame, are fundamental, direct and initial reactions to events and situations. Secondary emotions, by definition, are responses to thoughts or feelings, rather than the situation (e.g., anger in response to hurt, fear or guilt). Their theory posits that anger can be experienced as preferential to underlying, aversive, dysphoric states.

This taxonomy has been applied to research on veterans [115] and female crime victims [18]. The data support the view that anger deflects sufferers from intrusionactivated fear to a state less associated with feelings of vulnerability. This is consistent with the assertion by Riggs, Dancu, Gershuny, Greenberg and Foa that, in PTSD, anger and dissociation are both processes of disengagement or avoidance of the traumatic memory and fear network [18]. It is also consistent with Forbes and colleagues [22] finding that angry veterans with PTSD believe they are misunderstood and maltreated and tend to blame others for their mixed-emotion distress. These processes, are avoidant in nature. Although they may afford temporary relief from anxious distress through the pseudo-positivity of anger, they inhibit habituation. This prevents disconfirmatory or safety-related cues being incorporated into the trauma memory network to modify its associations and interpretations [18, 115, 116].

The neo-associationist memory network theory [106] extends the insights of the information processing and appraisal theories of anger. It proposes that anger involves a constellation of inter-related physiological, motoric and cognitive "responses". Associated with the inclination to defend against or attack a target, research on veterans with PTSD shows that associative networks connect negative affect with anger-related feelings, thoughts, intrusive memories and aggressive behavioural inclinations [117].

In addition to the PTSD-focused research on anger theories, studies of survivor mode [35, 118] have been undertaken in relation to anger in PTSD. This is a dysregulation model of anger in PTSD and not an anger theory per se. It views anger as governed by higher-order cognitive perceptual processes and emotional functions. It is the only PTSD specific, anger model designed and researched with PTSD in mind. It emphasises the importance of anger-related schemata in interpreting the self, others and the world. Such schemata reset anger activation-inhibition patterns toward a cognitive set revolving around mis-perceived threat. This invokes an unrecognised,


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

**Table 2.**

 *Perceptions, cognitions, emotions and constructs associated with anger in PTSD.* peremptory, all-consuming threat-anger action program that is enacted automatically in response to the merest or ambiguous, cues.

Studies of these three perspectives are few and their propositions around the mechanisms likely to contribute to anger in PTSD are not well-established. Taken together, their propositions emphasise anger's threat perception and appraisal-tendencies and its interconnectedness with other emotions (especially anxiety, guilt, shame and disgust). They also underscore that anger is linked to meaning making around responsibility and culpability associated with the conduct of the individuals or others. This is particularly true for behaviours with questionable morality, injustice or malevolence, diminishment and the self-focused expectations and behaviours of others.

Such a theoretical synthesis is supported by the testimony of individuals with PTSD involving prominent anger. McHugh [4] reported on the accounts of posttraumatic anger in a sample of 500 treatment seeking current and ex-serving military personal and first responders with PTSD. The sample was comprised primarily of police but also included ambulance officers, fire services personnel and other emergency services workers. The content of their intrusions and their recollections, cognitions and associated negative emotions, states of being and action tendencies are described in **Table 2**.

That testimony demonstrates the plethora of phenomena that can underlie the experience of anger in PTSD. It also conveys both the mental busyness of those with, enduring, angry PTSD and the powerful avoidant role anger plays in distracting from contemplation of crucial underlying issues.

In summary, theories and explanatory models of anger and anger in PTSD provide potentially important clinical understandings. Research suggest that frameworks such as the neo-associationist and primary/secondary taxonomy have direct clinical relevance to anger in PTSD. To date, however, research of anger has been limited in comparison to other affects such as anxiety and depression [52, 119] and there has been little attention given to anger in PTSD. Furthermore, empirical research focusing on the involvement of imagery in the facilitation, exacerbation and prolongation of anger in PTSD has thus far been negligible. Consequently, despite the involvement of imagery in emotional, cognitive and memory processes in PTSD, there is a dearth of theories and explanatory models of the relationship of imagery and anger in PTSD. There is therefore a clear need for multi-representational descriptive and explanatory theories and models.
