**3.3 The sequential impacts of anger and imagery on PTSD: a summary understanding**

Drawing on the theoretical models of anger and PTSD described in the preceding sections, this section outlines a conceptual understanding of imagery's role in the sequential processing of anger in PTSD. **Figure 1** lays out a hypothetical sequential processing map of how anger develops in response to trauma-related cues and triggers.

As shown in **Figure 1**, PTSD is considered to involve disordered information processing along the lines of the information processing and appraisal literatures. Such disordered processing is strongly associated with the experience of dysphoric and aversive emotional states. Typically, this involves anxiety, emotions of responsibility (e.g., guilt and shame) and emotions of repugnance (e.g., horror or disgust). As argued by Greenberg and Paivio [43], in this context anger emerges as a primary, secondary or substituted affect associated with such primary emotions.

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

#### **Figure 1.**

*Sequential processing map of the hypothetical development of in response to trauma-related cues and triggers.*

Anger is particularly evident where the PTE has involved human culpability and, above all, where there is malevolence or morally dubious behaviour. That is provided for in trauma typologies [4, 34, 120]. The impact and chronicity of PTSD is thus intimately associated with the event perpetrator's intention, the event's meaning and its moral status [121–123]. Under such circumstances, information processing demands are significant, and cognition becomes laboured and prone to be "affected by affect". Where such demands apply, consistent with Beck's cognitive model [109] imagery is likely to be invoked in a vicious circle where processing becomes automated due to the effect of priming or the encoding of information and schematic processing via mental maps. These maps interpret tasks and the environment in which they occur out of conscious memory. Such schematic pattern analysis and interpretive maps are likely to drive and respond to priming (**Figure 1**). This part of the framework is consistent with appraisal-focused theories of PTSD.

The encoding of information in memory, increases the capacity to recall the event and related information from cuing, intentionally or otherwise [124]. This robustly

exacerbates angry responses to post-priming trivial events [125, 126] and repetitive anger episodes lead to automaticity and secondary episodes that occur within 10–20 min of the first [126]. Anger episode duration increases with repetition and intensity. Primed by via repeated provocation (imagined or real) anger escalates in a non-linear fashion and significantly outlasts event duration (**Figure 1**). Thus provoked, anger can escalate even when the provocation remains constant (e.g., via a constant low-level annoying sound) and the sequence of escalation proceeds via reproaches, insults and threats [126]. Priming, perceived or actual provocation and externally-located causation are associated with rumination. That rumination may be verbal or imaginal in nature [34].

Other important anger moderating and mediating factors include disruption of anger due to fear, the presence/absence of distraction possibilities and apology [126, 127]. The duration and, concomitantly, rate of anger decline is influenced by the inability to control and cease rumination. Importantly, when anger occurs the form of revenge fantasies, rumination can have a half-life of more than a couple of weeks [128].

Because of the content of the intrusions and recollections involved in PTSD (**Table 3**) or the process repetition of the memory, poorly controlled verbal or imagery-based cognition increases the intensity of PTSD symptoms and associated anger. Appraisal theories of PTSD and anger suggest anger is likely to be prolonged


#### **Table 3.** *Evidence-based treatments for PTSD.*

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

where rumination is poorly controlled and potentially distracting factors and apology are absent. That perspective aligns with the cognitive vulnerabilities model of PTSD [114] and multi-representational theories of PTSD; such as the Dual Representation Theory of PTSD [129] and Schematic, Propositional, Analogue, Associative, and Representational Systems model of PTSD [132].

In this sequential model, anger can be ignited by the recollection of what happened, who caused or permitted it to happen and what occurred afterward. Anger can also emanate from the ruminative replaying of unfinished business in dreams or involuntary or, often unwitting, voluntary daytime recollections [133]. Shown in **Figure 1**, irrespective of the source or intentionality, the resulting distress intensifies avoidance.

The pressure to avoid is associated with deliberate and unwittingly attempts to suppress intrusions. This is especially the case for aversive negative-emotioninfluenced autobiographical imagery. Such imagery is typically experienced with a greater sense of reality (e.g., as measured by vividness), compared to non-emotional or semantic imagery [58]. Attempted suppression of intrusive phenomena is, however, almost always ineffective. This is well accounted for by Ironic Process Theory/the Zeigarnik Effect [134–136]. Efforts to suppress mental content, images included, can paradoxically lead to increased (re)occurrence of that specific content. Thus, rather than its intended outcome, avoidance leads to perverse, counter-intentional and unwitting rebounds [137] and even increases intrusions and imagery [138].

In an apparent case of the "greater the emotion, the greater the PSTD", symptoms are magnified when the dysphoric emotions associated with PTSD reach sufficient intensity thresholds. Anger can be either or both an initiator or potentiator of to this symptom escalation. Imagery is never far from such increases and the relationships among PTSD, anger and imagery are anything but coincidental [4].
