Anger in PTSD: Is there a need for a concept of PTSD-related posttraumatic anger

Clinical Psychology Review 32 (2012) 93–104

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Clinical Psychology Review

Anger in PTSD: Is there a need for a concept of PTSD-related posttraumatic anger?

Tony McHugh a,b,⁎, David Forbes b,d, Glen Bates c, Malcolm Hopwood a,b, Mark Creamer b,d

a The Victorian Psychological Trauma Recovery Service, University of Melbourne, Melbourne, Australiab Department of Psychiatry, University of Melbourne, Melbourne, Australiac Faculty of Life and Social Sciences, Swinburne University of Technology, Melbourne, Australiad Australian Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia

⁎ Corresponding author at: The Victorian PsychologHeidelberg Repatriation Hospital, Austin Health, PO BVictoria 3078, Australia. Tel.: +61 3 9496 2184; fax:

E-mail address: [email protected] (T. McH

0272-7358/$ – see front matter © 2011 Published by Eldoi:10.1016/j.cpr.2011.07.013

a b s t r a c t
a r t i c l e i n f o
Article history:Received 10 February 2010Received in revised form 8 July 2011Accepted 12 July 2011Available online 17 September 2011

Keywords:AngerTraumaPTSD

Despite extensive research on posttraumatic stress disorder (PTSD), anger in PTSD has received little atten-tion. This is surprising, given anger is a key predictor of treatment outcome in PTSD. This paper seeks tobuild an argument for investigating anger in PTSD as a discrete entity. A key argument is that the capacityto image visual mental phenomena is crucial to the aetiology and maintenance of anger in PTSD. Evidenceis reviewed for the influence of visual imagery in anger in PTSD from the perspectives of neuropsychology,psychopathology, anger and PTSD. An argument is advanced for including visual imagery in an integrated(visual–linguistic) cognitive model of anger in PTSD. Directions for research on visual imagery in anger in PTSDand its treatment implications are discussed.

ical Trauma Recovery Service,ox 5444, Heidelberg Heights,+61 3 9496 2360.ugh).

1 We used anger arience of PTSD or anment, children, adolor where PTSD or an

sevier Ltd.

© 2011 Published by Elsevier Ltd.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 932. The importance of anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 943. Current understandings of anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 944. Developing a clearer conceptualisation of anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 955. Visual imagery as a key underlying psychological process in anger in PTSD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

5.1. Neuroanatomy, anger and imagery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 965.2. Visual imagery in psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975.3. Visual imagery in anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985.4. Visual imagery in anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985.5. Summary of evidence for conceptualising visual imagery as a key underlying psychological process in anger in PTSD . . . . . . . . . . 99

6. Visual imagery and word-based cognitive processes in anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1007. Future directions for research of visual imagery in anger in PTSD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1018. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

1. Introduction

The inclusion of posttraumatic stress disorder (PTSD) in the thirdedition of Diagnostic and Statistical Manual of Mental disorders(DSM-III, American Psychiatric Association, 1980) stimulated consid-erable research and debate over how to conceptualise it. To date, only

a small proportion of this endeavour has reviewed the role of anger inPTSD. Two reviews of PTSD publications between 1987 and 2001(Bedard, Greif, & Buckley, 2004; Figueira et al., 2007) reveal only189 of 13,000 articles (i.e., approximately 1.5%) looked at the role ofanger and hostility in PTSD (Orth & Wieland, 2006). A confirmatorysearch of the PsycINFO, Embase and MEDLINE databases1 reveals littlehas changed since and that the proportion of anger-related articles in

nd variants of PTSD as terms, limited hits to where the adult expe-ger was the primary focus. This eliminated articles on measure-escents and health states or issues (e.g., cardiovascular disease)ger were described co-incidentally.

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94 T. McHugh et al. / Clinical Psychology Review 32 (2012) 93–104

PTSD research remains low (1.4% of approximately 16,300 articlespublished in 2011).

This disparity is hard to explain, given anger is unevenly distrib-uted across the anxiety disorders (Moscovitch, McCabe, Antony,Rocca, & Swinson, 2008) and most prevalent in and associated withPTSD (Novaco & Chemtob, 2002; Olatunji, Ciesielskil, & Tolin, 2010).It is also an underlying contributor to the aggressiveness (Riggs,Dancu, Gershuny, Greenberg, & Foa, 1992; Taft, Vogt, Marshall, Panuzio,& Niles, 2007) and poor physical health that characterise PTSD(Beckham, Calhoun, Glenn, & Barefoot, 2002; Ouimette et al.,2004; Schnurr & Green, 2004).

Faced with this gap, this paper reviews existing literature on theimportance of anger in PTSD. It presents an argument that anger inPTSD is a unique form of anger with theoretical and practical implica-tions and advances a rationale and supporting evidence for this. Itproposes a model for accounting for the role of anger in the courseand severity of PTSD symptoms in which visual imagery is identifiedas a key characteristic.

2. The importance of anger in PTSD

Over the past two decades, consistent emphasis has been given tothe importance of anger in PTSD. For example, the arousal symptomcluster of PTSD, which includes anger among its criteria, has emergedas the predominant predictor of overall PTSD severity with a substantialone-way effect on its intrusive phenomena cluster (Schell, Marshall, &Jaycox, 2004). Other studies describe anger itself as a critical predictorof PTSD severity (Andrews, Brewin, Rose, & Kirk, 2000; Frueh, Henning,Pellegrin, & Chobot, 1997; Orth & Maercker, 2009; Orth & Wieland,2006), with upper-end estimates suggesting 40% of PTSD score vari-ance may be attributable to anger (Novaco & Chemtob, 2002). In ad-dition, rumination associated with anger also has a substantial effecton PTSD (Orth, Cahill, Foa, & Maercker, 2008) and ruminative styleappears closely linked to PTSD's re-experiencing symptom cluster(Orth & Wieland, 2006). As anger's impact on PTSD scores far exceedswhat might be expected from its status as a single PTSD criterion(Novaco & Chemtob, 2002), the impact of anger on PTSD is thereforemore than a measurement artefact derived from anger's inclusion inthe arousal cluster of PTSD's diagnostic criteria (Orth & Wieland,2006; Orth et al., 2008).

Research has also shown anger to be problematic across a rangeof PTSD affected populations. Most often, it has been reported in mil-itary personnel and veterans of various conflicts, role-types and cul-tures (e.g., David et al., 2002; Hovens et al., 1992; Jakupcak et al.,2007; Johnson et al., 1996; O'Toole et al., 1996). Importantly, it hasalso been identified as significant in other PTSD populations. These in-clude those occupationally at risk for PTSD — for example, emergencyservices personnel and disaster relief workers (Evans, Giosan, Patt,Spielman, & Difede, 2006; Mearns & Mauch, 1998); crime victims(Cahill, Rauch, Hembree, & Foa, 2003; Feeny, Zoellner, & Foa, 2000;Zoellner, Goodwin, & Foa, 2000); survivors of torture (Dunnegan,1997); and transport accidents (Ehlers, Mayou, & Bryant, 1998).

From such research, it is clear problematic anger in PTSD is nei-ther population nor trauma-type specific. Lasko et al. (2004) observed“increased aggression in war veterans is more appropriately regardedas a property of PTSD, rather than a direct consequence of militarycombat” (page 373). Twelve years later, in the first meta-analysis un-dertaken in the area, Orth and Wieland (2006) re-emphasised this,concluding “anger and hostility are substantially related to PTSDamong samples who have experienced all possible types of traumaticevents, not only in individuals with combat-related PTSD” (page 704).Consequently, the particular relationship anger has with PTSD is in-creasingly understood as critical.

PTSD, especially when chronic, is difficult to treat (Bradley,Greene, Russ, Dutra, & Westen, 2005) and anger is an important im-pediment to treatment efficacy (Andrews et al., 2000; Forbes et al.,

2002, 2008). This may be the result of the general association ofanger with poor treatment outcome across psychiatric disorders(e.g., Burns, Johnson, Devine, Mahoney, & Pawl, 1998; Haaga, 1999;Rao, Broome, & Simpson, 2004). Equally, it may be a specific outcomeof anger in PTSD, which has been associated with early treatment ter-mination (Stevenson & Chemtob, 2000) and the need for additionalinterventions when prominent (Pitman et al., 1991; Stapleton, Taylor,& Asmundson, 2006). Ironically, treatment of anger reduces PTSDsymptoms, not only anger levels (Novaco & Chemtob, 1998). It is,thus, not surprising many observers continue to call for increased in-vestigation of anger in PTSD (e.g., Chemtob, Novaco, Hamada, Gross, &Smith, 1997; Orth & Wieland, 2006; Owens, Chard, & Cox, 2008;Schutzwohl & Maercker, 2000). Orth and Wieland (2006) summarisethis need, stating increased understanding and improved treatmentof anger in PTSD is critical, given anger's impact on the individualand society.

3. Current understandings of anger in PTSD

Various phenomena have been associated with anger in PTSD.Emphasising anger's enduring nature, some have noted the role ofpersonality-related and cognitive variables. Researchers have ex-plored the contribution of pre-trauma psychological traits to angerin PTSD using proven constructs. For example, Meffert et al. (2008),in a large prospective study of United States police, confirmed thefunction of pre-role trait anger in the development of PTSD symptomsand anger after 1 year of active police duty. Others have investigatedprototypical characteristics associatedwith anger. US studies of Vietnamveterans (Miller, 2003;Miller, Kaloupek, Dillon, & Keane, 2004) and sur-vivors of sexual assault (Miller & Resick, 2007) show externalising per-sonality style characterised by high negative emotion and lowbehavioural constraint is associated with anti-sociality and aggressionin PTSD sufferers. Forbes, Fletcher, Parslow, Creamer, and McHugh(2010) replicated this externalising finding in PTSD-treated AustralianVietnam veterans, having earlier established that externalising, fear ofanger and social alienation predict poorer recovery following treatment(Forbes et al., 2002, 2003, 2008).

Researchers have also explored the influence of cognitive phenome-na. Consistentwith general theories of anger (see Cox &Harrison, 2008)and PTSD (see Ehlers & Clark, 2000), some researchers have investigat-ed anger in PTSD in terms of appraisal theory. In one study, Whiting andBryant (2007) examined the role of a blaming style in the developmentof anger in PTSD. In a traumatised community population with andwithout PTSD, they found a strong association betweenmaladaptive ap-praisals and post-traumatic anger with catastrophic appraisals of theself and world a significant predictor of anger.

More complex cognitive propositions have been investigated. Threeconstructs reflect current thinking. One is the Regulatory Deficits Modelof Emotion in PTSD (Chemtob, Novaco, Hamada, Gross and Smith,1997) on which the Survivor Mode Theory of anger in PTSD is based. Inthis theory, Survivor Mode resets anger activation–inhibition patternsin PTSD toward a cognitive set revolving around (mis)perceived threatin an unrecognised and all-consuming threat-anger programme for ac-tion. The programme is activated in the context of ambiguity and facili-tates aggression (Novaco & Chemtob, 1998). Another is the primary–secondary Emotion Substitution Proposition (see Feeny et al., 2000;Riggs et al., 1992). Consistent with the anger-as-secondary-emotionidea of Greenberg and Paivio (1999), it asserts anger can deflect PTSDsufferers from intrusion-activated fear to the pseudo-positivity ofangry feelings. The third derives from Berkowitz's (1990) Neo-Associa-tionist Memory Networkingmodel. Applied to PTSD in a study of combatveterans by Taft et al. (2007), negative affect in PTSD was proposed tobe connected through associative networkswith anger-related feelings,thoughts, memories and aggressive inclinations.

We have synthesised descriptive characteristics from such ac-counts of anger in PTSD into five groupings in Table 1. The first

Table 1Key characteristics of anger in PTSD suggested by contemporary theoretical models.

Characteristic Consequence

1. A loss of volition ▪ A level of automaticity, consistent with an absence of control over the response to triggers;

▪ diminished self-monitoringAs per Chemtob, Novaco, Hamada, Gross, & Smith (1997) and Novaco and Chemtob (1998).

2. Extreme pervasiveness ▪ Intensity of feeling that can extend to explosiveness, intense cynicism, hatred or rage;

▪ longevity of feeling marked by a smouldering disposition and ruminationAs per Chemtob, Novaco, Hamada, Gross, & Smith (1997) and Novaco and Chemtob (1998).

3. Overarching coherence ▪ Increased memory network linking;

▪ tendency for anger to occur secondary to other emotions, especially anxiety, while being superordinate in statusAs per Berkowitz (1990), Feeny et al. (2000), Greenberg and Paivio (1997) and Taft et al. (2007).

4. Distorted and heightened cognitive processes ▪ Loss of the ability to discriminate between significant and insignificant triggers to anger;

▪ appraisals and causal attributions which go beyond mere externalisation to a ruminative preoccupationwith what happened, who allowed it to happen and being wronged or harmed;

▪ lack of awareness of a mode of (angry) being that is all consumingAs per Berkowitz (1990), Feeny et al. (2000) and Taft et al. (2007).

5. Loss of connectedness to others ▪ Low behavioural constraint, involving aggression

▪ externalising of cause, blame

▪ ultimate consequence of the above four key characteristic(s) setsAs per Forbes et al. (2002), Forbes et al. (2008), Forbes et al. (2010); Miller (2003) and Riggs et al. (1992).

95T. McHugh et al. / Clinical Psychology Review 32 (2012) 93–104

group understands anger in PTSD as characterised by emotional dys-control in the absence of self monitoring, due to lack of awareness orthe individual's fear experience. The second comprehends it as in-volving overarching, pervasive and persistent intense feelings whichare resistant to change. The third emphasises anger in PTSD occurswith what we term an overarching coherence in which anger islinked with other feelings in an affective memory network. The fourthsees it as characterised by distorted and heightened cognitive pro-cesses and angry rumination. The final group considers anger inPTSD as associated with social aggression, alienation and a loss of so-cial connection.

4. Developing a clearer conceptualisation of anger in PTSD

Such a character set is a useful platform for understanding angerin PTSD. There is a need for further study of anger in PTSD, however,although research momentum may be increasing,2 output is modestand the best means for conceptualising anger in PTSD and under-standing its underlying mechanisms (Orth & Wieland, 2006) remainsunclear. This deficiency relates to the inability of current conceptionsof anger in PTSD to discriminate it from other instances of anger.

The discrimination problem can be demonstrated through threecomparisons of anger in PTSD — with the basic affect of anger, dys-functional posttraumatic anger and non trauma-related problematicanger.

In terms of the basic affect of anger, from earliest conceptions, keycommentators — for example, Averill (1982), Bandura (1973) andBuss (1961) — have viewed anger as “multidimensional with distinctaffective, behavioural and cognitive dimensions” (Cox & Harrison,2008; page 372). It is experienced as an uncomfortable, negatively-felt subjective state (Kassinove & Sukhodolsky, 1995) which developsin response to a perceived aversive stimulus (Olatunji et al., 2010) andconsists of feelings varying in intensity, from mild irritation or annoy-ance to intense fury and rage (Spielberger, Jacobs, Russell, & Crane,1983). Such angry feelings are connectedwith cognitions (i.e., thoughts,beliefs and images) and their various associated verbal, facial, bodilyand autonomic reactions (Eckhardt, Norlander, & Deffenbacher, 2004;Fehr & Russell, 1994).

2 The above search found 145 articles published from 2001 to 2010, compared to 130from 1981 to 2000.

These elements readily correspond with the putative characteris-tics of anger in PTSD presented in Table 1. This comparison alone,therefore, does not allow definitive conclusions to be drawn onwhether the highly problematic anger associated with PTSD can bedifferentiated, characteristically or dimensionally, from other in-stances of anger. Hence there is a need for further comparisons.

The second contrast relates to dysfunctional anger in the contextof other prominent post-traumatic psychopathologies — for example,Panic Disorder and Major Depressive Disorder (PD and MDD), themost commonly occurring post-traumatic disorders, apart fromPTSD (Amstadter et al., 2009). The little evidence available suggeststhe characteristics purported to describe anger in PTSD may indeedalso be present in anger comorbid with PD and MDD. Illustrativeof this possibility, Whiting and Bryant (2007) found anger in post-trauma populations with and without PTSD. Referring back to theAnger in PTSD characteristics synthesised in Table 1, anger in the con-text of PD and MDD may also be due to the operation of any of thecognitive heuristics applied to anger in PTSD (i.e., secondary-emotionsubstitution, angry memory network and angry survival mode). It istherefore difficult to differentiate anger in PTSD from other instancesof post-trauma problematic anger.

The third comparison is with non-trauma related problematic anger.For this purpose, hostility is comparedwith anger in PTSD. Hostility is de-fined as an attitudinal disposition characterised by a negative valence to-ward others, decidedly unfavourable judgement of targeted individualsand a complex set of feelings which motivate aggression and vindictive-ness (Eckhardt et al., 2004). Hostility's central features involve “the cog-nitive variables of cynicism (believing others are selfishly motivated),mistrust (that others will be hurtful and intentionally provoking), anddenigration (evaluating others as dishonest, ugly, mean, and non-social)”(Eckhardt et al., 2004: page 19). Again, the phenomena establishedwith-in cognitive frameworks to account for anger in PTSD (Table 1) appear tobe present in hostility's core features.

Based on these three comparisons, it would be easy to conceptual-ise anger in PTSD as no different from the basic affect of anger andother instances of problematic anger. The contention of this paper,however, is that the salience of distorted visual imagery is the phe-nomenon that may best discriminate anger in PTSD from other in-stances of anger. We will assert that imagery is a core feature ofboth anger and PTSD and this combination makes it the salient fea-ture of anger in PTSD. We further propose that incorporation of visualimagery into a model of anger in PTSD offers a way forward to betterunderstanding such anger.


Holmes and Mathews (2010) offer an elegant summary of mentalimagery, describing it as the psychological experience of actual inter-nal and external events and experiences which may be derived fromany of the sensory modalities and bodily sensations. In consideringanger in PTSD, we focus specifically on visual imagery as a subset ofmental imagery on the basis that it is more directly connected toemotional experience, it closely resembles actual experiences andtheir autobiographical recall, and it is highly relevant to the treatmentof dysfunctional anger.

Demonstrating visual imagery as the salient feature of anger inPTSD would deliver two major outcomes. First, it would provide a ra-tionale for distinguishing anger in PTSD dimensionally or categorical-ly from other instances of anger, posttraumatic or otherwise, and viceversa. Second, and more importantly, it would provide a fuller de-scription of, and a better theoretical basis for understanding, theaetiology and maintenance of anger in PTSD. We now review evi-dence for the association of visual imagery with a unique constructof anger, anger in PTSD (AIP).

5. Visual imagery as a key underlying psychological processin anger in PTSD

There is little direct research on the role of visual imagery in AIP.Nevertheless, support for its importance can be derived from fournow-described sources of support; that is, evidence from neuroanat-omy, psychopathology, anger and PTSD research.

5.1. Neuroanatomy, anger and imagery

The connection of visual imagery to anger can be established bysequentially comparing brain areas associated with (a) anger, (b) im-agery and (c) their overlap. The evidence for each is now brieflyconsidered.

Distinct neural networks have long been known to be involved inthe experience of primary emotions (Lane et al., 1997), the foremostexample being that of anxiety and its associated anterior cingulate,orbito-frontal cortex, medial temporal structure, anterior insula andcerebellum activity (Malizia, 2003). Research evidence has begun to ar-ticulate a neurology of anger (Potegal & Stemmler, 2010). It highlightsthe prominent involvement of the amygdala, hypothalamus, hippocam-pus and cortical regions in the brain's anger response (Dougherty et al.,1999,2004; Potegal & Stemmler, 2010; Stein et al., 2007). It also indi-cates activation lateralisation— increased left cerebral activity being in-volved (Mitchell & Harrison, 2010; Potegal & Stemmler, 2010; Shenal &Harrison, 2004) on account of anger's offence orientation/approachmotivation (Harmon-Jones, Peterson, & Harmon-Jones, 2010; Potegal& Stemmler, 2010).

Research of anger's neurology further highlights the complexityand functional variability of this anger system. Evidence suggeststhe amygdala is involved in initial processing of stimuli, while corticalregions are likely to be involved in higher-order (typically response-downscaling) processing of such stimuli. For example, studies revealinvoluntary threat-attention tends to activate the amygdala, whilevoluntary attention tends to activate the superior temporal and ante-rior cingulate cortex (Vuilleumier, 2002). Again illustrating this com-plexity, Furmark et al. (2009) have shown that recognition of angryfacial expression is specifically associated with the amygdala, whileDougherty et al. (2004) have demonstrated that anger-eliciting nar-rative scripts are associated with activation in the left orbitofrontaland right anterior cingulate.

Additional brain areas are likely to be activated following the initialtriggering of an anger response. Hence, lesion studies have found that,subsequent to the amygdala's emotion recognition, the ventral striatumis involved in signal coding, and general co-ordination of behaviouralresponses to anger (Calder, Keane, Lawrence, & Manes, 2004). Codingand co-ordination may in turn be a prologue to the activation of other

brain areas concerned with behavioural ignition. Illustrating this, lesionstudies have implicated activation of subcortical areas by the temporallobe in anger (Iosifescu et al., 2007; Potegal & Stemmler, 2010).

Research also shows anger-related activation patterns may be af-fected by other factors. For instance, while initial anger appraisal istransmitted to the ventromedial frontal cortex (VMFC) and orbitalfrontal cortex (OFC), the relationship between the two areas is vari-able. This is illustrated by Dougherty et al.'s (2004) finding of a posi-tive correlation between the left amygdala anger activation and VMFCin individuals with depression and an inverse relationship betweensuch areas in the absence of depression. Again underscoring this com-plexity, it has been observed that the VMFC and OFC act to mediateanger according to possible payoffs and punishments for enactmentof anger-related behaviour (Potegal & Stemmler, 2010).

A body of evidence also implicates specific brain areas in the expe-rience and production of visual imagery. Researchers have empha-sised the role of the limbic system and, in particular, the amygdalain the experience and rapid processing of visual imagery. Further-more, the amygdala and the periamygdaloid cortex have been notedto be activated by imagery-based recollections of trauma (Bystritskyet al., 2001; Shin, Rauch, & Pitman, 2005; Shin et al., 2004). The amyg-dala has also been noted to have a specialised role in recognition ofemotional facial expression (e.g., Gobbini & Haxby, 2006). This rolehas been noted as automatic in quality (Vuilleumier & Sande, 2008)and established for a range of facial expression(s) — includingangry, happy, fearful and surprised faces (de Jong, Koster, van Wees,& Martens, 2009; Furmark et al., 2009; Kim et al., 2004; Mogg, Garner,& Brandley, 2007).

Similar to anger's neural network, brain activation due to visualimagery varies according to the characteristics of the event/task con-cerned and the individual's perception of it (Holmes & Mathews,2010). For example, in a series of PTSD studies, a range of corticalstructures – including the precuneus, superior lingual gyrus, insula,inferior temporal gyrus and fusiform gyrus – were shown to exhibitdecreases in activity during script-driven visual imagery recollectionsof personally traumatic events (Shin et al., 2004; Shin et al., 2005).Consistent with this, grief research has shown that distinct brain re-gions are activated by cued images: the cuneus, superior lingualgyrus, insula, dorsal anterior cingulate cortex, inferior temporalgyrus and fusiform gyrus. In contrast, words activate the precuneus,precentral gyrus, midbrain and vermis (Gundel, O'Connor, Littrell,Fort, & Lane, 2003). The same PTSD research (Shin et al., 2004;2005), showed that activation of the inferior frontal cortex, and inparticular the inferotemporal cortex, occurred in situations involvingdirect exposure to fearful stimuli. Likewise, investigation of panic dis-order patients, via exposure to fearful stimuli, has shown increasedbrain activity in the inferior frontal cortex and, in particular, infero-temporal cortex and suggested that executive control of imagery oc-curs via the prefrontal cortex during fearful tasks requiring imaginalrepresentation of objects (Bystritsky et al., 2001).

There is a high level of overlap in the brain areas activated in theexperience and production of anger emotion and visual imagery.Drawing together the cited studies, the strongest evidence of sharedfunction appears to relate to the limbic system and, in particular,the role of the amygdala. This is most pronounced where humanfaces are implicit to the experience of imagery and/or anger. Thereis also evidence for the mutual involvement of the paralimbicand periamygdaloid areas, depending on the imagery-trigger type.Co-involvement of such brain structures in visual processing ofanger in a multi-site-response may prime the anger response inPTSD and thereby underlie the peremptory nature of AIP.

There are caveats which apply to this necessarily brief review.First, available evidence does not suggest that every brain area andcircuit involved in the experience of anger is involved in imagery pro-duction and vice versa. Notably, the ventral striatum and subcorticalregions and the lateral orbitofrontal cortex are not involved in the


development of imagery. Nor does there appear to be any left hemi-sphere lateralisation involved in visual imagery. In the other direc-tion, the operation of the periamygdaloid areas does not appearcentral to the experience of anger. Second, the precise overlap of im-agery and anger-implicated brain regions cannot currently be thor-oughly mapped. This is because, although, anger and anxiety havedifferent (fight and flight) core themes which are reflected in differ-ences in neural circuitry (Potegal & Qiu, 2010; Potegal & Stemmler,2010), their circuits simultaneously share commonalities (Lanius,Frewen, Vermetten, & Yehuda, 2010) and the extent of overlappingand differentiation circuits involved is not well-known, the circuitryof anger being considered less well known and in need of furtherinvestigation (Denson, Pedersen, Ronquillo, & Nandy, 2008). Thisand the complex relationship of brain function to visual imagery(Singer, 2006) make further visual imagery-anger research highlydesirable.

Notwithstanding this, such anger-imagery neurology overlap maybe understood in different ways. In a summary of the neuropsycho-logical evidence surrounding visual imagery and facial expression,Vuilleumier (2002) asserted that the automaticity associated withimagery enables near instantaneous detailed processing of sensoryinputs from the environment. This biases attention toward survival-salient stimuli, thereby involving the peremptory connection of imag-ery to basic negative emotion, such as fear and anger. This is sup-ported by Holmes and Mathews' (2010) comprehensive review ofthe clinical implications of imagery on emotion. They argued that im-agery for emotion precedes language's development as an early-stageevolutionary response to danger. It is also consistent with the sum-mation of the brain–body–behaviour connection of imagery toanger offered by Mayne and Ambrose (1999) in their selective reviewof research evidence on the psychological treatment(s) of anger.Drawing on the work of contemporary researchers – such as Berkowitz(1990) and Chemtob, Novaco, Hamada, Gross and Smith (1997) – theyargue that such neural networks are likely to act as part of a complexbrain–body interaction. In this interface, anger emerges from: (a) an in-stinctive assessment of the environment in brain areas programmed forrapid processing of visual information, (b) a match between signalsdetected and brain networks designed to act upon emotion and, conse-quently, (c) interaction of physiological processes, emotions andthoughts to modify feelings of anger.

In summary, neural pathways which link the processing of visualimagery with activation of defensive emotions, such as fear andanger, are evolutionarily adaptive in that they enable rapid mobilisa-tion of responses to potential threats, human or otherwise (LeDoux,1999). When out-of-balance, this system may become maladaptivein its response-activation to neutral stimuli or reminders. Some ofthe ways in which this may occur are considered in the paper's nextthree-sub sections.

5.2. Visual imagery in psychopathology

The role of visual imagery in AIP is also implied from the heavy in-volvement of intrusive, distressing and repetitive imagery with arange of psychopathologies. Visual imagery is integral to human per-ceptual and intellectual processes and psychological function (Singer,2006). However, findings from studies reviewed in a special issue ofthe Journal of Behavior Therapy and Experimental Psychiatry show ithas a powerful impact on negative emotion in a variety of psycholog-ical disorders (Holmes, Artnz, & Smucker, 2007). Furthermore, visualimagery is clearly involved in the pathogenesis of psychotic, dissocia-tive and depressive disorders (Clark, 2002; Hackmann & Holmes,2004; Holmes, Brewin, & Hennessy, 2004)and anxiety, substance-re-lated and psycho-somatic disorders (Holmes & Mathews, 2010).

Precisely why visual imagery should be associated with negativeemotion and psychopathology is unclear, but many factors havebeen proposed. Holmes and Mathews (2010) discuss a wide array

of features capable of explaining the impact of imagery on emotionand mental health. These factors fit within three broad explanatorycategories: (a) the direct effect of images on emotional systems inthe brain; (b) the tendency for images to have a similar impact tothat of real events; and (c) the capacity of images to reactivate pastfeeling states.

The direct effect of imagery on emotion systems is evident in re-search showing that negative imagery produces affective and somaticactivation (e.g., Nelson & Harvey, 2003). In essence, visual imagerystimulates, and is stimulated by, associated emotional and physiologicalarousal. Reactions to emotion-imagery are similar to the actual experi-ence of that emotion and in a reciprocal manner mind–body feedbackloops involving arousal further intensify imagery and consolidating itsconnection to negative affect (Holmes & Mathews, 2010; Lang, Kozak,Miller, Levin, & MacLean, 1980). Interestingly, it appears that there isan optimum level of imagery for psychological wellbeing. The effect ofless-than-optimal imagery levels is described in Borkovec's well-knownobservation that imagery avoidance occurs in pathological worry on ac-count of the interfering effect of worry associated with, what might betermed, Language Based Cognitive Phenomena (LBCP) (Borkovec & Inz,1990). The effect of more-than-optimal imagery is evident from the ob-servations that excess imagery can become associated with dysfunction(Dadds, Hawes, Schaefer, & Vada, 2004) and a preponderance of senso-ry-imagery encodingof information is associatedwithpersistent anddys-functional intrusive memories (Bywaters, Andrade, & Turpin, 2004b).Hence, it appears that imagery prevalence at either extreme of thepossible continuum of imaginal experience can result in dysfunction.

Imagery's similar impact to actual experience is well established. Itis understood that images can be perceived as real (Singer, 2006) andeven realer than real (Richardson, 2000) and that imaging an act en-gages the same motor and sensory programmes involved in actuallycarrying it out (Doidge, 2007; Holmes & Mathews, 2010). An exampleof this exists in research indicating that the ability to form vivid im-ages is associated with enhanced aversive learning (Bywaters et al.,2004b; Dadds, Bovbjerg, Redd, & Cutmore, 1997). This effect hasbeen well-demonstrated in research on social phobia and on PTSD(Cuthbert et al., 2003; McTeague et al., 2010).

This similar-impact-effect is also shown in the effect of disparitiesbetween reality and imaginal representations of reality. This is exem-plified in the fixated and illusory thinking of Obsessive CompulsiveDisorder and the hallucinatory and delusional mental content(s) ofpsychosis (DSM-IV; 1994). Perhaps the most pertinent example,however, occurs in PTSD, where repetition of intrusive affect-ladenimagery enhances an individual's capacity to experience vivid imag-ery (Bryant & Harvey, 1995).

The effect of visual imagery on psychopathology may also reflectthe operation of dysfunctional, unconstrained goals discrepant withreality (Conway, Meares, & Standart, 2004). This gap-effect has beendemonstrated in McNally's (2003) work on the mechanisms of trau-matic memory in PTSD. He emphasised the role of priming processesas important not only to recall, but also to the subjective veracity withwhich such recall is held, even if mistakenly so. Priming is best under-stood as the encoding of information in memory and subsequent in-creased capacity to recall this or related information from cuing,intended or otherwise.

Consistent with Holmes and Mathews' (2010) analysis, the capac-ity of imagery to activate past memories is described by Ironic ProcessTheory/the Zeigarnik Effect (James & Kendell, 1997; Wegner, 1994;Wenzlaff, 2002). This is the proposition that efforts to suppress mentalcontents, images included, can paradoxically lead to increased (re)occur-rence of that specific content (image). Accordingly, where there isnegative-emotion-influenced imagery – which is typically experiencedwith a greater sense of reality (e.g., asmeasured by vividness), comparedto non-emotional or semantic imagery (Holmes &Mathews, 2010) – itsaversive potential often results in unwitting attempts to suppress its oc-currence, thereby producing counter-intentional outcomes.

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In summary, imagery processes and affect valence appear to actconjointly to increase distress, through a variety of mechanisms,thereby consolidating their connection to each other. Consequently,the tendency to experience repetitive mental imagery is associatedwith high levels of negative emotion and an inverse relationship ex-ists between high levels of poorly managed visual imagery and men-tal health. The effect of its association with image-driven anger is nowconsidered.

5.3. Visual imagery in anger

Visual imagery's role in AIP can be inferred from a third line of ev-idence pertaining to the effect of imagery and anger and negativeemotion on each other. Imagery's impact on anger is demonstrableat various levels. It has been shown to have the capacity to generatephysiological responses indicative of angry mood. This is evidentin imagery studies utilising a range of physiological markers, suchas heart rate, skin conductance, corrugator and zygomatic facialmuscle, bodily temperature perception and blood pressure change(Stemmler, 2010). Investigation of the effect of actual, imaged and re-collected instances of anger has found imaged anger can actually gen-erate a greater response (as measured by diastolic blood pressure)than that derived from recollection of actual anger-related events(Foster, Smith, & Webster, 1999). Importantly, while, imagery incorpo-rating negative emotion results in strong physiological responses(Bywaters, Andrade, & Turpin, 2004a; Miller, Patrick, & Levenston,2002; Witvliet & Vrana, 1995), it is imagery with angry content thathas the most profound effect on physiological responses (Schwartz,Weinberger, & Singer, 1981; Sinha, Lovallo, & Parsons, 1992).

Imagery's effect on anger is also evident in the treatment of prob-lem anger. First, imagery has routinely been used to elicit past expe-riences of anger, which then become the target of treatment, via aself-instruction training (SIT) approach to treatment of problematicanger (e.g., Novaco, 1997). Induction of anger in this manner indi-cates that (disordered) imagery has the capacity to stimulate dys-functional anger. Second, imagery has been utilised in the treatmentof dysfunctional anger across a range of populations (e.g., Chemtob,Novaco, Hamada & Gross, 1997; Taylor, Novaco, Gillmer, Robertson,& Thorne, 2005; Taylor, Novaco, Gillmer, & Thorne, 2002) and treat-ment approaches — for example, via cognitive behavioural therapy(see Deffenbacher, 1999), emotion focussed-therapy (see Greenberg& Paivio, 1999) and SIT. A changemechanism, of course, does not nec-essarily reflect aetiology, and causal explanations cannot be deducedfrom any association between treatment outcome and imagery's usein treatment. Logically, however, if (dysfunctional) imagery werenot intrinsic to maintenance of problematic anger, there would be littlerequirement for its use in remedial procedures. Recalling McNally's(2003) work on PTSD memory mechanisms, it is pertinent to observehere the noted tendency for imagery repetition to enhance imagery ca-pacity (Bryant & Harvey, 1995).

Sympathetic to this evidence, research has also highlighted thesignificant impact of visual imagery on emotion (Beck & Emery,1985; Holmes & Mathews, 2010; Martin & Williams, 1990). Imaginalprocessing is considered to be more emotionally coloured than verbalinformation processing (Holmes & Matthews, 2005), can influencethe ability to experience emotion (Suler, 1985) and has an enduring,significant impact on emotion. Large sample research has also shownthat imagery can imbue emotions with an intensity consistent withthe actual objects of emotion (Kunzendorf, Hartmann, Thomas, &Berensen, 1999).

Research has also revealed anger's impact on imagery. For in-stance, it has been shown in research of type-A personality individualsthat high or increasing levels of anger lead to greater responsivity toimagery (Janisse, Edguer, & Dyck, 1986). Similarly, a study of state-trait anger in undergraduate university students showed those withhigh trait anger had greater reactivity to angry imagery in the absence

of enhanced imagery ability (Slomine & Greene, 1993). This and thepreviously cited study by Bywaters et al. (2004b), which showedstrongly-valenced, high-emotion-arousing tasks (measured via theInternational Affective Picture System) are associated with increasedvivid visual imagery, suggests angry distress and imagery share an as-sociation beyond imagery capacity.

There are also logical possibilities which point to the association ofvisual imagery and anger. Anger has an externally-directed focus(Spielberger et al., 1995). Its foci often directly involve others andtheir behaviours and instances where this is not so are relativelyrare. Interestingly, evidence from studies of visual imaging suggestsit is easier to produce imaginal constructs when instructions aregiven to include others, particularly significant others (e.g., parentalfigures) (Bent &Wick, 2006; McKelvie, 1994). This inclusion of othersfurther facilitates a reciprocal, image-emotion experience that in-creases the incidence of imagery. Added to this, the experience ofanger, perhaps more than any other emotion, can follow from a mul-tiplicity of possible causes and attributions. These include causes re-lated to actual or perceived injustice(s); personally being wronged,ignored, disrespected or devalued; and threat(s) to oneself, a depen-dent or significant other. Those suffering from significant dysfunc-tional anger often describe multiple reasons for their anger at thehands of others, each successive angry component operating asunique, compounding stimulators of imagery's incidence and impact,thereby strengthening the relationship of imagery to angry mood.[See Novaco (2007) or Spielberger et al. (1995) for a catalogue ofanger's myriad mental contents.]

The characteristics by which imagery may be measured also pro-vides grounds for asserting the association of imagery to anger.These characteristics include frequency, nowness, controllability, ab-sorption and vividness (see Hackmann, Ehlers, Speckens, & Clark,2004; Michael, Ehlers, Halligan, & Clark, 2005). As noted, the impactof these qualities of imagery is to directly affect emotional systems,impact similarly to real events and reactivate past feeling states(Holmes & Mathews, 2010).

Detailed in the following subsection on the association of imageryand AIP, the effects of imagery prevalence illustrate that frequent, un-bidden visual imagery can be associated with increased anger due toits occurrence. Overall, although more research is required to estab-lish the specific, casual or otherwise, link between visual imageryand anger, this link is plausibly deducible.

5.4. Visual imagery in anger in PTSD

Like anger, visual imagery is critically important to PTSD. Intru-sions are described as a core symptom (Horowitz, 2001; Witvliet,1997), risk factor (Davies & Clark, 1998), key severity moderator(Stutman & Bliss, 1985), and prime mediator of PTSD's psychophysi-ological activation (Laor et al., 1998). When uncontrolled, it is defin-ing of PTSD (Horowitz, 1983; 2001; Laor et al., 1998) and thestrength of the relationship is considered unique to PTSD, being nei-ther common to other anxiety disorders (Cuthbert et al., 2003; Ola-tunji et al., 2010) nor post-traumatic psychopathologies (Brewin &Holmes, 2003).

Investigations and reviews emphasise repetitive, traumatic imag-ery is a well-established cause of post-traumatic distress, anger in-cluded (Orth & Wieland, 2006; Schutzwohl & Maercker, 2000). Theyalso stress that affective arousal and sympathetic nervous system re-activity is a primary driver of PTSD's intrusive imagery (Orth &Wieland,2006; Witvliet, 1997).

While treatment effects cannot be used to determine causation,the connection of the two phenomena in AIP can also be discernedfrom treatment outcome research showing imaginal exposure forPTSD reduces not only intrusions, but also post-traumatic anger(Cahill et al., 2003). Although rare, there have been direct attemptsto treat AIP using visual imagery. For instance, there is the emerging

Table 2The association between anger and traumatic events.


Imagery Rescripting and Reprocessing Therapy (IRRT; Smucker &Moos, 2005) body of work. IRRT aims to identify, confront and modify(typically visual) “hot” cognitions by manipulating recollections viaimagery. It has been described as having successfully reduced symp-toms in individuals with problematic PTSD presentations whichhave not responded to other PTSD treatments and as having better ef-fects on non-fear based problems such as anger (Arntz, Tiesema, &Kindt, 2007; Grunert, Weis, Smucker, & Christianson, 2007).

The precise reasons the two phenomena appear to bemore stronglylinked in the presence of PTSD are yet to be established. However,their link is at least partly a reflection of the effect of themeanings as-cribed to intrusions. A potentially powerful determinant of angrydistress, it is well established from research on PTSD and other psy-chopathologies – such as, depression (see Starr & Moulds, 2006) –

that where intrusions occur, (negative) meaning(s) given to themtypically increase negative mood. Repetitive intrusions thus come torepresent a threatening loss of mental control and significant, angry,distress is likely to occur. Horowitz (1976; 1983; 2001) recognisedthis many years ago in his imagery-based theory of PTSD. Essentiallyan information-processing model of PTSD, Horowitz's theory assertsimage control failure lies at the root of severe posttraumatic symptom-atology. It recognises that, although individuals can have a strong desireto resolve differences between pre and post-trauma views of the self,others and theworld, this processing task can often be so psychological-ly painful that it is serially interrupted outside conscious awareness.Over time, this not only results in the oscillation between intrusionand avoidance Horowitz identified, but also anger.

The little PTSD research specifically focused on imagery andanger am-plifies the importance of control. A study by Laor et al. (1999) suggestedimage control influences anger presence, such that thosewith high imagecontrol have greater anger control and fewer intrusions compared toPTSD sufferers with low image control. In a review, Kosslyn (2005)reached similar conclusions, proposing loss of image control in the pres-ence of emotionally charged high-stress (especially traumatic) eventsleads to high arousal, this combination creating the potential for imag-ery to become stuck (i.e., in recursive loops).

The salience of imagery's content matter provides a second sensein which meanings associated with visual intrusions may have an ef-fect on anger. Content inevitably concerns what happened in thetrauma and can relate to a variety of factors. Take the case of trau-ma-type. Interpersonal trauma results in more severe PTSD thannon-interpersonal trauma, especially where there is culpability andmalevolence (Chung & Breslau, 2008; Rosen & Lilienfeld, 2008) is ev-idence of this. As such, it may be plausibly hypothesised that humanharm caused recklessly, deliberately or malevolently is more likelyto be associated with anger (see Table 2). This is consistent with thegeneral tendency for anger to externalise focus to others and blame,or at least identify, those who allowed or “caused” the trauma or itsaftermath (Mueser, Rosenberg, & Rosenberg, 2009; Pitman et al.,1991; Whiting & Bryant, 2007). It is also evident in self-directed re-sponsibility attributions, such as guilt-related anger (Tangney, George,Wagner, Fletcher, & Gramzow, 2001; Tangney, George, Wagner, Hill-Barlow, Marschall, & Gramzow, 1996) occurring post-trauma.

Another trauma-related content that may affect AIP relates to theautobiographical nature of intrusions in PTSD (DSM-IV; AmericanPsychiatric Association, 1994). Consistent with Holmes and Mathews'(2010) emphasis on the capacity of images to reactivate past feelingstates, irritable aversion is highly probable where such imagery re-lates to (accurate or erroneous) causal attributions concerning theself or another's actions pre, peri or post-traumatically, especiallywhere misfortune and harm apply. This is illustrated in post-disastersituations where traumatised individuals express angry distress atthe misplaced (in)actions of others in the recovery effort.

Although this intrusion-derived distress may initially be anxiousin nature – PTSD is after all an anxiety disorder – anger is likely to fol-low and may be only one-step-removed emotionally. This can be

argued on several grounds. First, it is consistent with the aforemen-tioned cognitive theory-derived survivor-mode, emotional avoidanceand neo-associationist accounts of AIP. Second, it is predicted by theWarning Signal model of PTSD's intrusive memories (Ehlers et al.,2002). This model holds that intrusive memories, through their con-nection with stimuli in place at the time of the trauma, function aswarnings of the potential re-occurrence of the trauma, where thosesame stimuli are again encountered. Faced with warning-intrusions,survival cognitions ontologically become imperative and the univer-sally observed fight or flight response is invoked— anger and anxiety,being the two well-known emotional endpoints of this chain-of-events. Third, anger, anxiety and depression share status as the bigthree negative affects (Frisch, 2006). As high-prevalence, dysphoricaffects they demonstrably overlap in content and are often clinicallycomorbid and interdependent. Finally, anger has a role as an energis-ing, secondary or cloaking emotion for dysphoria generally — this lat-ter function being especially likely in the context of PTSD (Feeny et al.,2000). The effect of this is that, even if the initial emotional experi-ence in response to unwanted imagery is not characterised byanger, imagery may indirectly result in angry affect.

The relationship between anger and intrusions in PTSD (Orth &Wieland, 2006) in which physiological arousal associated withanger leads to intrusions and, in turn, is reciprocally potentiated bysuch intrusions, has two ironic outcomes, which again strengthenthis relationship. The first is that intrusion repetition increases the ca-pacity to experience imagery (see Bryant & Harvey, 1995; Rauch, Foa,Furr, & Filip, 2004) and imagery vividness (Laor et al., 1999). As noted,visual imagery beyond an optimal frequency is likely to result in dis-tress (Dadds et al., 2004). In turn, this distress leads to further intru-sions (Kosslyn, 2005). Given the interaction of intrusions and AIP,increased image frequency and clarity is an obvious risk for increasingthe experience of anger. The second irony is that, just as thought sup-pression has been shown to result in a rebound effect in PTSD intru-sions (e.g., Clark, 2002; Davies & Clark, 1998), attempts to suppressintrusive imagery are likely to lead to perverse and unintended in-creases in imagery. This effectively forms a psychological doublebind for the individual — between being assailed by frequent, out-of-control, vivid, intrusive visual material and associated loss-of-control of thoughts and feelings and succumbing to the false-refugeof attempting to suppress such material, with its potentially amplify-ing consequences.

5.5. Summary of evidence for conceptualising visual imagery as a keyunderlying psychological process in anger in PTSD

Although limited attention has been given to the contribution vi-sual imagery may make to AIP, there are several interwoven sourcesof evidence which indicate that it may contribute significantly to


the relationship of anger to PTSD. Fig. 1 presents a schematic repre-sentation of the hypothetical interaction of these neuropsychological,emotion, disorder-based and imagery influences on AIP. In accor-dance with the lines of evidence reviewed, it depicts visual imageryand anger as intimately connected, especially by threat vigilanceand other involvement. Visual imagery and anger are shown to po-tentiate and be potentiated by PTSD symptoms. This is particularlyso where responsibility cognitions are prominent. PTSD, through in-trusion-related distress and practice effect(s), reiteratively bringsabout increased anger and imagery. Simultaneously, neuropsycholog-ical functioning facilitates anger and visual imagery and their rela-tionship by differing, yet overlapping neural networks, and via anadded, recursive, independent pathway between anger and PTSDsymptoms.

6. Visual imagery and word-based cognitive processes in angerin PTSD

Recent evidence from a sequential series of studies conducted byHolmes and Mathews with others (summarised in Holmes & Mathews,2010) emphasises that imagery has a more powerful effect than verbalrepresentation of equivalent events.

Historical accounts of AIP have not recognised this and, instead,have been rooted in an understanding of cognition that emphasisesthe previously termed Language Based Cognitive Phenomena(LBCP). Consequently, it is the thoughts and ideas implicit to schema-ta, associative networks and appraisals which have been highlightedin such accounts of AIP.

A broader view of cognition in AIP, whereby the contribution of vi-sual imagery is duly recognised, is inherent to better understandingAIP. This will not diminish the role of LBCP in development of AIP forvisual and word-based thinking are fundamental cognitive processeswhich at times can be linked to each other. Further, each has the po-tential for limiting or expanding the role of the other in the aetiologyand maintenance of anger given high prevalence imagery interfereswith the capacity to reason (Knauff & Johnson-Laird, 2002). To inte-grate them in a model where heightened visual imagery or LBCPmay act, independently or interactively, in a serial or parallel fashion,to bring about anger would be an important development.

Fig. 1. Prototypical summary model of the relationship between PTSD

A cogent illustration for doing so exists in the case of rumination.A key characteristic of PTSD, rumination contributes to ongoing threatperception after the experience of trauma (Elwood, Hahn, Olatunji, &Williams, 2009), thereby maintaining PTSD symptoms, especially in-trusions and AIP (Orth & Wieland, 2006). In attempting to explainthe strong correlation between anger and PTSD, several authorshave observed that a (thought-based) ruminative style of emotionregulation is closely linked to re-experiencing in PTSD (e.g., see Ehlerset al., 1998; Orth & Wieland, 2006). Typical of this, Elwood et al.(2009), in discussing rumination as one of four cognitive vulnerabil-ities for the development of PTSD, describe it as the tendency to (ina word-based manner) think repetitively about negative emotions,events and distress and their meaning. This is highly plausible:anger regulation may indeed relate to language-based rumination as-sociated with intrusive material. Illustrations exist in the thinkingstyles implicit to survivor schema (Chemtob, Hamada, Roitblat, &Muraoka, 1994) and the persistent and excessively negative ap-praisals of trauma and its aftermath incorporated in cognitive modelsof PTSD, such as that of Ehlers and Clark (2000).

In an anger model which accommodates visual imagery, it is alsoplausible that repetitious, intrusive, visual imagery may characteriseangry rumination in PTSD. To recall earlier findings, visual imaginalprocessing is more emotionally coloured than verbal processing of in-formation and has a more powerful effect than that of verbal repre-sentation of equivalent events (Arntz, de Groot, & Kindt, 2005;Holmes & Mathews, 2010; Holmes & Matthews, 2005). Although ru-mination may be verbal in nature in some disorders [e.g., in depres-sion (Fresco, Frankel, Mennin, Turk, & Heimberg, 2002; Segal, Lau, &Rokke, 1999)], PTSD's intimate relationship with imagery suggeststhat its importance in AIP may also derive from rumination having astrong visual component.

Although not reflected in the literature, the role of visual imageryin evoking, amplifying and prolonging anger – in this instance via itsassociation with rumination – may not only be compatible with thecontribution of LBCP but also, on occasions, buttress it. This possibilitywas documented over 25 years ago by Beck and Emery (1985) intheir proposition that “Undesirable visual images often stimulate ver-bal cognitions” (page 222).

There is further precedence for understanding AIP from a visualimagery viewpoint — for example, in the so-called binary storage

symptoms, neuropsychological function, VIC and anger in PTSD.

image of Fig.�1


proposition of Brewin, Dalgleish, and Joseph (1996). This accountproposes PTSD's intrusive memories exist in verbally accessible mem-ory (VAM) and situationally accessible memory (SAM) storage systems.VAMs are thought to be consciously available for verbal processingand communication and relate to potential losses and past regrets;for example, in guilt over opportunities forgone or anger at carelessrisk-taking. SAMs are purported to contain information obtainedfrom lower-level perceptual processing of the traumatic scene. Suchmemories are restricted to those experienced during trauma or sub-sequent moments of intense arousal. They are most often colouredby emotions of fear, helplessness and horror, but may include otheremotions, such as anger.

These rumination and binary-storage examples of the interplaybetween word and image-based cognition sit within a larger field ofevidence corroborating the role of imagery that is well-summarisedby authors such as Singer (2006) and Holmes and Mathews (2010).To summarise, a theoretical model which emphasises the role of visu-al imagery and interaction(s) between it and LBCP – in an integrated,imaginal-linguistic cognitive model of AIP – is supported by, and hashistorical precedence in, explanations of disorders and emotions.

7. Future directions for research of visual imagery in anger in PTSD

Adoption of a model of AIP emphasising the role of visual imageryoffers a number of lines of further enquiry. To validate the role of im-agery in AIP, a number of challenges need to be addressed. First, thecontribution to AIP of key dimensions of visual imagery needs to bemapped. This will involve investigation of qualities such as preva-lence, absorption, vividness, brightness, nowness and control (seeHackmann et al., 2004; Kunzendorf, 1981; Laor et al., 1999; Laor etal., 1999; Suler, 1985). Given there is a continuum of imagery experi-ence, whereby “vivid imagers tend to construct sensory representa-tions of unconscious visual thoughts, whereas imageless thinkers donot” (Kunzendorf, Young, Beecy, & Beals, 2000: page 981), it will beimportant to consider the role of visual imagery capacity on AIP inmapping the effect of imagery on AIP. Visual imagery capacity is influ-enced by a range of factors, including age, gender, the effect of inter-personal style and developmental experiences, cultural practices,practice effects and motivation (Chambers, 1997; Giambra, 1977;2000; Kearins, 1981; 1986). Integral to this, it is important that diag-nostic markers are explored, so any visual imagery AIP-vulnerabilitythresholds may be identified.

There is also the need to account for possible trauma-related me-diators and moderators of visual imagery's effect on AIP. Take the caseof trauma dose. McTeague et al. (2010) have noted that PTSD's affec-tive responses differ according to whether response to discrete ormultiple traumas are involved. They note that in situations of discretetrauma, PTSD appears to be characterised by increased defensive re-activity to aversive imagery, while after multiple, higher magnitude,traumas, PTSD is marked by a higher anxious and depressive morbid-ity that results in a blunted response. Another factor likely to affectAIP is time (Orth & Wieland, 2006). Consistent with the long-estab-lished understanding that PTSD involves recursive, oscillating phasesof intrusion and denial/avoidance (Horowitz, 1992), AIP presence, in-tensity and expression may vary by trauma proximity and cyclicallyvary in strength and quality over time post-trauma.

The influence of non-trauma moderators on the relationship ofimagery and AIP is another important area of enquiry. A prime exam-ple is the role of temperament/personality factors in anger and visualimagery. Certain personality types are known to experience moreanger — for instance, those with personality traits of high negativeemotion and low behavioural constraint (Miller, 2003). Similarly,temperament and personality-related processes affect preference forimaginal processes. For example, it has been reported that hallucina-tors have more vivid imagery and higher scores on personality pa-thology scales (Lopez, Paino Pineiro, Martinez Suarez, Caro, & Lemos

Giraldez, 1997). Moreover, greater internal locus of control is associ-ated with greater imagery control (Bryan, 1999) and type-A personal-ity is associated with greater imagery vividness (Dyck, Moser, &Janisse, 1987).

Finally, to build a model to account for the operation of visual im-agery in AIP, it is essential to demonstrate how visual imagery inter-acts with other cognitive processes involved in AIP. To recall earlierargument, visual imagery alone is unlikely to account for all presenta-tions of AIP. At times, it may have little effect on AIP, interact withother cognitive mechanisms or have a large, singular and direct effecton anger. Thus an imagery-inclusive classification of AIP capable ofdiscriminating those with and without problematic anger and ac-counting for observed individual variations in it might be developed.There is precedence for attempting this in the regulatory deficits ty-pology of Chemtob, Novaco, Hamada, Gross, & Smith (1997), whichdescribes anger's varying presentations via the broad dimensions ofcognition, arousal and behaviour. A classification of AIP which placesemphasis on visual imagery may extend the reach of such typologies.It would also be consistent with the deeper-level, detailed, localisedand practical theorising Dalgleish (2004) advocated in his compre-hensive analysis of the requirements of PTSD research and simulta-neously avoid the narrowness-of-focus and alienating complexitypitfalls he warns against.

8. Conclusion

Current conceptualisations cannot provide a model sufficient toexplain the relationship of anger to PTSD. The role of visual imageryin AIP has the potential to address this deficiency. Theminting of a hy-pothetical construct to describe problematic AIP – that is, as angerinfluenced by visual imagery – offers impetus for a new, fruitful lineof enquiry. This imagery-broadened view of the role of cognition inAIP has the potential to offer new understandings of AIP and PTSDand their treatment. Taking up A.T. Beck's observation that “effectivecognitive therapy depends greatly on moving beyond purely verbalexchanges to encouraging patients and therapist to resort to their au-ditory or visual imagery capacities” (Singer, 2006: page 107), it hasthe potential to assist people to unlearn unwanted posttraumatic re-actions and develop new ways of responding to traumatisation.

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Anger in PTSD: Is there a need for a concept of PTSD-related posttraumatic anger

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