Case Study

Cognitive Processing in Anger and Verbal Aggression among Male Forensic Inpatients – a case series using metacognitive profiling

Stine Bjerrum Moeller*

Psychiatric Research Unit, Mental Health Centre Stolpegaard Stolpegardsvej 20, Copenhagen University, Denmark.

*Corresponding author: Stine Bjerrum Moeller, Psychiatric Research Unit, Mental Health Centre Stolpegaard Stolpegardsvej 20, DK-2820 Gentofte, Copenhagen University, Denmark.


Citation: Moeller SB (2019) Cognitive Processing in Anger and Verbal Aggression among Male Forensic Inpatients – a case series using metacognitive profiling. J Psychiatry Behav Ther 2019: 01-05

Received Date: 19 March 2019; Accepted Date: 29 March 2019; Published Date: 05 April 2019


Background: Maladaptive cognitive processes have been evidenced in problem anger, and anger rumination is empirically well-established to increase anger and aggression. Negative and positive beliefs about anger may be involved in the selection of maladaptive mental strategies such as angry rumination. The current study explored male forensic inpatients’ self-reports of meta-beliefs about anger in episodes involving anger and verbal aggression. Method: Five male forensic inpatients participated in a larger data collection were interviewed after a verbally aggressive episode to explore the problematic processing routines and metacognitions activated during anger arousal. Measures: Anger was measured using the NAS, aggression using the SOAS-R, and metacognitive beliefs using the MAP. Patients were interviewed using the `metacognitive profiling´ developed by Wells. Results: All five participants confirmed activated negative meta-beliefs, three confirmed positive meta-beliefs, and three patients confirmed rumination in association with the anger episode concerning the interview. Conclusion: Male forensic inpatients could successfully report details on their cognitive processes during a recent anger episode, and the metacognitive perspective on anger seems clinically relevant to apply in this setting. Modifying the cognitive structures responsible for the selection of rumination as a mental strategy in situations of anger might prove helpful in anger interventions.

Keywords: Anger; Male forensic inpatients; Metacognitive beliefs; Rumination; Verbal aggression


Dynamic risk factors, being changeable, have value for the prevention of aggression, because they constitute targets for specific treatment. Deeper understanding of dynamic variables contributing to aggression will permit the identification of high-risk individuals for violence and can pave the way toward articulating psychological interventions to prevent acts of aggression.

The association between anger and aggression is well-established as a range of independent studies with multiple control variables have confirmed anger as a predictor of aggression [1].  In a Danish study among hospitalized patients, anger predicted aggression with 10-unit increase on the NAS-DK (range 48 to 144) resulting in a 44% increase in aggressive incidents [2].  However, despite that anger obviously influences the cognitive processes leading to aggression, many studies have ignored the potential role of the patients´ anger. Thus, further research into anger processing and its potential to influence on aggression is required.

Maladaptive cognitive processes have been evidenced in problem anger [3,4] empirically well-established that anger activates angry rumination [5] which in turn increases anger and aggression [6]. Closer to this study´s population, using data from the large MacArthur Violence Risk Study [7] reported that the presence of violent fantasies was significantly related to anger and violence in the 20 week period after discharge. In a Danish study among hospitalized forensic patients found that 46% of the patients reported violent fantasies, which were strongly associated with anger and aggressive incidents [8].

The metacognitive approach [9-11] is a theoretical approach to studying cognitive processes in emotional disorders emphasizing the strategic aspects of cognitive processing. Wells and Matthews [9-11] formulated how the application of mental strategies during cognitive processing is guided by metacognitive beliefs. Metacognitive beliefs are beliefs about thinking processes, such as how controllable and how normal it is, and about the functions and the consequences of certain types of thinking. Due to the individual´s cognitive goals (e.g. escape negative feeling, avoid negative thoughts, be prepared for danger) the individual sees mental strategies, such as rumination, as the way to find a solution and fails to see them as part of the problem. Furthermore, due to inflexible mental strategies, the cognitive processing is locked maintaining emotional arousal. As such, the metacognitive approach offers a formulation of the selection of mental strategies and the consequence of those strategies.

Simpson and Papageorgiou et al. [12] were the first to explore the metacognitive components of anger in a clinical setting in an interview study. They reported that 100% of patients referred for anger problems ruminated and held negative beliefs about anger, and 80% held positive beliefs about anger. The initial attempt at constructing a metacognitive assessment tool for anger [13, 14] suggested that both positive and negative metacognitive beliefs, and uncontrollable rumination are involved in episodes of dysregulated anger.

Aim of the current study

This study aimed to explore male forensic inpatients’ selection of mental processing strategies during verbally aggressive episodes using the metacognitive profiling approach developed by Wells [10].


Participants were five male forensic inpatients drawn consecutively from a larger data collection with psychological instruments. For a detailed description of the full see Moeller et al. [2] and [14]. The mean age was 41.2, SD = 13.2, range 32 – 64 years, and the mean length of education was 9.8, SD = 2.2, range 7 – 12 years. All five participants had a diagnosis of schizophrenia, were single and received beneficiary compensation due to not being able to work, and four had co-morbid substance abuse.

Data were gathered between February 2010 and April 2010. Written information about the study was provided and informed consent obtained. The study was approved by the Danish Data Control system (2007-58-0015). It was emphasized that participants would not be identified in subsequent reports and that personal data would not be used in the psychiatric or the forensic system. Within 2 days of the verbally aggressive episode, patients were interviewed on their hospital wards by the author (psychologist specialized in CBT).


Novaco Anger Scale [15]. The NAS is a 60-item scale constructed to measure anger disposition. The reliability and validity of the NAS Danish have been investigated by Moeller et al. (2015).

The Metacognitive Anger Processing scale [13, 14]. The MAP is a 26- item scale assessing metacognition in relation to anger on 3 domains: (1) General positive beliefs about the functions of anger, (2) Negative conceptions related to anger, and (3) Uncontrollable angry rumination. Validity has been established in a general and a prison population [13], as well as among mixed clinical patients, and male forensic inpatients [14].

Staff Observation Aggression Scale – Revised [16] is a form used to register aggressive incidents onwards. The SOAS-R has shown good inter-rater reliability in countries comparable to Denmark [16, 17].

The `metacognitive profiling´ profiling interview [10] was adapted to focus specifically on cognitive experiences associated with anger structured by: (1) use of mental processing strategies, (2) goal in using the mental strategy, (3) the perceived effectiveness of the mental strategy, and (4) meta-beliefs/appraisals regarding anger in that situation. Others have successfully applied this method [12, 18].


The mean score of NAS in this subsample (95.7, SD = 17.5) was in the same range as the full sample 105.4, SD = 28.9; the mean score of MAP Rumination in this subsample (21.6, SD = 8.9) was in the same range as the full sample 19.9, SD = 7.6; the mean score of MAP Positive beliefs in this subsample (14.0, SD = 7.0) was in the same range as the full sample 17.7, SD = 7.4; the mean score of MAP Negative beliefs in this subsample (25.4, SD = 7.6) was in the same range as the full sample 21.2, SD = 6.6  reported by Moeller & Bech et al. [14].

 All patients confirmed being angry during the episode of verbal aggression, all five participants confirmed activated negative meta-beliefs, three patients confirmed positive meta-beliefs regarding anger, and three patients confirmed rumination in the anger episode concerning the interview. The interviews exposed the following themes of metacognitive beliefs: Attempt at understanding, Preparing for threat, Controlling emotions, Justification and securing authority, Avoiding unwanted self, Overriding control, Madness and irrational, Socially unacceptable.


The study revealed that male forensic inpatients with diagnoses of schizophrenia could successfully report details on their cognitive processes during a recent anger episode. In the study on anger by Simpson & Papageorgiou et al. [12], they identified themes involved in metacognitive beliefs; the current study replicated and expanded on those findings, signifying the broad clinical applicability of the metacognitive perspective to apply also in a setting of male forensic inpatients. (Table 1) displays the metacognitive beliefs.

Positive metacognitive beliefs

Attempt at understanding. Because seeking insight and understanding (i.e. ruminating) may sometimes be a helpful mental strategy in response to anger arousal it may be more resistant to extinction than if reinforced continuously. Extinction following intermittent reinforcement can take thousands, even tens of thousands, of responses [19]. In depression, Watkins [20] differentiated between an abstract analytical inner focus and a concrete experiential inner focus, arguing that the abstract thinking style constitutes a maladaptive mental strategy. These findings suggest that a similar maladaptive thinking process could be relevant for understanding problematic anger.  Preparing for threat. With anger´s link to the survival system preparing the organism to overcome aversive stimuli, evidence supports how such a meta-belief could be reinforced [21-23]. Controlling emotions. When feeling threatened, anger was reinforced by repressing anxiety, as well as controlling the experience of other negative emotions (e.g. “I felt “crap” and had self-critical thoughts but ruminating about what others had done wrong made me energetic”). Justification and securing authority. Rumination seemed to be used to hold on to the angry emotion with the ultimate goal of problem-solving in a broad sense, which may be maintained as a response through contingencies of reinforcement. Bandura [24] wrote: “to the extent that forcible responsiveness produces good results, the rewarding consequences can shape aggressive styles of behavior” (p. 91). Avoiding unwanted self. In the interviews, anger also seemed to serve the function of avoiding an unwanted self. For example, participant A perceived himself as a strong and competent person when responding with anger when other people intimidated him, and a sense of being vulnerable and weak was an unwanted and feared self-experience. Thus, anger served the function of avoiding that unwanted self [20].

Negative metacognitive beliefs

Overriding control. Because a little anger can lead to a lot of anger culminating in overriding inhibitory control with harmful effects, anger becomes cemented as a dangerous emotion linked to experiences of uncontrollability. In the interview, participants reported trying to control the anger arousal, however evidence suggests that suppression is an ineffective strategy [25 – 27]. By offering an immediately relief, suppression may be negatively reinforced and thus maintained even though in the long term inefficient. Socially unacceptable. The negative social consequences regarding anger arousal were identified in the interviews (e.g. “they (the staff) get mad at me for getting angry”).  This is supported by the findings from Gilbert et al. [28] among depressed people, finding that people restrained their anger due to negative beliefs about the social consequences of expressing anger (e.g., fear of rejection by others, fear of losing control, fear of harming others). Madness and irrational. Anger was perceived as signifying madness which has been discussed as having deep historical roots [29]. This state of madness as reflecting a subjective experience of the detrimental influence of high arousal on higher cognitive functioning is evidenced in experimental research [30].

Limitations and Conclusion

The results of this study are clearly preliminary and explorative. The sample is small and heterogeneous. Schizophrenia or associated abnormal thought disorders could possibly modify the explored selection of mental processing strategies during verbally aggressive episodes, which will need to be investigated in future studies. However, this study could inspire other researchers to further investigate cognitive processes involved in anger to enhance anger treatment. Anger treatment may benefit from focusing on the potential structures (meta-beliefs) involved in maintaining dysfunctional processing strategies in anger such as rumination.


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