Emotional processing in posttraumatic stress disorder

Emotion in psychogenic nonepileptic seizures: responses to affective pictures

We examined emotional responses to standard affective pictures in 18 psychogenic nonepileptic seizure (PNES) patients. Given reports of trauma and posttraumatic stress symptoms (PTS) in many PNES patients, comparison groups were seizure-free individuals high and low in PTS (PTS-high, PTS-low; n=18 per group). Patients with psychogenic nonepileptic seizures (1) reported more emotional intensity to neutral and pleasant pictures than PTS-low and more intensity to neutral pictures than PTS-high, and (2) showed less positive emotional behavior to pleasant pictures than PTS-high. Groups did not differ in pleasantness/unpleasantness ratings, negative emotional behavior, cardiac interbeat interval, or respiratory sinus arrhythmia (RSA) reactivity to the pictures. Patients with psychogenic nonepileptic seizures reported more general emotion regulation difficulties and showed lower baseline RSA than PTS-low but not PTS-high. In sum, intense emotional experience and diminished positive emotional behavior characterized PNES patients' emotional responses.

Longitudinal linkages between depressive and posttraumatic stress symptoms in adolescent survivors following the Wenchuan earthquake in China: A three-wave, cross-lagged study

This study aimed to determine the relationships between depressive and posttraumatic stress disorder (PTSD) symptoms in a sample of adolescent survivors following the Wenchuan earthquake in China. Two-hundred adolescent survivors were reviewed at 12, 18 and 24-months post-earthquake. Depression and PTSD were assessed by two self-report questionnaires: The revised Center for Epidemiologic Studies Depression Scale for Children and the Revised Child PTSD Symptom Scale, respectively. The cross-lagged structural equation analysis with latent variables indicated that the PTSD symptoms and depression could be considered as two distinct and high-correlated constructs, and depression symptomatology pre-event could predict post-event PTSD. Depression symptoms play a crucial role in the development of PTSD symptoms. Implications of the results for psychological service providers to children and youth are discussed.

Distress after a Single Violent Crime: How Shame-Proneness and Event-Related Shame Work Together as Risk Factors for Post-Victimization Symptoms

To increase understanding of post-victimization symptom development, the present study investigated the role of shame- and guilt-proneness and event-related shame and guilt as potential risk factors. 35 individuals ( M age = 31.7 yr.; 48.5% women), recently victimized by a single event of severe violent crime, were assessed regarding shame- and guilt-proneness, event-related shame and guilt, and post-victimization symptoms. The mediating role of event-related shame was investigated with structural equation modeling (SEM), using bootstrapping. The guilt measures were unrelated to each other and to post-victimization symptoms. The shame measures were highly intercorrelated and were both positively correlated to more severe post-victimization symptom levels. Event-related shame as mediator between shame-proneness and post-victimization symptoms was demonstrated by prevalent significant indirect effects. Both shame measures are potent risk factors for distress after victimization, whereby part of the effect of shame-proneness on post-victimization symptoms is explained by event-related shame.

Posttraumatic stress, difficulties in emotion regulation, and coping-oriented marijuana use

In an effort to better understand factors that may explain prior findings of a positive relation between posttraumatic stress symptom severity and coping-oriented marijuana use motivation, the present study tested whether the association between posttraumatic stress symptom severity and marijuana use coping motives is mediated by difficulties in emotion regulation. Participants were 79 (39 women; M(age) = 22.29 years, SD = 6.99) community-recruited adults who reported (1) lifetime exposure to at least one posttraumatic stress disorder Criterion A traumatic event and (2) marijuana use in the past 30 days. Results indicated that difficulties in emotion regulation, as indexed by the Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004), fully mediated the association between posttraumatic stress symptom severity and marijuana use coping motives. Implications for the treatment of co-occurring posttraumatic stress and marijuana use are discussed.

Childhood maltreatment and difficulties in emotion regulation: associations with sexual and relationship satisfaction among young adult women

This study examined relations among childhood maltreatment, difficulties in emotion regulation, and sexual and relationship satisfaction among young adult women reporting current involvement in committed, romantic relationships. A sample of 192 women (ages 18-25) completed self-report questionnaires as part of an Internet-based survey. It was hypothesized that severity of childhood maltreatment and difficulties in emotion regulation would each independently and negatively predict (a) sexual satisfaction, (b) relationship intimacy, and (c) expression of affection within the context of the relationship. Furthermore, it was hypothesized that greater emotion regulation difficulties would moderate the effects of childhood maltreatment on these sexual and relationship variables (i.e., sexual satisfaction, relationship intimacy, and expression of affection). Findings suggest that difficulties in emotion regulation demonstrated an incremental effect with regard to sexual satisfaction, but not with intimacy and affection expression. In contrast to predictions, no significant interactive effects were documented. Clinical implications and future directions related to this line of inquiry are discussed.

Alexithymia and posttraumatic stress: subscales and symptom clusters

This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difficulty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed.

Posttraumatic distress and the presence of posttraumatic growth and meaning in life: Experiential avoidance as a moderator

Existing models of trauma suggest that for recovery to occur, trauma related cues and emotions require awareness and openness while survivors continue committing action toward valued life aims (other than regulating emotions). Based on this theoretical framework, an unwillingness to be in contact with distressing thoughts and feelings (experiential avoidance) might operate together with posttraumatic distress to predict when people find benefits and meaning in the aftermath of trauma. We hypothesized that people reporting posttraumatic distress and less reliance on experiential avoidance would report greater posttraumatic growth and meaning in life compared with other trauma survivors. We administered questionnaires to 176 college students reporting at least one traumatic event. Results supported these moderation models. This is the fourth study (with different samples, measures, and methodologies) to provide evidence that a combination of excessive anxiety and a heavy reliance on experiential avoidance leads to attenuated well-being. We discuss the implications for understanding heterogeneous trauma reactions.

Emotion regulation difficulties in trauma survivors: the role of trauma type and PTSD symptom severity

Two different hypotheses regarding the relationship between emotion regulation and PTSD are described in the literature. First, it has been suggested that emotion regulation difficulties are part of the complex sequelae of early-onset chronic interpersonal trauma and less common following late-onset or single-event traumas. Second, PTSD in general has been suggested to be related to emotion regulation difficulties. Bringing these two lines of research together, the current study aimed to investigate the role of trauma type and PTSD symptom severity on emotion regulation difficulties in a large sample of trauma survivors (N=616). In line with the hypotheses, PTSD symptom severity was significantly associated with all variables assessing emotion regulation difficulties. In addition, survivors of early-onset chronic interpersonal trauma showed higher scores on these measures than survivors of single-event and/or late-onset traumas. However, when controlling for PTSD symptom severity, the group differences only remained significant for 2 out of 9 variables. The most robust findings were found for the variable "lack of clarity of emotions." Implications for future research, theoretical models of trauma-related disorders, and their treatment will be discussed.

Longitudinal associations between post-traumatic distress and depressive symptoms following a traumatic event: a test of three models

BACKGROUND

Symptoms of post-traumatic stress disorder (PTSD) and depression are highly co-morbid following a traumatic event. Nevertheless, decisive evidence regarding the direction of the relationship between these clinical entities is missing.

METHOD

The aim of the present study was to examine the nature of this relationship by comparing a synchronous change model (PTSD and depression are time synchronous, possibly stemming from a third common factor) with a demoralization model (i.e. PTSD symptoms causing depression) and a depressogenic model (i.e. depressive symptoms causing PTSD symptoms). Israeli adult victims of single-event traumas (n=156) were assessed on measures of PTSD and depression at 2, 4 and 12 weeks post-event.

RESULTS

A cross-lagged structural equation modeling (SEM) analysis provided results consistent with the synchronous change model and the depressogenic model.

CONCLUSIONS

Depressive symptoms may play an important role in the development of post-traumatic symptoms.

Exaggerated and disconnected insular-amygdalar blood oxygenation level-dependent response to threat-related emotional faces in women with intimate-partner violence posttraumatic stress disorder

BACKGROUND

Intimate-partner violence (IPV) is one of the most common causes of posttraumatic stress disorder (PTSD) among women. PTSD neuroimaging studies have identified functional differences in the amygdala and anterior cingulate cortex (ACC)/medial prefrontal cortex during emotion processing. Recent investigations of the limbic sensory system and its associated neural substrate, the insular cortex, have demonstrated its importance for emotional awareness. This study examined the hypothesis that women with IPV-PTSD show a dysregulation of this limbic sensory system while processing threat-related emotional faces.

METHODS

12 women with IPV-PTSD and 12 nontraumatized comparison women underwent blood oxygenation level-dependent functional magnetic resonance imaging while completing an emotional face-matching task.

RESULTS

IPV-PTSD subjects relative to comparison subjects displayed increased activation of the anterior insula and amygdala and decreased connectivity among the anterior insula, amygdala, and ACC while matching to fearful versus happy target faces. A similar pattern of activation differences was also observed for angry versus happy target faces. IPV-PTSD subjects relative to comparison subjects also displayed increased dorsal ACC/medial prefrontal cortex activation and decreased ventral ACC activation when matching to a male versus a female target, and the extent of increased dorsal ACC activation correlated positively with hyperarousal symptoms.

CONCLUSIONS

Women with IPV-PTSD display hyperactivity and disconnection among affective and limbic sensory systems while processing threat-related emotion. Furthermore, hyperactivity of cognitive-appraisal networks in IPV-PTSD may promote hypervigilant states of awareness through an exaggerated sensitivity to contextual cues, i.e., male gender, which relate to past trauma.

Everyday strivings in war veterans with posttraumatic stress disorder: suffering from a hyper-focus on avoidance and emotion regulation

This research investigated whether combat veterans' daily strivings are related to the presence of post-traumatic stress disorder (PTSD) and well-being. Veterans created a list of their most important strivings, which were content-analyzed for emotion regulation and approach or avoidance themes. It was hypothesized that veterans pursuing strivings with themes of emotion regulation or avoidance experience deleterious consequences compared with other veterans. For all veterans, devoting finite time and energy in daily life to regulating emotions was associated with less purpose, meaning, and joy compared with other strivings. Veterans with PTSD endorsed more strivings related to emotion regulation and devoted considerable effort to emotion regulation and avoidance strivings. Yet, these efforts failed to translate into any discernible benefits; veterans without PTSD derived greater joy and meaning from strivings focusing on approac- oriented behavior and themes other than emotion regulation. The presence of PTSD and a high rate of emotion regulation strivings led to the lowest global well-being and daily self-esteem during a 14-day assessment period. The presence of PTSD and a high rate of avoidance strivings also led to lower emotional well-being. Results indicate that strivings devoted to regulating emotions or avoidance efforts influence the mental health of veterans with and without PTSD. Studying personality at different levels of analysis-traits, strivings, and life narratives-allows for a fine-grained understanding of emotional disorders.

Structure of posttraumatic stress disorder symptoms and psychosocial functioning in Veterans of Operations Enduring Freedom and Iraqi Freedom

Posttraumatic stress disorder (PTSD) is one of the most prevalent psychiatric conditions in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF-OIF), but little is known about the structure of PTSD symptoms, and associations between PTSD symptom clusters and psychosocial functioning in this population. A total of 272 OEF-OIF Veterans in Connecticut completed a mail survey containing measures of psychopathology, resilience, and psychosocial functioning. Confirmatory factor analyses revealed that the 4-factor dysphoria model, which is comprised of separate re-experiencing, avoidance, dysphoria, and hyperarousal symptom clusters, provided the best representation of PTSD symptom structure in this sample. Dysphoria symptoms were independently associated with a broad range of psychosocial measures, even after controlling for age, combat exposure, and other PTSD symptom clusters. Re-experiencing symptoms were associated with alcohol use problems, and avoidance symptoms were associated with increased psychosocial difficulties and decreased perceptions of postdeployment social support. These results suggest that dysphoria symptoms were strongly related to a broad range of psychosocial measures in this sample of OEF-OIF Veterans. Dysphoria symptoms may deserve special attention in the assessment and treatment of symptomatic OEF-OIF Veterans.

Depression and anger as risk factors underlying the relationship between maternal substance involvement and child abuse potential

OBJECTIVE

This study examines how emotion regulation deficits in the area of anger arousal and reactivity are associated with child abuse potential in mothers with substance use and depressive disorders in order to identify targeted areas for prevention and treatment.

METHODS

A sample of 152 urban mothers was interviewed on measures of substance use, diagnosis of depression, anger arousal and reactivity, and child abuse potential.

RESULTS

Linear hierarchical regressions revealed that anger arousal and reactivity exceeded diagnostic and demographic variables in predicting maternal child abuse potential. Additionally, anger arousal and reactivity was found to be a partial mediator of the relationship between diagnostic category and child abuse potential.

CONCLUSIONS

Findings are discussed in relation to a multifaceted model of child abuse potential which broadens the existing literature to include an examination of depression and emotion regulation in order to more fully understand how substance use and child abuse potential are linked.

PRACTICE IMPLICATIONS

Models and approaches which help clients to manage and regulate difficult feeling states, specifically anger, could be helpful, and may be most readily applied in such populations.

Fear conditioning and early life vulnerabilities: two distinct pathways of emotional dysregulation and brain dysfunction in PTSD

The newly proposed criteria for posttraumatic stress disorder (PTSD) in the Diagnostic and Statistical Manual (DSM-V) include dysregulation of a variety of emotional states including fear, anger, guilt, and shame, in addition to dissociation and numbing. Consistent with these revisions, we postulate two models of emotion dysregulation in PTSD in which fear is not the prevailing emotion but is only one of several components implicated in a dysregulated emotional system that also mediates problems regulating anger, guilt, shame, dissociation, and numbing.We discuss whether there is a relationship between fear and other emotion regulation systems that may help further our understanding of PTSD and its underlying neurocircuitry. Two pathways describing the relationship between fear and other emotion regulation systems in PTSD are proposed. The first pathway describes emotion dysregulation as an outcome of fear conditioning through stress sensitization and kindling. The second pathway views emotion dysregulation as a distal vulnerability factor and hypothesizes a further exacerbation of fear and other emotion regulatory problems, including the development of PTSD after exposure to one or several traumatic event(s) later in life. Future research and treatment implications are discussed.

Approach-avoidance coping conflict in a sample of burn patients at risk for posttraumatic stress disorder

BACKGROUND

Following an acute burn injury, higher distress is consistently observed among individuals exhibiting a conflict between approach coping (e.g., processing) and avoidance coping (e.g., suppression) relative to those individuals who use only one of these methods. Study objectives were to determine if contradictory coping messages would lead to such approach-avoidance coping conflict and to determine if experiment-induced coping conflict is also associated with higher distress.

METHODS

Participants (n=59 adults hospitalized with acute burn injuries) were assigned randomly to experimental conditions differing in the order in which training was provided in two ways of coping with posttrauma re-experiencing symptoms (i.e., process-then-suppress versus suppress-then-process). The primary dependent variable was coping behavior during the 24-hr posttraining period. Coping behavior was categorized as approach coping (processing), avoidance coping (suppressing), or approach-avoidance coping conflict (both) on the basis of median splits on subscales assessing these behaviors. Secondary analyses examined the relationship between this experiment-induced coping conflict and re-experiencing symptoms.

RESULTS

Results indicated that participants in the process-then-suppress condition, relative to the suppress-then-process condition, were significantly more likely to exhibit approach-avoidance coping conflict (i.e., above median split on both processing and suppressing) during the next 24 hr. Furthermore, approach-avoidance coping conflict was associated with greater re-experiencing symptoms assessed via self-report and by blinded coding of recorded speech.

CONCLUSIONS

It is concluded that the order of coping skill training can influence treatment outcome, success of coping methods, and overall levels of distress. therefore, training in stabilizing and calming methods should precede training in active processing following stressful life events.

A developmental approach to complex PTSD: childhood and adult cumulative trauma as predictors of symptom complexity

Exposure to multiple traumas, particularly in childhood, has been proposed to result in a complex of symptoms that includes posttraumatic stress disorder (PTSD) as well as a constrained, but variable group of symptoms that highlight self-regulatory disturbances. The relationship between accumulated exposure to different types of traumatic events and total number of different types of symptoms (symptom complexity) was assessed in an adult clinical sample (N = 582) and a child clinical sample (N = 152). Childhood cumulative trauma but not adulthood trauma predicted increasing symptom complexity in adults. Cumulative trauma predicted increasing symptom complexity in the child sample. Results suggest that Complex PTSD symptoms occur in both adult and child samples in a principled, rule-governed way and that childhood experiences significantly influenced adult symptoms.

Testing gender effects on the mechanisms explaining the association between post-traumatic stress symptoms and substance use frequency

The present study examines gender differences in the mechanisms that explain the association between PTSD symptoms and substance use frequency in a sample of 182 urban substance users. Specifically, the current study examined gender differences in the role of two potential explanatory variables, namely, difficulties controlling impulsive behavior when distressed (IMP), and a lack of emotional awareness and clarity (AW/CLAR). Multiple-group path modeling (across males and females) was used to examine gender differences in the path coefficients from PTSD symptoms to IMP and AW/CLAR, and from these latter variables to drug use frequency. Results indicated that PTSD symptoms were associated with IMP and AW/CLAR, and these path coefficients did not vary by gender. However, gender differences emerged when considering the path coefficients from AW/CLAR and IMP to substance use frequency. Specifically, for women, the association between PTSD and substance use was partially explained by IMP, whereas for men, the association between PTSD and substance use was partially explained by AW/CLAR. The current study is the first to examine gender differences in mechanisms accounting for the association between PTSD and substance use frequency, and these results also support the value and importance of examining gender differences in mechanisms underlying PTSD-SUD comorbidity.

Thought suppression failures in combat PTSD: a cognitive load hypothesis

The present study investigated the relation between thought suppression of emotionally neutral content [i.e., Wegner's (1994) "white bear"], incidental traumatic thought intrusion, and skin conductance responses in combat-related Posttraumatic Stress Disorder (PTSD). Participants included service members who either: a) had PTSD following an Operation Iraqi Freedom deployment; b) were free of psychiatric diagnosis following deployment (Combat Equivalent), or c) were pre-deployed and without psychiatric diagnosis (Pre-Deployed). PTSD Service Members reported the greatest intrusion of combat thoughts during the suppression task and demonstrated a post-suppression rebound effect with a neutral thought. Non-specific skin conductance responses indicated that the suppression task was related to similar levels of increased sympathetic activity for both the PTSD and Pre-Deployed groups, whereas the Combat Equivalent group showed no increased activation during thought suppression. Intrusive traumatic thoughts combined with failures in neutral thought suppression may be a consequence of increased cognitive load in PTSD.

Emotional processing in PTSD: heightened negative emotionality to unpleasant photographic stimuli

This study evaluated evidence for 2 forms of emotional abnormality in posttraumatic stress disorder (PTSD): numbing and heightened negative emotionality. Forty-nine male veterans with PTSD and 75 without the disorder rated their emotional responses to photographs that depicted scenes of Vietnam combat or were drawn from the International Affective Picture System (Lang et al., 2005). Images varied in their trauma-relatedness and affective qualities. A series of repeated measures ANOVAs revealed that Vietnam combat veterans with PTSD responded to unpleasant images with greater negative emotionality (i.e., enhanced arousal and lower valence ratings) than those without the disorder and this effect was modified by the trauma-relatedness of the image with stronger effects for trauma-related images. In contrast, the 2 groups showed equivalent patterns of responses to pleasant images. Findings raise questions about the sensitivity of the International Affective Picture System rating protocol for the assessment of PTSD-related emotional numbing.

Post-traumatic stress disorder, social anxiety disorder, and depression in survivors of the Kosovo War: experiential avoidance as a contributor to distress and quality of life

Few studies have been conducted on psychological disorders other than post-traumatic stress disorder (PTSD) in war survivors. The aim of this study was to examine PTSD, social anxiety disorder (SAD), and major depressive disorder (MDD) and their associations with distress and quality of life in 174 Albanian civilian survivors of the Kosovo War. This included testing of conceptual models suggesting that experiential avoidance might influence associations between anxiety and mood disorders with psychological functioning. Each of the three psychiatric disorders was associated with greater experiential avoidance and psychological distress, and lower quality of life. Being a refugee was associated with a higher likelihood of having SAD and MDD. We found evidence for experiential avoidance as a partial mediator of the respective effects of SAD and PTSD on quality of life; experiential avoidance did not mediate the effects of disorders on global distress. We also found support for a moderation model showing that only war survivors without SAD and low experiential avoidance reported elevated quality of life; people with either SAD or excessive reliance on experiential avoidance reported compromised, low quality of life. This is the third independent study, each using a different methodology, to find empirical support for this moderation model [Kashdan, T. B., & Breen, W. E. (2008). Social anxiety and positive emotions: a prospective examination of a self-regulatory model with tendencies to suppress or express emotions as a moderating variable. Behavior Therapy, 39, 1-12; Kashdan, T. B., & Steger, M. F. (2006). Expanding the topography of social anxiety: an experience sampling assessment of positive emotions and events, and emotion suppression. Psychological Science, 17, 120-128]. Overall, we provided initial evidence for the importance of addressing PTSD, SAD, MDD, and experiential avoidance in primarily civilian war survivors.

Evaluating symptom expression as a function of a posttraumatic stress disorder severity

Little is known about the relative severity or typical sequence of Diagnostic and Statistical Manual (DSM-IV) symptoms of posttraumatic stress disorder (PTSD). Using data from the National Comorbidity Study-Replication (NCS-R) [Kessler, R. C., Berglund, P., Chiu, W. T., Demler, O., Heeringa, S., & Hiripi, E., et al. (2004). The US National Comorbidity Survey-Replication (NCS-R): design and field procedures. International Journal of Methods in Psychiatric Research, 13(2), 69-92], the current study used a logistic item response model to assess the degree to which DSM-IV symptoms combine to define a primary construct underlying PTSD, to identify which symptoms are associated with greater severity of PTSD, and to determine whether the symptoms and symptom patterns are influenced by gender. Results suggested that PTSD symptoms can be combined to assess a single dimension of PTSD severity, providing support for a continuum of symptom severity. However, several DSM-IV symptoms provided overlapping information, potentially reducing the effectiveness of these symptoms in describing a broad range of PTSD. More precise assessment of PTSD severity may help improve the descriptive value of PTSD measures relationship to continuous measures of treatment outcomes, and ultimately inform more effective treatments.

Posttraumatic stress symptoms and brain function during a response-inhibition task: an fMRI study in youth

Youth who experience interpersonal trauma and have posttraumatic stress symptoms (PTSS) can exhibit difficulties in executive function and physiological hyperarousal. Response inhibition has been identified as a core component of executive function. In this study, we investigate the functional neuroanatomical correlates of response inhibition in youth with PTSS. Thirty right-handed medication-naïve youth between the ages of 10 and 16 years underwent a 3-Tesla Functional Magnetic Resonance Imaging scan during a response-inhibition (Go/No-Go) task. Youth with PTSS (n = 16) were age and gender matched to a control group of healthy youth (n = 14). Between-groups analyses were conducted to identify brain regions of greater activation in the No/Go-Go contrasts. PTSS and control youth performed the task with similar accuracy and response times. Control subjects had greater middle frontal cortex activation when compared with PTSS subjects. PTSS subjects had greater medial frontal activation when compared with control subjects. A sub-group of youth with PTSS and a history of self-injurious behaviors demonstrated increased insula and orbitofrontal activation when compared with those PTSS youth with no self-injurious behaviors. Insula activation correlated positively with PTSS severity. Diminished middle frontal activity and enhanced medial frontal activity during response-inhibition tasks may represent underlying neurofunctional markers of PTSS.

[Childhood-onset versus acute, adult-onset traumatized patients in the light of amnestic tendencies and derealisation]

OBJECTIVES

In the present study we examined the facial affective behaviour of acute adult-onset traumatized patients versus childhood-onset traumatized patients. Furthermore, we analyzed whether a decrease in emotional numbing results from a reduction of symptoms. We used amnestic tendencies as a moderator variable.

METHODS

The facial affective behaviour was coded with the Emotional Facial Acting Coding System, an instrument for the registration of facial movements with emotional relevance. The facial affective behaviour of the patient's first and last EMDR sessions was compared.

RESULTS

Childhood-onset and acute adult-onset traumatized patients showed the same reduction of overall facial activity. We found significantly higher psychic complaints (global severity index) (SCL-90-R) in childhood-onset traumatized patients and no difference in amnestic tendencies (FDS) between the two groups. Childhood-onset traumatized patients showed higher values of derealisation (FDS).

CONCLUSIONS

The facial affective reduction remains constant over time. Also childhood-onset traumatized patients developed more psychic complaints and greater derealisation.

Meta-analysis of alexithymia in posttraumatic stress disorder

The authors present a meta-analysis investigating the prevalence of alexithymia in 12 studies encompassing 1,095 individuals with posttraumatic stress disorder (PTSD). A large effect size was found associating PTSD with alexithymia. Effect sizes were higher in studies of male combat PTSD samples in comparison with studies of other PTSD samples. Clinical and research directions are discussed.

Difficulty identifying feelings predicts the persistence of trauma symptoms in a sample of veterans who experienced military sexual trauma

The current study examined the prospective association between alexithymia and the persistence of trauma symptoms in a clinical sample of 175 male and female veterans who experienced sexual trauma during military service (military sexual trauma; MST). Trauma symptoms decreased significantly over the course of a specialized residential treatment program. Difficulty identifying feelings was related to persistence of the following trauma symptoms: overall symptoms, sexual abuse trauma symptoms, dissociative symptoms, and anxiety. Men exhibited more persistent symptoms overall, more persistent sexual problems, and more sexual abuse trauma symptoms compared with women (over and above controlling for symptoms at intake). The results speak to the significant role that difficulty identifying feelings has in the treatment of PTSD. In addition, the results suggest that MST has different implications for men compared with women. Specifically, men who were sexually abused in the military experienced greater persistence of symptoms compared with women, especially in the areas of sexual functioning.

The role of emotional inexpressivity and experiential avoidance in the relationship between posttraumatic stress disorder symptom severity and aggressive behavior among men exposed to interpersonal violence

Posttraumatic stress disorder (PTSD) has been found to be associated with aggressive behavior. Recent evidence suggests that the ways in which individuals respond to their emotions may account for this relationship. In particular, to the extent that aggressive behaviors serve an emotion regulatory function, responding to emotions with avoidance (i.e., experiential avoidance) or the active suppression of emotional expression may heighten emotion dysregulation, increasing the risk for aggressive behavior as individuals attempt to regulate that dysregulated state. This study examined whether these two ways of responding to emotions account for the relationship between PTSD symptom severity and self-reported engagement in aggressive behavior among a diverse sample of 113 men with past exposure to interpersonal violence. Experiential avoidance and emotional inexpressivity each accounted for a significant amount of unique variance in aggressive behavior, above and beyond PTSD symptom severity and trait anger. Clinical and research implications of findings are discussed.

The development and psychometric evaluation of the emotional reactivity and numbing scale

Recent research has highlighted the role of hyperresponsivity and numbing of emotions in posttraumatic stress disorder. Preliminary research suggests that emotional numbing symptoms impact the development, maintenance, and treatment of posttraumatic stress disorder. However, research in this area has been hindered, in part, due to the absence of a psychometrically sound, conceptually based measure of emotional numbing. The present study examined the psychometric properties of the Emotional Reactivity and Numbing Scale in a sample of 92 trauma-exposed men and women veterans. Results provide preliminary support for the internal consistency, test-retest reliability, convergent, and discriminant validity of the measure. Implications for future research are discussed.

A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms

This study examined the relationship between posttraumatic stress (PTS) symptoms and particular aspects of emotion regulation difficulties among trauma-exposed individuals. Participants were an ethnically diverse sample of 108 undergraduates from an urban university. PTS symptom severity was found to be associated with lack of emotional acceptance, difficulty engaging in goal-directed behavior when upset, impulse-control difficulties, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall difficulties in emotion regulation were associated with PTS symptom severity, controlling for negative affect. Finally, individuals exhibiting PTS symptoms indicative of a PTSD diagnosis reported greater difficulties with emotion regulation than those reporting PTS symptoms at a subthreshold level. The implications of these findings for research and treatment are discussed.

Anhedonia, Emotional Numbing, and Symptom Overreporting in Male Veterans with PTSD

We used measures of positive affect and emotional expression to distinguish and better understand veterans with PTSD with symptom overreporting presentation styles. Based on prior research, symptom overreporting was defined as scores greater than eight on the F(p) (Infrequency-Psychopathology) scale of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Data were drawn from an archival dataset of 227 combat veteran outpatients. Results were consistent with theory and research on the distinction between negative and positive affect. Major findings indicated that (a) veterans endorsing greater anhedonia had a greater likelihood of being classified as a symptom overreporter (controlling for PTSD symptoms), and (b) compared to non-symptom overreporting veterans, overreporters showed greater congruency in their presentation of diminished positive affect and their expression across self- and clinician-ratings. Our data suggest that diminished positive emotions and their behavioral expression are uniquely associated with veterans' psychological experiences, providing insight into the nature of symptom overreporters.

Interpretation biases in victims and non-victims of interpersonal trauma and their relation to symptom development

Previous studies examining information processing in posttraumatic stress disorder (PTSD) have focused on attention and memory biases, with few studies examining interpretive biases. The majority of these studies have employed lexically based methodologies, rather than examining the processing of visual information. In the present study, victims (N=40) and non-victims (N=41) of interpersonal trauma viewed a series of short positive, neutral, and threatening filmstrips of social situations with ambiguous endings. Participants were then asked about their perceptions and interpretations of the situations. Victims perceived threatening situations as more predictable and more quickly increasing in risk than non-victims. Trauma status interacted with the perceived predictability of positive situations and the perceived speed with which neutral situations reached their conclusion to predict anxious symptoms. In addition, trauma status interacted with the perceived increase in risk of positive situations to predict PTSD symptoms. The implications of these findings for theories of PTSD are discussed.

The role of negative affect intensity and the fear of emotions in posttraumatic stress symptom severity among victims of childhood interpersonal violence

Heightened negative affect (NA) intensity and the tendency to negatively evaluate emotions may be associated with the development and maintenance of posttraumatic stress symptoms. However, the specific role of these vulnerabilities has yet to be explored. Thus, this study was conducted to examine the influence of NA intensity and the fear of emotions in posttraumatic symptom severity among 102 childhood interpersonal violence victims. Fear of emotions significantly predicted posttraumatic symptom severity above and beyond NA intensity and NA. Findings suggest that posttraumatic outcomes may not be influenced by an underlying vulnerability of heightened NA intensity, but instead, are affected by the extent to which emotional responses are negatively evaluated. Results are discussed in terms of their implications for interventions and future research on posttraumatic responding.

Predictors of psychological distress and positive resources among Palestinian adolescents: trauma, child, and mothering characteristics

OBJECTIVE

The aim was to examine how traumatic and stressful events, responses to violence, child characteristics, and mothering quality, as measured in middle childhood predict psychological distress and positive resources in adolescence.

METHOD

The participants were 65 Palestinian adolescents (17+/-.85 years; 52% girls), who had been studied during the First Intifada (T1), during the Palestinian Authority rule (T2) and before the Second Al Aqsa Intifada (T3) in Gaza. Psychological distress was indicated by PTSD, and depressive symptoms and positive resources by resilient attitudes and satisfaction with quality of life, all measured at T3. The predictors that were measured at T1 were exposure to military violence, active coping with violence and children's intelligence, cognitive capacity, and neuroticism. Mothering quality and stressful life-events were measured at T2, the former reported by both the mother and the child, and the latter by the mother.

RESULTS

Adolescents' PTSD symptoms were most likely if they had been exposed to high levels of traumatic and stressful experiences and had poor cognitive capacity and high neuroticism in middle childhood. Only high levels of childhood military violence and stressful life-events predicted high depressive symptoms and low satisfaction with quality of life in adolescence.

CONCLUSIONS

Military violence in childhood forms risks for both increased psychological distress and decreased positive resources. However, child characteristics such as cognitive capacity and personality are important determinants of psychological vulnerability in military trauma.

Emotion regulation and anxiety disorders

Recent attention has been given to the role of emotion regulation in the development and maintenance of psychopathology. Gross [Gross, J. J., & John, O. P. (1998). Mapping the domain of expressivity: multimethod evidence for a hierarchical model. Journal of Personality and Social Psychology, 74, 170-191] provided a framework from which to understand emotion regulation processes, and it is within this framework that the literature on emotion regulation/dysregulation in the anxiety disorder population is reviewed, with a focus on possible deficiencies that lead to or maintain the disorders. The present paper aims to: (1) briefly introduce emotion regulation strategies of suppression and reappraisal; (2) summarize the empirical studies of emotion regulation within anxiety disorders; (3) discuss the neurobiological markers of emotion regulation within these disorders; (4) provide future directions for research; and (5) summarize possible treatment implications resulting from this important area of research.

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

Fragile self-esteem and affective instability in posttraumatic stress disorder

Temporal fluctuations in self-esteem and affect are prominent features of several clinical conditions (e.g., depression), but there is an absence of empirical work examining their role in posttraumatic stress disorder (PTSD). Individuals who experience large fluctuations in self-evaluations and affect are considered more vulnerable to psychopathology than individuals able to adequately modulate their self-image and emotional responses. We examined the relevance of self-esteem and affective instability to PTSD. Veterans with and without PTSD completed 14 daily ratings of self-esteem, positive affect, negative affect, and gratitude. Compared to veterans without PTSD, veterans with PTSD exhibited more temporal fluctuations in self-esteem, negative affect, and gratitude, with a smaller effect for positive affect. For all veterans, self-esteem and negative affective instability was associated with diminished well-being. Except for self-esteem instability, most findings were substantially reduced after accounting for variance attributable to PTSD diagnoses and mean intensity levels over the 14-day monitoring period. These data suggest self-esteem instability is important in understanding the lives of veterans with and without PTSD.

Gratitude and hedonic and eudaimonic well-being in Vietnam war veterans

Little information exists on the contribution of psychological strengths to well-being in persons with post-traumatic stress disorder (PTSD). Data from other populations suggest that gratitude, defined as the positive experience of thankfulness for being the recipient of personal benefits, may have salutary effects on everyday functioning. We investigated whether dispositional gratitude predicted daily hedonic and eudaimonic well-being in combat veterans with and without PTSD. We also examined associations between daily gratitude and daily well-being across time. Veterans with PTSD, compared to those without PTSD, exhibited significantly lower dispositional gratitude; no differences were found on daily gratitude. Dispositional gratitude predicted greater daily positive affect, percentage of pleasant days over the assessment period, daily intrinsically motivating activity, and daily self-esteem over and above effects attributable to PTSD severity and dispositional negative and positive affect in the PTSD group but not the non-PTSD group. Daily gratitude was uniquely associated with each dimension of daily well-being in both groups. Although preliminary, these results provide support for the further investigation of gratitude in trauma survivors.

The intellectual performance of traumatized children and adolescents with or without posttraumatic stress disorder

This study compared the Wechsler Intelligence Scale for Children-III (WISC-III) scores of traumatized youth with posttraumatic stress disorder (PTSD) to the scores of trauma-exposed and nonexposed comparison groups without PTSD. All groups were free of additional major childhood psychiatric disorders. The PTSD group scored significantly lower than the comparison groups on verbal subtests, but not on performance subtests. The scores of the trauma-exposed PTSD negatives and nontrauma exposed controls were not significantly different. Accordingly, PTSD and not a history of trauma exposure in the absence of PTSD was associated with lower verbal IQ.

Über das Verhältnis von Traumatisierungen, Amnesie und Symptombelastung - eine empirische Pilotstudie/ On the relationship between traumatization, amnesia and symptom stress – an empirical pilot study

OBJECTIVES

In the present study we examined facial affective behavior in acutely traumatized patients undergoing EMDR therapy. Furthermore, we analyzed whether a decrease in emotional numbing was due to a reduction of symptoms. Amnestic tendencies were used as a moderator variable.

METHODS

The facial affective behaviour was coded using the Emotional Facial Acting Coding System, an instrument for the registration of facial movements with emotional relevance. The facial affective behavior of the patient's first and last EMDR session was compared.

RESULTS

A significant increase in facial affective behavior as well as an increase in mental complaints were found. Furthermore, the reduction in amnestic tendencies did not result in a reduction of symptoms.

CONCLUSIONS

Under the influence of the treatment it is possible to improve access to episodic affective memory. Nevertheless, a positive influence cannot be denoted at the end of the treatment.

Anhedonia and emotional numbing in combat veterans with PTSD

We explored relationships between anhedonia and posttraumatic stress disorder (PTSD) symptom clusters, including their role in predicting psychiatric comorbidity. Our measure of anhedonia was derived from an examination of the latent structure of the Beck Depression Inventory. We found evidence for a two-factor solution, leading to anhedonia and undifferentiated, global depressive symptoms scales. In primary analyses, anhedonia had a unique positive relationship with PTSD's emotional numbing symptoms and minimal relationships with other PTSD symptoms. Upon examining the incremental validity of appetitive functioning (i.e., anhedonia, emotional numbing) over and above aversive functioning (i.e., re-experiencing, avoidance, and hyper-arousal PTSD symptoms) variables, greater emotional numbing increased the likelihood of being diagnosed with a major depressive disorder, and greater anhedonia increased the likelihood of being diagnosed with additional anxiety disorders and to a lesser extent, psychotic disorders. Results were consistent with research on the distinction of appetitive and aversive functioning, providing insight into the nature of PTSD.

Initial physiological responses and perceived hyperarousal predict subsequent emotional numbing in pediatric injury patients

The present study tested the hypothesis that acute posttraumatic hyperarousal would lead to the development of emotional numbing (EN) symptoms in a pediatric injury population. Eighty-two youths aged 8-18 years were recruited from the emergency department of a Midwestern children's hospital. Heart rate was recorded from emergency medical services reports and a 12-hour urine collection was initiated upon admission. Six weeks and 6 months later, depression and PTSD symptoms were assessed. Initial heart rate and urinary cortisol levels predicted 6-week and 6-month EN after controlling for concurrent depression, avoidance, and reexperiencing symptoms and 6-week hyperarousal symptoms. These findings provide empirical support for prior hypotheses concerning the development of PTSD symptoms over time.

Striving for emotional survival in palliative cancer nursing

In this grounded theory study, the authors analyze interviews and participant observation data related to palliative cancer nursing in hospitals. Striving for Emotional Survival emerged as the pattern of behavior through which nurses deal with their main concern, the risk of being emotionally overloaded by their work. It involved three main strategies: Emotional Shielding through Professional Shielding or Cold Shielding; Emotional Processing through Chatting, Confirmation Seeking, Self-Reflecting, or Ruminating; and Emotional Postponing through Storing or Stashing. Emotional Competence is a property of Striving for Emotional Survival that explains more or less adequate ways of dealing with emotional overload. The theory Striving for Emotional Survival can be useful in the nurses' daily work and provides a comprehensive framework for understanding how nurses deal with emotional difficulties. The authors suggest that health care organizations encourage self-care, prioritize time to talk, and offer counseling to nursing staff with emotionally difficult working conditions.

Selective numbing and hyperarousal in male and female Bosnian refugees with PTSD

Emotional numbing is an important symptom of PTSD, but it is not clear whether it affects both positive and negative affect equally or not. To address this question we administered Lang's Looking at Pictures test, in which a series of pictures are rated for valence (pleasant-unpleasant) and arousal (high-low), to 10 male and 11 female Bosnian refugees suffering from PTSD (DSM-IV criteria) and to control groups of 11 male and 10 female Bosnian refugees with similar trauma exposure but without PTSD or any other major mental illness. The mean valence ratings for unpleasant, neutral, and pleasant pictures of both PTSD and control males and females were similar to normal ratings. Likewise, the mean arousal ratings for unpleasant, neutral, and pleasant pictures of both male and female controls were similar to normals, with both unpleasant and pleasant pictures rated more arousing than neutral pictures. In contrast, in both males and females with PTSD pleasant pictures were rated as almost completely non-arousing. Thus, in Bosnian refugees affective numbing is seen primarily with pleasant or positive stimuli.

An investigation of the construct validity of the 20-Item Toronto Alexithymia Scale through the use of a verbalization task

OBJECTIVE

The construct validity of the 20-Item Toronto Alexithymia Scale (TAS-20) was examined through a verbalization task requiring participants to discuss a past distressing event.

METHODS

Verbalizations were transcribed and coded for the frequency and number of different negative and positive emotion words used. Relationships between the TAS-20 and these variables were examined.

RESULTS

Controlling for negative affect (NA), the difficulty identifying feelings (DIF) subscale was positively associated with the frequency of negative emotion words used and negatively associated with the frequency and number of different positive emotion words used during the verbalization task. High, compared with low, scoring TAS-20 participants used a lower frequency of and fewer different positive emotion words.

CONCLUSION

The TAS-20 may be measuring negative emotional expressivity separate from negative affectivity, as well as a reduced capacity to access and elaborate upon positive emotion. Findings are discussed in regard to improving the conceptualization and measurement of emotional deficits in alexithymia.

Emotional-processing in posttraumatic stress disorder II: startle reflex modulation during picture processing

This study examined the impact of a trauma-related stressor on subsequent emotional behavior in veterans with (n = 35) and without (n = 24) posttraumatic stress disorder (PTSD). Self-report and physiological responses, including acoustic startle, were recorded during viewing of emotionally evocative photographs at baseline and following exposure to trauma-related and non-trauma-related stressors. The 2 groups exhibited equivalent patterns of emotional response across self-report and physiological measures at baseline. In contrast, following the trauma challenge, participants with PTSD showed a pattern of startle modulation suggestive of greater defensive reactivity and reduced visual perceptual engagement. These findings, along with augmented corrugator EMG reactivity during the same interval, suggest that trauma-related reexperiencing primes subsequent negative emotional responding in individuals with PTSD.