The role of emotion dysregulation in negative affect reactivity to a trauma cue: Differential associations through elicited posttraumatic stress disorder symptoms

Influence of affective instability on suicidal ideation beyond traumatic brain injury and posttraumatic stress disorder in veterans

OBJECTIVE

Mild traumatic brain injury (TBI) is associated with long-term consequences, including greater risk for posttraumatic stress disorder (PTSD) and suicidal ideation. Affective instability is also independently related to PTSD and suicidality, which may explain why some individuals continue to experience chronic psychiatric complaints following mild TBI. The purpose of the present study was to evaluate affective instability as a key factor for PTSD and suicidal ideation among Veterans with and without TBI.

METHOD

Participants (N = 299 Veterans; 86.96% male) completed the Personality Assessment Inventory (PAI) and structured clinical interviews for TBI and psychiatric diagnoses. Hierarchical linear regression was used to evaluate main and interaction effects.

RESULTS

There were no significant differences in affective instability (p = 0.140) or suicidal ideation (p = 0.453) between Veterans with or without TBI. Individuals with TBI were more likely to have a PTSD diagnosis (p = 0.001). Analyses evaluating PTSD diagnosis as an outcome indicated a main effect of affective instability (p < 0.001), but not TBI (p = 0.619). Analyses evaluating suicidal ideation as an outcome demonstrated an interaction effect between PTSD and affective instability beyond the effects of TBI (p = 0.034).

CONCLUSIONS

Severe Affective instability appears to be a key factor in suicidal ideation among Veterans beyond TBI or PTSD history. PTSD was more strongly associated with suicidality at lower and moderate levels of affective instability. At severe levels of affective instability, however, Veterans with and without PTSD experienced suicidal ideation at similar rates. Findings suggests that high levels of affective instability not better explained by other psychiatric conditions confers similar suicidality risk to that of PTSD in a Veteran population.

Daily exposure to combat-related cues and posttraumatic stress symptoms among veterans: Moderating effects of peri- and postdeployment experiences

One of the central symptoms of posttraumatic stress disorder (PTSD) is a heightened reactivity to trauma cues. The current study used experience sampling to investigate the associations between exposure to combat-related cues and PTSD symptoms in 93 U.S. veterans who served in support of recent military operations in Afghanistan and Iraq. We also examined the effects of peri- and postdeployment factors, including exposure to combat, unit support during deployment, and postdeployment social support on PTSD. Participants completed eight brief random surveys daily for 2 weeks using palmtop computers. The results indicated that more daytime exposure to trauma cues was associated with experiencing more PTSD symptoms at the within-person level, B = 3.18. At the between-person level, combat exposure, B = 4.20, was associated with more PTSD symptoms, whereas unit support, B = -0.89, was associated with experiencing fewer symptoms. At the cross-level interaction, unit support, B = -0.80, moderated the association between trauma cue exposure and PTSD symptom count. Contrary to our hypothesis, postdeployment social support, B = -0.59, was not associated with PTSD symptoms. These findings suggest a functional association between exposure to trauma cues and PTSD symptoms among recent-era U.S. veterans and underscore the importance of unit support during deployment.

Effects of MDMA-assisted therapy for PTSD on self-experience

INTRODUCTION

There is a resurgence of interest in the therapeutic potential of psychedelic substances such as 3,4-methylenedioxymethamphetamine (MDMA). Primary findings from our randomized, double-blind, placebo-controlled, multi-site Phase 3 clinical trial of participants with severe PTSD (NCT03537014) showed that MDMA-assisted therapy induced significant attenuation in the Clinician-Administered PTSD Scale for DSM-5 compared to Therapy with placebo. Deficits in emotional coping skills and altered self-capacities constitute major obstacles to successful completion of available treatments. The current analysis evaluated the differential effects of MDMA-assisted therapy and Therapy with placebo on 3 transdiagnostic outcome measures and explored the contribution of changes in self-experience to improvement in PTSD scores.

METHODS

Participants were randomized to receive manualized therapy with either MDMA or placebo during 3 experimental sessions in combination with 3 preparation and 9 integration therapy visits. Symptoms were measured at baseline and 2 months after the last experimental session using the 20-item Toronto Alexithymia Scale (TAS-20), the 26-item Self Compassion Scale (SCS), and the 63-item Inventory of Altered Self-Capacities (IASC).

RESULTS

90 participants were randomized and dosed (MDMA-assisted therapy, n = 46; Therapy with placebo, n = 44); 84.4% (76/90) had histories of developmental trauma, and 87.8% (79/90) had suffered multiple traumas. MDMA-assisted therapy facilitated statistically significant greater improvement on the TAS-20, the SCS, and most IASC factors of interpersonal conflicts; idealization disillusionment; abandonment concerns; identity impairment; self-awareness; susceptibility to influence; affect dysregulation; affect instability; affect skill deficit; tension reduction activities; the only exception was identity diffusion.

CONCLUSION

Compared with Therapy with placebo, MDMA-assisted therapy had significant positive effects on transdiagnostic mental processes of self-experience which are often associated with poor treatment outcome. This provides a possible window into understanding the psychological capacities facilitated by psychedelic agents that may result in significant improvements in PTSD symptomatology.

Progesterone Attenuates the Stress Response in Individuals with Alcohol Dependence and Post-Traumatic Stress Disorder - A Pilot Study

OBJECTIVE

Evidence from laboratory studies suggests that progesterone may be effective in reducing stress and craving, and may improve cognitive performance in smokers and individuals with cocaine dependence. The objective of this study was to examine if progesterone would attenuate stress-induced craving, anxiety, affect and physiological measures, as well as improve stress-induced cognitive performance (processing speed and selective attention) in individuals diagnosed with alcohol use disorder (AUD) and post traumatic stress disorder (PTSD).

METHODS

This laboratory study included (n = 13) participants who were diagnosed with current AUD and PTSD who were randomly assigned to recive either progesterone (200mg bid) or placebo in identical looking capsules for 3 days. On the fourth day they completed a laboratory session. In the morning of the test session, they received the last dose of medication and completed the rest of the laboratory procedures. The procedures included presentation in random order of personalized trauma and neutral scripts with relaxation in between. Main outcomes included measure of craving, anxiety, affect and cognitive performance.

RESULTS

Consistent with other research, trauma scripts produced significantly greater increases in craving, anxiety and negative affect when compared with neutral scripts. Progesterone significantly reduced stress-induced symptoms of craving, anxiety, fear, anger and sadness but had no effect on positive emotions (joy, relaxation). Progesterone was effective in ameliorating stress-induced decreases in cognitive performance.

CONCLUSIONS

The findings from this study demonstrate that progesterone can be effective in reducing stress-induced craving, anxiety and negative affect in a laboratory setting in individuals with comorbid AUD and PTSD. Interestingly, progesterone also improved cognitive performance. These findings require replication in a larger clinical trial and may have implications for treatment among individuals with AUD and PTSD.This study was registered as NCT02187224, at www.clinicaltrials.gov.

Biopsychosocial Correlates and Individual Differences for Eliciting Moral Elevation in Veterans With PTSD: An Experimental Case Series

ABSTRACT

A promising approach to enhancing trauma-focused treatment is moral elevation-feeling inspired by witnessing a virtuous act. This study explored potential links between eliciting elevation and relevant outcomes in a series of case examples. Veterans with probable posttraumatic stress disorder completed experimental tasks including a written trauma narrative exercise and watching elevation-eliciting videos. Participants also completed baseline assessments, repeated measures of trauma-related cognitions, emotions, elevation, and saliva sample collection. Four cases were identified and reviewed: two positive responders (high elevation after videos) and two nonresponders (restricted elevation response). Positive responder cases reported decreased cognitions, emotions, and moral injury distress from after the trauma narrative to after elevation exercises, whereas nonresponders reported minimal to no changes. Positive responders also demonstrated decreases in cortisol, whereas nonresponders demonstrated increases in cortisol. Future work should examine whether elevation contributes to changes in biopsychosocial outcomes and identify individual factors that indicate who might benefit from elevation-based interventions.

Emotional Dysregulation and Post-Traumatic Stress Symptoms: Which Interaction in Adolescents and Young Adults? A Systematic Review

Emotional dysregulation (ED) has recently been conceptualized as a transnosographic entity in major mental disorders, and increasing evidence has suggested association between ED and post-traumatic stress symptoms (PTSS), though the nature of this association is unclear. The aim of the present review was to examine the possible interplay between ED and trauma exposure in the literature, as well as a possible role for the comorbidity of PTSD or PTSS in adolescents and young adults. In particular, we explored whether ED may represent a risk factor for PTSD or, conversely, a consequence of traumatic exposure. This systematic review was conducted according to PRISMA 2020 guidelines in three databases (PubMed, Scopus, and Embase). The 34 studies included showed a wide heterogeneity in terms of the populations selected and outcomes examined. Most studies used the Difficulties in Emotion Regulation Scale (DERS) and examined the relationship between ED, trauma, and psychopathological manifestations after the occurrence of trauma, with a focus on child abuse. Although current data in the literature are heterogeneous and inconclusive, this research highlights the role of ED as a mechanism that may mediate vulnerability to PTSD, but also as a predictor of severity and maintenance of typical, atypical, or associated PTSD symptoms, suggesting prevention programs for PTSD and other mental disorders should support the development of emotion regulation strategies.

Childhood Trauma and PTSD Symptoms: Disentangling the Roles of Emotion Regulation and Distress Tolerance

Research documents that a history of childhood trauma increases risk for post-traumatic stress disorder (PTSD), greater emotion regulation difficulties (ERD), and reduced distress tolerance (DT). Independent lines of research implicate ERD and DT as transdiagnostic risk factors and link them to PTSD. To elucidate how such mechanisms may influence the etiology, maintenance, and treatment of PTSD, the current study investigates the distinct mediating roles of emotion regulation and DT, exploring which explains a larger indirect effect from childhood trauma to PTSD symptom severity. Participants (N = 385, aged 18-48) who endorsed a history of childhood trauma provided retrospective report of cumulative childhood trauma exposure, and of current ERD, DT, and PTSD symptom severity. Single and dual mediation analyses were used to assess indirect effects through ERD and DT in the relation between cumulative childhood trauma exposure and current PTSD symptom severity. ERD and DT were significantly and inversely related. Higher current self-ratings of PTSD symptom severity were explained by cumulative childhood trauma through ERD (B = 0.93, p < 0.001) and DT (B = 0.50, p < 0.05). The full model explained 36% of the variance in PTSD symptom severity. Current findings provide preliminary evidence of DT and emotion regulation (with specific facets identified) as distinct mechanisms in the development of PTSD. Of clinical relevance, current findings support post-trauma processing theories that contend individuals' recovery requires accepting and learning to modulate trauma-related emotional states. Implications for methods of treatment and prevention are discussed.

PTSD Symptom Cluster Severity Predicts Momentary Emotion Dynamics During Couple Conversations

This study investigated the associations between momentary emotion dynamics and posttraumatic stress disorder (PTSD) symptoms. Using a sample of 61 couples (N = 122 individuals) in which all individuals were trauma exposed and at least one partner screened positive for PTSD, we examined the intra- and interpersonal regulation of vocally encoded emotional arousal (fundamental frequency [f0]) and how these momentary emotion regulatory patterns relate to specific PTSD symptoms during two couple conversations: one designed to elicit conflict and one to elicit intimacy. PTSD symptoms were assessed using a gold standard clinical interview. In both conversations, higher reexperiencing symptoms were associated with greater emotional inertia (i.e., more resistance to change in emotional state following deviation from one's emotional equilibrium), and higher avoidance symptoms were associated with less emotional inertia (i.e., quicker return to emotional equilibrium). In the intimacy conversations, individuals also responded to their partners' arousal. Furthermore, individuals whose partners exhibited higher emotional numbing symptoms exhibited more emotional inertia, suggesting that emotion regulation may be a function of both one's own and one's partner's PTSD symptoms. Attending to the interpersonal context of emotion dynamics during PTSD treatment may enhance outcomes.

Reduced working memory performance in PTSD and suicide among veterans presenting for treatment

Suicide is among the leading causes of death in the United States, underscoring the continued need to understand the mechanisms underlying suicide risk. A growing body of research has examined the role of working memory deficits in suicidal thoughts and behaviors (STBs), yet little research has evaluated putative pathways via which working memory impairments may heighten suicide risk. Elevated posttraumatic stress symptoms (PTSS) represent one plausible mechanism through which poor working memory performance may increase STBs. The present study utilized data from 140 treatment-seeking veterans who presented for an intake evaluation in the PTSD Clinical Team of a large VA Medical Center. Veterans completed self-report measures, a semi-structured PTSD evaluation, and a digit span working memory test. In addition to concurrent suicidal ideation assessed during the intake, additional information regarding past suicide attempts, presence of a safety plan, documentation of past suicidal behaviors, and engagement with suicide crisis lines were collected via electronic medical records. Consistent with hypotheses, a significant indirect path emerged such that poor working memory performance predicted greater suicidal ideation, greater likelihood of a past suicide attempt, and greater latent suicide risk via increased PTSS. However, no direct effect of working memory on STBs or indirect paths of PTSS on STBs via working memory emerged. These findings suggest that the relation between working memory and STBs may be explained by PTSS severity.

Examination of daily-level associations between posttraumatic stress disorder symptoms and COVID-19 worries

OBJECTIVE

Stressors and worries related to the COVID-19 pandemic have contributed to the onset and exacerbation of psychological symptoms such as posttraumatic stress disorder (PTSD). Using a microlongitudinal framework, we uniquely investigated bidirectional associations between daily-level PTSD symptoms and COVID-19 worries.

METHOD

Data from 42 trauma-exposed university students (Mage = 22.67 ± 5.02, 86.7% female) were collected between March and August 2020. Participants completed daily surveys for 10 days to assess PTSD symptom severity and COVID-19 worries. Multilevel regression was conducted to examine both lagged and simultaneous models of daily person-centered mean PTSD symptom severity predicting COVID-19 worries, and vice-versa.

RESULTS

Days with greater COVID-19 worries were associated with greater same-day (b = .53, SE = .19, p = .006) and next-day (b = .65, SE = .21, p = .003) PTSD symptom severity. Additionally, days with greater PTSD symptom severity were associated with greater same-day COVID-19 worries (b = .06, SE = .02, p = .006).

CONCLUSIONS

COVID-19 worries may influence same-day and next-day PTSD symptoms, and PTSD symptoms may influence same day COVID-19 worries. Findings substantiate the interplay between ongoing stress related to the COVID-19 pandemic and posttrauma symptoms and support therapeutically targeting COVID-19 stress in PTSD treatments to potentially impact posttrauma symptoms. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dissociation and emotion regulation strategies: A meta-analytic review

OBJECTIVE

Clinical and neurobiological models posited that dissociative mechanisms might affect processes involved in emotional generation and regulation. However, there is a lack of a comprehensive theoretical framework that systematically includes dissociation within emotional functioning.

METHODS

The current study aims at conducting a meta-analytic review on the relationship between dissociation and emotion regulation in order to empirically estimate to what extent dissociation is related to emotion regulation processes. The meta-analysis was based on r coefficient as effect size measure, using a random-effect approach.

RESULTS

The meta-analysis included 57 independent studies for a total of 11596 individuals. Findings showed an overall moderate relationship between dissociation and emotion regulation (r_w = .32; p < .05). The association between dissociation and emotion regulation was the same among clinical samples than non-clinical ones. Furthermore, dissociation showed moderate to large relationships with maladaptive domains of emotion regulation, namely disengagement (r_w = 0.34; p < .01) (i.e., behavioral avoidance, experiential avoidance, thought and emotional suppression) and aversive cognitive perseveration (r_w = 0.38; p < .001) (i.e., rumination, worry and nonacceptance). The analysis did not find significant relationship between dissociation and adaptive domain of emotional regulation (i.e., problem solving, mindfulness).

CONCLUSION

Dissociation in the context of emotion regulation might be viewed as a basic neuro-mental mechanism that automatically contribute to the over-modulation of emotional states through avoidance reactions from internal and external reality. Future longitudinal studies are needed to clarify the causal relationships between dissociation and emotion regulation.

Cumulative Trauma Exposure and Chronic Homelessness Among Veterans: The Roles of Responses to Intrusions and Emotion Regulation

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans.