The interactive effects of emotional clarity and cognitive reappraisal in Posttraumatic Stress Disorder☆
Highlights
► We investigated emotional clarity and cognitive reappraisal in patients with PTSD. ► High clarity combined with frequent use of reappraisal predicted higher positive affect. ► High clarity combined with frequent use of reappraisal predicted lower PTSD severity. ► Findings held after accounting for shared variance with covariates.
Introduction
Posttraumatic Stress Disorder (PTSD) is a debilitating psychiatric condition prevalent in populations with high rates of trauma exposure, such as military veterans (Bremner et al., 1996, Milliken et al., 2007). Current research on PTSD has demonstrated the underlying role of emotional disturbances, including a broad pattern of low emotional awareness and poor emotion regulation (Bonn-Miller et al., 2011, Frewen et al., 2008, Kashdan et al., 2010a, Lanius et al., 2010, Tull et al., 2007). In the present study, our goal was to examine the interactive effects of one facet of emotional awareness (i.e., emotional clarity) and one type of emotion regulation (i.e., cognitive reappraisal) on PTSD symptom severity and positive affect among military Veterans with PTSD.
Mounting evidence suggests that emotion regulation plays a crucial role in a wide range of psychological outcomes (Gross, 2007). One emotion regulation strategy that has received particular attention is cognitive reappraisal, which refers to altering how potentially emotion-eliciting situations are construed in order to change their emotional impact. Cognitive reappraisal is typically considered an adaptive strategy in that unpleasant emotions can be down-regulated following stressful events with minimal physiological and cognitive strain (Gross & John, 2003). Indeed, habitual use of cognitive reappraisal tends to be associated with greater mental health (Gross & John, 2003) and lower levels of psychopathology (Eftekhari et al., 2009, Werner and Gross, 2010).
What is not yet clear is why some people are able to successfully engage in cognitive reappraisal while others are not. One explanation derives from the idea that successful self regulation is dependent on information about the intended target of regulation. Specifically, successful emotion regulation should require information about what is being felt from moment-to-moment (Feldman Barrett & Gross, 2001). Therefore, individual differences in emotional clarity (i.e., the extent to which one can identify, differentiate, and understand one's emotions; Gohm and Clore, 2000, Gohm and Clore, 2002) might moderate the success of cognitive reappraisal.
Individual differences in emotional clarity underlies several higher order constructs such as emotional awareness, alexithymia, and emotional intelligence (Coffey et al., 2003, Gohm and Clore, 2000, Gohm and Clore, 2002). Individuals low (versus high) in emotional clarity are likely to be more limited in their ability to choose an adaptive emotion regulation strategy, such as cognitive reappraisal, and they may misinterpret and amplify physiological sensations that accompany emotional arousal (Pond et al., in press, Taylor et al., 1997). Consistent with this line of reasoning, a growing body of research has found that low emotional clarity (as indexed by individual difference measures, such as the Toronto Alexithymia Scale [TAS; Bagby, Parker, & Taylor, 1994]) strongly predicts a range of psychopathology, independent of other aspects of alexithymia and emotional awareness, such as the extent to which people attend to their emotions (e.g., Berenbaum et al., 2006, Berenbaum et al., in press, Boden et al., 2003). By contrast, individuals high in emotional clarity are likely to have increased ability to choose an adaptive emotion regulation strategy, such as cognitive reappraisal, and to be more successful in their efforts to manage emotions (Barrett et al., 2001, Kang and Shaver, 2004, Kashdan et al., 2010b) and to have greater mental health (e.g., Palmer, Donaldson & Stough, 2002). In summary, theory and research suggests that emotional clarity is a key factor influencing mental health and illness by direct and indirect, via emotion regulation, routes (also see Berenbaum, Raghavan, Le, Vernon, & Gomez, 2003).
One promising context within which to examine the interactive effects of emotional clarity and cognitive reappraisal is among individuals with PTSD. First, a large body of research has documented associations between PTSD and alexithymia, which is characterized in part by a combination of low attention to emotions and low emotional clarity (Frewen et al., 2008). Furthermore, research has found that low levels of emotional clarity strongly predict PTSD symptom severity above and beyond other aspects of alexithymia, emotional awareness, and emotion dysregulation (Tull et al., 2007). Third, features of PTSD include abnormal, heightened stress reactivity (Yehuda & McFarlane, 1995), and the corresponding use of avoidance-oriented coping strategies (Hepp et al., 2005, Jacobsen et al., 2002). In fact, PTSD has been characterized in part as a disorder of emotional avoidance (Feeny and Foa, 2005, Marx and Sloan, 2005), which further suggests that individuals with PTSD under-utilize active emotion-regulation strategies, such as cognitive reappraisal. Two studies investigating the use of cognitive reappraisal in the context of PTSD support this hypothesis, finding that less frequent use of cognitive reappraisal was associated with higher levels of PTSD symptom severity (Eftekhari et al., 2009, Ehring and Quack, 2010).
Moving beyond symptoms of PTSD, recent work has sought to understand the processes that contribute to well-being and positive adjustment following the experience of trauma (e.g., Kashdan et al., 2010a, Kashdan et al., 2010b, Tedeschi and Calhoun, 2004). It might reasonably be assumed that a combination of strong emotional clarity and frequent use of cognitive reappraisal would not only predict fewer and less severe PTSD symptoms, but, based on a growing body of evidence finding that psychopathology is relatively independent from positive experience (e.g., Carver et al., 2000, Keyes, 2005), would also predict well-being among individuals with PTSD. This hypothesis follows from theories of psychological flexibility, which posit that the ability to match a given emotion regulation strategy with situational demands and goals is of more importance to psychological health than the particular strategy used (Kashdan & Rottenberg, 2010). Emotional clarity provides information that allows for the optimal selection and use of emotion regulation strategies to modulate emotions in a manner consistent with current goals (e.g., Feldman Barrett & Gross, 2001). Therefore, the benefits of cognitive reappraisal on well-being would in part dependent upon when and under what circumstances it is used to regulate emotions, which is largely influenced by emotional clarity. Findings addressing this hypothesis are especially important in terms of the treatment of PTSD, as: (1) evidence-based interventions that attempt to increase adaptive emotion regulation (e.g., cognitive processing therapy; Resick & Schnicke, 1992) have been shown to lead to reductions in PTSD symptoms (Monson et al., 2006); and yet, (2) a significant number of Veterans do not optimally respond to these treatments and retain diagnoses of PTSD following treatment (Monson et al., 2006).
The goal of the present investigation was to examine the interaction of emotional clarity and cognitive reappraisal in predicting PTSD symptom severity and positive affect among military Veterans seeking treatment at a Department of Veterans Affairs (VA) Medical Center. It was hypothesized that veterans with PTSD who frequently used cognitive reappraisal would report less symptom severity and more positive affect, especially if they also had high levels of emotional clarity. Furthermore, it was hypothesized that these interactive effects would be significant even after accounting for shared variance with the extent to which participants attended to their emotions (i.e., attention to emotions). Attention to emotions is a second facet that underlies alexithymia and emotional awareness (Coffey et al., 2003, Gohm and Clore, 2000, Gohm and Clore, 2002). Thus, we attempted to demonstrate that significant effects were specific to the interaction of emotional clarity and cognitive reappraisal, and not to emotional awareness or alexithymia more broadly.
Section snippets
Participants
A total of 75 military Veteran patients (93% male; Mage = 45.2 years, SD = 14.4; range = 21–66) participated in this study. All participants had a primary diagnosis of PTSD. Diagnoses were provided by VA staff clinicians prior to treatment entry and confirmed upon entry into PTSD treatment at the residential rehabilitation programs (see next paragraph). The majority of the sample identified their racial/ethnic composition as Caucasian (59.5%), followed by Hispanic/Latino/a (23.0%), African American
Results
In a preliminary set of analyses, we investigated zero-order correlations between predictor and outcome variables. As shown in Table 1, emotional clarity and cognitive reappraisal were negatively associated with total PTSD symptom severity, whereas cognitive reappraisal but not emotional clarity was associated with positive affect.
Two hierarchical multiple regression analyses were conducted to test our primary hypotheses (see Table 2). In Step 1, covariates were entered as predictors. Attention
Discussion
The current study is the first to investigate the interactive effects of emotional clarity and the use of cognitive reappraisal in predicting psychopathology and trait emotionality in any population. We found that, among military Veterans seeking treatment for PTSD, the interaction between emotional clarity and cognitive reappraisal significantly predicted: (a) positive affect after accounting for shared variance with attention to emotions and total PTSD symptom severity; and (b) total PTSD
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This work was supported by a Veterans Affairs Clinical Science Research and Development (CSR&D) Career Development Award – 2 and a California HIV/AIDS Research Program IDEA Award (163836), granted to Dr. Bonn-Miller. Todd B. Kashdan was financially supported as the senior scientist of the Center for Consciousness and Transformation, George Mason University.