Emotion regulation difficulties as a prospective predictor of posttraumatic stress symptoms following a mass shooting
Highlights
► We examined pre-shooting emotion regulation difficulties (ERD) and posttraumatic stress symptoms (PTSS) in predicting post-shooting ERD and PTSS. ► ERD and PTSS were reciprocally influential from pre- to post-shooting. ► Higher post-shooting ERD predicted higher PTSS at eight months post-shooting. ► Post-shooting PTSS did not predict ERD at eight months post-shooting.
Introduction
Posttraumatic stress disorder (PTSD) is comprised of symptoms including intense distress at exposure to trauma-related reminders, avoidance of internal and external cues associated with the traumatic experience, emotional numbing, and hyperarousal (American Psychiatric Association [APA], 2000). The symptom constellation of PTSD reflects a broad range of difficulties regulating emotions, spanning from hyperreactivity in the form of reexperiencing symptoms to emotional hyporeactivity in the form of anhedonia and restricted range of affect (Ehring and Quack, 2010, Frewen and Lanius, 2006, Litz et al., 2000, Litz, 1992). Deficits in adaptive emotion regulation have been identified as a central feature of PTSD (e.g., Frewen and Lanius, 2006, Litz et al., 2000), and results of field trials for the DSM-IV indicated that over 70% of those with PTSD endorsed difficulties in regulating emotions (van der Kolk, Roth, & Pelcovitz, 1993). Theoretical perspectives regarding factors that promote and maintain posttraumatic stress symptoms (PTSS) indicate a disruption in cognitive, physiological, or behavioral affect regulatory processes (Brewin et al., 1996, Ehlers and Clark, 2000, Foa and Kozak, 1986, Frewen and Lanius, 2006). However, despite a growing body of literature indicating a link between emotion regulation deficits and PTSD symptomatology (Eftekhari et al., 2009, Ehring and Quack, 2010, Tull et al., 2007), the precise nature of the relationships among emotion dysregulation and PTSD is unclear.
Gratz and Roemer (2004) identify emotion regulation as the ability to monitor, evaluate, and modulate emotional reactions within the context of goal-directed behavior. Gratz and Roemer's integrated conceptualization of emotion regulation has been shown to involve awareness and clarity of emotional responses, emotional acceptance, access to effective emotion regulation strategies, and control of impulses and engagement in goal-directed behaviors when experiencing negative emotion. Difficulties with emotion regulation have been associated with a range of psychopathology, including depression (Gross & Munoz, 1995), borderline personality disorder (Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006), anxiety disorders in general (for a review, see Cisler, Olatunji, Feldner, & Forsyth, 2010), and PTSD (Eftekhari et al., 2009, Ehring and Quack, 2010, Tull et al., 2007).
Although emotion regulation deficits are associated with multiple forms of psychopathology, they may be specifically salient in the context of PTSD. The current diagnostic classification of PTSD indicates that the subjective experience of intense peritraumatic fear, helplessness, or horror in response to a traumatic stressor (Criterion A2) is a vital etiological component (APA, 2000). However, at present, Criterion A2 is the topic of much debate, with some suggesting that the criterion has limited clinical utility (Breslau and Kessler, 2001, Brewin et al., 2009), and others suggesting an expansion of Criterion A2 (Bovin and Marx, 2011, Kilpatrick et al., 2009) to include additional acute trauma-related emotional reactions (e.g., shame, guilt, anger; Rubin, Berntsen, & Bohni, 2008).
Regardless, the appraisal of a stressor as threatening and in excess of an individual's coping resources, as well as the subjective experience of intense peritraumatic emotion, has been proposed as increasing risk of developing PTSD (Bovin & Marx, 2011). Deficits in emotion regulation would likely lead to greater appraisals of threat, diminished coping resources, and more intense emotional responding upon exposure to a traumatic stressor, and thus, these deficits may function in the etiology of PTSD. Consistent with this hypothesis, threat appraisal has emerged as a more reliable predictor of PTSD symptoms than objective measures of danger in some samples (Bernat et al., 1998, Ehlers et al., 1998, King et al., 1995, Ullman and Filipas, 2001). Additional empirical evidence, however, suggests complex relationships between emotion regulation, trauma exposure, and PTSS (Ehring & Quack, 2010) when examined concurrently. Available research relies on cross-sectional designs, therefore, the precise nature of these associations is unknown.
Intense emotional reactions to trauma-related cues are common in the aftermath of traumatic events (e.g., Rothbaum et al., 1992, Shalev et al., 1998); however, these reactions diminish for most trauma survivors (Kessler et al., 1995, Rothbaum et al., 1992, Shalev et al., 1998). Thus, peritraumatic emotional responding alone is not sufficient to account for the development of PTSD. Possessing adequate emotion regulation skills may be characteristic of those able to recover in the aftermath of a traumatic experience, while individuals lacking the emotion regulation capacity necessary to attenuate their arousal and distress may be at risk of chronic disruptions in emotional responding associated with PTSD (Frewen & Lanius, 2006). Deficits in emotion regulation likely contribute to the maintenance of PTSD in multiple ways. Individuals may perceive their emotions as uncontrollable (Frewen & Lanius, 2006) and subsequently learn to fear internal and external cues that elicit emotional reactions. A lack of access to adaptive emotion regulation strategies may then lead to avoidance of trauma-related experiences, thus preventing exposure to trauma relevant reminders that would otherwise facilitate habituation (Foa & Kozak, 1986).
Despite a growing body of literature implicating emotion dysregulation in the development and maintenance of PTSD, it is currently unknown whether emotion dysregulation is primarily a cause or consequence of PTSS. Cross-sectional research demonstrated that severity of PTSS was positively associated with self-reported difficulties with multiple components of emotion regulation (i.e., lack of emotional acceptance, impulse control difficulties, and lack of access to effective emotion-regulation strategies), even when overall level of negative affect was taken into account (Tull et al., 2007). Furthermore, individuals reporting PTSS suggestive of a diagnosis of PTSD endorsed subjective deficits in overall emotion regulation, as well as specific components of impulse control difficulties, lack of access to effective emotion regulation strategies, and lack of emotional clarity when controlling for the effects of negative affect (Tull et al., 2007). Severity of PTSS has also been linked cross-sectionally to reduced subjective capacity and self-reported frequency of emotion regulation strategies, suggesting that deficits in emotion regulation flexibility play a role in PTSS (Eftekhari et al., 2009). Psychophysiological research also has demonstrated an association between PTSD and deficits in emotional processing and positive emotional expression (Litz et al., 2000). Individuals with PTSD exhibit heightened negative emotion and diminished positive emotion in response to emotionally evocative stimuli (Amdur, Larsen, & Liberzon, 2000) and exposure to trauma-related cues has been associated with enhanced negative affective reactions and subsequent defensive responding to negatively valenced stimuli in the context of PTSD (Miller & Litz, 2004). Interestingly, in an experimental study by Badour and Feldner (2013) PTSS were found to be predictive of emotional reactivity to trauma cue exposure, but only among individuals who had relatively higher levels of emotion regulation difficulties (ERD).
Although the sum of the available literature supports a meaningful link between deficits in emotion regulation and PTSD, the lack of prospective studies examining to what extent emotion regulation deficits are a risk factor for, or a consequence of, psychological distress in the aftermath of a traumatic experience limits directional conclusions. One proposition within the literature is that trauma exposure creates a disruption in emotion regulation capacity (e.g., Frewen and Lanius, 2006, van der Kolk, 1996). Marked disruptions in emotion regulation have been noted in individuals exposed to chronic interpersonal trauma, such as prolonged childhood abuse (e.g., Cloitre et al., 2005, van der Kolk, 1996), suggesting that trauma exposure itself may degrade the capacity for emotion regulation. However, recent research suggests ERD are not unique to survivors of early-onset interpersonal trauma and that the relationship between emotion regulation and trauma type is a function of PTSD symptom severity (Ehring & Quack, 2010), raising further questions regarding the role of emotion dysregulation in the course of PTSD. Moreover, Ehring and Quack (2010) voiced concerns regarding the high degree of overlap between definitions of emotion regulation and symptoms of PTSD, which may lead to inflated associations between the constructs. This would be of particular concern when symptomatology and emotion regulation are measured concurrently.
To address limitations in the available research and clarify associations between ERD and PTSS, the present prospective study investigates the role of pre-trauma difficulties with emotion regulation in the development of PTSS following exposure to a potentially traumatic event. Initially, we had intended to examine prospective predictors of sexual victimization in a sample of undergraduate women enrolled in a longitudinal study. However, the course of the longitudinal study took an unexpected turn in February of 2008, when a gunman opened fire on a classroom of students on the Northern Illinois University (NIU) campus, in DeKalb, Illinois. It was the fourth deadliest school shooting in U.S. history; before taking his own life, the gunman left five students dead and 21 wounded. Due to the trauma-focused nature of the initial longitudinal study, we were in a unique position to examine the effects of ERD in the development of PTSS following an episode of mass-violence.
The extant literature provides important clues about the relationships between ERD and PTSS; however, a number of questions remain. Due to a lack of prospective research examining predictive relationships between ERD and PTSS, the temporal relationship between these constructs remains unclear. Research that includes pre-trauma assessments of emotion regulation and accounts for the effects of previously reported PTSS is needed for the affirmation of temporal precedence. As suggested by some (e.g., Cloitre et al., 2005, van der Kolk, 1996), trauma exposure itself may degrade the capacity for emotion regulation. On the other hand, a deficit in one's ability to down-regulate emotional arousal may lead one to perceive emotions as uncontrollable and increase the likelihood of fear acquisition (Bouton, Mineka, & Barlow, 2001). Individuals with emotion regulation deficits may be more likely to associate trauma cues with the negative affect and arousal experienced during the event, thus resulting in avoidance of feared situations and the subsequent development of PTSS. The prospective nature of the present study provides a unique opportunity to clarify the temporal nature of the association between these constructs.
The lack of prospective research in this area precluded a priori hypotheses regarding temporal specificity of the relationship between emotion regulation and PTSS. That is, as described above, it may be that deficits in emotion regulation are the result of trauma exposure and prior PTSS, or ERD may be a vulnerability factor in the development of PTSS. Additionally, in order to examine the specificity of observed temporal relations between ERD and PTSS, a second analysis was conducted in which a general distress construct was substituted for PTSS.
Section snippets
Participants and procedure
One thousand and forty-five female undergraduate students from Northern Illinois University (NIU), aged 18 or older, were recruited for participation (T1) in a longitudinal study originally designed to examine trauma and sexual revictimization. In order to participate, the sole requirements were that women were over the age of 18 and fluent in English; although the study focused on sexual revictimization, participants were not selected based on the presence or absence of trauma history of any
Preliminary analyses
Bivariate correlations were calculated in order to examine associations among descriptive statistics (i.e., age, race/ethnicity, physical exposure to the shooting [exposure]) and variables of interest (i.e., DERS subscales, DEQ cluster scores, DASS-21 subscales) for covariate inclusion. Among potential covariates, age was associated with T1 DERS-Nonacceptance (r = −.08, p < .05), and race/ethnicity (0 = all others/1 = White and Non-Hispanic) was significantly associated with the following: T1, T2, and
Discussion
The present study sought to clarify the temporal nature of relations between ERD and PTSS from pre- to post-trauma. We utilized a three time-point prospective investigation with a sample of 691 undergraduate women who were involved in an ongoing longitudinal study at the time of a campus shooting. Further, a cross-lagged panel design was implemented in order to strengthen causal inferences about the directional relations between ERD and PTSS. A reciprocal model, in which ERD and PTSS mutually
Acknowledgements
This research was funded by grants to the third author from the Joyce Foundation, the National Institute for Child and Human Development (1R15HD049907-01A1), and the National Institute of Mental Health (5R21MH085436-02).
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