Trauma-related reactivity and regulation of emotion: Associations with posttraumatic stress symptoms

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Abstract

Background and objectives

Both emotional reactivity to traumatic event cues and difficulties regulating emotion have been linked to posttraumatic stress symptom severity. The current study uniquely extended these two lines of research by examining the degree to which these two factors alone, and in combination, account for variability in posttraumatic stress symptom severity.

Method

Self-reported emotion regulation difficulties, and both subjective and physiological reactivity in response to a script-driven imagery procedure, were assessed among a community sample of 21 adult women with a history of interpersonal assault. Relationships with an interview-based measure of posttraumatic stress symptom severity were examined.

Results

Results were consistent with hypotheses. Both traumatic event-related emotional reactivity and emotion regulation difficulties independently predicted posttraumatic stress symptom severity. A significant interaction also emerged such that traumatic event-related emotional reactivity and posttraumatic stress symptom severity were only significantly associated at relatively elevated levels of emotion regulation difficulties.

Limitations

Limitations included the use of a self-report questionnaire to assess emotion regulation difficulties, relatively small sample size, and lack of evidence regarding generalizability across gender or other traumatic event types.

Conclusions

These results highlight that the interaction of heightened emotional reactivity and difficulties regulating emotion may be particularly influential in posttraumatic stress symptom severity.

Highlights

► Reactivity to traumatic event cues have been related to posttraumatic stress. ► Emotion regulation difficulties have also been linked to posttraumatic stress. ► This study examined how these factors interact to predict posttraumatic stress. ► Physiological and subjective reactivity predicted posttraumatic stress. ► This relation was only significant for those with difficulties regulating emotion.

Introduction

Re-experiencing symptoms, including unwanted and intrusive memories of a traumatic event, flashbacks, nightmares and emotional and physiological reactivity to traumatic event reminders, have been considered hallmark symptoms of posttraumatic stress disorder (PTSD; Foa, Zinbarg, & Rothbaum, 1992). Conditioning-based theories suggest powerful associative learning occurs during a traumatic event, such that fear responses become paired via classical conditioning with stimuli present during the event (e.g., Foa and Kozak, 1986, Keane et al., 1985). As a result of this pairing, previously neutral cues associated with the traumatic event become capable of eliciting anxious reactions, even in the absence of present danger. The experience of increased emotional reactivity to traumatic event cues immediately following traumatic event exposure is an expected and normative response (Riggs et al., 1995, Rothbaum et al., 1992) that decreases over time with repeated exposure to traumatic event cues via extinction learning (Foa and Kozak, 1986, Keane et al., 1985). However, persistent traumatic event-related emotional reactivity is a well-documented phenomenon among individuals exhibiting sustained posttraumatic stress reactions including those with PTSD.

Research demonstrates that compared to traumatic event-exposed individuals without elevated posttraumatic stress symptoms, those with higher symptom levels (Badour et al., 2011, McDonagh-Coyle et al., 2001, Pitman et al., 2001), including those with a diagnosis of PTSD (Lanius et al., 2003, Liberzon et al., 1999, Orr et al., 1993, Pitman et al., 1990, Pitman et al., 1987, Shin et al., 1999, Shin et al., 2004, Wolfe et al., 2000), display greater emotional reactivity in response to traumatic event cues. For example, male veterans with PTSD display significantly greater subjective distress and skin conductance responses when presented with combat sounds as compared to those without PTSD (Liberzon et al., 1999). Similarly, Wolfe et al. (2000) found female veterans with a current diagnosis of PTSD respond to combat-related images and sounds with increased subjective distress, skin conductance response, and systolic blood pressure compared to those with no history of PTSD. Moreover, skin conductance response positively correlates with severity of each of the three symptom clusters of PTSD (i.e., re-experiencing, avoidance-numbing, hyperarousal).

Several studies in this area have moved beyond the use of generalized traumatic event stimuli to utilize more ecologically valid methods of eliciting emotional responding to traumatic event cues. The script-driven imagery procedure, which involves the development and presentation of individualized narratives of traumatic event experiences, allows for a more refined assessment of traumatic event-related emotional reactivity while maintaining the internal validity associated with a controlled laboratory study. Studies employing this procedure have established links between posttraumatic stress symptom levels and both self-reported increases in negative affect (e.g., fear/anxiety; Badour et al., 2011, Pitman et al., 1987, Pitman et al., 1990, Shin et al., 2004) and heightened physiological reactivity (e.g., skin conductance, heart rate, facial electromyography [EMG]; see Orr & Roth, 2000 for a review). For example, in response to individualized combat scripts, Vietnam veterans with PTSD evidence increased skin conductance and facial EMG activity, as well as higher ratings of fear (and other negative emotions) as compared to veterans without PTSD (Pitman et al., 1987, Shin et al., 2004) and those with other anxiety disorders (Pitman et al., 1990). Similarly, posttraumatic stress symptom severity significantly correlates with increased heart rate and self-reported negative affect in response to individualized sexual abuse scripts (McDonagh-Coyle et al., 2001) and self-reported anxious reactivity in response to a range of individualized traumatic event scripts (e.g., interpersonal victimization, motor vehicle accidents, natural disasters), even after accounting for general negative affect (Badour et al., 2011).

A second process likely to be critical in understanding posttraumatic stress reactions is ineffective regulation of emotion (Etkin and Wager, 2007, Liberzon and Garfinkel, 2009, Tull et al., 2007). People with PTSD devote significant resources to the regulation of negative emotions (Kashdan, Breen, & Julian, 2010) and frequently exhibit difficulties with this process (Chemtob et al., 1997, Cloitre et al., 2005, Ehring and Quack, 2010, Klemanski et al., 2012, Price et al., 2006, Tull et al., 2007). Emotion regulation is broadly defined as the ability to identify, evaluate, and modify the experience and expression of affect (Gratz and Roemer, 2004, Gross, 1998). Skills for identifying, accepting, processing, and down-regulating arousal and distress are thought to be essential to the effective management of heightened emotional reactivity resulting from exposure to reminders of traumatic events (Tull et al., 2007).

At least two lines of evidence suggest emotion regulation ability may be involved in the maintenance of posttraumatic stress reactions. First, it has been suggested that non-acceptance of negative emotions, a subtype of emotion regulation linked to severity of PTSD symptoms (Ehring and Quack, 2010, Tull et al., 2007), may actually increase traumatic event-related distress by leading to the development of secondary emotions such as guilt or shame associated with one’s initial response to the event (Tull et al., 2007). It has further been suggested that non-acceptance of emotion may result in the expenditure of additional resources for the regulation of negative emotions at the cost of reducing engagement in goal-directed adaptive behaviors which may improve general well-being (Kashdan et al., 2010). Second, emotion regulation difficulties have been linked to a relative reliance on avoidant regulation strategies. For example, emotion regulation difficulties predict behavioral avoidance and functional impairment among victims of childhood abuse (Cloitre et al., 2005, Gratz et al., 2007), and improvement in emotion regulation ability predicts greater symptom reduction during exposure-based PTSD treatment, which specifically targets engagement with traumatic event cues in an effort to extinguish associated emotional reactivity (Cloitre et al., 2002, Price et al., 2006). Specific difficulty in identifying, describing, and distinguishing between emotion states following exposure to a traumatic event (i.e., secondary alexithymia; Hendryx et al., 1991, Taylor et al., 1991) has been linked to PTSD (Badura, 2003, Hyer et al., 1990, Monson et al., 2004), and has been conceptualized as a form of avoidance employed to help an individual cope with the experience of aversive emotional states. This is critical given that avoidance and escape in the face of traumatic event reminders serves to maintain posttraumatic stress reactions by interfering with extinction learning needed to reduce traumatic event-related emotional reactivity (Foa and Kozak, 1986, Foa and Rothbaum, 1998, Keane and Barlow, 2002, Keane et al., 1985, Pineles et al., 2011). Collectively, this work suggests emotion regulation difficulties may serve as a maintaining factor for posttraumatic stress reactions.

While these distinctive literatures converge to suggest that both persistent heightened emotional reactivity to traumatic event cues and difficulties regulating emotion should be linked to elevated posttraumatic stress symptomatology, empirical research has yet to examine the potential combined effects of these factors. When presented with distress associated with exposure to traumatic event cues, we might expect individuals equipped with the ability to effectively manage emotional experiences to be better able to appropriately identify and respond to the heightened traumatic event-related emotional reactivity that emerges as a consequence of fear conditioning during a traumatic event (Foa and Kozak, 1986, Keane et al., 1985). Conversely, we would expect those with difficulties regulating emotional experiences to engage in less adaptive strategies for coping with emotional reactivity elicited by traumatic event cues (e.g., cognitive/behavioral avoidance; Cloitre et al., 2005, Gratz et al., 2007) thus interfering with natural extinction processes and serving to maintain elevated posttraumatic stress reactions. The current study sought to provide a preliminary test of this model. Specifically, we examined the impact of emotion regulation difficulties on the association between subjective (i.e., self-reported anxiety) and physiological (i.e., skin conductance) reactivity to individualized traumatic event cues and posttraumatic stress symptom severity in the controlled environment of the laboratory using the well-established script-driven imagery procedure. This method was chosen based on a wealth of research linking posttraumatic stress symptomatology to both subjective and physiological arousal in response to the script-driven imagery procedure (Badour et al., 2011, Lanius et al., 2003, Liberzon et al., 1999, McDonagh-Coyle et al., 2001, Orr et al., 1993, Pitman et al., 1987, Pitman et al., 1990, Pitman et al., 2001, Shin et al., 1999, Shin et al., 2004, Wolfe et al., 2000). It was hypothesized that, consistent with prior research, positive associations would emerge between posttraumatic stress symptom severity and both emotion regulation difficulties and traumatic event-related emotional reactivity. It was further hypothesized that a stronger relation between reactivity to traumatic event cues and posttraumatic stress symptom severity would emerge among individuals exhibiting relatively high levels of emotion regulation difficulties.

Section snippets

Participants

Twenty-one adult women (Mage = 33.24, SD = 16.19) with a history of at least one sexual or physical assault meeting criteria for a traumatic event, defined as satisfying Criterion A of the PTSD diagnosis (i.e., A1: an event involving life threat, threatened or actual serious injury, or threat to one’s physical integrity, A2: that is accompanied by intense feelings of either fear, helplessness, or horror; American Psychiatric Association [APA], 2000), were recruited from the community as part of

Results

Table 1 includes means, standard deviations, and zero-order correlations. As hypothesized, emotion regulation difficulties and both subjective and physiological reactivity to the traumatic event script were significantly positively correlated with posttraumatic stress symptom severity. Emotion regulation difficulties were not significantly associated with either traumatic event-related subjective or physiological reactivity, suggesting that these measures assessed distinct factors. Other

Discussion

There is increasing recognition of the link between emotion regulation difficulties and posttraumatic stress symptom severity (Chemtob et al., 1997, Cloitre et al., 2005, Price et al., 2006, Tull et al., 2007). However, there has been a dearth of research examining the nature of this association. The current study was the first to explore the interaction between emotion regulation difficulties and traumatic event-related emotional reactivity in predicting posttraumatic stress symptom severity.

Role of funding organizations

This research was supported, in part, by a NIMH National Research Service Award (F31 MH092994-01) as well as a grant from the Marie Wilson Howells Foundation in the Department of Psychological Science at the University of Arkansas, both awarded to the first author.

Declaration of interest

There are no conflicts of interest to be declared for either author.

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      Negative emotional reactivity to daily, minor stressors, has been linked to various kinds of psychopathology (van Nierop et al., 2018), including depression (Booij, Snippe, Jeronimus, Wichers, & Wigman, 2018), and was found to be predictive of depressive symptoms (Wichers et al., 2009). Reactivity to trauma-related lab-induced stimuli is linked to PTSS severity in trauma-exposed populations (Cavanagh, Fitzgerald, & Urry, 2014; Kaczmarek & Zawadzki, 2012) and people with PTSD (Badour & Feldner, 2013; Spiller et al., 2019), and is predictive of PTSD (Pineles et al., 2013). Regarding positive emotional reactivity, studies have been scarce.

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