Emotion in Posttraumatic Stress Disorder

Etiology, Assessment, Neurobiology, and Treatment

Matthew Tull, Nathan Kimbrel

• Publisher: Academic Press
• Year: 2020
• Print ISBN: 9780128160220
• eBook ISBN: 9780128162897
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Emotion in Posttraumatic Stress Disorder provides an up-to-date review of the empirical research on the relevance of emotions, such as fear, anxiety, shame, guilt, and disgust to posttraumatic stress disorder (PTSD). It also covers emerging research on the psychophysiology and neurobiological underpinnings of emotion in PTSD, as well as the role of emotion in the behavioral, cognitive, and affective difficulties experienced by individuals with PTSD. It concludes with a review of evidence-based treatment approaches for PTSD and their ability to mitigate emotion dysfunction in PTSD, including prolonged exposure, cognitive processing therapy, and acceptance-based behavioral therapy.- Identifies how emotions are central to understanding PTSD.- Explore the neurobiology of emotion in PTSD.- Discusses emotion-related difficulties in relation to PTSD, such as impulsivity and emotion dysregulation.- Provides a review of evidence-based PTSD treatments that focus on emotion.

Section 1

Emotions

Chapter 1

Assessment of emotion and emotion-related processes in PTSD

Meghan E. McDevitt-Murphy; Rebecca J. Zakarian; Cecilia C. Olin The University of Memphis, Memphis, TN, United States

Abstract

This chapter reviews methods for assessing emotions and emotion-related processes in the context of posttraumatic stress disorder (PTSD). We present brief descriptions of emotions including anger, anxiety, fear, guilt, sadness, shame, guilt, and anger and offer recommendations for their measurement. We also review assessment strategies for emotion-related processes that are particularly relevant to PTSD presentations, including alexithymia, anhedonia, anxiety sensitivity, distress tolerance, emotion regulation, and experiential avoidance. All assessment strategies were identified based on the available literature and the frequency of their use with trauma samples. For most constructs, we present recommendations and descriptions for self-report questionnaires although, where appropriate, we also describe lab-based or behavioral measures. Brief psychometric information and administration details are also provided.

Keywords

Assessment; Measures; Emotion dysfunction; Emotional processes

Assessment of emotion and emotion-related processes in PTSD

Posttraumatic stress disorder (PTSD) is a complex disorder characterized by intense emotions across several domains, including not only prominent fear and anxiety but also sadness, guilt, and shame. PTSD has also been characterized by emotional numbing and anhedonia (i.e., a loss of interest or pleasure), both of which reflect a diminished experience of positive emotion. Additionally, some research has pointed to emotion-related processes (e.g., emotion regulation and experiential avoidance) as risk factors that may contribute to the onset or maintenance of PTSD following trauma exposure. Key to research and clinical work with these emotions and processes is a thorough assessment of PTSD. There are two psychometrically sound, DSM-correspondent, assessment instruments available from the National Center for PTSD (www.ncptsd.org): the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013), a structured interview, and the PTSD Checklist (PCL-5; Weathers, Litz, et al., 2013), a self-report questionnaire. For clinicians and researchers who also wish to thoroughly assess the emotions and emotion-related processes that accompany or contribute to PTSD or have implications for psychotherapy, this chapter offers insight into the available, research-supported assessment options. Herein, we briefly review key emotions and emotion-related processes that have relevance for PTSD and recommend assessment instruments for each domain based on the available research. The recommended measures presented in this chapter do not reflect an exhaustive list, but instead represent some of the measures with the most support in the published literature.

Assessment of emotions in PTSD

We begin with the assessment of emotions in the context of PTSD. In this section, we include emotions that are either components of the diagnostic criteria for PTSD or frequently present alongside PTSD. In general the most well-established assessment methods for most constructs are questionnaires. All recommended measures appear in Table 1.

Table 1

Assessment of emotion in PTSD.

Measure	Citation	Construct measured	Trauma samples studied	Psychometric evidence	Administration details
Anxiety
State-Trait Anxiety Inventory (STAI)	Spielberger (1983)	State and trait anxiety	Civilian trauma survivors, veterans	Evidence of reliability and validity; state anxiety and trait anxiety reflect distinct constructs	40 items total. Each of 20 items is rated both with respect to “right now” (state) and “generally” (trait). Items rated on a 4-point scale
Anger
State-Trait Anger Expression Inventory (STAXI-II)	Spielberger (1999)	State anger, trait anger, anger expression (out/in), anger control (out/in)	9/11 disaster workers, veterans with PTSD, combat veterans, adolescent survivors of sexual violence	Extensive factor structure analysis, international adaptation, and psychometric evaluation; normative data derived from large clinical and nonclinical samples	57 items rated on a 4-point Likert scale. May be administered online or on paper. Gender-normed T-scores available
Buss-Perry Aggression Questionnaire (BPAQ)	Buss and Perry (1992)	Anger, hostility, aggression	Has been used extensively with survivors of a wide range of traumas, including childhood abuse and sexual assault; prisoners of war; and combat veterans	Demonstrated strong convergent validity, discriminant validity, construct validity, test-retest reliability, and internal consistency	Anger subscale: 8 items rated on 5-point Likert scale
Fear
NPU-Threat Test	Schmitz and Grillon (2012)	Fear, anxiety	Small sample of patients with PTSD	Discriminates between state fear and state anxiety	Lab-administered physiological task. Measures startle response to predictable or unpredictable shock
Shame & guilt
Internalized Shame Scale	Cook (2001)	Internalized (trait) shame, general self-esteem	Survivors of intimate partner violence, combat veterans, treatment-seeking veterans with PTSD, sexual assault survivors	Performed well on indices of internal consistency, temporal stability, convergent validity, discriminant validity	30 items rated on 5-point Likert scale
Tests of Self-Conscious Affect (TOSCA-3)	Tangney, Dearing, Wagner, and Gramzow (2000)	Shame proneness, guilt proneness, blame, unconcern	Has been used extensively with trauma survivors, including military, interpersonal, and childhood traumas	Strong test-retest reliability, internal consistency, and convergent/divergent validity	15 vignettes with item response likelihood rated on a 5-point scale; adolescent and child versions are also available
Trauma-Related Guilt Inventory	Kubany et al. (1996)	Global guilt, guilt distress, guilt cognitions	Vietnam veterans, post-9/11 veterans, survivors of intimate partner violence, refugees	Performed well on indices of internal consistency, temporal stability, and convergent validity	32 items rated on 5-point Likert scale
Trauma-Related Shame Inventory	Øktedalen, Hagtvet, Hoffart, Langkaas, and Smucker (2014)	Internal and external trauma-related shame	Inpatient and outpatient treatment seekers diagnosed with PTSD, trauma-exposed veterans, adult sexual assault survivors	Demonstrated strong construct validity and convergent validity	24 items rated on 4-point Likert scale
Various
Positive and Negative Affect Scale	Watson, Clark, and Tellegen (1988)	Items assess positive or negative emotion. PANAS-X includes scales assessing fear, hostility, and guilt, in addition to sadness, joviality, self-assurance, attentiveness, shyness, fatigue, serenity, and surprise	Has been used extensively with a range of trauma samples	All versions have shown evidence of discriminant and convergent validity	Three versions exist: the PANAS has 20 items, the International PANAS-Short Form has 10 items, and the PANAS-X has 60 items and 11 scales Items for all versions are rated on a 5-point scale

Anger

Individuals with PTSD frequently report problems with anger, ranging from the manifestation of high anger emotional states to behavioral dyscontrol in the form of aggressive, violent, or risky behaviors (American Psychiatric Association, 2000, 2013). Heightened irritability and angry outbursts are frequent features of the disorder and have been implicated among some trauma survivors as the most impairing feature of PTSD’s emotional landscape (e.g., Biddle, Elliott, Creamer, Forbes, & Devilly, 2002; Rosen, Adler, & Tiet, 2013). In a metaanalytic review of anger expression in PTSD, Olatunji, Ciesielski, and Tolin (2010) examined over 2000 patients with anxiety disorders across 28 studies and found that anger was uniquely heightened in patients with PTSD relative to other anxiety disorders, where high levels of irritability were also found. Moreover, results from the study indicated that individuals with PTSD distinctively struggle with the expression and control of anger, suggesting that problems with anger may be part of a broader network of emotional dysregulation and behavioral dysfunction.

The eroding effects of anger on interpersonal relationships (Kubany, Bauer, Muraoka, Richard, & Read, 1995) and links between anger and further negative outcomes (e.g., comorbidity (Gonzalez, Novaco, Reger, & Gahm, 2016) and aggressive/violent behavior (Jakupcak et al., 2007)) suggest that the assessment of anger in clinical contexts is necessary for comprehensive trauma care. Researchers studying trauma populations would also benefit from further investigation of this important emotional feature of PTSD emotional profiles. Additionally, certain populations of trauma survivors have been more frequently studied (e.g., combat veterans) than others, suggesting that there are unique gaps in the literature that warrant greater inquiry to understand the contextual role of anger across trauma types and populations.

Like other measures intended to capture emotional expression, measures of anger are frequently conceptualized in terms of state anger (e.g., specific, cued anger responses) and trait anger (e.g.,...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Introduction: Understanding the role of emotion in the etiology, assessment, neurobiology, and treatment of posttraumatic stress disorder
• Section 1: Emotions
• Section 2: Biological bases of emotional responding and dysfunction
• Section 3: Difficulties in responding and relating to emotion
• Section 4: Treatment and cultural considerations
• Index