The role of emotional inexpressivity and experiential avoidance in the relationship between posttraumatic stress disorder symptom severity and aggressive behavior among men exposed to interpersonal violence

Posttraumatic stress disorder (PTSD) has been found to be associated with aggressive behavior. Recent evidence suggests that the ways in which individuals respond to their emotions may account for this relationship. In particular, to the extent that aggressive behaviors serve an emotion regulatory function, responding to emotions with avoidance (i.e., experiential avoidance) or the active suppression of emotional expression may heighten emotion dysregulation, increasing the risk for aggressive behavior as individuals attempt to regulate that dysregulated state. This study examined whether these two ways of responding to emotions account for the relationship between PTSD symptom severity and self-reported engagement in aggressive behavior among a diverse sample of 113 men with past exposure to interpersonal violence. Experiential avoidance and emotional inexpressivity each accounted for a significant amount of unique variance in aggressive behavior, above and beyond PTSD symptom severity and trait anger. Clinical and research implications of findings are discussed.     

The relationship between acute stress disorder and posttraumatic stress disorder in severely injured trauma survivors

This prospective longitudinal study was designed to investigate the relationship between acute stress disorder (ASD) and the subsequent development of posttraumatic stress disorder (PTSD) in a population of severely injured hospitalised trauma survivors. Symptoms of ASD were assessed just prior to discharge in 307 consecutive admissions to a Level 1 Trauma Centre, with PTSD assessments completed at 3 and 12 months post-injury. A well-established structured clinical interview was adopted for both assessments. Only 1% of the sample met criteria for an ASD diagnosis (at a mean of 8 days post-injury), while the incidence of PTSD was 9% at 3 months and 10% at 12 months. Although all ASD symptom clusters contributed to the prediction of subsequent PTSD severity, logistic regression indicated that only re-experiencing and arousal predicted a categorical PTSD diagnosis. The dissociative symptoms that form the core of ASD were rarely endorsed and showed high specificity but low sensitivity, resulting in a high proportion of false negative diagnoses. Reducing the number of dissociative symptoms required for a diagnosis ameliorated, but did not resolve, the problem. In this particular population, the low sensitivity of the ASD diagnosis renders it a poor screening test for use in identifying high risk individuals for early intervention and prevention strategies.     

Peritraumatic dissociation mediates the relationship between acute panic and chronic posttraumatic stress disorder

Although peritraumatic dissociation predicts subsequent posttraumatic stress disorder (PTSD), little is understood about the mechanism of this relationship. This study examines the role of panic during trauma in the relationship between peritraumatic dissociation and subsequent PTSD. Randomized eligible admissions to 4 major trauma hospitals across Australia (n = 244) were assessed during hospital admission and within one month of trauma exposure for panic, peritraumatic dissociation and PTSD symptoms, and subsequently re-assessed for PTSD three months after the initial assessment (n = 208). Twenty (9.6%) patients met criteria for PTSD at 3-months post injury. Structural equation modeling supported the proposition that peritraumatic derealization (a subset of dissociation) mediated the effect of panic reactions during trauma and subsequent PTSD symptoms. The mediation model indicated that panic reactions are linked to severity of subsequent PTSD via derealization, indicating a significant indirect relationship. Whereas peritraumatic derealization is associated with chronic PTSD symptoms, this relationship is influenced by initial acute panic responses.     

The role of the glutamatergic system in posttraumatic stress disorder

Antiglutamatergic agents, such as lamotrigine, have been used successfully for the treatment of posttraumatic stress disorder (PTSD). They could be potentially acting through the stabilization of the corticotropin-releasing factor (CRF) systems. Glutamate mediates CRF release in various brain regions involved in the pathophysiology of PTSD, antiglutamatergic agents could stabilize the CRF system and, thereby, improve the symptom complex of PTSD (reexperiencing, hyperarousal, and avoidance). The role of glutamate and CRF in PTSD and other anxiety disorders are still being elucidated. However, it is clear that the glutamatergic systems play a role in the pathophysiology of PTSD.     

Effects of live exposure on symptoms of posttraumatic stress disorder: the role of reduced behavioral avoidance in improvement

Although the effectiveness of cognitive-behavioral treatment in posttraumatic stress disorder (PTSD) is well established, few studies examined its effects on individual PTSD symptoms and possible mechanisms of improvement in symptoms. In a previous randomized controlled study [Ba?og lu, M., Salciog lu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waitlist controlled trial. Journal of Traumatic Stress, 18, 1-11] a single session of behavioral treatment involving self-exposure instructions was highly effective in reducing earthquake-related PTSD. In the present study we examined the effects of treatment on each PTSD symptom and which symptoms improved early in treatment. Because the intervention focused solely on behavioral avoidance, we hypothesized that avoidance would be the first symptom to change and that reduction in avoidance would generalize to all other symptoms. The results showed significant between-groups treatment effect on only behavioral avoidance early in treatment (week 6). At 6 months post-treatment recovery rates ranged from 60% to 89% for 15 PTSD symptoms, including the numbing symptoms. Lack of improvement in avoidance was associated with lack of improvement in 12 symptoms. The critical process in recovery thus appeared to be increased sense of control associated with reduction in avoidance. These findings imply that live exposure to fear cues designed to enhance sense of control might be sufficient for recovery from PTSD.     

The moderating role of positive beliefs about worry in the relationship between stressful events and worry

Some theorists suggest that worry is elevated by positive beliefs when stressful events occur. Although several cross-sectional studies have revealed an association between positive beliefs and worry, few longitudinal studies have been conducted on this topic. Moreover, the effect of positive beliefs as a moderator on worry when stressful events occur has not been investigated. Against this background, the present study conducted a two-wave longitudinal survey to examine the moderating role of positive beliefs. One hundred and ninety-four college students voluntarily completed questionnaires. Hierarchical regression analysis showed a prospective relationship between the experience of stressful events and the subjective report of worry. Moreover, this relationship was moderated by an interaction with positive beliefs; stressful events were a stronger predictor of the extent of worry for individuals with a high level of positive beliefs than for those with a low level of positive beliefs. The moderating role of positive beliefs suggests that the level of positive beliefs amplifies the threat of worry caused by stressful events.     

Examining the association between emotion regulation difficulties and probable posttraumatic stress disorder within a sample of African Americans

This study examined the associations between emotion dysregulation and probable posttraumatic stress disorder (PTSD) among 180 African American undergraduates enrolled in a historically black college in the southern United States. Trauma-exposed participants with probable PTSD reported significantly higher levels of overall emotion dysregulation and the specific dimensions of lack of emotional acceptance, difficulties engaging in goal-directed behavior when upset, difficulties controlling impulsive behaviors when distressed, and limited access to effective emotion regulation strategies than participants without Criterion A traumatic exposure and those with Criterion A traumatic exposure but no PTSD (controlling for age and negative affect). Furthermore, results indicated that participants with Criterion A traumatic exposure but no PTSD were significantly less likely to report difficulties controlling impulsive behaviors when distressed and limited access to effective emotion regulation strategies than participants without Criterion A traumatic exposure (controlling for age and negative affect). These findings extend extant research on the role of emotion dysregulation in PTSD, thus providing support for the relevance of emotion dysregulation to PTSD among African American adults in particular.     

Comparing posttraumatic stress disorder's symptom structure between deployed and nondeployed veterans

We tested two empirically validated 4-factor models of posttraumatic stress disorder (PTSD) symptoms using the PTSD Checklist: King, Leskin, King, and Weathers' (1998) model including reexperiencing, avoidance, emotional numbing, and hyperarousal factors, and Simms, Watson, and Doebbeling's (2002) model including reexperiencing, avoidance, dysphoria, and hyperarousal. Our aim was to determine which fit better in two groups of military veterans: peacekeepers previously deployed to a war zone (deployed group) and those trained for peacekeeping operations who were not deployed (nondeployed group). We compared the groups using multigroup confirmatory factor analysis. Adequate model fit was demonstrated among the nondeployed group, with no significant difference between King et al.'s (1998) model (separating avoidance and numbing) and Simms et al.'s (2002) similar model involving a dysphoria factor. A better fitting factor structure consistent with Simms et al.'s (2002) model was found in the deployed group. Comprehensive measurement invariance testing demonstrated significant differences between the deployed and nondeployed groups on all structural parameters, except observed variable intercepts (thus indicating similarities only in PTSD item severity). These findings add to researchers' understanding of PTSD's factor structure, given the revision of PTSD that will appear in the forthcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2010)--namely, that the factor structure may be quite different between groups with and without exposure to major traumatic events.     

Understanding the relationship between posttraumatic stress disorder and trauma cognitions: The impact of thought control strategies

Several models of PTSD suggest that dysfunctional beliefs play an important role in the maintenance of PTSD. This study examined whether thought control strategies intermediated in the relationship between PTSD and dysfunctional cognitions. It was hypothesized that PTSD would be positively associated with dysfunctional cognitions and that negative thought control strategies (worry and self-punishment) would partially account for this relationship. These maladaptive strategies were predicted to be associated with increased levels of PTSD and more trauma-related beliefs. Additionally, it was predicted that positive thought control strategies (social control and reappraisal) would be associated with decreased levels of PTSD and fewer trauma-related beliefs. Finally, because the literature supports distraction as both an adaptive and a maladaptive thought control strategy, no a priori hypothesis was made. Results support worry and self-punishment as maladaptive intervening variables in the association between PTSD and dysfunctional cognitions, resulting in greater levels of PTSD and trauma cognitions. Social control and distraction emerged as adaptive strategies, resulting in lower levels of PTSD and trauma cognitions, while reappraisal showed no relationship with PTSD severity. Although the results are cross-sectional, continued focus on the effects of thought control strategies as meditational maintenance variables over time appears warranted.     

A test of written emotional disclosure as an intervention for posttraumatic stress disorder

This study examined the efficacy of the written emotional disclosure (WED) procedure with a sample of young adults who met diagnostic criteria for posttraumatic stress disorder (PTSD). Participants were randomly assigned to either WED or a control writing condition and were assessed at baseline and one month following the writing sessions. During each writing session, participants’ heart rate was recorded; participants also provided self-report ratings of emotional responding. Findings indicated no significant group differences for PTSD and depression symptom severity at follow-up assessment. Relative to control participants, WED participants displayed significantly greater heart rate activity and reported greater emotional responding during the first writing session; however, no reduction in emotional responding occurred for either condition from the first to the last writing session. Taken together, these findings indicate that WED may not be an efficacious intervention for PTSD. Suggestions are made for future work in this area.     

The role of anxiety sensitivity in the relationship between posttraumatic stress symptoms and negative outcomes in trauma-exposed adults

Background: The development of posttraumatic stress symptoms (PTSs) following a trauma is related to impairment, diminished quality of life, and physical health issues. Yet it is not clear why some trauma-exposed individuals experience negative outcomes while others do not. The purpose of this study was to determine the role of several influential factors related to PTS severity and negative outcomes. Methods: One hundred and twenty-two trauma-exposed adults were administered the following self-report measures: the Posttraumatic Stress Disorder Checklist-Civilian, the Trauma History Questionnaire-Short, the Anxiety Sensitivity Index-3, Depression and Anxiety Stress Scale 21, Sheehan Disability Scale, World Health Organization Quality of Life-BREF, and an abbreviated Patient Health Questionnaire. Primary Results: PTS severity was positively correlated with depressive symptom severity (r = 0.54, p < 0.001), chronicity of the most distressing trauma (r = 0.21, p = 0.017), and number of traumas (r = 0.22, p = 0.012). Main effects were found for PTS severity (β = ?0.38, p < 0.01) and anxiety sensitivity (AS; β = ?0.39, p < 0.01) on quality of life. No interaction was found between PTS severity and AS with any negative outcome. PTS severity mediated the relationship between AS and physical health issues (0.05; 95% CI: 0.02–0.08). Conclusion: This study helps clarify the role of various factors in the relationship between trauma and negative outcomes. Clinical and research implications are discussed.     

Genetics of posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a prevalent anxiety disorder marked by behavioral, physiologic, and hormonal alterations. PTSD is disabling and commonly follows a chronic course. The etiology of PTSD is unknown, although exposure to a traumatic event constitutes a necessary, but not sufficient, factor. A twin study of Vietnam veterans has shown significant genetic contribution to PTSD. The fact that PTSD's underlying genotypic vulnerability is only expressed following trauma exposure limits the usefulness of family-based linkage approaches. In contrast to the other major psychiatric disorders, large studies for the search of underlying genes have not been described in PTSD to date. Complementary approaches for locating involved genes include association-based studies employing case-control or parental genotypes for transmission dysequilibrium analysis and quantitative trait loci studies in animal models. Identification of susceptibility genes will increase our understanding of traumatic stress disorders and help to elucidate their molecular basis. The current review provides an up-to-date outline of progress in the field of PTSD.     

The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder

Research findings on the specific relationships between beliefs and OCD symptoms have been inconsistent, yet the existing studies vary in their approach to measuring the highly heterogeneous symptoms of this disorder. The Dimensional Obsessive-Compulsive Scale (DOCS) is a new measure that allows for the assessment of OCD symptom dimensions, rather than types of obsessions and compulsions per se. The present study examined the relationship between OCD symptom dimensions and dysfunctional (obsessive) beliefs believed to underlie these symptom dimensions using a large clinical sample of treatment-seeking adults with OCD. Results revealed that certain obsessive beliefs predicted certain OCD symptom dimensions in a manner consistent with cognitive-behavioral conceptual models. Specifically, contamination symptoms were predicted by responsibility/threat estimation beliefs, symmetry symptoms were predicted by perfectionism/certainty beliefs, unacceptable thoughts were predicted by importance/control of thoughts beliefs and symptoms related to being responsible for harm were predicted by responsibility/threat estimation beliefs. Implications for cognitive conceptualizations of OCD symptom dimensions are discussed.     

Gender differences in posttraumatic stress disorder

One of the most consistent findings in the epidemiology of posttraumatic stress disorder (PTSD) is the higher risk of this disorder in women. Explanations reviewed within a psychobiological model of PTSD suggest that women's higher PTSD risk may be due to the type of trauma they experience, their younger age at the time of trauma exposure, their stronger perceptions of threat and loss of control, higher levels of peri-traumatic dissociation, insufficient social support resources, and greater use of alcohol to manage trauma-related symptoms like intrusive memories and dissociation, as well as gender-specific acute psychobiological reactions to trauma. This review demonstrates the need for additional research of the gender differences in posttraumatic stress. Recommendations are made for clinical practice.     

Emotional processing in posttraumatic stress disorder

The emotional deficits associated with posttraumatic stress disorder (PTSD) are the least understood and the most understudied aspect of the syndrome. In this study, the connection was evaluated between trauma-context reactivity and subsequent emotional deficits in PTSD. Combat veterans with PTSD and well-adjusted veteran control participants were exposed to reminders of combat, after which their emotional behavior was assessed in response to a series of emotionally evocative images. Under the neutral condition, both groups exhibited emotional behavior modulated by stimulus valence. Partially consistent with the conceptual model described by B. Litz (1992), the PTSD group exhibited suppressed expressive-motor responses to positively valenced images, in comparison with the control group, only after being exposed to a trauma-related prime. Contrary to expectations, the PTSD group showed no augmentation of emotional response to negatively valenced cues after being exposed to trauma reminders. However, the PTSD group responded to all images, in both prime conditions, with higher heart rate reactivity, suggesting an automatic preparation for demand or threat in any uncertain emotional context. Possible causes and consequences of these results are discussed.     

Possible role of posttraumatic stress disorder in suicide terrorists: an hypothesis

Recent reports by journalists of suicidal terrorists suggest that exposure to recent violence in traumatic situations, combined with childhood exposure to violence, may lead to posttraumatic stress disorder, which in turn may result in suicidal violence.     

Psychotic symptoms in posttraumatic stress disorder

Recent data suggest that the presence of psychotic symptoms in patients suffering from posttraumatic stress disorder (PTSD) may represent an underrecognized and unique subtype of PTSD. Among combat veterans with PTSD, 30% to 40% report auditory or visual hallucinations and/or delusions. The presence of psychotic symptoms in PTSD is associated with a more severe level of psychopathology, similar to that of chronic schizophrenia. In this review, the differential diagnosis of psychotic symptoms in PTSD is discussed, including possible comorbid schizophrenia, psychotic depression, substance-induced psychosis, and personality disorder. A recent biologic study supporting the existence of a unique subtype of PTSD with psychotic features is also addressed, as are the similarities between PTSD with psychotic features and psychotic depression disorder. Finally, data on the treatment implications of psychotic symptoms in PTSD are presented. The intriguing recent findings on psychotic symptoms in PTSD need further investigation in noncombat-related PTSD populations before findings can be generalized to all individuals with PTSD.     

The MMPI-2 as a predictor of symptom change following treatment for posttraumatic stress disorder

This study sought to examine the impact of personality factors on symptom change following treatment for 141 Vietnam veterans with chronic combat-related posttraumatic stress disorder (PTSD) using the Minnesota Multiphasic Personality Inventory-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). A series of partial correlation and linear multivariate regression analyses identified social alienation, associated with anger and substance use, as the most potent negative predictor of symptom change. Of the scales assessing personality disorder, Borderline Personality was identified as the strongest negative predictor of outcome. Regression analyses examining the most salient scales identified 5 items that contributed 14% of the variance in the prediction of change scores independently of the 21% accounted for by pretreatment PTSD severity.     

The relationships between posttraumatic stress symptom clusters and marital intimacy among war veterans

This study examined (a) the relationships between posttraumatic stress disorder (PTSD) symptom clusters and marital intimacy among Israeli war veterans and (b) the role of self-disclosure and verbal violence in mediating the effects of PTSD avoidance and hyperarousal symptoms on marital intimacy. The sample consisted of 219 participants divided into 2 groups: ex-prisoners of war (ex-POWs; N = 125) and a comparison group of veterans who fought in the same war but were not held in captivity (N = 94). Ex-POWs displayed higher levels of PTSD symptoms and verbal violence and lower levels of self-disclosure than did controls. Although ex-POWs and controls did not differ in level of marital intimacy, they did, however, present a different pattern of relationships between PTSD clusters and intimacy. In ex-POWs, self-disclosure mediated the relations between PTSD avoidance and marital intimacy. Verbal aggression was also found via indirect effect of hyperarousal on marital intimacy. The results point to the importance of self-disclosure and verbal violence as interpersonal mechanisms for the relations between posttraumatic symptoms on marital intimacy of ex-POWs.