Interoceptive Exposure Therapy Combined with Trauma‐related Exposure Therapy for Post‐traumatic Stress Disorder: a Case Report

Trauma‐related exposure therapy is a useful but not universally effective treatment for post‐traumatic stress disorder. Anxiety sensitivity may play an important role in this disorder, as it does in panic disorder. Studies have shown that interoceptive exposure therapy reduces anxiety sensitivity in panic disorder. The present case study was a preliminary investigation of the merits of including interoceptive exposure therapy in the treatment of post‐traumatic stress disorder, in order to improve treatment outcome for a patient who had no history of panic disorder or panic attacks. Interoceptive exposure therapy (4 sessions) was one component of treatment, combined with trauma‐related exposure therapy (4 sessions of imaginal exposure followed by 4 sessions of in vivo exposure). Treatment outcome was assessed with the Clinician‐Administered Post‐traumatic Stress Disorder Scale, a self‐report measure of post‐traumatic stress disorder symptoms, and measures of symptoms and cognitions commonly associated with post‐traumatic stress disorder. Scores on all outcome measures decreased over the course of treatment, with gains maintained at 1‐ and 3‐month follow‐up. Symptoms of anxiety sensitivity and post‐traumatic stress disorder decreased during interoceptive exposure therapy. The results indicate that interoceptive exposure therapy is a promising adjunctive intervention for post‐traumatic stress disorder. Further research is needed into the merits of combining interoceptive exposure therapy and trauma‐related exposure therapy as a means of boosting treatment efficacy.     

MATERNAL TRAUMA AFFECTS PRENATAL MENTAL HEALTH AND INFANT STRESS REGULATION AMONG PALESTINIAN DYADS

We examined how diverse and cumulated traumatic experiences predicted maternal prenatal mental health and infant stress regulation in war conditions and whether maternal mental health mediated the association between trauma and infant stress regulation. Participants were 511 Palestinian mothers from the Gaza Strip who reported exposure to current war trauma (WT), past childhood emotional (CEA) and physical abuse, socioeconomic status (SES), prenatal mental health problems (posttraumatic stress disorder and depression symptoms), and perceived stress during their secondtrimester of pregnancy as well as infant stress regulation at 4 months. While all trauma types were associated with high levels of prenatal symptoms, CEA had the most wide‐ranging effects and was uniquely associated with depression symptoms. Concerning infant stress regulation, mothers’ CEA predicted negative affectivity, but only among mothers with low WT. Against hypothesis, the effects of maternal trauma on infant stress regulation were not mediated by mental health symptoms. Mothers’ higher SES was associated with better infant stress regulation whereas infant prematurity and male sex predisposed for difficulties. Our findings suggest that maternal childhood abuse, especially CEA, should be a central treatment target among war‐exposed families. Cumulated psychosocial stressors might increase the risk for transgenerational problems.     

Maternal experience of their infants’ crying in the context of war trauma: Determinants and consequences

We examined, first, how prenatal maternal mental health and war trauma predicted mothers’ experience of their infant crying, indicated by emotions, cognitions, and behavior; and second, how these experiences influenced the mother–infant interaction and infant development. Participants were 511 Palestinian mothers from the Gaza Strip, reporting their war trauma, symptoms of posttraumatic stress disorder (PTSD), depression, and perceived stress during pregnancy (Time 1). They reported experiences of infant crying at 4 months (Time 2), and the mother–infant interaction and infant sensorimotor and language development at 12 months of infants’ age (Time 3). Results revealed that maternal mental health problems, but not war trauma, were important to experiences of infant crying. A high level of PTSD symptoms predicted negative emotions evoked by infant crying, and high depressive symptoms predicted low active and positive responses to crying. Unexpectedly, high prenatal perceived stress predicted high active and positive responsiveness. Concerning the consequences, mothers’ sensitive interpretation of infant crying predicted optimal infant sensorimotor development, and mothers’ active and positive responses predicted high emotional availability in mother–infant interaction. Crying is the first communication tool for infants, and mothers’ sensitive responses to crying contribute to infant well-being. Therefore, reinforcing mother's optimal responses is important when helping war-affected dyads.     

A comparison of dyadic interactions and coping with still‐face in healthy pre‐term and full‐term infants

Pre‐term birth has a significant impact on infants' social and emotional competence, however, little is known about regulatory processes in pre‐term mother‐infant dyads during normal or stressful interactions. The primary goals of this study were to investigate the differences in infant and caregiver interactive behaviour and dyadic coordination of clinically healthy pre‐term compared to full‐term infant‐mother dyads and to examine pre‐term infants' capacity for coping with stress using the face‐to‐face still‐face paradigm (FFSF). Fifty mother‐infant dyads, including 25 pre‐term infants and 25 full‐term infants were videotaped during the FFSF. All infants were 6–9 months of age (corrected for gestational age in the pre‐term group). Infant and maternal socio‐emotional expressivity and self‐regulatory behaviours were coded and measures of dyadic coordination (Matching, Reparation Rate, and Synchrony) were calculated. There were no significant differences in infant and caregiver socio‐emotional behaviours between the two groups and both groups demonstrated the still‐face (SF) effect and the reunion effect. There was a difference in self‐regulatory behaviour. Pre‐term infants were more likely than full‐term infants to use distancing (e.g., by turning away, twisting, or arching) from their mothers during the FFSF. Additionally, during the Reunion episode of the FFSF pre‐term infants showed more social monitoring compared to full‐term infants. Regardless of the birth status, the dyads showed less coordination and a slower rate of reparation during the Reunion episode than during the Play episode. The higher proportion of distancing in the pre‐term group and the increase in social monitoring suggest that even in normal interactions pre‐term infants may experience a higher level of stress and have less capacity for self‐regulation compared to the full‐terms and that pre‐term infants appear to use a compensatory strategy of increased social monitoring to cope with the stress of renegotiating the interaction during Reunion. The findings suggest that pre‐term infants have different regulatory and interactive capacities than full‐term infants.     

The effects of torture‐related stressors on long‐term complex post‐traumatic symptoms in South Korean torture survivors

This study explored whether perceived distress from specific stressors during and after torture explain long‐term complex post‐traumatic symptoms of South Korean torture survivors. We conducted a cross‐sectional survey of survivors who had been tortured by the homeland regime from the 1970s to the 2000s. Data from 206 survivors were gathered by key informants using target sampling and snowballing techniques. Project staff designed scales to encompass the specific types of stressors related to torture techniques used in Korea. Frequencies and distress ratings of exposure to torture, post‐torture psychosocial stressors and physical damage related to torture were gathered. Psychological symptoms were assessed by the Impact of Event Scale‐Revised‐Korean version and subscales of the Symptom Checklist 90‐Revised‐Korean version. Perceived distress from torture stressors was mainly divided into factors representing physical, psychological and deprivation torture by adapting a principal axis factor analysis. Hierarchical regression analyses showed that distress from psychological torture explained post‐traumatic stress disorder (PTSD) and that distress from deprivation explained PTSD and anxiety after controlling for demographic variables, psychological preparedness, time span since torture and distress from trauma other than torture. Among post‐torture stressors, distress from physical damage related to torture and social exclusion were strong indicators of complex symptoms.     

Maternal posttraumatic stress symptoms and infant emotional reactivity and emotion regulation

The current study examined associations between maternal posttraumatic stress disorder (PTSD) symptoms and infant emotional reactivity and emotion regulation during the first year of life in a primarily low-income, urban, ethnic/racial minority sample of 52 mother–infant dyads. Mothers completed questionnaires assessing their own trauma exposure history and current PTSD and depressive symptoms and their infants’ temperament when the infants were 6 months old. Dyads participated in the repeated Still-Face Paradigm (SFP-R) when the infants were 6 months old, and infant affective states were coded for each SFP-R episode. Mothers completed questionnaires assessing infant trauma exposure history and infant current emotional and behavioral symptoms when the infants were 13 months old. Maternal PTSD symptoms predicted infants’ emotion regulation at 6 months as assessed by (a) infant ability to recover from distress during the SFP-R and (b) maternal report of infant rate of recovery from distress/arousal in daily life. Maternal PTSD symptoms also predicted maternal report of infant externalizing, internalizing, and dysregulation symptoms at 13 months. Maternal PTSD was not associated with measures of infant emotional reactivity. Neither maternal depressive symptoms nor infant direct exposure to trauma accounted for the associations between maternal PTSD symptoms and infant outcomes. These findings suggest that maternal PTSD is associated with offspring emotion regulation difficulties as early as infancy. Such difficulties may contribute to increased risk of mental health problems among children of mothers with PTSD.     

Young children's understanding of pretend crying: The effect of context

Reasoning about another's pretend and real crying is related to ma'ny important social cognitive abilities (e.g., emotional understanding, appearance–reality, and theory of mind). This study investigated whether children aged 6 years and younger could distinguish between instances of pretend crying and real crying as presented in stories. Sixty‐five Japanese children aged 4–6 years were given stories within two contexts (Play and Non‐play). In the Play context, the protagonist of the story was pretending to cry or really crying during a pretend play activity. In the Non‐play context, the protagonist was also pretending to cry or really crying after his/her toy had been hidden by another child. The children answered questions about these crying events. The results showed that the 4‐ and 5‐year‐olds showed significantly better understanding of pretend crying in the Play context compared to the Non‐play context. In the Non‐play context, they were significantly less likely to understand the cause of pretend crying compared to the 6‐year‐olds. The results suggest that the context of pretend play facilitates the children's understanding of pretend crying.     

Emotional Processing Theory (EPT) and Exposure Therapy for PTSD

Emotional processing theory developed by E. B. Foa and M. J. Kozak (1986) has informed the conceptualization of anxiety disorders and the development of effective treatments for these disorders, including posttraumatic stress disorder (PTSD). This article presents a summary and update of emotional processing theory as it applies to the treatment of PTSD, data in support of this theory, and clinical examples of how the theory can be used to assist in the treatment of clients with PTSD. Common difficulties confronted during exposure therapy for PTSD, including underengagement and overengagement, are discussed in the context of emotional processing theory and suggestions for how to manage these difficulties are presented.     

Maternal and infant touching behaviours during perturbed interactions: Associations with maternal depressive symptomatology and infant crying

Touch is an important means through which mothers and infants co-regulate during periods of stress or perturbation. The present study examined the synchrony of maternal and infant touching behaviours among 41 mother-infant dyads, some of whom were deemed at-risk due to maternal depressive symptomatology. Mothers and their 4-month-old infants participated in the Still-Face (maternal emotional unavailability; SF) and Separation (maternal physical unavailability; SP) procedures. Infant crying was examined across procedures and investigated as a brief period of perturbation. Results revealed that mothers and infants displayed a positive pattern of tactile synchrony (coordinated, analogous changes in touch) during infant crying episodes. However, dyads in the high depression group displayed significantly less affectionate touch during instances of infant crying. Furthermore, more depressive symptoms were associated with less maternal and infant touch and lower rates of infant crying. This group of dyads may be less expressive via touch, be less affected by disruptions in their interactions, have impaired regulatory abilities, or simply require minimal amounts of touch to mutually regulate following social stressors and during brief perturbation periods. These findings enrich our limited knowledge about the dynamic interplay of maternal and infant touch and inform preventative intervention programs for at-risk groups.     

Predicting post‐traumatic growth and post‐traumatic stress in firefighters

Emergency service workers (e.g., firefighters, police, and paramedics) are exposed to elevated levels of potentially traumatising events through the course of their work. Such exposure can have lasting negative consequences (e.g., post‐traumatic stress disorder (PTSD)) and/or positive outcomes (e.g., post‐traumatic growth (PTG)). Research had implicated trauma, occupational and personal variables that account for variance in post‐trauma outcomes yet at this stage no research has investigated these factors and their relative influence on both PTSD and PTG in a single study. Based in Calhoun and Tedeschi's model of PTG and previous research, in this study regression models of PTG and PTSD symptoms among 218 firefighters were tested. Results indicated organisational factors predicted symptoms of PTSD, while there was partial support for the hypothesis that coping and social support would be predictors of PTG. Experiencing multiple sources of trauma, higher levels of organisational and operational stress, and utilising cognitive reappraisal coping were all significant predictors of PTSD symptoms. Increases in PTG were predicted by experiencing trauma from multiple sources and the use of self‐care coping. Results highlight the importance of organisational factors in the development of PTSD symptoms, and of individual factors for promoting PTG.     

Emotion Regulation Strategies,Secondary Traumatic Stress,and Compassion Satisfaction in Healthcare Providers

The aim of the present study is to examine the relationships between two emotion regulation strategies (cognitive reappraisal and expressive suppression), secondary traumatic stress, and compassion satisfaction in a sample of 190 healthcare providers. Another aim of this study is to examine if the relations between emotion regulation strategies and traumatic stress symptoms are moderated by compassion satisfaction. The respondents volunteered to take part in the research and completed self-reporting measures describing the use of emotional regulation strategies, the symptoms of secondary traumatic stress, and the compassion satisfaction. The results revealed negative associations between cognitive reappraisal and secondary traumatic stress, while expressive suppression is positively associated with arousal. Moreover, cognitive reappraisal is positively related to compassion satisfaction, while secondary traumatic stress symptoms are negatively correlated with compassion satisfaction. Furthermore, the relationship between expressive suppression and intrusions is moderated by compassion satisfaction. The implications of these results for enhancing professional quality of life in the context of secondary exposure to traumatic life events are discussed.     

Infant crying and parent–infant interaction: Theory and measurement

Infant crying is frequently quantified as a primary dependent variable in studies where the goal is to understand and soothe infant crying within the context of the parent–infant relationship. Through a historical review and an examination of studies and measurement techniques, the utility of quantifying infant crying is discussed. Although duration and timing of infant crying may be a practical concern for families and health professionals, the effectiveness of soothing interventions may not be best examined by attempts to measure unit reductions in infant crying. Rather, developing an understanding of infant crying within the context of parent–infant relationships may have more utility. Understanding infant crying in context may provide direction to the selection of soothing interventions and to more appropriate measures of the effectiveness of such interventions. ©1999 Michigan Association for Infant Mental Health.     

Post‐traumatic stress disorder and anxiety symptoms in children exposed to the 1999 Greek earthquake

Five months after the Athens earthquake of September 1999, 178 children from three districts of Athens at increasing distances from the epicenter were administered questionnaires to identify symptoms of post‐traumatic stress disorder (PTSD), anxiety and the extent of personal threat experienced. It was found that PTSD and anxiety symptoms were significantly related to proximity to the epicenter, exposure to threat and female gender. Age did not have a significant main effect on either anxiety or PTSD symptoms, but there were significant interactions between age and the other main variables. In the region closest to the epicenter, the youngest children reported the highest PTSD and anxiety symptom scores, but in the group furthest from the epicenter the older children reported the highest PTSD and anxiety symptom scores. These findings were discussed in relation to direct and media‐imparted exposure to the earthquake.     

Reflecting on imagery: A clinical perspective and overview of the special issue of Memory on mental imagery and memory in psychopathology

The authors provide an overview of the papers in the special issue of Memory on mental imagery and memory in psychopathology. The papers address emotional, intrusive mental imagery across a range of psychological disorders including post‐traumatic stress disorder (PTSD), agoraphobia, body dysmorphic disorder, mood disorders, and psychosis. They include work on information processing issues including modelling cravings, conditioning, and aversions, as well as imagery qualities such as vividness and emotionality. The overview aims to place the articles in a broader context and draw out some exciting implications of this novel work. It provides a clinical context to the recent growth in this area from a cognitive behavioural therapy (CBT) perspective. We begin with PTSD, and consider links to imagery in other disorders. The clinical implications stemming from this empirical work and from autobiographical memory theory are discussed. These include consideration of a variety of techniques for eliminating troublesome imagery, and creating healthy, realistic alternatives.     

"Dwelling in the Past": The Role of Rumination in the Treatment of Posttraumatic Stress Disorder

Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an "optimal dose" of exposure during treatment.     

Examining the role of emotional avoidance in the relationship between posttraumatic stress disorder symptom severity and worry

A growing body of literature suggests that worry is a cognitive activity functioning to avoid unpleasant internal experiences such as negative thoughts, emotions, and somatic responses. Given the highly aversive internal events associated with posttraumatic stress disorder (PTSD), individuals experiencing PTSD symptoms following exposure to a traumatic event may be particularly motivated to engage in avoidant regulation strategies such as worry. Surprisingly, however, few studies to date have examined the relationship between PTSD and worry as well as potential factors that might explain this association. Therefore, the goal of this study was to examine the association between PTSD symptom severity and worry and the extent to which emotional avoidance explains this relationship. To this end, 207 college students with a history of traumatic exposure (meeting Criterion A for a PTSD diagnosis) completed a series of questionnaires assessing history of exposure to potentially traumatic events, PTSD symptom severity, emotional avoidance tendencies, and worry. Results demonstrated that PTSD symptom severity was positively associated with worry and emotional avoidance. Further, emotional avoidance was found to fully account for this relationship, providing support for the proposed emotionally avoidant function of worry. The implications of these findings for future research and the treatment of worry among individuals with a history of traumatic exposure are discussed.     

Origins of Mothers' and Fathers' Beliefs about Infant Crying

Origins of mothers' and fathers' beliefs about infant crying were examined in 87 couples. Parents completed measures of emotion minimization in the family of origin, depressive symptoms, empathy, trait anger, and coping styles prenatally. At 6 months postpartum, parents completed a self-report measure of their beliefs about infant crying. Mothers endorsed more infant-oriented and less parent-oriented beliefs about crying than did fathers. Consistent with prediction, a history of emotion minimization was linked with more parent-oriented and fewer infant-oriented beliefs about infant crying for both mothers and fathers either as a main effect or in conjunction with the partners' infant-oriented beliefs. Contrary to expectation, parents' own emotional dispositions had little effect on parents' beliefs about crying. The pattern of associations varied for mothers and fathers in a number of ways. Implications for future research and programs promoting sensitive parenting are discussed.     

Children's perceptions and comforting strategies to infant crying: Relations to age,sex, and empathy‐related responding

This study aimed to examine child characteristics associated with the understanding of and responses to infant crying. Seven hundred and twenty‐four 1st to 7th grade children (383 boys, 341 girls) were shown a picture depicting a crying infant, whereupon they were asked to generate the potential causes for infant crying along with the action responses that they might utilize to assist a crying baby. Self‐reports of children's empathy‐related responding were also obtained. As hypothesized, an age‐related increase in the number, variety, and quality for causes for infant crying and strategies to help a crying infant were observed. Girls generated a higher mean number and variety of causes compared to boys. For older children (grades 4–7), dimensions of empathy‐related responding, namely sympathy and perspective taking, were significantly associated with the number and variety of causes for infant crying and caregiving strategies. The findings support the conclusion for a developmental progression of understanding of facial expressions of infant crying across middle childhood.     

Hopelessness as a Risk Factor for Post‐traumatic Stress Disorder Symptoms Among Interpersonal Violence Survivors

Post‐traumatic stress disorder often co‐occurs with depression, and they may share common risk factors. One possible common cognitive risk factor is hopelessness. Thus, we examined whether hopelessness was related to symptoms of post‐traumatic stress disorder. Participants were 202 female survivors of interpersonal violence. Relationships between self‐reported and interviewer‐rated measures of hopelessness gathered at 2 weeks post‐trauma and self‐reported and interviewer‐rated symptoms of post‐traumatic stress disorder gathered at 2 weeks and 3 months post‐trauma were examined. Hierarchical, simultaneous regression analyses that co‐varied trauma type revealed that hopelessness was related to self‐reported symptoms of post‐traumatic stress disorder, both concurrently and prospectively. Follow‐up analyses revealed that relationships between hopelessness and symptoms of post‐traumatic stress disorder were due almost entirely to shared variance with depression. No relationships were found between hopelessness and interviewer‐rated symptoms of post‐traumatic stress disorder.