Emotion in Posttraumatic Stress Disorder: Etiology, Assessment, Neurobiology, and Treatment

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EMOTION IN
POSTTRAUMATIC
STRESS DISORDER
Etiology, Assessment,
Neurobiology, and
Treatment
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Contributors
Introduction: Understanding the role of emotion in the etiology, assessment, neurobiology, and treatment of posttraumatic  ...
	References
Section 1: Emotions
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Assessment of emotion and emotion-related processes in PTSD
	Assessment of emotion and emotion-related processes in PTSD
	Assessment of emotions in PTSD
		Anger
		Anxiety
		Fear
		Guilt and shame
		Sadness
		Negative and positive affect
	Emotion-related processes
		Alexithymia
		Anhedonia/numbing
		Anxiety sensitivity
		Distress tolerance
		Emotion regulation
		Experiential avoidance
	Conclusion
	References
2
Anxiety and fear in PTSD☆
	Anxiety and fear
		Neurobiology of anxiety and fear in PTSD
		Heightened sensitivity to threat
			Anxiety sensitivity
			Attentional bias to threat
		Fear overgeneralization
		Excessive avoidance
		Impaired fear extinction
		Implications of anxiety and fear in PTSD
	References
3
Anger in PTSD
	Introduction
	Defining anger
	Associations between PTSD and anger
	Associations over time: Is anger a cause or consequence of PTSD?
	Theoretical models to explain the association between anger and PTSD
		Fear avoidance theory
		Survival mode” theory
		Social information processing theories
		Cognitive appraisal theories
	Treatment outcomes and implications
		Impact of anger on PTSD treatment efficacy
		Impact of PTSD treatment on anger
		Treatments for anger in PTSD
		PTSD and intimate partner violence: The strength at home program
		The role of gender in treatment for anger in PTSD
		Novel approaches to treating anger in PTSD
	Conclusions and future directions
	References
4
Sadness and depression in PTSD
	Overview
	Comorbidity of PTSD and depression
	Sadness in PTSD
	Anhedonia/emotional numbing in PTSD
		Theoretical underpinnings of anhedonia/emotional numbing in PTSD
		Costs of emotional numbing in PTSD
	Implications for PTSD presentation
		Dissociation
		Understanding the relationship between dissociation and PTSD
	Rumination
	Social functioning deficits
		PTSD, depression, and social impairment in intimate relationships
	Suicide
		Suicidality and comorbid PTSD and depression
	Treatment implications
	Conclusions
	References
5
Disgust in PTSD
	Disgust
	Relevance of disgust to trauma and PTSD
	Models of disgust and PTSD
	Disgust proneness
	Peritraumatic disgust
	Posttraumatic disgust
	Clinical assessment and treatment implications
	Cultural considerations
	Conclusion
	References
6
Shame and guilt in PTSD
	Introduction
	Shame and guilt as self-evaluative social emotions
	Differentiating shame and guilt
	Theoretical models of trauma-related guilt and shame
		Guilt
		Shame
	Challenges in measurement
	Guilt and PTSD
	Shame and PTSD
	Sex differences
	Shame, guilt, and suicide risk
	Shame and guilt in PTSD treatment
	Complimentary treatment approaches for shame and guilt
	Conclusions and future directions
	References
Section 2: Biological bases of emotional responding and dysfunction
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Neurobiology and neuromodulation of emotion in PTSD
	Brain regions and networks implicated in PTSD
		The hippocampus
		The amygdala
		The ventromedial prefrontal cortex
		The fear extinction model
		The role of prefrontal regions in emotion regulation
		The role of network connectivity: The “triple network model”
			Task-related functional connectivity
			Resting-state functional connectivity
	Noninvasive and nonconvulsive brain stimulation techniques
		Repetitive transcranial magnetic stimulation for PTSD
			Spatial parameters: Cortical target, targeting approach, and coil shape
			Stimulation waveform parameters: Frequency, number of pulses, and intensity
			Parameters of acute and maintenance rTMS treatment for PTSD
			rTMS for the treatment of PTSD
			Optimizing rTMS efficacy for PTSD: Development of state-dependent rTMS therapies
			Investigations of the neural mechanisms underlying response to rTMS
		Transcranial electrical stimulation for PTSD
			Studies of transcranial direct current stimulation (tDCS) to treat PTSD
	Noninvasive and convulsive brain stimulation techniques
		Electroconvulsive therapy and magnetic seizure therapy
			Efficacy of electroconvulsive therapy to treat PTSD
	Invasive brain stimulation techniques
		Deep brain stimulation
			Deep brain stimulation to treat PTSD
		Vagus nerve stimulation
			Vagus nerve stimulation to treat PTSD
	Future directions
	References
8
Genetic influences on PTSD
	Behavioral genetics of PTSD
	Molecular genetic studies
		Candidate gene studies
		Candidate gene by environment (cGxE) studies
		Genome-wide association studies (GWAS)
	Novel statistical genetic procedures using GWAS data
		Polygenic risk scores
		PRS and PTSD
		Genomic relatedness matrix restricted maximum likelihood (GREML)
		GREML and PTSD
		Linkage Disequilibrium Score Regression (LDSC, also called LDSR)
		LDSC and PTSD
		Mendelian randomization
		MR and PTSD
	Other genomic platforms
	DNA methylation
		Candidate-gene methylation studies
		Epigenome-wide methylation studies
		Methylation age
		Translating epigenetic findings
		Considerations and limitations in DNAm
	Gene expression
		Candidate gene expression studies
		Genome-wide gene expression studies
		Network and pathway analyses
		Considerations and limitations in expression studies
	Unique considerations for PTSD genomics
	Conclusions and future directions
	References
9
Psychophysiology of emotional responding in PTSD
	Introduction
	Psychophysiological indices revealing emotion dysregulation in PTSD
		Cardiovascular indices
		Electrodermal indices
		Electromyographic indices
	Translational psychophysiological research: Fear conditioning
		Overview
	Translational fear conditioning models
		Fear acquisition
	Fear extinction (extinction learning and extinction recall)
		Extinction learning
		Within-session extinction learning
	New directions: Individual differences in extinction learning
		Extinction recall
		Fear load
		Return of fear
		Renewal
		Spontaneous recovery
		Reinstatement
		Fear inhibition
		Generalization of fear
		Reversal learning
	Psychobiological factors that moderate fear processing
		Hormones
			Stress hormones
			Sex hormones
		Behavioral contributions
			Sleep
		Frontiers in pharmacotherapy
		d-Cycloserine
			Dexamethasone
	Conclusion
	References
Section 3: Difficulties in responding and relating to emotion
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Emotion regulation difficulties in PTSD
	Definitions of emotion regulation
		An emotion regulation strategy model
		An emotion regulation abilities model
	Integrating models of emotion regulation
	Evaluating emotion regulation strategy and abilities models in the context of PTSD
	Emotion regulation strategies and PTSD
	Emotion regulation abilities in PTSD
	Regulation of positive emotion in PTSD
	Implications of emotion regulation research for the treatment of PTSD
	Conclusion
	References
11
The regulatory role of attention in PTSD from an information processing perspective
	Introduction: Overview of attentional deployment as a form of emotion regulation
	Information processing in PTSD: The fear network
	Attentional bias to threat: Bottom-up, top-down, or both?
	Vigilance-avoidance versus attention maintenance
	Dual-process models of ABT: Considering the role of attentional control
	Measuring ABT in PTSD
	Attentional control as a trauma-related regulatory mechanism
	Attention bias modification
	References
12
Distress tolerance in PTSD
	Introduction
	Theoretical framework
	Defining and measuring DT
	DT and PTSD symptoms
		Community adults
			Interactive effects
			Longitudinal studies
		Undergraduate students
		Psychiatric inpatient adults
		Outpatient treatment-seeking adults
		Adolescents
	Applications to suicidal ideation and behavior
	Applications to substance use
		Community adults
		Undergraduate students
		Treatment-seeking adults
		Military veterans
	Limitations and future directions
	References
13
Emotional granularity in PTSD
	Introduction: Emotional granularity and emotion differentiation
	Emotional granularity, related constructs, and PTSD
		Emotional clarity
		Alexithymia
	PTSD and emotional granularity: A preliminary road map
		Close/attachment relationships, emotional granularity, and trauma exposure
		Emotional granularity and coping with traumatic stressors: Context probably matters
		Emotional granularity as a moderator between trauma exposure and PTSD
		PTSD symptoms and emotional granularity
	PTSD and arousal focus
	PTSD and valence focus
	Psychological constructionism, PTSD, and emotional granularity
	Conclusion
	References
14
Experiential avoidance and PTSD
	What is experiential avoidance?
		Distinguishing experiential avoidance from emotion regulation
		The role of language
		Summary
	Experiential avoidance and posttraumatic stress disorder
		Models of experiential avoidance and posttraumatic stress disorder
		Longitudinal evidence
			Pretrauma EA
			Posttrauma EA
			EA and treatment response
		Summary
	Possible mechanisms of the EA PTSD relationship
		Inflexible use of experiential avoidance
		Experiential avoidance and subjective arousal
		Experiential avoidance and rumination
		Summary
	Malleability of experiential avoidance
		Summary
	Conclusions
		Clinical implications
	Limitations and future directions
	References
15
Emotion-driven impulsivity in PTSD
	Posttraumatic stress disorder and emotion-driven impulsivity
	Conceptualizing emotion-driven impulsivity
	Emotion-driven impulsivity and PTSD
	Psychological mechanisms
	Biological mechanisms
		Neurotransmitters
		Brain pathways
		Gene polymorphisms
	Empirical evidence
	Important avenues for future research
		Positive emotions
		Biological mechanisms
		Directionality
	Clinical implications
	Acknowledgment
	References
Section 4: Treatment and cultural considerations
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Prolonged Exposure for PTSD: Impact on emotions
	Prolonged Exposure (PE)
	Emotional processing theory
	The influence of PE on specific emotions
	Case study
	Impact of culture on PE on emotion
	Limitations and future research
	Conclusion
	Acknowledgments and disclosures
	References
17
Emotion in cognitive processing therapy for PTSD
	Emotion in cognitive processing therapy
		Overview of cognitive processing therapy
		Research on natural and manufactured emotions
	Specific emotional changes in CPT
		Theoretical rationale
		Empirical support
			Guilt
			Shame
			Anger
			Fear
			Depression
		Emotion regulation
	Mechanisms of action in CPT
		Biological mechanisms
	Limitations and future directions
	References
18
Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy: Making meaning while learning skills
	Treatment development and rationale
	Theoretical frame
		Conservation of resources and the resource loss model
		Attachment theory
		Narrative Therapy
	An overview of STAIR Narrative Therapy
		Module one: STAIR
			Emotion awareness and regulation skills (sessions 1–5)
			Relationship patterns and interpersonal skills (sessions 6–10)
			Case example part 1: Response to the STAIR module
		Module two: Narrative Therapy
			Case example part 2: Response to the Narrative Therapy module
	Evidence and applications of STAIR Narrative Therapy
	Future directions and adaptations of STAIR Narrative Therapy
	Acknowledgments
	References
19
Acceptance-based behavioral therapy for PTSD
	Overview of acceptance-based behavioral therapies
		Acceptance and commitment therapy
			Overview of the treatment model
			Review of treatment outcomes
		Mindfulness-based stress reduction
			Overview of the treatment model
			Review of treatment outcomes
		Mantram repetition program
			Overview of the treatment model
			Review of treatment outcomes
		Behavioral activation
			Overview of the treatment model
			Review of treatment outcomes
		Dialectical behavior therapy
			Overview of the treatment model
			Review of treatment outcomes
	Benefits of acceptance-based behavioral therapies
	Summary of the literature, limitations, and areas for future research
	In closing
	References
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Self-compassion in PTSD *
	Defining self-compassion
		Self-kindness versus self-judgment
		Common humanity versus isolation
		Mindfulness versus overidentification
	Self-compassion and PTSD
	Self-compassion, shame, and PTSD
	Self-compassion and the treatment of PTSD
	Understanding fears and barriers to self-compassion
	Safely navigating unchartered attachment trauma territory
		Attachment
		Emotion regulation
		Mentalization
	Principles for selecting a starting point in treatment
		Desensitization: Warming up slowly
		Direction: Who is caring for whom?
		Differentiation: Who needs what from whom?
	Integrating self-compassion into treatment of complex PTSD
		Attuned presence helps to establish safety for shame and perpetrator parts
		Self-reflection: Strengthening compassionate presence with high shame clients
		Titrating the receiving of compassion from another
		Empowerment through fierce self-compassion
			Informal practice for trauma survivors: Yang self-compassion break for protection
		Mourning the life lost
			Informal practice for trauma survivors: Yin self-compassion break for grief
		Allowing in happiness and play
	Conclusion
	References
21
Culture, PTSD, and emotion regulation: An anthropological perspective
	Introduction
	Emotion regulation in context: Part 1
	Emotion regulation in context: Part 2
	Emotion regulation in context: Part 3
	Conclusion
	References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	K
	L
	M
	N
	O
	P
	R
	S
	T
	U
	V
	W
	Y
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