Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 2, 131–137
© 2014 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/a0037764
Emotion Regulation Difficulties and Posttraumatic Stress Disorder Symptom Cluster Severity Among Trauma-Exposed College Students Emily M. O’Bryan, Alison C. McLeish, Kristen M. Kraemer, and John B. Fleming
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Cincinnati The present investigation examined the role of emotion regulation difficulties in predicting severity of the 3 posttraumatic stress disorder (PTSD) symptom clusters (i.e., reexperiencing, hyperarousal, avoidance) in a sample of undergraduates who reported exposure to at least 1 DSM–IV–TR Criterion A traumatic event (n ⫽ 297; 77.1% female, Mage ⫽ 20.46, SD ⫽ 4.64, range ⫽ 18 –50 years). Results indicated that greater difficulties with emotional acceptance significantly predicted greater avoidance and hyperarousal symptom severity above and beyond the effects of number of trauma types endorsed and negative affect. Emotion regulation difficulties were not significantly predictive of reexperiencing symptom severity. Results from an exploratory analysis indicated that greater difficulties with emotional acceptance and greater difficulties accessing effective emotion regulation strategies when upset significantly predicted the DSM–5 negative alterations in cognitions and mood symptom cluster. These findings suggest that difficulties accepting one’s emotional responses, in particular, may heighten emotional responding to and avoidance of trauma-related cues. Thus, individuals who experience such difficulties may be more likely to experience negative outcomes after experiencing a traumatic event. Keywords: avoidance, emotion regulation, hyperarousal, PTSD, reexperiencing, trauma
tional acceptance, or the ability to experience negative emotions without negative secondary emotional responses; e) the ability to engage in goal-directed behavior when upset; and f) access to effective emotion regulation strategies when upset. For individuals who have experienced a traumatic event, encountering reminders of the trauma (e.g., situations, people; Mennin, 2005) may produce heightened emotional and physiological responses that need to be regulated. Difficulties in any of the emotion regulation domains described above would make regulating this arousal difficult, and could lead to an individual experiencing their emotions as both unpredictable and uncontrollable. As a result, internal and external cues that produce these emotions may begin to be feared and ultimately avoided preventing further exposure to trauma-related cues and increasing the risk of developing PTSD. A small, but growing, body of literature has used Gratz and Roemer’s (2004) conceptualization to examine the role of emotion regulation deficits in PTSD and posttraumatic stress disorder symptoms. In terms of PTSD diagnoses, compared to women without a history of child maltreatment, women with a current, primary diagnosis of PTSD related to child maltreatment (assessed with the Clinician Administered PTSD Scale; Blake et al., 1995) reported greater global difficulties with emotion regulation as well as difficulties in all six DERS domains (Frewen, Dozois, Neufeld, & Lanius, 2012). Similarly, compared to those with exposure to a Criterion A event and no PTSD diagnosis and those with no exposure to a traumatic event, African American college students who had experienced a DSM–IV Criterion A traumatic event and had a probable PTSD diagnosis (assessed by the PTSD Checklist– Civilian version [PCL-C]; Weathers, Litz, Herman, Huska, & Keane, 1993) reported greater overall emotion regulation difficulties and difficulties in all DERS domains except difficulties with
Adaptive emotion regulation involves the flexible, contextspecific application of strategies to modulate emotions and engage in goal-directed behavior (Gratz & Roemer, 2004; Gross & Thompson, 2007). Emotion dysregulation occurs when the emotion regulation strategies used do not change the emotional response in the desired direction, or the long-term costs of utilizing such strategies outweigh the short-term benefits of their use. Thus, it is not surprising that difficulties with emotion regulation are the hallmark characteristics of mood and anxiety disorders, including posttraumatic stress disorder (PTSD; Campbell-Sills & Barlow, 2007; Hofmann, Sawyer, Fang, & Asnaani, 2012; Tull, Gratz, Salters, & Roemer, 2004; Tull, Jakupcak, Paulson, & Gratz, 2007; Werner & Gross, 2010). Using Gratz and Roemer’s (2004) integrated conceptualization of emotion regulation, emotion dysregulation, as assessed by the Difficulties in Emotion Regulation Scale (DERS), can consist of difficulties across six domains: a) emotional clarity, which encompasses the extent to which an individual is clear about their current emotional state; b) emotional awareness, or the extent to which an individual is able to attend to and acknowledge their emotions; c) impulse control, which reflects the ability to remain in control of one’s behavior when experiencing negative emotions; d) emo-
This article was published Online First August 25, 2014. Emily M. O’Bryan, Alison C. McLeish, Kristen M. Kraemer, and John B. Fleming, Department of Psychology, University of Cincinnati. John B. Fleming is now at Northwestern University Feinberg School of Medicine. Correspondence concerning this article should be addressed to Alison C. McLeish, Department of Psychology, University of Cincinnati, PO Box 2120376, Cincinnati, OH 45221-0376. E-mail: [email protected] 131
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
132
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
emotional awareness and clarity (Weiss et al., 2012). Moreover, partial correlations controlling for age and negative affect indicated significant associations between PTSD-related reexperiencing and hyperarousal symptoms and difficulties in four of the six DERS domains (i.e., all but difficulties with emotional awareness and clarity). PTSD-related avoidance symptoms were significantly associated with five of the six DERS domains (i.e., all but difficulties with emotional awareness). Given that subclinical PTSD symptoms are associated with levels of impairment similar to those found in individuals meeting criteria for PTSD (Stein, Walker, Hazen, & Forde, 1997), several studies have examined emotion regulation difficulties among individuals who have experienced a DSM–IV Criterion A traumatic event. In a web-based study, Ehring and Quack (2010) found that greater PTSD symptom severity, assessed by the Impact of Events Scale–Revised (IES-R; Weiss & Marmar, 1997), was significantly correlated with all six DERS domains. Tull, Barrett, McMillan, and Roemer (2007) found similar results when looking at global PTSD symptoms and the three PTSD symptom clusters in an undergraduate sample; five of the six DERS domains (i.e., all except emotional awareness) were associated with greater global PTSD symptom severity as well as reexperiencing, avoidance, and hyperarousal symptom severity (assessed by the PCL-C). Taken together, there appear to be significant associations between PTSD symptoms and difficulties with emotion regulation across various populations and levels of symptomatology. The most consistent findings have been for difficulties with impulse control, emotional acceptance, engaging in goal-directed behavior, and access to emotion regulation strategies; whereas findings for difficulties with emotional clarity and awareness have been less consistent. To date, only Tull, Barrett et al. (2007) examined associations between PTSD symptom clusters (i.e., reexperiencing, hyperarousal, avoidance) and each specific emotion regulation domain. However, these associations were only at the zero-order level and did not take into account the effects of relevant covariates. Moreover, no study has examined the unique predictive ability of each domain within the same model. Therefore, it remains unclear whether one domain of emotion regulation better predicts PTSD symptom severity and whether these patterns differ across the three PTSD symptom clusters. Further, continued examination of these issues among undergraduates is important as approximately 65% of college students report experiencing a lifetime DSM–IV Criterion A traumatic event (Read, Ouimette, White, Colder, & Farrow, 2011), with 25% reporting experiencing three or more such events. Although college student samples are often considered convenience samples, it appears that a large number of college students are at high risk for trauma exposure and the resulting negative sequelae. Thus, college students represent an important group in terms of empirical examinations of factors that might impact PTSD symptomatology after experiencing a traumatic event. Thus, the aim of the current study was to examine the unique predictive ability of difficulties in a) emotional clarity; b) emotional awareness; c) impulse control when distressed; d) emotional acceptance; e) the ability to engage in goal-directed behavior when upset; and f) access to effective emotion regulation strategies in terms of the PTSD symptom clusters of reexperiencing, avoidance, and hyperarousal among a sample of undergraduate students exposed to a DSM–IV–TR Criterion A traumatic event. Given the
dearth of research examining PTSD symptoms and the difficulties in emotion regulation domains as a group, no specific hypotheses were made. However, based on their consistent associations with PTSD symptoms in previous research, it is likely that some combination of difficulties in impulse control when upset, emotional acceptance, the ability to engage in goal directed behavior when upset, and access to effective emotion regulation strategies when upset will significantly predict reexperiencing, avoidance, and hyperarousal symptom severity. The covariates of number of trauma types endorsed and negative affect were chosen on an a priori basis. Number of trauma types endorsed was chosen to ensure that any significant findings were not due to an individual having a more complex trauma history. Negative affect, defined as the tendency to experience negative emotional states (Watson, Clark, & Tellegen, 1988), was chosen to ensure that results were due to the unique association between difficulties with emotion regulation and PTSD symptoms and not simply the frequency with which an individual experiences negative emotions. To begin to examine these associations using DSM–5 criteria for PTSD (American Psychiatric Association [APA], 2013), an exploratory analysis was conducted to examine the associations between emotion regulation difficulties and an approximation of the new DSM–5 negative alterations in cognitions and mood symptom cluster. For this analysis items on the avoidance subscale of the Posttraumatic Diagnostic Scale (PDS; Foa, 1995) assessing the inability to recall key features of the traumatic event, diminished interest in activities, feeling alienated from others, and constricted affect (PDS items 29 –32) were used to create a negative alterations in cognitions and mood symptom cluster. Although these items do not assess the symptoms of persistent negative beliefs about oneself or the world, persistent distorted blame of self or others for the causes or consequences of the traumatic event, and persistent negative trauma-related emotions, this approach provides an approximation that can guide future research in this area.
Method Participants The sample consisted of 297 undergraduates (77.1% female, Mage ⫽ 20.46, SD ⫽ 4.64, range ⫽ 18 –50 years) who endorsed exposure to at least one DSM–IV–TR PTSD Criterion A traumatic life event (APA, 2000). The current sample represents a subset of a larger sample of undergraduate students in introductory psychology courses (N ⫽ 859) participating in a study on anxiety and health. The racial composition of the sample was 84.5% Caucasian, 8.4% African American, and 7.1% Other. Participants endorsed an average of 2.04 (SD ⫽ 1.31) types of traumatic events on the PDS (Foa, 1995). See Table 1 for prevalence rates of trauma types and trauma-related functional impairment. Examples of “Other” types of trauma endorsed by participants include emotional abuse, suicide of a family member, and near drowning experience. The percentage of participants who reported that the index traumatic event happened less than 1 month ago was 4.1, 6.4% 1 to 3 months ago, 5.4% 3 to 6 months ago, 33.1% 6 months to 3 years ago, 22.3% 3 to 5 years ago, and 28.7% reported experiencing the trauma more than 5 years ago. Overall, participants reported a mean posttraumatic stress symptom sever-
EMOTION REGULATION AND PTSD
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Table 1 Prevalence of Trauma Types and Trauma-Related Impairment
Trauma type Accident/fire/explosion Natural disaster Nonsexual assault by known other Nonsexual assault by stranger Sexual assault by known other Sexual assault by stranger Military combat Sexual contact under age 18 Imprisonment Torture Life-threatening illness Other trauma Type of impairment Work Household chores and duties Relationships with friends Fun and leisure activities Schoolwork Relationships with family Sex life Satisfaction with life Overall functioning
%
n
49.8 32.0 18.2 13.5 12.8 10.1 2.7 14.1 5.1 1.3 38.4 4.4
148 95 54 40 38 30 8 42 15 4 114 13
15.2 15.2 27.9 26.8 28.0 26.1 20.3 28.3 23.6
45 45 82 79 83 77 60 83 70
ity level of 9.19 (SD ⫽ 9.96). 34.6% of the sample reported experiencing symptoms for less than 1 month, 14.2% had been experiencing symptoms for 1 to 3 months, and 51.2% for more than 3 months. Although difficult to compare due to differences in self-report measures used and the methods of combining types of events, rates of trauma types in the current sample appear to be similar to those found among undergraduates in the Tull, Barrett et al., (2007) study. Compared to an epidemiological sample of individuals with PTSD, the current sample reported lower rates of combat; similar rates of sexual assault, nonsexual assault, and imprisonment; and higher rates of accidents, natural disasters, and life-threatening illnesses (Pietrzak, Goldstein, Southwick, & Grant, 2011).
Procedure Undergraduate students in introductory psychology classes at a large urban university who were over the age of 18 were invited to participate in the study. Interested students were given a link and password to complete the measures. Participants were then able to complete the questionnaires at their convenience and submit them online. Extant work indicates that rates of trauma and PTSD do not differ by mode of assessment (i.e., online vs. in-person) and that such assessments are significantly associated with clinical interview (Read, Farrow, Jaanimägi, & Ouimette, 2009; Read et al., 2011). Information regarding participants’ IP addresses was not collected to ensure anonymity. Participants received course credit for their participation in the study. The Institutional Review Board approved all study procedures and materials prior to collection of data.
Measures Difficulties in Emotion Regulation Scale (DERS). The DERS is a 36-item self-report measure that assesses difficulties
133
with emotion regulation along six domains: a) emotional clarity (Clarity); b) emotional awareness (Awareness); c) impulse control when distressed (Impulse); d) emotional acceptance (Acceptance); e) the ability to engage in goal-directed behavior when upset (Goals); and f) access to effective emotion regulation strategies when upset (Strategies) (Gratz & Roemer, 2004). Respondents rate the degree to which each item applies to them on a 5-point Likert-type scale (1 ⫽ almost never to 5 ⫽ almost always). The DERS demonstrates high levels of internal consistency and test– retest reliability (Gratz & Roemer, 2004). Internal consistency for all subscales in the current study was good to excellent (range ⫽ .83 to .92). Posttraumatic Diagnostic Scale (PDS). The PDS (Foa, 1995) is a 49-item self-report measure that assesses the presence of posttraumatic stress symptoms based on DSM–IV criteria (APA, 2000). First, respondents report whether they have experienced any of 13 traumatic events, including an “other” category, and then indicate which event was most disturbing. Participants then answer questions as to whether this trauma exposure was consistent with PTSD Criterion A (APA, 2000). Participants also rate the frequency (0 ⫽ not at all or only one time to 3 ⫽ five or more times a week/almost always) of 17 PTSD symptoms experienced in the last month in relation to the most disturbing event. The PDS has been shown to have excellent psychometric properties (Foa, Cashman, Jaycox, & Perry, 1997). In the current study, the PDS was used to a) assess traumatic event exposure based on PTSD criterion A; b) determine trauma exposure history (i.e., number of different types of traumas endorsed); c) assess self-reported impairment across a variety of domains; and d) assess posttraumatic stress symptom severity across each PTSD symptom cluster. Internal consistency for each of the symptom cluster severity scores of the PDS in the current sample was good (range: .83 to .89). Positive and Negative Affect Schedule (PANAS). The PANAS (Watson et al., 1988) is a self-report measure commonly used in psychopathology research (Watson, 2000) that assesses negative and positive dimensions of affect. In the present study, only the negative affect subscale (PANAS-NA) was used, as an index of the broad-based disposition to experience negative affective states (e.g., anger, anxiety, depression, guilt). Internal consistency for the PANAS-NA in the current sample was good (␣ ⫽ .88).
Analytic Approach First, correlations between all predictor and criterion variables were examined. Next, three hierarchical multiple regression analyses were conducted to examine the incremental predictive validity of the six emotion regulation domains, as assessed by the DERS. Separate models were constructed for each dependent measure (reexperiencing, avoidance, and hyperarousal symptom severity). In each model, number of trauma types endorsed and negative affect were entered simultaneously as covariates in step one. At the second step in the model, the main effects of the six DERS subscales (clarity, awareness, impulse, acceptance, goals, strategies) were entered into the model in order to estimate the amount of unique variance accounted for by these variables. A Bonferroni correction was utilized in order to reduce the likelihood of Type I error by adjusting alpha to .017 (totaling to an overall value of .05). This same approach was used for the exploratory analysis examining the role of emotion regulation difficulties in
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
134
the DSM–5 negative alterations in cognitions and mood symptom cluster; however, given the exploratory nature of this analysis, a Bonferroni correction was not used.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Results See Table 2 for descriptive data for all study variables. Associations among predictor and criterion variables are presented in Table 3. Trauma history (i.e., number of types of trauma experienced) was significantly positively correlated with all three PTSD symptom clusters (range: .17–.27), but none of the DERS subscales. Negative affect was significantly positively associated with all three PTSD symptom clusters (range: .38 to .45) and all of the DERS subscales (range: .24 to .69). Greater scores on all three PTSD symptom clusters were significantly correlated with all of the DERS domains except lack of emotional awareness (reexperiencing range: .18 –.38; avoidance range: .28 to .48; hyperarousal range: .20 –.44). Results of the three regression analyses are presented in Table 4. In terms of reexperiencing symptom severity, the first step accounted for 14.7% of the variance. Experiencing greater negative affect ( ⫽ .35, t ⫽ 6.16, sr2 ⫽ .12, p ⫽ .000) was the only significant predictor of greater reexperiencing symptom severity at this step. The second step accounted for 5.1% of unique variance. However, while the overall step was significant, there were no significant individual predictors at step 2.1 In terms of avoidance symptom severity, the first step accounted for 21.0% of the variance. Experiencing more types of trauma ( ⫽ .17, t ⫽ 3.10, sr2 ⫽ .03, p ⫽ .002) and reporting greater negative affect ( ⫽ .41, t ⫽ 7.66, sr2 ⫽ .17, p ⫽ .000) were both significantly predictive of greater avoidance symptom severity at this step. Step two of the model accounted for 9.2% of unique variance, and greater difficulties with emotional acceptance was the only significant predictor ( ⫽ .21, t ⫽ 2.73, sr2 ⫽ .02, p ⫽ .007) of greater avoidance symptom severity at this step. In terms of hyperarousal symptom severity, Step 1 of the model accounted for 22.7% of the variance. Experiencing more types of trauma ( ⫽ .19, t ⫽ 3.60, sr2 ⫽ .04, p ⫽ .000) and reporting Table 2 Descriptive Data for Predictor and Criterion Variables
Trauma history Negative affect DERS subscales Clarity Awareness Impulse Acceptance Goals Strategies PDS subscales Reexperiencing Avoidance Arousal
Range
M
SD
1–10 10–43
2.11 20.74
1.31 6.76
5–23 6–30 6–28 6–30 5–25 8–38
11.44 15.61 11.33 12.43 14.64 16.66
3.96 4.93 4.75 5.79 4.74 6.76
0–15 0–19 0–13
2.88 3.69 2.80
3.24 4.55 3.42
Note. Trauma history: number of different types of traumatic events endorsed on the PDS (Foa, 1995); Negative affect: Positive and Negative Affect Schedule-Negative Affect subscale (Watson et al., 1988); DERS ⫽ Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004); PDS ⫽ Posttraumatic Diagnostic Scale (Foa, 1995).
greater negative affect ( ⫽ .42, t ⫽ 7.87, sr2 ⫽ .18, p ⫽ .000) were significantly predictive of greater hyperarousal symptom severity. Step 2 of the model accounted for an additional 7.7% of the variance, and greater difficulties with emotional acceptance ( ⫽ .29, t ⫽ 3.80, sr2 ⫽ .03, p ⫽ .000) and fewer difficulties with emotional awareness ( ⫽ ⫺.16, t ⫽ ⫺2.61, sr2 ⫽ .02, p ⫽ .010) were the only significant predictors of greater hyperarousal symptom severity at this step. In terms of the exploratory analysis approximating severity of the DSM–5 negative cognitions and mood symptom cluster, step one accounted for 17.3% unique variance. Experiencing more types of trauma ( ⫽ .15, t ⫽ 2.75, sr2 ⫽ .02, p ⫽ .006) and reporting greater negative affect ( ⫽ .37, t ⫽ 6.79, sr2 ⫽ .14, p ⫽ .000) were both significant predictors at this step. Step 2 of the model accounted for 11.9% unique variance, and greater difficulties with emotional acceptance ( ⫽ .20, t ⫽ 2.62, sr2 ⫽ .02, p ⫽ .009) and greater difficulties accessing effective emotion regulation strategies when upset ( ⫽ .22, t ⫽ 2.27, sr2 ⫽ .01, p ⫽ .024) were the only significant predictors of greater negative cognitions and mood symptom severity at this step.
Discussion Building on extant work demonstrating an association between emotion regulation difficulties and PTSD symptom severity (Ehring & Quack, 2010; Tull, Barrett et al., 2007; Weiss et al., 2012), the present study sought to examine the role of the six domains of emotion regulation difficulty in terms of each of the three PTSD symptom clusters (i.e., reexperiencing, avoidance, hyperarousal). An exploratory analysis was also conducted to approximate these associations in the DSM–5 negative alterations in cognitions and mood symptom cluster. Consistent with previous research (Tull, Barrett et al., 2007; Weiss et al., 2012), results indicated that all domains of emotion regulation difficulty except emotional awareness were significantly correlated, at the zero-order level, with reexperiencing, avoidance, and hyperarousal symptom severity. Results of the regression analyses indicate that, after controlling for the effects of number of trauma types endorsed and negative affect, greater difficulties with emotional acceptance significantly predicted greater avoidance and hyperarousal symptom severity, accounting for approximately 2.0% and 3.8% of unique variance, respectively. These findings suggest that the inability to experience negative emotions without a negative secondary response or a negative reaction to one’s own distress contributes to increased levels of arousal as well as avoidance of reminders of the traumatic event. This negative emotional response to negative emotional reactions likely contributes to a greater sense of emotions as being uncontrollable and unpredictable in the context of a situation that already has the tendency to elicit heightened emotional responses. Research has demonstrated that experiencing emotions as uncontrollable and unpredictable contributes to greater fear acquisition (Bouton, Mineka, & Barlow, 2001). Thus, this difficulty with emotional acceptance could contribute to a negative feedback loop 1 Since there is significant overlap between negative affect and emotion regulation difficulties, analyses were conducted removing negative affect as a covariate without any significant changes in results. These results can be obtained from the corresponding author upon request.
EMOTION REGULATION AND PTSD
135
Table 3 Intercorrelations Among Predictor and Criterion Variables
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. ⴱ
Trauma history Negative affect Clarity Awareness Impulse Acceptance Goals Strategies Reexperiencing Avoidance Arousal
p ⬍ 05.
ⴱⴱ
— — — — — — — — — — —
2 .10 — — — — — — — — — —
3
4
5
⫺.03 .24ⴱⴱ .55ⴱⴱ — — — — — — — —
.02 .46ⴱⴱ — — — — — — — — —
.10 .56ⴱⴱ .55ⴱⴱ .26ⴱⴱ — — — — — — —
.03 .56ⴱⴱ .50ⴱⴱ .27ⴱⴱ .59ⴱⴱ — — — — — —
7 ⫺.00 .47ⴱⴱ .39ⴱⴱ .23ⴱⴱ .49ⴱⴱ .51ⴱⴱ — — — — —
8 ⫺.00 .69ⴱⴱ .54ⴱⴱ .27ⴱⴱ .69ⴱⴱ .75ⴱⴱ .61ⴱⴱ — — — —
9
10 ⴱⴱ
.17 .38ⴱⴱ .23ⴱⴱ .08 .35ⴱⴱ .34ⴱⴱ .18ⴱⴱ .34ⴱⴱ — — —
ⴱⴱ
.25 .45ⴱⴱ .33ⴱⴱ .10 .44ⴱⴱ .48ⴱⴱ .28ⴱⴱ .48ⴱⴱ .76ⴱⴱ — —
11 .27ⴱⴱ .45ⴱⴱ .25ⴱⴱ .01 .37ⴱⴱ .44ⴱⴱ .20ⴱⴱ .40ⴱⴱ .64ⴱⴱ .76ⴱⴱ —
p ⬍ .01.
resulting in further increases in negative emotions and arousal symptoms, likely resulting in the avoidance of situations that elicit these symptoms. As a result of this decreased exposure to trauma cues, the fear produced by these cues are never fully extinguished
Table 4 Emotion Regulation Difficulties Predicting Posttraumatic Stress Symptom Cluster Severity ⌬R2
t (each predictor)

Criterion variable: PDS Reexperiencing Step 1 .15 Trauma history 2.38 .13 Negative affect 6.16 .35 Step 2 .05 Clarity 1.15 .09 Awareness ⫺1.57 ⫺.10 Impulse 1.58 .12 Acceptance 2.27 .19 Goals ⫺0.84 ⫺.06 Strategies ⫺0.16 ⫺.02
Step 1 Trauma history Negative affect Step 2 Clarity Awareness Impulse Acceptance Goals Strategies
Criterion variable: PDS Avoidance .21 3.10 .17 7.66 .41 .09 0.72 .05 ⫺1.47 ⫺.10 1.38 .10 2.73 .21 ⫺1.10 ⫺.07 1.60 .16
Step 1 Trauma history Negative affect Step 2 Clarity Awareness Impulse Acceptance Goals Strategies
Criterion variable: PDS Hyperarousal .23 3.60 .19 7.87 .42 .08 0.47 .03 ⫺2.61 ⫺.16 0.65 .05 3.80 .29 ⫺1.42 ⫺.09 0.16 .02
sr2
.02 .12 .00 .01 .01 .02 .00 .00
.03 .17 .00 .01 .00 .02 .00 .01
.04 .18 .00 .02 .00 .03 .01 .00
p .000ⴱ .018 .000ⴱ .011ⴱ .252 .117 .115 .024 .399 .876 .000ⴱ .002ⴱ .000ⴱ .000ⴱ .471 .143 .167 .007ⴱ .271 .110 .000ⴱ .000ⴱ .000ⴱ .000ⴱ .638 .010ⴱ .518 .000ⴱ .155 .870
Note.  ⫽ standardized beta weight; sr2 ⫽ squared semi-partial correlation. p ⬍ .016.
ⴱ
6
and could place an individual at risk for developing PTSD (Foa, Zinbarg, & Rothbaum, 1992). It is interesting that fewer difficulties with emotional awareness also significantly predicted greater hyperarousal symptom severity. As this domain of emotion regulation difficulty is most consistently not significantly associated with PTSD symptoms (e.g.,Tull, Barrett et al., 2007; Weiss et al., 2012), this finding is somewhat more difficult to explain. One possibility is that attending to and acknowledging one’s emotional responses results in an individual paying closer attention to the distress produced by trauma cues, reinforcing that such cues are anxiety-provoking and resulting in even greater physiological arousal. Alternatively, there is some evidence that the difficulties in emotional awareness domain does not belong to the same higher-order emotion regulation construct as the other five DERS domains (Bardeen, Fergus, & Orcutt, 2012). Therefore, these findings may be an artifact of the self-report measure used. Further research using other self-report measures of emotional awareness or behavioral tasks is needed to further explicate these findings. In terms of PTSD-related reexperiencing symptoms, although the overall step was significant, none of the individual difficulties with emotion regulation domains significantly predicted reexperiencing symptom severity. It may be that while emotion regulation difficulties, in general, are associated with more severe reexperiencing symptoms, deficits in one particular domain are not necessarily worse than in any other domain. It should be noted, however, that using a traditional p value of .05 would have resulted in difficulties with emotional acceptance being a significant predictor of reexperiencing symptoms. Thus, there may be consistency for the importance of emotional acceptance across all symptom domains. However, further research is needed to strengthen confidence in this finding. Similar to the results for PTSD-related hyperarousal and avoidance, results of the exploratory analysis examining an approximation of the DSM–5 negative alterations in cognitions and mood symptom cluster indicated that greater difficulties experiencing emotional distress without negatively reacting to it (i.e., difficulties in emotional acceptance) was associated with greater numbing symptom severity. In addition, greater difficulties accessing effective emotion regulation strategies when upset was also significantly associated with greater numbing symptom severity. This finding may initially seem paradoxical given that these emotion
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
136
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
regulation deficits typically result in increased emotional arousal rather than emotional with numbing. However, individuals with posttraumatic stress symptoms often experience different clusters of symptoms at different times. An individual may experience heightened negative affect when experiencing hyperarousal and reexperiencing symptoms. For those who not only have difficulties accepting the experience of negative affect, but also are unable to effectively manage their negative emotions during such times, this heightened emotional arousal likely depletes their resources for coping with such symptoms. As a result, such individuals may then report symptoms of emotional numbing rather than arousal (Foa et al., 1992; Litz, 1992). Alternatively, the relative absence of emotion during periods of numbing (Litz, 1992) may prevent individuals from having the opportunity to learn to accept and/or adaptively regulate difficult emotions in general. However, these results should be interpreted with caution, as they do not assess all of the symptoms in this domain. Further research using assessment tools based on the DSM–5 conceptualization of PTSD is needed. There are, however, a number of interpretive caveats and directions for future study that warrant comment. First, given that the present sample, by virtue of selection criteria, was comprised of young adults, the findings may not be generalizable to all segments of society (e.g., clinical populations). Relatedly, there was a restricted range of responding to items on the PDS. Thus, while this sample appears to have experienced a greater number of traumatic events, they do not appear to be experiencing high levels of PTSD symptomatology. However, on average participants reported experiencing difficulty in two functional domains. Thus, although symptom levels are not high, participants are still experiencing functional impairment related to experiencing a traumatic event. It is noteworthy that significant results were found despite this low level of responding; nevertheless, research using clinical samples is needed. To help address this issue, the data was reanalyzed using only those individuals meeting criteria for a PTSD diagnosis. The sample size was small (n ⫽ 53), so the analysis was significantly underpowered; however, difficulties with emotional acceptance did significantly predict avoidance symptoms, lending some further support for the current findings. Second, the present cross-sectional design does not permit for inferences about causality or temporal order relationships. Thus, the present data will need to be extended to exploring how specific emotion regulation difficulties impact PTSD symptom cluster severity as well as a PTSD diagnosis over time. Third, self-report methods were used to index the variables of interest, thus there is the possibility of shared method variance contributing to the study results. For example, the correlations between the three PTSD clusters were quite high (41%–58% shared variance). Although similarly strong correlations were found in Tull, Barrett et al., (2007) and Weiss et al. (2012), such significant overlap indicates that the symptom clusters may not be entirely distinct. Thus, future studies could therefore usefully incorporate a multimethod assessment approach. For example, laboratory-based emotion elicitation paradigms (e.g., viewing film clips) or cue-exposure paradigms could be used to examine difficulties with emotion regulation in real time and how they might impact PTSD symptomatology or avoidance behavior (e.g., using behavioral avoidance tasks, psychophysiological assessment). Despite these limitations, the current study represents an important extension of previous work by examining which difficulties in
emotion regulation domain plays the strongest role in PTSD symptom severity. The findings suggest that nonacceptance of one’s emotional responses is associated with greater severity across PTSD symptom domains among individuals who have experienced a traumatic event. Individuals who experience such difficulties may be more likely to experience negative outcomes. Thus, assessing difficulties with emotional acceptance among individuals who have experienced a traumatic event may help identify individuals who may be at risk for developing significant PTSD symptomatology.
References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Bardeen, J. R., Fergus, T. A., & Orcutt, H. K. (2012). An examination of the latent structure of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 34, 382–392. doi:10.1007/s10862-012-9280-y Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress, 8, 75–90. doi:10.1002/jts.2490080106 Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4 –32. doi:10.1037/0033-295X.108.1.4 Campbell-Sills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 542–559). New York, NY: Guilford Press. Ehring, T., & Quack, D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy, 41, 587–598. doi:10.1016/j.beth.2010.04.004 Foa, E. B. (1995). Manual for the Posttraumatic Stress Diagnostic Scale (PDS). Minneapolis, MN: NCS Assessments. Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Postraumatic Diagnostic Scale. Psychological Assessment, 9, 445– 451. doi:10.1037/ 1040-3590.9.4.445 Foa, E. B., Zinbarg, R., & Rothbaum, B. O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112, 218 –238. doi:10.1037/0033-2909.112.2 .218 Frewen, P. A., Dozois, D. J. A., Neufeld, R. W. J., & Lanius, R. A. (2012). Disturbances of emotional awareness and expression in posttraumatic stress disorder: Meta-mood, emotion regulation, mindfulness, and interference of emotional expressiveness. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 152–161. doi:10.1037/a0023114 Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54. doi: 10.1023/B:JOBA.0000007455.08539.94 Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–26). New York, NY: Guilford Press. Hofmann, S. G., Sawyer, A. T., Fang, A., & Asnaani, A. (2012). Emotion dysregulation model of mood and anxiety disorders. Depression and Anxiety, 29, 409 – 416. doi:10.1002/da.21888
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
EMOTION REGULATION AND PTSD Litz, B. T. (1992). Emotional numbing in combat-related post-traumatic stress disorder: A critical review and reformulation. Clinical Psychology Review, 12, 417– 432. doi:10.1016/0272-7358(92)90125-R Mennin, D. S. (2005). Emotion and the acceptance-based approaches to the anxiety disorders. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (pp. 37– 68). New York, NY: Springer. doi:10.1007/0-387-259899_2 Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456 – 465. doi:10.1016/j.janxdis.2010.11.010 Read, J. P., Farrow, S. M., Jaanimägi, U., & Ouimette, P. C. (2009). Assessing trauma and traumatic stress via the Internet: Measurement equivalence and participant reactions. Traumatology, 15, 94 –102. doi: 10.1177/1534765608325121 Read, J. P., Ouimette, P., White, J., Colder, C., & Farrow, S. (2011). Rates of DSM–IV–TR trauma exposure and posttraumatic stress disorder among newly matriculated college students. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 148 –156. doi:10.1037/a0021260 Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154, 1114 –1119. doi:10.1177/ 019251396017003001 Tull, M. T., Barrett, H. M., McMillan, E. S., & Roemer, L. (2007). A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms. Behavior Therapy, 38, 303–313. doi:10.1016/j.beth.2006.10.001 Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. The Journal of Nervous and
137
Mental Disease, 192, 754 –761. doi:10.1097/01.nmd.0000144694 .30121.89 Tull, M. T., Jakupcak, M., Paulson, A., & Gratz, K. L. (2007). 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. Anxiety, Stress, & Coping, 20, 337–351. doi:10.1080/10615800701379249 Watson, D. (2000). Mood and Temperament. New York: Guilford Press. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. doi:10.1037/0022-3514.54.6.1063 Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th annual meeting of the International Society for Traumatic Stress Studies, Austin, TX. Weiss, D. S., & Marmar, C. R. (1997). The Impact of Event Scale–Revised. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399 – 411). New York, NY: Guilford Press. Weiss, N. H., Tull, M. T., Davis, L. T., Dehon, E. E., Fulton, J. J., & Gratz, K. L. (2012). Examining the association between emotion regulation difficulties and probable posttraumatic stress disorder within a sample of African Americans. Cognitive Behaviour Therapy, 41, 5–14. doi:10.1080/16506073 .2011.621970 Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 13–37). New York, NY: Guilford Press.
Received August 5, 2013 Revision received July 4, 2014 Accepted July 21, 2014 䡲
E-Mail Notification of Your Latest Issue Online! Would you like to know when the next issue of your favorite APA journal will be available online? This service is now available to you. Sign up at http://notify.apa.org/ and you will be notified by e-mail when issues of interest to you become available!
© 2014 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/a0037764
Emotion Regulation Difficulties and Posttraumatic Stress Disorder Symptom Cluster Severity Among Trauma-Exposed College Students Emily M. O’Bryan, Alison C. McLeish, Kristen M. Kraemer, and John B. Fleming
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of Cincinnati The present investigation examined the role of emotion regulation difficulties in predicting severity of the 3 posttraumatic stress disorder (PTSD) symptom clusters (i.e., reexperiencing, hyperarousal, avoidance) in a sample of undergraduates who reported exposure to at least 1 DSM–IV–TR Criterion A traumatic event (n ⫽ 297; 77.1% female, Mage ⫽ 20.46, SD ⫽ 4.64, range ⫽ 18 –50 years). Results indicated that greater difficulties with emotional acceptance significantly predicted greater avoidance and hyperarousal symptom severity above and beyond the effects of number of trauma types endorsed and negative affect. Emotion regulation difficulties were not significantly predictive of reexperiencing symptom severity. Results from an exploratory analysis indicated that greater difficulties with emotional acceptance and greater difficulties accessing effective emotion regulation strategies when upset significantly predicted the DSM–5 negative alterations in cognitions and mood symptom cluster. These findings suggest that difficulties accepting one’s emotional responses, in particular, may heighten emotional responding to and avoidance of trauma-related cues. Thus, individuals who experience such difficulties may be more likely to experience negative outcomes after experiencing a traumatic event. Keywords: avoidance, emotion regulation, hyperarousal, PTSD, reexperiencing, trauma
tional acceptance, or the ability to experience negative emotions without negative secondary emotional responses; e) the ability to engage in goal-directed behavior when upset; and f) access to effective emotion regulation strategies when upset. For individuals who have experienced a traumatic event, encountering reminders of the trauma (e.g., situations, people; Mennin, 2005) may produce heightened emotional and physiological responses that need to be regulated. Difficulties in any of the emotion regulation domains described above would make regulating this arousal difficult, and could lead to an individual experiencing their emotions as both unpredictable and uncontrollable. As a result, internal and external cues that produce these emotions may begin to be feared and ultimately avoided preventing further exposure to trauma-related cues and increasing the risk of developing PTSD. A small, but growing, body of literature has used Gratz and Roemer’s (2004) conceptualization to examine the role of emotion regulation deficits in PTSD and posttraumatic stress disorder symptoms. In terms of PTSD diagnoses, compared to women without a history of child maltreatment, women with a current, primary diagnosis of PTSD related to child maltreatment (assessed with the Clinician Administered PTSD Scale; Blake et al., 1995) reported greater global difficulties with emotion regulation as well as difficulties in all six DERS domains (Frewen, Dozois, Neufeld, & Lanius, 2012). Similarly, compared to those with exposure to a Criterion A event and no PTSD diagnosis and those with no exposure to a traumatic event, African American college students who had experienced a DSM–IV Criterion A traumatic event and had a probable PTSD diagnosis (assessed by the PTSD Checklist– Civilian version [PCL-C]; Weathers, Litz, Herman, Huska, & Keane, 1993) reported greater overall emotion regulation difficulties and difficulties in all DERS domains except difficulties with
Adaptive emotion regulation involves the flexible, contextspecific application of strategies to modulate emotions and engage in goal-directed behavior (Gratz & Roemer, 2004; Gross & Thompson, 2007). Emotion dysregulation occurs when the emotion regulation strategies used do not change the emotional response in the desired direction, or the long-term costs of utilizing such strategies outweigh the short-term benefits of their use. Thus, it is not surprising that difficulties with emotion regulation are the hallmark characteristics of mood and anxiety disorders, including posttraumatic stress disorder (PTSD; Campbell-Sills & Barlow, 2007; Hofmann, Sawyer, Fang, & Asnaani, 2012; Tull, Gratz, Salters, & Roemer, 2004; Tull, Jakupcak, Paulson, & Gratz, 2007; Werner & Gross, 2010). Using Gratz and Roemer’s (2004) integrated conceptualization of emotion regulation, emotion dysregulation, as assessed by the Difficulties in Emotion Regulation Scale (DERS), can consist of difficulties across six domains: a) emotional clarity, which encompasses the extent to which an individual is clear about their current emotional state; b) emotional awareness, or the extent to which an individual is able to attend to and acknowledge their emotions; c) impulse control, which reflects the ability to remain in control of one’s behavior when experiencing negative emotions; d) emo-
This article was published Online First August 25, 2014. Emily M. O’Bryan, Alison C. McLeish, Kristen M. Kraemer, and John B. Fleming, Department of Psychology, University of Cincinnati. John B. Fleming is now at Northwestern University Feinberg School of Medicine. Correspondence concerning this article should be addressed to Alison C. McLeish, Department of Psychology, University of Cincinnati, PO Box 2120376, Cincinnati, OH 45221-0376. E-mail: [email protected] 131
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
132
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
emotional awareness and clarity (Weiss et al., 2012). Moreover, partial correlations controlling for age and negative affect indicated significant associations between PTSD-related reexperiencing and hyperarousal symptoms and difficulties in four of the six DERS domains (i.e., all but difficulties with emotional awareness and clarity). PTSD-related avoidance symptoms were significantly associated with five of the six DERS domains (i.e., all but difficulties with emotional awareness). Given that subclinical PTSD symptoms are associated with levels of impairment similar to those found in individuals meeting criteria for PTSD (Stein, Walker, Hazen, & Forde, 1997), several studies have examined emotion regulation difficulties among individuals who have experienced a DSM–IV Criterion A traumatic event. In a web-based study, Ehring and Quack (2010) found that greater PTSD symptom severity, assessed by the Impact of Events Scale–Revised (IES-R; Weiss & Marmar, 1997), was significantly correlated with all six DERS domains. Tull, Barrett, McMillan, and Roemer (2007) found similar results when looking at global PTSD symptoms and the three PTSD symptom clusters in an undergraduate sample; five of the six DERS domains (i.e., all except emotional awareness) were associated with greater global PTSD symptom severity as well as reexperiencing, avoidance, and hyperarousal symptom severity (assessed by the PCL-C). Taken together, there appear to be significant associations between PTSD symptoms and difficulties with emotion regulation across various populations and levels of symptomatology. The most consistent findings have been for difficulties with impulse control, emotional acceptance, engaging in goal-directed behavior, and access to emotion regulation strategies; whereas findings for difficulties with emotional clarity and awareness have been less consistent. To date, only Tull, Barrett et al. (2007) examined associations between PTSD symptom clusters (i.e., reexperiencing, hyperarousal, avoidance) and each specific emotion regulation domain. However, these associations were only at the zero-order level and did not take into account the effects of relevant covariates. Moreover, no study has examined the unique predictive ability of each domain within the same model. Therefore, it remains unclear whether one domain of emotion regulation better predicts PTSD symptom severity and whether these patterns differ across the three PTSD symptom clusters. Further, continued examination of these issues among undergraduates is important as approximately 65% of college students report experiencing a lifetime DSM–IV Criterion A traumatic event (Read, Ouimette, White, Colder, & Farrow, 2011), with 25% reporting experiencing three or more such events. Although college student samples are often considered convenience samples, it appears that a large number of college students are at high risk for trauma exposure and the resulting negative sequelae. Thus, college students represent an important group in terms of empirical examinations of factors that might impact PTSD symptomatology after experiencing a traumatic event. Thus, the aim of the current study was to examine the unique predictive ability of difficulties in a) emotional clarity; b) emotional awareness; c) impulse control when distressed; d) emotional acceptance; e) the ability to engage in goal-directed behavior when upset; and f) access to effective emotion regulation strategies in terms of the PTSD symptom clusters of reexperiencing, avoidance, and hyperarousal among a sample of undergraduate students exposed to a DSM–IV–TR Criterion A traumatic event. Given the
dearth of research examining PTSD symptoms and the difficulties in emotion regulation domains as a group, no specific hypotheses were made. However, based on their consistent associations with PTSD symptoms in previous research, it is likely that some combination of difficulties in impulse control when upset, emotional acceptance, the ability to engage in goal directed behavior when upset, and access to effective emotion regulation strategies when upset will significantly predict reexperiencing, avoidance, and hyperarousal symptom severity. The covariates of number of trauma types endorsed and negative affect were chosen on an a priori basis. Number of trauma types endorsed was chosen to ensure that any significant findings were not due to an individual having a more complex trauma history. Negative affect, defined as the tendency to experience negative emotional states (Watson, Clark, & Tellegen, 1988), was chosen to ensure that results were due to the unique association between difficulties with emotion regulation and PTSD symptoms and not simply the frequency with which an individual experiences negative emotions. To begin to examine these associations using DSM–5 criteria for PTSD (American Psychiatric Association [APA], 2013), an exploratory analysis was conducted to examine the associations between emotion regulation difficulties and an approximation of the new DSM–5 negative alterations in cognitions and mood symptom cluster. For this analysis items on the avoidance subscale of the Posttraumatic Diagnostic Scale (PDS; Foa, 1995) assessing the inability to recall key features of the traumatic event, diminished interest in activities, feeling alienated from others, and constricted affect (PDS items 29 –32) were used to create a negative alterations in cognitions and mood symptom cluster. Although these items do not assess the symptoms of persistent negative beliefs about oneself or the world, persistent distorted blame of self or others for the causes or consequences of the traumatic event, and persistent negative trauma-related emotions, this approach provides an approximation that can guide future research in this area.
Method Participants The sample consisted of 297 undergraduates (77.1% female, Mage ⫽ 20.46, SD ⫽ 4.64, range ⫽ 18 –50 years) who endorsed exposure to at least one DSM–IV–TR PTSD Criterion A traumatic life event (APA, 2000). The current sample represents a subset of a larger sample of undergraduate students in introductory psychology courses (N ⫽ 859) participating in a study on anxiety and health. The racial composition of the sample was 84.5% Caucasian, 8.4% African American, and 7.1% Other. Participants endorsed an average of 2.04 (SD ⫽ 1.31) types of traumatic events on the PDS (Foa, 1995). See Table 1 for prevalence rates of trauma types and trauma-related functional impairment. Examples of “Other” types of trauma endorsed by participants include emotional abuse, suicide of a family member, and near drowning experience. The percentage of participants who reported that the index traumatic event happened less than 1 month ago was 4.1, 6.4% 1 to 3 months ago, 5.4% 3 to 6 months ago, 33.1% 6 months to 3 years ago, 22.3% 3 to 5 years ago, and 28.7% reported experiencing the trauma more than 5 years ago. Overall, participants reported a mean posttraumatic stress symptom sever-
EMOTION REGULATION AND PTSD
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Table 1 Prevalence of Trauma Types and Trauma-Related Impairment
Trauma type Accident/fire/explosion Natural disaster Nonsexual assault by known other Nonsexual assault by stranger Sexual assault by known other Sexual assault by stranger Military combat Sexual contact under age 18 Imprisonment Torture Life-threatening illness Other trauma Type of impairment Work Household chores and duties Relationships with friends Fun and leisure activities Schoolwork Relationships with family Sex life Satisfaction with life Overall functioning
%
n
49.8 32.0 18.2 13.5 12.8 10.1 2.7 14.1 5.1 1.3 38.4 4.4
148 95 54 40 38 30 8 42 15 4 114 13
15.2 15.2 27.9 26.8 28.0 26.1 20.3 28.3 23.6
45 45 82 79 83 77 60 83 70
ity level of 9.19 (SD ⫽ 9.96). 34.6% of the sample reported experiencing symptoms for less than 1 month, 14.2% had been experiencing symptoms for 1 to 3 months, and 51.2% for more than 3 months. Although difficult to compare due to differences in self-report measures used and the methods of combining types of events, rates of trauma types in the current sample appear to be similar to those found among undergraduates in the Tull, Barrett et al., (2007) study. Compared to an epidemiological sample of individuals with PTSD, the current sample reported lower rates of combat; similar rates of sexual assault, nonsexual assault, and imprisonment; and higher rates of accidents, natural disasters, and life-threatening illnesses (Pietrzak, Goldstein, Southwick, & Grant, 2011).
Procedure Undergraduate students in introductory psychology classes at a large urban university who were over the age of 18 were invited to participate in the study. Interested students were given a link and password to complete the measures. Participants were then able to complete the questionnaires at their convenience and submit them online. Extant work indicates that rates of trauma and PTSD do not differ by mode of assessment (i.e., online vs. in-person) and that such assessments are significantly associated with clinical interview (Read, Farrow, Jaanimägi, & Ouimette, 2009; Read et al., 2011). Information regarding participants’ IP addresses was not collected to ensure anonymity. Participants received course credit for their participation in the study. The Institutional Review Board approved all study procedures and materials prior to collection of data.
Measures Difficulties in Emotion Regulation Scale (DERS). The DERS is a 36-item self-report measure that assesses difficulties
133
with emotion regulation along six domains: a) emotional clarity (Clarity); b) emotional awareness (Awareness); c) impulse control when distressed (Impulse); d) emotional acceptance (Acceptance); e) the ability to engage in goal-directed behavior when upset (Goals); and f) access to effective emotion regulation strategies when upset (Strategies) (Gratz & Roemer, 2004). Respondents rate the degree to which each item applies to them on a 5-point Likert-type scale (1 ⫽ almost never to 5 ⫽ almost always). The DERS demonstrates high levels of internal consistency and test– retest reliability (Gratz & Roemer, 2004). Internal consistency for all subscales in the current study was good to excellent (range ⫽ .83 to .92). Posttraumatic Diagnostic Scale (PDS). The PDS (Foa, 1995) is a 49-item self-report measure that assesses the presence of posttraumatic stress symptoms based on DSM–IV criteria (APA, 2000). First, respondents report whether they have experienced any of 13 traumatic events, including an “other” category, and then indicate which event was most disturbing. Participants then answer questions as to whether this trauma exposure was consistent with PTSD Criterion A (APA, 2000). Participants also rate the frequency (0 ⫽ not at all or only one time to 3 ⫽ five or more times a week/almost always) of 17 PTSD symptoms experienced in the last month in relation to the most disturbing event. The PDS has been shown to have excellent psychometric properties (Foa, Cashman, Jaycox, & Perry, 1997). In the current study, the PDS was used to a) assess traumatic event exposure based on PTSD criterion A; b) determine trauma exposure history (i.e., number of different types of traumas endorsed); c) assess self-reported impairment across a variety of domains; and d) assess posttraumatic stress symptom severity across each PTSD symptom cluster. Internal consistency for each of the symptom cluster severity scores of the PDS in the current sample was good (range: .83 to .89). Positive and Negative Affect Schedule (PANAS). The PANAS (Watson et al., 1988) is a self-report measure commonly used in psychopathology research (Watson, 2000) that assesses negative and positive dimensions of affect. In the present study, only the negative affect subscale (PANAS-NA) was used, as an index of the broad-based disposition to experience negative affective states (e.g., anger, anxiety, depression, guilt). Internal consistency for the PANAS-NA in the current sample was good (␣ ⫽ .88).
Analytic Approach First, correlations between all predictor and criterion variables were examined. Next, three hierarchical multiple regression analyses were conducted to examine the incremental predictive validity of the six emotion regulation domains, as assessed by the DERS. Separate models were constructed for each dependent measure (reexperiencing, avoidance, and hyperarousal symptom severity). In each model, number of trauma types endorsed and negative affect were entered simultaneously as covariates in step one. At the second step in the model, the main effects of the six DERS subscales (clarity, awareness, impulse, acceptance, goals, strategies) were entered into the model in order to estimate the amount of unique variance accounted for by these variables. A Bonferroni correction was utilized in order to reduce the likelihood of Type I error by adjusting alpha to .017 (totaling to an overall value of .05). This same approach was used for the exploratory analysis examining the role of emotion regulation difficulties in
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
134
the DSM–5 negative alterations in cognitions and mood symptom cluster; however, given the exploratory nature of this analysis, a Bonferroni correction was not used.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Results See Table 2 for descriptive data for all study variables. Associations among predictor and criterion variables are presented in Table 3. Trauma history (i.e., number of types of trauma experienced) was significantly positively correlated with all three PTSD symptom clusters (range: .17–.27), but none of the DERS subscales. Negative affect was significantly positively associated with all three PTSD symptom clusters (range: .38 to .45) and all of the DERS subscales (range: .24 to .69). Greater scores on all three PTSD symptom clusters were significantly correlated with all of the DERS domains except lack of emotional awareness (reexperiencing range: .18 –.38; avoidance range: .28 to .48; hyperarousal range: .20 –.44). Results of the three regression analyses are presented in Table 4. In terms of reexperiencing symptom severity, the first step accounted for 14.7% of the variance. Experiencing greater negative affect ( ⫽ .35, t ⫽ 6.16, sr2 ⫽ .12, p ⫽ .000) was the only significant predictor of greater reexperiencing symptom severity at this step. The second step accounted for 5.1% of unique variance. However, while the overall step was significant, there were no significant individual predictors at step 2.1 In terms of avoidance symptom severity, the first step accounted for 21.0% of the variance. Experiencing more types of trauma ( ⫽ .17, t ⫽ 3.10, sr2 ⫽ .03, p ⫽ .002) and reporting greater negative affect ( ⫽ .41, t ⫽ 7.66, sr2 ⫽ .17, p ⫽ .000) were both significantly predictive of greater avoidance symptom severity at this step. Step two of the model accounted for 9.2% of unique variance, and greater difficulties with emotional acceptance was the only significant predictor ( ⫽ .21, t ⫽ 2.73, sr2 ⫽ .02, p ⫽ .007) of greater avoidance symptom severity at this step. In terms of hyperarousal symptom severity, Step 1 of the model accounted for 22.7% of the variance. Experiencing more types of trauma ( ⫽ .19, t ⫽ 3.60, sr2 ⫽ .04, p ⫽ .000) and reporting Table 2 Descriptive Data for Predictor and Criterion Variables
Trauma history Negative affect DERS subscales Clarity Awareness Impulse Acceptance Goals Strategies PDS subscales Reexperiencing Avoidance Arousal
Range
M
SD
1–10 10–43
2.11 20.74
1.31 6.76
5–23 6–30 6–28 6–30 5–25 8–38
11.44 15.61 11.33 12.43 14.64 16.66
3.96 4.93 4.75 5.79 4.74 6.76
0–15 0–19 0–13
2.88 3.69 2.80
3.24 4.55 3.42
Note. Trauma history: number of different types of traumatic events endorsed on the PDS (Foa, 1995); Negative affect: Positive and Negative Affect Schedule-Negative Affect subscale (Watson et al., 1988); DERS ⫽ Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004); PDS ⫽ Posttraumatic Diagnostic Scale (Foa, 1995).
greater negative affect ( ⫽ .42, t ⫽ 7.87, sr2 ⫽ .18, p ⫽ .000) were significantly predictive of greater hyperarousal symptom severity. Step 2 of the model accounted for an additional 7.7% of the variance, and greater difficulties with emotional acceptance ( ⫽ .29, t ⫽ 3.80, sr2 ⫽ .03, p ⫽ .000) and fewer difficulties with emotional awareness ( ⫽ ⫺.16, t ⫽ ⫺2.61, sr2 ⫽ .02, p ⫽ .010) were the only significant predictors of greater hyperarousal symptom severity at this step. In terms of the exploratory analysis approximating severity of the DSM–5 negative cognitions and mood symptom cluster, step one accounted for 17.3% unique variance. Experiencing more types of trauma ( ⫽ .15, t ⫽ 2.75, sr2 ⫽ .02, p ⫽ .006) and reporting greater negative affect ( ⫽ .37, t ⫽ 6.79, sr2 ⫽ .14, p ⫽ .000) were both significant predictors at this step. Step 2 of the model accounted for 11.9% unique variance, and greater difficulties with emotional acceptance ( ⫽ .20, t ⫽ 2.62, sr2 ⫽ .02, p ⫽ .009) and greater difficulties accessing effective emotion regulation strategies when upset ( ⫽ .22, t ⫽ 2.27, sr2 ⫽ .01, p ⫽ .024) were the only significant predictors of greater negative cognitions and mood symptom severity at this step.
Discussion Building on extant work demonstrating an association between emotion regulation difficulties and PTSD symptom severity (Ehring & Quack, 2010; Tull, Barrett et al., 2007; Weiss et al., 2012), the present study sought to examine the role of the six domains of emotion regulation difficulty in terms of each of the three PTSD symptom clusters (i.e., reexperiencing, avoidance, hyperarousal). An exploratory analysis was also conducted to approximate these associations in the DSM–5 negative alterations in cognitions and mood symptom cluster. Consistent with previous research (Tull, Barrett et al., 2007; Weiss et al., 2012), results indicated that all domains of emotion regulation difficulty except emotional awareness were significantly correlated, at the zero-order level, with reexperiencing, avoidance, and hyperarousal symptom severity. Results of the regression analyses indicate that, after controlling for the effects of number of trauma types endorsed and negative affect, greater difficulties with emotional acceptance significantly predicted greater avoidance and hyperarousal symptom severity, accounting for approximately 2.0% and 3.8% of unique variance, respectively. These findings suggest that the inability to experience negative emotions without a negative secondary response or a negative reaction to one’s own distress contributes to increased levels of arousal as well as avoidance of reminders of the traumatic event. This negative emotional response to negative emotional reactions likely contributes to a greater sense of emotions as being uncontrollable and unpredictable in the context of a situation that already has the tendency to elicit heightened emotional responses. Research has demonstrated that experiencing emotions as uncontrollable and unpredictable contributes to greater fear acquisition (Bouton, Mineka, & Barlow, 2001). Thus, this difficulty with emotional acceptance could contribute to a negative feedback loop 1 Since there is significant overlap between negative affect and emotion regulation difficulties, analyses were conducted removing negative affect as a covariate without any significant changes in results. These results can be obtained from the corresponding author upon request.
EMOTION REGULATION AND PTSD
135
Table 3 Intercorrelations Among Predictor and Criterion Variables
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. ⴱ
Trauma history Negative affect Clarity Awareness Impulse Acceptance Goals Strategies Reexperiencing Avoidance Arousal
p ⬍ 05.
ⴱⴱ
— — — — — — — — — — —
2 .10 — — — — — — — — — —
3
4
5
⫺.03 .24ⴱⴱ .55ⴱⴱ — — — — — — — —
.02 .46ⴱⴱ — — — — — — — — —
.10 .56ⴱⴱ .55ⴱⴱ .26ⴱⴱ — — — — — — —
.03 .56ⴱⴱ .50ⴱⴱ .27ⴱⴱ .59ⴱⴱ — — — — — —
7 ⫺.00 .47ⴱⴱ .39ⴱⴱ .23ⴱⴱ .49ⴱⴱ .51ⴱⴱ — — — — —
8 ⫺.00 .69ⴱⴱ .54ⴱⴱ .27ⴱⴱ .69ⴱⴱ .75ⴱⴱ .61ⴱⴱ — — — —
9
10 ⴱⴱ
.17 .38ⴱⴱ .23ⴱⴱ .08 .35ⴱⴱ .34ⴱⴱ .18ⴱⴱ .34ⴱⴱ — — —
ⴱⴱ
.25 .45ⴱⴱ .33ⴱⴱ .10 .44ⴱⴱ .48ⴱⴱ .28ⴱⴱ .48ⴱⴱ .76ⴱⴱ — —
11 .27ⴱⴱ .45ⴱⴱ .25ⴱⴱ .01 .37ⴱⴱ .44ⴱⴱ .20ⴱⴱ .40ⴱⴱ .64ⴱⴱ .76ⴱⴱ —
p ⬍ .01.
resulting in further increases in negative emotions and arousal symptoms, likely resulting in the avoidance of situations that elicit these symptoms. As a result of this decreased exposure to trauma cues, the fear produced by these cues are never fully extinguished
Table 4 Emotion Regulation Difficulties Predicting Posttraumatic Stress Symptom Cluster Severity ⌬R2
t (each predictor)

Criterion variable: PDS Reexperiencing Step 1 .15 Trauma history 2.38 .13 Negative affect 6.16 .35 Step 2 .05 Clarity 1.15 .09 Awareness ⫺1.57 ⫺.10 Impulse 1.58 .12 Acceptance 2.27 .19 Goals ⫺0.84 ⫺.06 Strategies ⫺0.16 ⫺.02
Step 1 Trauma history Negative affect Step 2 Clarity Awareness Impulse Acceptance Goals Strategies
Criterion variable: PDS Avoidance .21 3.10 .17 7.66 .41 .09 0.72 .05 ⫺1.47 ⫺.10 1.38 .10 2.73 .21 ⫺1.10 ⫺.07 1.60 .16
Step 1 Trauma history Negative affect Step 2 Clarity Awareness Impulse Acceptance Goals Strategies
Criterion variable: PDS Hyperarousal .23 3.60 .19 7.87 .42 .08 0.47 .03 ⫺2.61 ⫺.16 0.65 .05 3.80 .29 ⫺1.42 ⫺.09 0.16 .02
sr2
.02 .12 .00 .01 .01 .02 .00 .00
.03 .17 .00 .01 .00 .02 .00 .01
.04 .18 .00 .02 .00 .03 .01 .00
p .000ⴱ .018 .000ⴱ .011ⴱ .252 .117 .115 .024 .399 .876 .000ⴱ .002ⴱ .000ⴱ .000ⴱ .471 .143 .167 .007ⴱ .271 .110 .000ⴱ .000ⴱ .000ⴱ .000ⴱ .638 .010ⴱ .518 .000ⴱ .155 .870
Note.  ⫽ standardized beta weight; sr2 ⫽ squared semi-partial correlation. p ⬍ .016.
ⴱ
6
and could place an individual at risk for developing PTSD (Foa, Zinbarg, & Rothbaum, 1992). It is interesting that fewer difficulties with emotional awareness also significantly predicted greater hyperarousal symptom severity. As this domain of emotion regulation difficulty is most consistently not significantly associated with PTSD symptoms (e.g.,Tull, Barrett et al., 2007; Weiss et al., 2012), this finding is somewhat more difficult to explain. One possibility is that attending to and acknowledging one’s emotional responses results in an individual paying closer attention to the distress produced by trauma cues, reinforcing that such cues are anxiety-provoking and resulting in even greater physiological arousal. Alternatively, there is some evidence that the difficulties in emotional awareness domain does not belong to the same higher-order emotion regulation construct as the other five DERS domains (Bardeen, Fergus, & Orcutt, 2012). Therefore, these findings may be an artifact of the self-report measure used. Further research using other self-report measures of emotional awareness or behavioral tasks is needed to further explicate these findings. In terms of PTSD-related reexperiencing symptoms, although the overall step was significant, none of the individual difficulties with emotion regulation domains significantly predicted reexperiencing symptom severity. It may be that while emotion regulation difficulties, in general, are associated with more severe reexperiencing symptoms, deficits in one particular domain are not necessarily worse than in any other domain. It should be noted, however, that using a traditional p value of .05 would have resulted in difficulties with emotional acceptance being a significant predictor of reexperiencing symptoms. Thus, there may be consistency for the importance of emotional acceptance across all symptom domains. However, further research is needed to strengthen confidence in this finding. Similar to the results for PTSD-related hyperarousal and avoidance, results of the exploratory analysis examining an approximation of the DSM–5 negative alterations in cognitions and mood symptom cluster indicated that greater difficulties experiencing emotional distress without negatively reacting to it (i.e., difficulties in emotional acceptance) was associated with greater numbing symptom severity. In addition, greater difficulties accessing effective emotion regulation strategies when upset was also significantly associated with greater numbing symptom severity. This finding may initially seem paradoxical given that these emotion
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
136
O’BRYAN, MCLEISH, KRAEMER, AND FLEMING
regulation deficits typically result in increased emotional arousal rather than emotional with numbing. However, individuals with posttraumatic stress symptoms often experience different clusters of symptoms at different times. An individual may experience heightened negative affect when experiencing hyperarousal and reexperiencing symptoms. For those who not only have difficulties accepting the experience of negative affect, but also are unable to effectively manage their negative emotions during such times, this heightened emotional arousal likely depletes their resources for coping with such symptoms. As a result, such individuals may then report symptoms of emotional numbing rather than arousal (Foa et al., 1992; Litz, 1992). Alternatively, the relative absence of emotion during periods of numbing (Litz, 1992) may prevent individuals from having the opportunity to learn to accept and/or adaptively regulate difficult emotions in general. However, these results should be interpreted with caution, as they do not assess all of the symptoms in this domain. Further research using assessment tools based on the DSM–5 conceptualization of PTSD is needed. There are, however, a number of interpretive caveats and directions for future study that warrant comment. First, given that the present sample, by virtue of selection criteria, was comprised of young adults, the findings may not be generalizable to all segments of society (e.g., clinical populations). Relatedly, there was a restricted range of responding to items on the PDS. Thus, while this sample appears to have experienced a greater number of traumatic events, they do not appear to be experiencing high levels of PTSD symptomatology. However, on average participants reported experiencing difficulty in two functional domains. Thus, although symptom levels are not high, participants are still experiencing functional impairment related to experiencing a traumatic event. It is noteworthy that significant results were found despite this low level of responding; nevertheless, research using clinical samples is needed. To help address this issue, the data was reanalyzed using only those individuals meeting criteria for a PTSD diagnosis. The sample size was small (n ⫽ 53), so the analysis was significantly underpowered; however, difficulties with emotional acceptance did significantly predict avoidance symptoms, lending some further support for the current findings. Second, the present cross-sectional design does not permit for inferences about causality or temporal order relationships. Thus, the present data will need to be extended to exploring how specific emotion regulation difficulties impact PTSD symptom cluster severity as well as a PTSD diagnosis over time. Third, self-report methods were used to index the variables of interest, thus there is the possibility of shared method variance contributing to the study results. For example, the correlations between the three PTSD clusters were quite high (41%–58% shared variance). Although similarly strong correlations were found in Tull, Barrett et al., (2007) and Weiss et al. (2012), such significant overlap indicates that the symptom clusters may not be entirely distinct. Thus, future studies could therefore usefully incorporate a multimethod assessment approach. For example, laboratory-based emotion elicitation paradigms (e.g., viewing film clips) or cue-exposure paradigms could be used to examine difficulties with emotion regulation in real time and how they might impact PTSD symptomatology or avoidance behavior (e.g., using behavioral avoidance tasks, psychophysiological assessment). Despite these limitations, the current study represents an important extension of previous work by examining which difficulties in
emotion regulation domain plays the strongest role in PTSD symptom severity. The findings suggest that nonacceptance of one’s emotional responses is associated with greater severity across PTSD symptom domains among individuals who have experienced a traumatic event. Individuals who experience such difficulties may be more likely to experience negative outcomes. Thus, assessing difficulties with emotional acceptance among individuals who have experienced a traumatic event may help identify individuals who may be at risk for developing significant PTSD symptomatology.
References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Bardeen, J. R., Fergus, T. A., & Orcutt, H. K. (2012). An examination of the latent structure of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 34, 382–392. doi:10.1007/s10862-012-9280-y Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a Clinician-Administered PTSD Scale. Journal of Traumatic Stress, 8, 75–90. doi:10.1002/jts.2490080106 Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological Review, 108, 4 –32. doi:10.1037/0033-295X.108.1.4 Campbell-Sills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 542–559). New York, NY: Guilford Press. Ehring, T., & Quack, D. (2010). Emotion regulation difficulties in trauma survivors: The role of trauma type and PTSD symptom severity. Behavior Therapy, 41, 587–598. doi:10.1016/j.beth.2010.04.004 Foa, E. B. (1995). Manual for the Posttraumatic Stress Diagnostic Scale (PDS). Minneapolis, MN: NCS Assessments. Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Postraumatic Diagnostic Scale. Psychological Assessment, 9, 445– 451. doi:10.1037/ 1040-3590.9.4.445 Foa, E. B., Zinbarg, R., & Rothbaum, B. O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: An animal model. Psychological Bulletin, 112, 218 –238. doi:10.1037/0033-2909.112.2 .218 Frewen, P. A., Dozois, D. J. A., Neufeld, R. W. J., & Lanius, R. A. (2012). Disturbances of emotional awareness and expression in posttraumatic stress disorder: Meta-mood, emotion regulation, mindfulness, and interference of emotional expressiveness. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 152–161. doi:10.1037/a0023114 Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54. doi: 10.1023/B:JOBA.0000007455.08539.94 Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–26). New York, NY: Guilford Press. Hofmann, S. G., Sawyer, A. T., Fang, A., & Asnaani, A. (2012). Emotion dysregulation model of mood and anxiety disorders. Depression and Anxiety, 29, 409 – 416. doi:10.1002/da.21888
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
EMOTION REGULATION AND PTSD Litz, B. T. (1992). Emotional numbing in combat-related post-traumatic stress disorder: A critical review and reformulation. Clinical Psychology Review, 12, 417– 432. doi:10.1016/0272-7358(92)90125-R Mennin, D. S. (2005). Emotion and the acceptance-based approaches to the anxiety disorders. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (pp. 37– 68). New York, NY: Springer. doi:10.1007/0-387-259899_2 Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456 – 465. doi:10.1016/j.janxdis.2010.11.010 Read, J. P., Farrow, S. M., Jaanimägi, U., & Ouimette, P. C. (2009). Assessing trauma and traumatic stress via the Internet: Measurement equivalence and participant reactions. Traumatology, 15, 94 –102. doi: 10.1177/1534765608325121 Read, J. P., Ouimette, P., White, J., Colder, C., & Farrow, S. (2011). Rates of DSM–IV–TR trauma exposure and posttraumatic stress disorder among newly matriculated college students. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 148 –156. doi:10.1037/a0021260 Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154, 1114 –1119. doi:10.1177/ 019251396017003001 Tull, M. T., Barrett, H. M., McMillan, E. S., & Roemer, L. (2007). A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms. Behavior Therapy, 38, 303–313. doi:10.1016/j.beth.2006.10.001 Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. The Journal of Nervous and
137
Mental Disease, 192, 754 –761. doi:10.1097/01.nmd.0000144694 .30121.89 Tull, M. T., Jakupcak, M., Paulson, A., & Gratz, K. L. (2007). 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. Anxiety, Stress, & Coping, 20, 337–351. doi:10.1080/10615800701379249 Watson, D. (2000). Mood and Temperament. New York: Guilford Press. Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54, 1063–1070. doi:10.1037/0022-3514.54.6.1063 Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the 9th annual meeting of the International Society for Traumatic Stress Studies, Austin, TX. Weiss, D. S., & Marmar, C. R. (1997). The Impact of Event Scale–Revised. In J. P. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399 – 411). New York, NY: Guilford Press. Weiss, N. H., Tull, M. T., Davis, L. T., Dehon, E. E., Fulton, J. J., & Gratz, K. L. (2012). Examining the association between emotion regulation difficulties and probable posttraumatic stress disorder within a sample of African Americans. Cognitive Behaviour Therapy, 41, 5–14. doi:10.1080/16506073 .2011.621970 Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: A conceptual framework. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 13–37). New York, NY: Guilford Press.
Received August 5, 2013 Revision received July 4, 2014 Accepted July 21, 2014 䡲
E-Mail Notification of Your Latest Issue Online! Would you like to know when the next issue of your favorite APA journal will be available online? This service is now available to you. Sign up at http://notify.apa.org/ and you will be notified by e-mail when issues of interest to you become available!
