تحقیقات مقدماتی از رابطه مشکلات تنظیم احساسات و علائم استرس پس از سانحه

This study examined the relationship between posttraumatic stress (PTS) symptoms and particular aspects of emotion regulation difficulties among trauma-exposed individuals. Participants were an ethnically diverse sample of 108 undergraduates from an urban university. PTS symptom severity was found to be associated with lack of emotional acceptance, difficulty engaging in goal-directed behavior when upset, impulse-control difficulties, limited access to effective emotion regulation strategies, and lack of emotional clarity. Further, overall difficulties in emotion regulation were associated with PTS symptom severity, controlling for negative affect. Finally, individuals exhibiting PTS symptoms indicative of a PTSD diagnosis reported greater difficulties with emotion regulation than those reporting PTS symptoms at a subthreshold level. The implications of these findings for research and treatment are discussed.

Exposure to a potentially traumatic event is defined in part by the experience of an intense emotional response (i.e., fear, helplessness, and horror; American Psychiatric Association [APA], 1994), and in the immediate aftermath of the event, it is common for individuals to experience heightened emotional and physiological responses to frequent reminders of the event (e.g., Rothbaum et al., 1992 and Shalev et al., 1998). Over time, these responses diminish for many, if not most, survivors (Kessler et al., 1995, Rothbaum et al., 1992 and Shalev et al., 1998), whereas others go on to develop chronic symptoms of reexperiencing, avoidance, and hyperarousal (APA, 1994). A substantial body of research has attempted to identify factors that may be associated with the persistence of these posttraumatic stress (PTS) symptoms (for a review, see Brewin, Andrews, & Valentine, 2000); however, little attention has been paid to the role of difficulties in the ways in which individuals respond to or regulate their intense emotions. Theorists have highlighted the potential importance of emotion regulation difficulties in PTS and PTSD (Cloitre, 1998, Cloitre et al., 2002 and van der Kolk, 1996). Further, findings of an association between posttraumatic stress disorder (PTSD) and more intense emotional (subjective and psychophysiological) responding to emotionally evocative stimuli (Litz et al., 2000, Orsillo et al., 2004, McDonagh-Coyle et al., 2001 and Veazey et al., 2004) indicate that PTS symptoms might be associated with heightened emotional responses, which would then require greater regulation efforts (Mennin, 2005). An inability to effectively down-regulate this emotional arousal or difficulties in the awareness and differentiation of emotional states may contribute to the perception of emotions as uncontrollable and unpredictable—two factors that have been found to influence the likelihood of fear acquisition (Bouton, Mineka, & Barlow, 2001). Consequently, individuals may learn to fear (and subsequently avoid) situations where certain emotions may be elicited, thus preventing functional exposure to trauma-relevant cues (Foa & Kozak, 1986). In addition, difficulties in emotion regulation may indirectly influence the maintenance of PTS symptoms (e.g., avoidance) through their negative effect on interpersonal relationships and an individual’s overall functional capacity (see Cloitre et al., 2002). Thus, difficulties in emotion regulation abilities might serve to maintain posttraumatic symptoms in multiple ways. However, the particular difficulties in emotion regulation (using a comprehensive definition) that may be associated with posttraumatic responding have yet to be extensively explored (Hunt and Evans, 2004). Examination of the relationship between emotion regulation difficulties and PTS symptoms is clinically important and may enhance our understanding of the maintenance of PTS symptoms. Our conceptualization of emotion regulation emphasizes the functional nature of emotional responses, with regulation referring to an ability to act effectively in the context of emotionally salient events. Gratz and Roemer (2004), consistent with Thompson (1994), broadly define emotion regulation as the ability to monitor, evaluate, and modulate emotional reactions, especially in the context of goal-directed behavior. As such, they propose that effective emotion regulation involves several domains, including: (a) the awareness and understanding of emotions, (b) the acceptance of emotions, (c) the ability to control impulsive behaviors and engage in goal-congruent behaviors in the context of distressing emotional experiences, and (d) access to and flexible use of situationally appropriate emotion regulation strategies. Empirical evidence supports the distinct but related nature of these domains (Gratz & Roemer, 2004). Inherent in this definition of emotion regulation is the distinction between the modulation and avoidance of an emotion. Modulating an emotion involves altering the intensity or duration of an emotion as opposed to attempting to avoid or extinguish the emotion altogether (which is commonly associated with psychopathology and impairment rather than emotional health; see Hayes, Luoma, Bond, Masuda, & Lillis, 2006, for a review). Monitoring and evaluating emotional reactions are also important regulatory components; understanding and accepting one’s emotions are seen as crucial components of emotion regulation, as nonacceptance or lack of understanding may prolong emotional distress by adding negative secondary emotions to the primary negative emotion (e.g., feeling shameful about having the experience of anxiety or fear; Gratz & Roemer, 2004, Greenberg & Safran, 1987 and Hayes et al., 1999). For example, Salters-Pedneault, Gentes, and Roemer (2007) found that self-reported trait levels of fear of depression, anxiety, and positive emotions predicted increased subjective and physiological reactivity to a trauma-related, emotionally evocative stimulus. Further, given that many individuals experience their emotions as preventing them from carrying out necessary activities, the emphasis on behavioral responding in the face of emotional experience (e.g., inhibiting impulses and pursuing goals when upset) is especially important. An individual’s behavior and ability to pursue self-care, pleasure, and mastery activities is an important indicator of an individual’s ability to regulate emotions (Gross & Munoz, 1995). Trauma-exposed individuals who are faced with memories of emotionally evocative events may struggle with each aspect of emotion regulation. Evidence suggests an association between PTSD and elevations in alexithymia, which is defined by difficulty identifying feelings, as well as a limited ability to distinguish between feelings and bodily sensations of emotional arousal (Taylor, Bagby, & Parker, 1991). Several studies have revealed significant positive associations between the severity of PTSD, traumatic exposure, and alexithymia (e.g., Fukunishi et al., 1996 and Yehuda et al., 1997). Further, Monson, Price, Rodriguez, Ripley, and Warner (2004) found that difficulty describing emotions (combined with the avoidance of internal emotional experiences) was associated with greater PTS symptom severity, especially for reexperiencing symptoms. These findings suggest that poor understanding of emotions may be associated with PTS. Although no studies have directly tested the relationship between the behavioral aspect of emotion regulation difficulties (i.e., an inability to engage in goal-directed behaviors and a tendency to engage in impulsive behaviors when upset) and PTS, indirect evidence suggests that PTS symptoms may be associated with these difficulties. The psychosocial impairment associated with PTSD (Kessler et al., 1995) and the PTS symptom of behavioral avoidance may indicate that individuals exhibiting PTS symptoms are refraining from engaging in important relationship or work behaviors as a result of their emotional distress, which may result in a worsening of their symptoms. Consistent with this, Bryant and Harvey (1995) found that an avoidant coping style, characterized by behavioral disengagement and denial, predicted intrusive symptoms in motor vehicle accident victims. When activities are avoided in order to alter emotional experience, this avoidant coping style may be considered an (unsuccessful) emotion regulation strategy. However, the intention behind these strategies is rarely assessed in studies of coping. And, although avoidance of situational cues of the traumatic event (one indicator of this emotion regulation difficulty) is included as a symptom of PTSD, broader avoidance of a range of emotionally evocative symptoms is not included, but may be an important target of intervention. Thus, research is needed to explore whether difficulty engaging in goal-directed behavior (or controlling impulsive behaviors) when distressed is related to PTS symptoms. Finally, a growing body of research suggests that PTS symptoms are associated with limited access to and inflexible use of emotion regulation strategies, characterized predominantly by unsuccessful efforts to avoid internal experiences. Associations have been demonstrated between PTSD and PTS symptoms and (a) experientially avoidant tendencies (Marx & Sloan, 2005, Plumb et al., 2004 and Tull & Roemer, 2003, see Salters-Pedneault, Tull, & Roemer, 2004, for a review), (b) the intentional withholding of emotions (Roemer, Litz, Orsillo, & Wagner, 2001), and (c) a tendency to suppress thoughts (Ehlers et al., 1998, Harvey & Bryant, 1998, Steil & Ehlers, 2000 and Tull et al., 2004), which is ineffective (Shipherd & Beck, 1999). If PTS symptoms are associated with these ineffective efforts to alter internal experiences, we expect that PTS symptoms will be associated with reports of generally limited access to strategies to successfully regulate emotions. Given the theoretical basis for considering broad emotion regulation difficulties relevant to the maintenance of PTS, and the growing empirical literature supporting the relevance of specific types of regulation difficulties, we explored the relationship between difficulties in emotion regulation and severity of PTS symptoms in a sample of individuals who reported at least one traumatic incident that elicited feelings of fear, helplessness, or horror. We predicted that PTS symptoms would be positively correlated with difficulties in emotion regulation. Further, as we were interested in examining the unique relationship between emotion-regulation difficulties and PTS symptom severity, negative affect was controlled for. Negative affect, as a construct, represents individual differences in the extent to which emotional distress or unpleasant negative emotional arousal is experienced (Watson et al., 1988 and Watson & Tellegen, 1985). It is possible that any demonstrated relationship between emotion regulation difficulties and PTS symptom severity may simply be due to individual differences in the frequency with which emotional distress is experienced (i.e., the more frequent experience of emotional distress may contribute to the perception of PTS symptoms as more severe, as well as more difficulties in the regulation of that distress). Indeed, negative affect is associated with both difficulties in emotion regulation (e.g., Diamond & Aspinwall, 2003) and anxiety disorder-related psychopathology (e.g., Brown, Chorpita, & Barlow, 1998), and it has been demonstrated that the negative affect component underlying many self-report measures may overestimate relationships between a measure and outcomes (Watson & Pennebaker, 1989). By controlling for negative affect, then, we can begin to speak to the unique relationships between emotion regulation difficulties and PTS symptoms. In addition, we explored the relationships between emotion regulation difficulties and PTS symptom clusters as well as between PTS and specific facets of emotion regulation difficulties; however, given the dearth of previous research in this area, we did not make any specific predictions regarding these relationships. We initially focused on individuals exposed to a potentially traumatic event who reported a range of PTS symptoms (as opposed to individuals reporting severity consistent with a PTSD diagnosis), given that the experience of subthreshold PTSD symptoms following traumatic exposure has been associated with levels of difficulty and distress comparable to full PTSD (Stein et al., 1997 and Yarvis et al., 2005). However, in order to begin to examine the clinical relevance of these findings, we also examined whether individuals who were above the clinical cutoff in PTS symptom severity reported more difficulties in emotion regulation than those below the cutoff, as well as group differences in each type of emotion regulation difficulty.