مشکلات تنظیم هیجانی در بازماندگان از تروما : نقش نوع تروما و شدت علائم در بیماران PTSD

Abstract Two different hypotheses regarding the relationship between emotion regulation and PTSD are described in the literature. First, it has been suggested that emotion regulation difficulties are part of the complex sequelae of early-onset chronic interpersonal trauma and less common following late-onset or single-event traumas. Second, PTSD in general has been suggested to be related to emotion regulation difficulties. Bringing these two lines of research together, the current study aimed to investigate the role of trauma type and PTSD symptom severity on emotion regulation difficulties in a large sample of trauma survivors (N = 616). In line with the hypotheses, PTSD symptom severity was significantly associated with all variables assessing emotion regulation difficulties. In addition, survivors of early-onset chronic interpersonal trauma showed higher scores on these measures than survivors of single-event and/or late-onset traumas. However, when controlling for PTSD symptom severity, the group differences only remained significant for 2 out of 9 variables. The most robust findings were found for the variable “lack of clarity of emotions.” Implications for future research, theoretical models of trauma-related disorders, and their treatment will be discussed. Although posttraumatic stress disorder (PTSD) is mostly regarded as a reliable, valid, and clinically useful diagnostic category (Nemeroff et al., 2006), some aspects of the diagnosis nevertheless remain controversial (e.g., McHugh and Treisman, 2007 and McNally, 2004). Most importantly, a number of authors have argued that it is too much focused on the sequelae of single-event traumas, but does not adequately capture the more complex problems experienced by adult survivors of childhood interpersonal trauma, especially if the traumatic events have occurred repeatedly or chronically (Briere and Spinazzola, 2005, Cloitre et al., 2005, Herman, 1992a, Herman, 1992b, van der Kolk, 2005 and van der Kolk et al., 2005). A number of additional trauma-related diagnoses for this specific subgroup have therefore been suggested, including complex PTSD (Herman, 1992b), disorder of extreme stress not otherwise specified (DESNOS; van der Kolk et al., 2005), and, more recently, developmental trauma disorder (van der Kolk, 2005). Other authors have described groups of symptoms that are thought to be typical sequelae of early-onset interpersonal trauma without suggesting a separate diagnostic category (Briere et al., 2008, Briere and Spinazzola, 2005 and Cloitre et al., 2005). Although the different conceptualizations of complex trauma sequelae show considerable differences, they also agree on a number of key symptoms, including emotion regulation difficulties. The suggestion that exposure to chronic interpersonal trauma early in life should lead to emotion regulation difficulties is based on findings from developmental psychology. Research has shown that adaptive emotion regulation is learned in interaction with primary caregivers (Calkins and Hill, 2007 and Cole et al., 1994). On the one hand, caregivers' own emotion regulation behavior serves as a model for the developing child as to how to deal with emotional states. In addition, caregivers guide the child in understanding and labeling his/her own emotions and ultimately regulating them in a way to achieve his/her goals. In addition, there is evidence that compromised attachment is associated with emotion regulation deficits (Cloitre, Stovall-McClough, Zorbas, & Charuvastra, 2008), which supports the idea that the interpersonal context is important for the development of emotion regulation. On a theoretical level, it is therefore conceivable that the experience of chronic interpersonal trauma in early developmental stages should disrupt the development of adaptive emotion regulation, especially when the perpetrator is one of the key caregivers (Cloitre et al., 2005, Cloitre et al., 2008, Ford, 2009 and van der Kolk et al., 1996); however, to our knowledge no prospective studies testing this hypothesis have been conducted to date. On the basis of the theoretical assumptions regarding the effects of trauma on the development of emotion regulation, a number of authors suggest that emotion regulation difficulties are one of the complex symptoms that specifically develop after early-onset chronic interpersonal trauma (e.g., Cloitre et al., 2005 and van der Kolk et al., 2005). The suggestion that survivors of early-onset interpersonal trauma typically show pronounced emotion regulation difficulties also forms the rationale for treatment approaches specifically developed for this group that include strategies to build up emotion regulation skills (Cloitre et al., 2002 and Wolfsdorf and Zlotnick, 2001). A review of evidence supporting this view is complicated by the fact that emotion regulation is a broad concept that has been defined in different ways (see Gross and Thompson, 2007 and Kring and Werner, 2004). The current study is based on Gratz and Roemer's (2004) integrative conceptualization, which suggests four key dimensions of emotion regulation: (a) awareness and understanding of one's emotions, (b) acceptance of negative emotions, (c) the ability to successfully engage in goal-directed behavior and control impulsive behavior when experiencing negative emotions, and (d) the ability to use situationally appropriate emotion regulation strategies. On the basis of this conceptualization, Gratz and Roemer developed the Difficulties in Emotion Regulation Scale (DERS). Results of factor analyses support a six-factor solution for the DERS, whereby the first and third dimension suggested by the authors are represented by two factors each (Dimension 1: Lack of Emotional Awareness and Lack of Emotional Clarity; Dimension 3: Difficulties Engaging in Goal-Directed Behavior and Impulse Control Difficulties). Evidence for the idea that survivors of early-onset interpersonal trauma suffer from alterations in emotion regulation comes from three groups of studies. First, survivors of early-onset interpersonal trauma were found to report higher levels of alexithymia than nontraumatized controls (Cloitre et al., 1997, McLean et al., 2006 and Zlotnick et al., 1996). Alexithymia is defined as difficulty with identifying and labeling one's own emotional state and corresponds to the first dimension of Gratz and Roemer's (2004) conceptualization. Second, a number of studies have investigated acceptance of negative emotions. When compared to nontraumatized controls, survivors of early-onset interpersonal trauma were found to report more difficulties tolerating and regulating negative emotions (Briere & Rickards, 2007), higher levels of fear of emotions (Tull, Jakupcak, McFadden, & Roemer, 2007), and higher experiential avoidance, defined as an unwillingness to experience negative thoughts and feelings and high efforts to escape from them (Batten et al., 2001 and Marx and Sloan, 2002). Furthermore, studies conducted as part of the DSM-IV field trial showed that a majority of survivors of early-onset interpersonal trauma reported difficulties appropriately regulating their emotions (e.g., fear, anger) or impulses (e.g., self-destructive behavior, sexual involvement; Pelcovitz et al., 1997, van der Kolk et al., 1996 and van der Kolk et al., 2005). Finally, a recent study found self-reported emotion regulation problems to be strongly associated with functional impairment beyond PTSD symptom severity in treatment-seeking women who had experienced early-onset interpersonal trauma ( Cloitre et al., 2005). Taken together, earlier findings support the view that psychological problems following early-onset interpersonal trauma include emotion regulation difficulties. However, to our knowledge, no prospective studies have been conducted to date investigating the suggested temporal precedence of traumatic events leading to emotion regulation difficulties. In addition, it is less clear whether these difficulties are indeed specific for survivors of this type of events or whether they are also present in individuals with PTSD who have experienced traumas later in life and/or only once. In line with the latter view, it is interesting to note that the DSM-IV diagnosis of PTSD includes symptoms that may directly reflect difficulties in emotion regulation, with emotional hyperreactivity to trauma-related cues on the one hand and hyporeactivity in the form of emotional numbing on the other hand (see Frewen and Lanius, 2006 and Litz et al., 2000). A number of studies have shown that PTSD in general, even following adult-onset traumas, is related to alterations in emotion regulation. Specifically, PTSD has been found to be related to (a) alexithymia ( Frewen, Dozois, Neufeld, & Lanius, 2008); (b) a negative attitude towards emotional expression and a tendency to suppress and/or withhold negative emotions ( Lowery and Stokes, 2005, Moore et al., 2008, Nightingale and Williams, 2000 and Roemer et al., 2001), as well as high levels of experiential avoidance ( Kashdan et al., 2009, Marx and Sloan, 2005, Morina et al., 2008 and Plumb et al., 2004); and (c) self-reported problems regulating one's emotions ( Tull, Barrett, McMillan, & Roemer, 2007). Taken together, these findings show an association of emotion regulation difficulties with PTSD following late-onset single-event traumas, which may call into question the widespread assumption that they are a specific characteristic of early-onset chronic interpersonal trauma. An alternative hypothesis would be that emotion regulation difficulties are simply related to the severity of PTSD symptoms irrespective of the type of traumatic event experienced. We suggest that studies testing these two hypotheses against each other need to fulfill two requirements. First, they need to directly compare survivors of early-onset interpersonal traumas with survivors of late-onset and/or noninterpersonal traumas regarding characteristics of emotion regulation that are thought to be implicated in trauma-related disturbances. Secondly, PTSD symptom severity needs to be controlled for in order to ensure that possible differences between different types of trauma survivors are not just due to differences in the severity of PTSD symptoms experienced. To our knowledge, there is no published study that fulfills both requirements. However, a small number of studies have directly compared different types of trauma survivors regarding characteristics of emotion regulation. Results showed that survivors of early-onset interpersonal trauma report higher levels of alexithymia (Cloitre et al., 1997), more difficulties tolerating and regulating negative emotions (Briere & Rickards, 2007), and more problems with the regulation of anger as well as more self-destructive behavior (Pelcovitz et al., 1997, Scoboria et al., 2008 and van der Kolk et al., 1996) when compared to survivors of late-onset interpersonal trauma and/or noninterpersonal trauma (but see also Ford, Stockton, Kaltman, & Green, 2006, who failed to find differences in emotion regulation between different types of trauma survivors). Thus, results of most studies directly comparing different types of trauma survivors support the view that emotion regulation difficulties are more pronounced in survivors of early-onset interpersonal than late-onset or single-event traumas. However, as none of the existing studies has controlled for levels of PTSD, it is unclear whether the emotion regulation difficulties observed are indeed due to the type of event experienced or simply due to higher levels of PTSD in the early-onset group. In addition, past studies differ considerably regarding their definition of the different trauma types that were compared. Whereas some studies compared survivors of early-onset versus late-onset interpersonal trauma regardless of the number of events experienced (e.g., Cloitre et al., 1997, Pelcovitz et al., 1997 and van der Kolk et al., 2005), others distinguished between single incidents vs. ongoing/chronic traumatization within the group of early-onset interpersonal traumas (e.g., Ford et al., 2006 and Roth et al., 1997). Most studies used the age of 14 as the cutoff to distinguish between early vs. late traumas. However, some studies chose the higher cutoff of 18 years of age (e.g., Cloitre et al., 1997). In the current study, self-reported characteristics of emotion regulation were assessed in a large group of trauma survivors via a web-based survey. The assessment battery for emotion regulation was compiled with the aim to assess all four groups of emotion regulation variables suggested by Gratz and Roemer (2004), with at least two measures per group. In addition, emotion suppression and cognitive reappraisal were assessed as two specific emotion regulation strategies that have been found in earlier research to be significantly related to PTSD symptomatology (Moore et al., 2008) as well as other types of emotional problems (e.g., Gross & John, 2003). As emotion suppression can be assumed to be related to low acceptance of negative emotions, it was included in the group of variables assessing emotion acceptance. Reappraisal, on the other hand, was added to the fourth group of variables assessing the functional and flexible use of emotion regulation strategies. In line with most earlier studies (e.g., Pelcovitz et al., 1997 and van der Kolk et al., 2005), early-onset interpersonal trauma was defined as sexual or physical violence experienced before the age of 14. We also distinguished whether the trauma was “chronic” (i.e., for the duration of at least 1 year) or not, as done in earlier studies (e.g., Roth et al., 1997). Based on the developmental literature, we expected chronic interpersonal trauma experienced at an early age to be specifically associated with emotion regulation deficits. The hypotheses were as follows: 1. Emotion regulation difficulties are significantly related to levels of PTSD symptoms. 2. Survivors of early-onset chronic interpersonal trauma report higher levels of emotion regulation difficulties than survivors of late-onset, early-onset single/repeated and noninterpersonal traumas. 3. The differences in emotion regulation between the different types of trauma survivors remain significant when controlling for PTSD symptoms.

Results Preliminary Analysis: Group Differences on Demographic Variables Before testing the hypotheses, we first checked whether the groups differed on any demographic variables. As shown in Table 1, no difference in age, marital status, or employment between the groups emerged. However, the rate of female participants was higher in the interpersonal trauma groups than the noninterpersonal trauma group. As would be expected, the groups also differed regarding the severity of PTSD symptoms assessed with the IES-R. Survivors of early chronic interpersonal trauma showed the highest IES-R mean scores (between anchor points quite a bit and extremely), followed by early single interpersonal and late interpersonal trauma survivors (between anchor points moderately and quite a bit), and noninterpersonal trauma survivors showed the lowest scores (between anchor points a little bit and moderately). Hypothesis 1: Relationship Between Emotion Regulation Difficulties and PTSD Symptom Severity Correlations between the different emotion regulation scores and PTSD symptom severity are shown in Table 2. In line with Hypothesis 1, IES-R scores showed significant correlations with all indices of emotion regulation difficulties in the expected direction. Table 2. Pearson Correlations between PTSD Symptom Severity and Characteristics of Emotion Regulation Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. IES-R − Awareness and Clarity 2. DERS − lack of awareness .34⁎⁎ − 3. DERS − lack of clarity .48⁎⁎ .55⁎⁎ − Acceptance 4. DERS − non-acceptance .48⁎⁎ .40⁎⁎ .61⁎⁎ − 5. AAQ − experiential avoidance .49⁎⁎ .41⁎⁎ .62⁎⁎ .61⁎⁎ − 6. ERQ − emotion suppression .36⁎⁎ .46⁎⁎ .46⁎⁎ .44⁎⁎ .35⁎⁎ − - Difficulties with goal-directed behavior and impulse control 6. DERS − goal-directed behavior .49⁎⁎ .34⁎ .59⁎⁎ .57⁎⁎ .70⁎⁎ .33⁎⁎ − 7. DERS − impulse control difficulties .49⁎⁎ .36⁎⁎ .60⁎⁎ .58⁎⁎ .65⁎⁎ .28⁎⁎ .76⁎⁎ − Strategy Use 8. DERS − limited access to strategies .52⁎⁎ .42⁎⁎ .66⁎⁎ .72⁎⁎ .74⁎⁎ .42⁎⁎ .77⁎⁎ .74⁎⁎ − 10. ERQ − reappraisal -.23⁎⁎ -.38⁎⁎ -.39⁎⁎ -.25⁎⁎ -.45⁎⁎ -.15⁎⁎ -.44⁎⁎ -.42⁎⁎ -.50⁎⁎ − Note. IES-R = Impact of Event Scale−Revised; DERS = Difficulties in Emotion Regulation Scale; ERQ = Emotion Regulation Questionnaire; AAQ = Acceptance and Action Questionnaire. ⁎ p < .01. ⁎⁎ p < .001. Table options Hypothesis 2: Differences in Emotion Regulation According to Trauma Type As shown in Table 3, results of MANOVAs showed significant main effects of trauma type for all four groups of emotion regulation variables. Follow-up ANOVAs revealed significant main effects of trauma type on all emotion regulation variables. In line with Hypothesis 2, simple contrasts comparing all groups to the last one showed that survivors of early-onset chronic interpersonal trauma reported significantly higher emotion regulation difficulties than all other groups for almost all variables. Only one contrast was nonsignificant, showing that survivors of early-onset chronic interpersonal trauma did not differ from survivors of early-onset single interpersonal traumas regarding their reappraisal scores. Table 3. Characteristics of Emotion Regulation by Trauma Type Non-interpersonal (n = 135) M (SD) Late interpersonal (n = 211) M (SD) Early single interpersonal (n = 101) M (SD) Early chronic interpersonal (n = 169) M (SD) (M)ANOVA (M)ANCOVA F(6, 1224) a or F(3, 612) η2 F(10, 1530) a or F(5, 766) η2 Awareness and Clarity 16.23⁎⁎ .07 3.93⁎⁎ .02 DERS − lack of awareness 16.33 (4.50)c 17.32 (5.20)c 17.51 (5.49)c 19.53 (5.54) 10.53⁎⁎ .05 1.19 .01 DERS − lack of clarity 11.40 (4.79)b 13.52 (5.18)b 13.99 (5.12)b 17.24 (5.16) 35.08⁎⁎ .15 7.69⁎⁎ .04 Acceptance 8.82⁎⁎ .04 1.21 .01 DERS − non-acceptance 13.78 (5.88)c 16.76 (6.66)c 17.31 (6.65)c 19.83 (6.51) 22.21⁎⁎ .10 N/A AAQ − experiential avoidance 35.60 (7.74)c 37.96 (8.63)c 39.43 (7.82)c 42.54 (7.72) 20.10⁎⁎ .09 N/A ERQ − emotion suppression 13.24 (5.69)c 14.33 (6.34)c 14.40 (6.75)c 16.57 (6.20) 7.86⁎⁎ .04 N/A Difficulties with goal-directed behavior and impulse control 14.03⁎⁎ .06 2.29⁎ .01 DERS − goal-directed behavior 13.72 (5.13)b 15.35 (5.61)b 16.98 (5.03)c 18.75 (4.96) 26.08⁎⁎ .11 4.09⁎ .02 DERS − impulse control difficulties 12.65 (5.56)c 14.98 (6.20)c 16.05 (6.22)c 18.67 (6.85) 24.41⁎⁎ .11 2.51 .01 Strategy Use 13.19⁎⁎ .06 2.09 .01 DERS − limited access to strategies 18.81 (8.31)c 23.05 (8.75)c 25.35 (9.29)c 27.43 (7.37) 28.11⁎⁎ .12 N/A ERQ − reappraisal 25.86 (7.37)c 24.24 (8.07)c 23.14 (8.23) 22.04 (8.30) 6.14⁎ .03 N/A PANAS = Positive and Negative Affect Schedule; DERS = Difficulties in Emotion Regulation Scale; AAQ = Acceptance and Action Questionnaire; ERQ = Emotion Regulation Questionnaire. a Pillai's Trace; N/A: ANCOVA not computed because of nonsignificant MANCOVA. b Significant contrast between this group and early-onset chronic interpersonal trauma group in both ANOVA and ANCOVA controlling for IES-R scores. c Significant contrast between this group and early-onset chronic interpersonal trauma group in ANOVA, but not significant in ANCOVA controlling for IES-R scores. ⁎ p < .01. ⁎⁎ p < .001. Table options Hypothesis 3: Group Differences When Controlling for PTSD Symptom Severity According to Hypothesis 3, we expected that survivors of early-onset interpersonal trauma would still show higher scores on measures of emotion regulation difficulties when PTSD symptom severity is controlled for. In contrast to the hypothesis, two of the four MANCOVAs conducted were nonsignificant, indicating that the different groups of trauma survivors did not differ regarding their acceptance of negative emotions as well as strategy use when symptom levels of PTSD were controlled. However, significant main effects remained in the MANOVAs for Awareness and Clarity and Difficulties With Goal-Directed Behavior and Impulse Control. Follow-up ANCOVAs showed that the DERS subscale Lack of Clarity was the only emotion regulation variable for which survivors of early chronic interpersonal trauma remained to show higher scores than all other trauma groups. On the DERS subscale Difficulties Engaging in Goal-Directed Behavior, survivors of early chronic interpersonal trauma still reported higher levels than survivors of noninterpersonal and late-onset interpersonal traumas, but did not differ from early-onset single interpersonal trauma survivors. Testing the Robustness of the Findings In order to test the robustness of the findings, we repeated the analyses with slight variations. First, we combined all survivors of early-onset interpersonal trauma to one group, regardless of whether the event met criteria for chronic trauma or not. This did not change the results. Second, as the proportion of females was significantly higher for the early-onset groups than the late-onset groups, we reran all analyses for female participants only.1 All correlations between emotion regulation variables and PTSD symptom severity remained significant. In addition, the same pattern of group differences were found as in the total sample, although some simple contrasts failed to reach significance. As the trauma groups still significantly differed regarding their IES-R scores, the (M)ANCOVAs controlling for PTSD symptom severity were also repeated for female participants only. When controlling for IES-R scores, Clarity of Negative Emotions was the only remaining variable for which significant group differences were found. Dropout Analysis A set of t tests was conducted comparing participants with complete data (n = 616) with those who did not complete the whole online questionnaire. Data for the latter group were available for the AAQ (n = 800), the DERS (396 < n < 745 for the different subscales) and the ERQ (n = 308). Participants with complete data reported significantly higher emotion regulation difficulties on the AAQ and the DERS than participants who dropped out, all t's > 2.3, all p's < .01. No significant difference emerged for the ERQ subscales, both t's < 1.7, both p's < .09.