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

Emotion in Posttraumatic Stress Disorder provides an up-to-date review of the empirical research on the relevance of emotions, such as fear, anxiety, shame, guilt, and disgust to posttraumatic stress disorder (PTSD).  It also covers emerging research on the psychophysiology and neurobiological underpinnings of emotion in PTSD, as well as the role of emotion in the behavioral, cognitive, and affective difficulties experienced by individuals with PTSD.  It concludes with a review of evidence-based treatment approaches for PTSD and their ability to mitigate emotion dysfunction in PTSD, including prolonged exposure, cognitive processing therapy, and acceptance-based behavioral therapy.

• Identifies how emotions are central to understanding PTSD.
• Explore the neurobiology of emotion in PTSD.
• Discusses emotion-related difficulties in relation to PTSD, such as impulsivity and emotion dysregulation.
• Provides a review of evidence-based PTSD treatments that focus on emotion.

• Language: English
• Publisher: Academic Press
• Release date: Jan 31, 2020
• ISBN: 9780128162897

Book preview

States

Introduction: Understanding the role of emotion in the etiology, assessment, neurobiology, and treatment of posttraumatic stress disorder

Matthew T. Tulla; Nathan A. Kimbrelb, a Department of Psychology, University of Toledo, Toledo, OH, United States, b Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, United States

Abstract

Although posttraumatic stress disorder (PTSD) has always been recognized as a disorder characterized by disruptions in the experience of and responses to emotion, recent advances in research have led to an improved understanding of the role of emotion and emotion-related processes in the development, maintenance, and treatment of PTSD. While there has been a substantial increase in our knowledge of the role of emotion in PTSD in recent years, there is currently not a single text that effectively organizes this information. Therefore, the goal of this edited book is to provide an overview of this literature, with the hope that it will integrate diverse bodies of literature and lay the foundation for future research on PTSD and emotion. In this book, four areas of research are covered. Section 1 reviews the theoretical and empirical literature concerning the relation between specific emotions and PTSD. Section 2 describes the neurobiological underpinnings of emotion and emotion regulation in PTSD. Section 3 provides a review of specific difficulties in responding and relating to emotional experience in PTSD and their associated consequences. Finally, Section 4 discusses different treatment approaches for PTSD, their influence on emotion and emotion dysfunction, and the role of culture in understanding the relation between PTSD and emotion.

Keywords:

PTSD; DSM-5; Emotion dysregulation; Impulsivity; Neurobiology

Since its inclusion in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1980), posttraumatic stress disorder (PTSD) has been recognized as a psychological disorder characterized by disruptions in the experience of and responses to emotion. Yet, despite consensus across models for the relevance of emotional dysfunction in understanding PTSD (Cahill & Foa, 2007; Keane & Barlow, 2002), the specific deficits in emotional experience and processing exhibited by individuals with PTSD and their role in the development and maintenance of PTSD remained poorly understood at the turn of the century (Litz, Orsillo, Kaloupek, & Weathers, 2000). This was further evident in the DSM-IV (American Psychiatric Association, 2000) diagnostic criteria for PTSD, which arguably did not capture the full extent of the diverse emotion dysfunction observed in PTSD. Moreover, despite early recognition of PTSD’s broad impact on emotional experience, PTSD has largely been considered and discussed as a disorder of fear and anxiety (e.g., Keane & Barlow, 2002; Shin & Handwerger, 2009). Until the publication of the DSM-5 (where PTSD is currently categorized as a trauma- and stressor-related disorder; American Psychiatric Association, 2013), PTSD was classified as an anxiety disorder, and early theories on the development and maintenance of PTSD largely emphasized fear-related processes in PTSD (Foa & Kozak, 1986).

However, in the past 15 years, there has been an exponential increase in research on emotion and emotion regulation (Barrett, 2013; Gross, 2015; Tull & Aldao, 2015). As research on emotion has progressed, so has research on the role of emotions in PTSD. This rapidly growing body of research has demonstrated the importance of considering emotions besides fear and anger in understanding PTSD pathology, such as shame, guilt, sadness, and disgust (e.g., Beck et al., 2011; Engelhard, Olatunji, & de Jong, 2011; Lee, Scragg, & Turner, 2001). In addition, research has shown that well-established cognitive-behavioral treatments for PTSD are not only effective at reducing excessive fear and anxiety among individuals with PTSD but also effective at reducing excesses in and problems with other emotions, such as shame, guilt, and anger (Cahill, Rauch, Hembree, & Foa, 2003; Resick, Nishith, Weaver, Astin, & Feuer, 2002; Stapleton, Taylor, & Asmundson, 2006). Researchers are also increasingly finding support for the relevance of specific emotional processes (e.g., emotion regulation, distress intolerance, and impulsivity) in the development and maintenance of PTSD (Roley, Contractor, Weiss, Armour, & Elhai, 2017; Seligowski, Lee, Bardeen, & Orcutt, 2015; Vujanovic & Bernstein, 2011), and there is growing understanding of the psychophysiological and neurobiological markers of emotional dysfunction in PTSD (Yehuda & LeDoux, 2007).

These findings have led to modifications of existing theories or the development of new theories on PTSD that take into account all emotions and their role in the development and maintenance of PTSD (Frewen & Lanius, 2006; Rauch & Foa, 2006) and the investigation of treatments for PTSD that specifically target emotion dysregulation (Cloitre et al., 2010; Orsillo & Batten, 2005; Steil, Dyer, Priebe, Kleindienst, & Bohus, 2011). In addition, with the publication of the DSM-5 (American Psychiatric Association, 2013), changes were made to the operationalization of PTSD that deemphasized the specific role of fear and anxiety in PTSD while including symptoms that specifically mention the role of other emotions. For example, to be considered as a traumatic event, an event is no longer required to include the experience of fear-spectrum emotions (fear, helplessness, or horror). In addition, the DSM-5 conceptualization of PTSD now includes a symptom characterized by the experience of persistent negative emotions, such as fear, horror, anger, guilt, or shame. The growth of research on emotion and emotional processes in PTSD and recent changes to the symptom structure of PTSD that highlight the relevance of multiple emotions will no doubt lead to a more nuanced understanding of the development, maintenance, and treatment of PTSD. It is for this reason that we decided there was a need for a text that organizes the large body of theoretical and empirical literature on PTSD and emotion.

This book is organized into four sections, with each composed of multiple chapters written by leading experts in the field that cover specific topics associated with the section content area. The first section of the book reviews the theoretical and empirical literature concerning the relation between specific emotions and PTSD. This section begins with a chapter that describes the current state of the art with respect to the assessment of emotion and emotion-related processes in PTSD. This is then followed by a series of chapters that cover the role of specific emotions in PTSD, including anxiety and fear, anger, sadness and depression, disgust, and shame and guilt.

The second section of the book describes the neurobiological underpinnings of emotion and emotion regulation in PTSD. This section begins with an overview of the current literature on the neurobiology and neuromodulation of emotional dysfunction in PTSD. Notably, in addition to describing the current literature on neurobiology, this chapter provides a thorough summary of a variety of neuromodulation techniques (e.g., repetitive transcranial magnetic stimulation and direct transcranial stimulation) that have only begun to be applied to PTSD in recent years. The next chapter in this section provides a comprehensive summary of the current state of the literature concerning the genetic and epigenetic basis of PTSD. This section then concludes with a chapter exploring the benefits of using objective psychophysiological paradigms to characterize PTSD and how the use of such paradigms can lead to a better understanding of PTSD symptoms and the development of more effective PTSD treatments.

The third section of the book provides a review of specific difficulties in responding and relating to emotional experience in PTSD and their associated consequences. This section begins with a review of the theoretical and empirical literature on emotion regulation difficulties in PTSD. The next chapter reviews the regulatory role of attention in PTSD from an information processing perspective, followed by chapters on distress intolerance and PTSD, emotional granularity in PTSD, experiential avoidance and PTSD, and emotion-driven impulsivity and PTSD. The chapters on emotional granularity and emotion-driven impulsivity deserve particular attention in this section as they cover a relatively new area of research in PTSD, highlighting the relevance of this particular line of investigation and its implications for understanding the symptoms, associated problems (e.g., substance abuse), and treatment of PTSD.

The final section of the book discusses different treatment approaches for PTSD, their influence on emotion and emotion dysfunction, and the role of culture in understanding the relation between PTSD and emotion. This section begins with a chapter describing prolonged exposure (PE) for PTSD and the impact of this treatment on ameliorating the diverse emotional consequences of traumatic exposure. This chapter is followed by a discussion of cognitive processing therapy (CPT) and how this PTSD treatment can also be used to effectively influence emotional responding in PTSD. Next, Skills Training in Affective and Interpersonal Regulation (STAIR) Narrative Therapy is presented, including an overview of the theoretical foundation of this treatment, its specific components, and recent applications of this treatment approach. The next chapter describes the growing body of evidence supporting the potential use of acceptance-based behavioral therapy to treat PTSD, followed by a chapter on self-compassion therapy, a relatively new treatment approach that may hold promise for individuals with PTSD who have not responded to previous therapeutic approaches. This section concludes with a chapter discussing how an anthropological approach can be used to better understand the ways in which culture might impact the expression and regulation of emotion in PTSD.

Although we do believe this book is comprehensive in its coverage of PTSD and emotion, we also recognize that it is in no way exhaustive in its review of the literature. Research on the role of emotion in the development, maintenance, and treatment of PTSD is being produced at a pace much too rapid to cover in its entirety. That said, it is our expectation that these chapters effectively represent the current state of the literature on PTSD and emotion, and by integrating diverse bodies of literature, it is our hope that this text will lay the foundation for future research on PTSD and emotion. We also hope that this text will provide a guide for clinicians interested in understanding the broad difficulties in the experience and regulation of emotion that may be exhibited by patients with PTSD and how existing treatments for PTSD can effectively be used to target these difficulties.

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Section 1

Emotions

Chapter 1

Assessment of emotion and emotion-related processes in PTSD

Meghan E. McDevitt-Murphy; Rebecca J. Zakarian; Cecilia C. Olin    The University of Memphis, Memphis, TN, United States

Abstract

This chapter reviews methods for assessing emotions and emotion-related processes in the context of posttraumatic stress disorder (PTSD). We present brief descriptions of emotions including anger, anxiety, fear, guilt, sadness, shame, guilt, and anger and offer recommendations for their measurement. We also review assessment strategies for emotion-related processes that are particularly relevant to PTSD presentations, including alexithymia, anhedonia, anxiety sensitivity, distress tolerance, emotion regulation, and experiential avoidance. All assessment strategies were identified based on the available literature and the frequency of their use with trauma samples. For most constructs, we present recommendations and descriptions for self-report questionnaires although, where appropriate, we also describe lab-based or behavioral measures. Brief psychometric information and administration details are also provided.

Keywords

Assessment; Measures; Emotion dysfunction; Emotional processes

Assessment of emotion and emotion-related processes in PTSD

Posttraumatic stress disorder (PTSD) is a complex disorder characterized by intense emotions across several domains, including not only prominent fear and anxiety but also sadness, guilt, and shame. PTSD has also been characterized by emotional numbing and anhedonia (i.e., a loss of interest or pleasure), both of which reflect a diminished experience of positive emotion. Additionally, some research has pointed to emotion-related processes (e.g., emotion regulation and experiential avoidance) as risk factors that may contribute to the onset or maintenance of PTSD following trauma exposure. Key to research and clinical work with these emotions and processes is a thorough assessment of PTSD. There are two psychometrically sound, DSM-correspondent, assessment instruments available from the National Center for PTSD (www.ncptsd.org): the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013), a structured interview, and the PTSD Checklist (PCL-5; Weathers, Litz, et al., 2013), a self-report questionnaire. For clinicians and researchers who also wish to thoroughly assess the emotions and emotion-related processes that accompany or contribute to PTSD or have implications for psychotherapy, this chapter offers insight into the available, research-supported assessment options. Herein, we briefly review key emotions and emotion-related processes that have relevance for PTSD and recommend assessment instruments for each domain based on the available research. The recommended measures presented in this chapter do not reflect an exhaustive list, but instead represent some of the measures with the most support in the published literature.

Assessment of emotions in PTSD

We begin with the assessment of emotions in the context of PTSD. In this section, we include emotions that are either components of the diagnostic criteria for PTSD or frequently present alongside PTSD. In general the most well-established assessment methods for most constructs are questionnaires. All recommended measures appear in Table 1.

Table 1

Anger

Individuals with PTSD frequently report problems with anger, ranging from the manifestation of high anger emotional states to behavioral dyscontrol in the form of aggressive, violent, or risky behaviors (American Psychiatric Association, 2000, 2013). Heightened irritability and angry outbursts are frequent features of the disorder and have been implicated among some trauma survivors as the most impairing feature of PTSD’s emotional landscape (e.g., Biddle, Elliott, Creamer, Forbes, & Devilly, 2002; Rosen, Adler, & Tiet, 2013). In a metaanalytic review of anger expression in PTSD, Olatunji, Ciesielski, and Tolin (2010) examined over 2000 patients with anxiety disorders across 28 studies and found that anger was uniquely heightened in patients with PTSD relative to other anxiety disorders, where high levels of irritability were also found. Moreover, results from the study indicated that individuals with PTSD distinctively struggle with the expression and control of anger, suggesting that problems with anger may be part of a broader network of emotional dysregulation and behavioral dysfunction.

The eroding effects of anger on interpersonal relationships (Kubany, Bauer, Muraoka, Richard, & Read, 1995) and links between anger and further negative outcomes (e.g., comorbidity (Gonzalez, Novaco, Reger, & Gahm, 2016) and aggressive/violent behavior (Jakupcak et al., 2007)) suggest that the assessment of anger in clinical contexts is necessary for comprehensive trauma care. Researchers studying trauma populations would also benefit from further investigation of this important emotional feature of PTSD emotional profiles. Additionally, certain populations of trauma survivors have been more frequently studied (e.g., combat veterans) than others, suggesting that there are unique gaps in the literature that warrant greater inquiry to understand the contextual role of anger across trauma types and populations.

Like other measures intended to capture emotional expression, measures of anger are frequently conceptualized in terms of state anger (e.g., specific, cued anger responses) and trait anger (e.g., the dispositional tendency to experience anger). Similarly, although anger is often conceptualized as a prelude to hostility or aggression, the constructs of anger, aggression, and hostility are best understood as distinct, albeit related, phenomena. As such the following provides a selection of well-validated, frequently-used self-report measures of anger in the context of PTSD assessment. For a broader review of measures of anger, see Fernandez, Day, and Boyle (2015).

The State-Trait Anger Expression Inventory (STAXI; Spielberger & Sydeman, 1994; STAXI-II; Spielberger, 1999) is an internationally used, self-report measure of state and trait anger. The original STAXI is composed of 44 items that make up 5 major scales (anger-state, anger-trait, anger in, anger-out, and anger control) with 2 subscales (anger temperament and anger reaction). The STAXI-II comprises 57 items organized into 6 major scales (anger-state, anger-trait, anger expression-out, anger expression-in, anger control-out, and anger control-in) and an expression index. Both versions of the STAXI can be administered via paper-and-pencil or online. Online administrations generate a report that provides raw scores, gender-normed T-scores and percentile conversions, and brief interpretative text. A sample interpretative report is provided at the publisher’s website. The STAXI and STAXI-II are intended for use with individuals between 16 and 63 years of age; child and adolescent versions are also available. Both measures have also been adapted for Spanish-speakers and have been translated into multiple languages.

The STAXI has been widely used and evaluated in clinical and nonclinical populations (e.g., Lievaart, Franken, & Hovens, 2016), including a range of trauma survivor samples such as adult survivors of interpersonal assault (e.g., Galovski, Mott, Young-Xu, & Resick, 2011), civilians exposed to war (Thabet, Abu Tawahina, El Sarraj, & Vostanis, 2008), crime victims (Orth & Maercker, 2009), child abuse survivors (Cloitre, Koenen, Cohen, & Han, 2002), and Vietnam veterans (Lasko, Gurvits, Kuhne, Orr, & Pitman, 1994). The STAXI-II has similarly been used among trauma populations, including treatment-seeking adolescent survivors of sexual violence (Kaczkurkin, Asnaani, Zhong, & Foa, 2016), veterans with PTSD (Owens, Chard, & Cox, 2008; Rauch et al., 2009; Roberge, Allen, Taylor, & Bryan, 2016), disaster responders (Palmieri, Weathers, Difede, & King, 2007), and 9/11 survivors (Difede et al., 2014). Factor analyses of the STAXI have supported its content structure (e.g., Forgays, Forgays, & Spielberger, 1997), and normative data for the STAXI and STAXI-II were derived from clinical and nonclinical samples (e.g., Spielberger, 1999).

The Buss-Perry Aggression Questionnaire (BPAQ; Buss & Perry, 1992) is an updated and revised version of the historically widely used Buss-Durkee Hostility Inventory (BDHI; Buss & Durkee, 1957). The BPAQ measures anger, hostility, and aggression. The anger subscale of the BPAQ comprises 8 items that are scored on a 5-point Likert scale in which respondents are asked to rate how characteristic an item is of them (e.g., Sometimes I fly off the handle for no good reason). An internationally used measure of the anger-hostility-aggression triumvirate, the BPAQ evidenced strong convergent validity, divergent validity, and construct validity in initial psychometric evaluations (Buss & Perry, 1992). Subsequent investigations of the scale’s psychometric properties demonstrated strong internal consistency, test-retest reliability, convergence with other measures of aggression, and divergence with social desirability measures (Harris, 1997). Additionally, the measure has been adapted internationally including for Dutch (Meesters, Muris, Bosma, Schouten, & Beuving, 1996), Japanese (Nakano, 2001), and Greek (Tsorbatzoudis, 2006) audiences with corresponding psychometric evaluations. The BPAQ has been used frequently among trauma survivors, including veterans with military sexual trauma-related PTSD (David, Simpson, & Cotton, 2006), children of mothers exposed to genocide (Roth, Neuner, & Elbert, 2014), combat veterans and former prisoners of war (Kip et al., 2013; Savic, Knezevic, Damjanovic, Spiric, & Matic, 2012), incarcerated persons endorsing childhood trauma exposure (Cima, Smeets, & Jelicic, 2008), and treatment seekers with comorbid substance use disorders (Barrett, Mills, & Teesson, 2011).

Anxiety

Anxiety and fear are related; anxiety reflects a state of moderately elevated arousal that may persist for an extended period of time, as opposed to briefer flares of acute fear, which may be more intense but shorter-lived. Anxiety is typically characterized by physiological arousal, apprehension, and worry. Historically, anxiety has been measured with self-report, physiological assessment, and behavioral measures. In terms of self-report measures, we recommend the State-Trait Anxiety Inventory (STAI; Spielberger, 1983), which assesses a litany of anxiety-related symptoms with one page asking respondents to consider how they generally feel (i.e., trait anxiety) and the other page asking individuals how they feel right now (i.e., state anxiety). Items include statements such as I feel calm (reverse scored), I feel strained, I feel frightened, and I feel nervous each rated on a 4-point scale from not at all to very much so. The STAI has been used extensively in research and clinical settings. STAI scores are generally correlated with measures of PTSD, but these correlations are not as strong as those between different measures of PTSD, suggesting that, while there is some shared variance, the STAI is not redundant with measures of PTSD. In a sample of trauma survivors, the STAI showed stronger test-retest reliability and similar internal consistency reliability relative to other measures of anxiety (Adkins, Weathers, McDevitt-Murphy, & Daniels, 2008). Barnes, Harp, and Jung (2002) reviewed over 800 studies that reported psychometric properties for the STAI and reported satisfactory internal consistency and temporal stability across a range of populations.

Fear

Fear is a prominent emotion in PTSD, particularly fear resulting from trauma-related stimuli. While fear and anxiety are somewhat overlapping, fear refers specifically to acute hyperarousal, generally occurring in the presence of real or perceived threat as opposed to anxious apprehension or worry, which may be of a lower intensity but more persistent across time. Although research has suggested that PTSD shows more similarities to disorders characterized by a high degree of generalized negative affect (e.g., major depressive disorder [MDD] and generalized anxiety disorder), compared with those characterized as fear disorders (e.g., panic or phobia; Watson, 2005), cue-elicited fear remains a salient aspect of PTSD.

A behavioral task called the NPU-threat test was recently developed to discriminate between anxiety and fear (Schmitz & Grillon, 2012). This lab paradigm involves using different stimuli to systematically elicit responses consistent with fear or anxiety. A detailed protocol is provided by Schmitz and Grillon (2012). The name of the test is derived from the three conditions of (a) no aversive event (N), (b) predictable aversive conditions (P), and (c) unpredictable aversive events (U). Briefly each condition lasts 120 seconds, and over each testing session, participants experience the P and U conditions twice, separated by the N condition. During the P condition, participants are presented with a visual cue and an aversive stimulus (typically a shock) such that the cue reliably predicts the shock. In the U condition, shocks are not preceded by a cue and are therefore unpredictable. Fear and anxiety responses are assessed using the startle reflex. Specifically, electromyogram is used to measure the eyeblink during each elicited startle response. The responses elicited in the P and U conditions are thought to reflect fear-potentiated and anxiety-potentiated startle responses, respectively. The startle responses during P sessions are generally stronger than those during N sessions, and the startle responses during U sessions are stronger than those during both P and N sessions.

The NPU paradigm is similar to procedures used to model fear and anxiety in animals, making it well suited for translational research. The validity of the NPU-threat test has been supported by research showing that the startle response in the U condition correlated with trait anxiety and anxiety sensitivity (Stegmann, Reicherts, Andreatta, Pauli, & Wieser, 2019). Self-report of anxiety using a Likert scale during the task, however, has not always corresponded to physiological anxiety response (Grillon et al., 2008). Some research suggests the NPU-threat test may discriminate between PTSD and generalized anxiety disorder (Grillon et al., 2009), although it has not been extensively evaluated in samples of individuals with PTSD, and there are few studies that have compared the physiological responses elicited to self-reported emotion ratings.

Because fear generally presents as a state rather than a trait, it is difficult to meaningfully assess the affective experience of fear in real time without employing a trigger. In the context of PTSD, individuals may experience frequent fear cued by the presence of trauma-related stimuli or reminders. Trauma-related triggers may include environmental stimuli or interoceptive experiences (internal experiences such as memories, emotions, or bodily sensations that are associated with the traumatic event in some way). In a setting where the individual feels safe and is not actively being triggered, their self-reported fear rating may be low, but this conveys little about the frequency and intensity of the person’s experience of fear when it occurs outside of the ecological boundaries of the laboratory setting.

Trauma script-driven imagery is a paradigm for assessing individuals’ responses to a salient trauma-related reminder. Typically, this paradigm involves the researcher recording a second-person narrative of the respondent’s index trauma. While listening to the recording, respondents’ reactivity is assessed vis a vis various physiological channels. The trauma script paradigm has been used to elicit PTSD symptoms in studies using psychophysiological assessment (McDonagh-Coyle et al., 2001), positron-emission tomography (PET; Barkay et al., 2012; Rauch, van der Kolk, Fisler, & Alpert, 1996), and functional magnetic resonance imagery (fMRI; Lanius et al., 2003). These studies have assessed brain activation and/or physiological arousal during script exposure, which are related to fear, though not exclusively. Studies of trauma script-driven imagery often include self-rated assessments of different emotional states, in which the individual is asked to rate their experience of a set of specific emotions in the moment. In some studies, researchers used a standardized measure like the Positive and Negative Affect Schedule (PANAS; Watson et al., 1988), while in others researchers used a locally derived set of questions to assess adverse emotional states (e.g., McDonagh-Coyle et al., 2001).

Although the script-driven imagery paradigm is a viable method for eliciting fear, it has most often been employed for the opportunity to observe physiological phenomena in real time. Given that few studies have used standardized self-report assessments of responses to script-driven imagery, Hopper, Frewen, Sack, Lanius, and Van der Kolk (2007) developed the Responses to Script-Driven Imagery Scale (RSDI), which assesses reexperiencing, avoidance, and dissociative symptoms. Although the RSDI does not assess the subjective experience of fear, per se, reexperiencing symptoms are frequently accompanied by fear, and both avoidance and dissociation reflect attempts to cope with intense negative affect. Thus the RSDI alone would not provide a measure of the intensity of fear, but could provide additional useful information as a supplement to a self-reported scale of fear and other negative emotions, such as the PANAS.

Guilt and shame

Although fear and anxiety have historically been emphasized as core emotions in PTSD, other negative affective experiences have gained recognition more recently as important emotional components of the disorder. Guilt and shame were both explicitly mentioned for the first time in the diagnostic criteria for PTSD in DSM-5 (APA, 2013; see also Lee, Scragg, & Turner, 2001), although both have been recognized for decades as part of the posttraumatic emotional experience for many survivors (e.g., Herman, 1992; Lewis, 1971). Individuals with PTSD report high levels of guilt and shame across trauma experiences, including combat trauma (e.g., Crocker, Haller, Norman, & Angkaw, 2016), sexual assault (Vidal & Petrak, 2007), intimate partner violence (e.g., Beck et al., 2011), child abuse (e.g., Feiring, Taska, & Lewis, 2002; Wolfe, Sas, & Wekerle, 1994), and even noninterpersonal traumas such as natural disasters (e.g., Carmassi et al., 2017).

Guilt and shame are classified as self-conscious emotions, or emotions that require some degree of developmental self-reflection and self-evaluation (pride and embarrassment are also self-conscious feelings; Tangney, 1999). Both guilt and shame involve a negative self-evaluation informed by deeply held societal constructions of morality, honor, and belonging (Tangney, 1999; Wilson, Droždek, & Turkovic, 2006), wherein the self is determined to, in some way, fail to meet desired or expected standards. Although they are often considered in tandem, guilt and shame are distinct. Whereas guilt refers to a negative evaluation of an action or behavior (e.g., participating in or failing to act to prevent an event that transgresses one’s moral convictions), shame orients the negative appraisal specifically toward the individual (Lewis, 1971; Tangney, 1996). In other words, guilt is about an action (e.g., I committed this act), and shame is about the individual (e.g., I committed this act). Although both posttraumatic guilt and shame are associated with broader PTSD symptomatology (e.g., Andrews, Brewin, Rose, & Kirk, 2000; Crocker et al., 2016; Leskela, Dieperink, & Thuras, 2002), guilt may also be ameliorated through acts of reparation. Shame, on the other hand, tends to invite isolation and withdrawal (Leskela et al., 2002).

Self-report measures of shame and guilt can be organized into two types: measures that assess cued emotional states (e.g., feelings of shame or guilt when cued by specific contexts or events) and measures of the dispositional tendency to experience shame or guilt (e.g., shame or guilt proneness; Tangney, 1996). Clinicians may particularly benefit from measures that capture guilt or shame proneness or attribution styles as the persistent experience of these negative emotional states is also implicated in other forms of psychopathology. Here, we recommend measures of shame and guilt based on the frequency with which they are used in the contemporary trauma literature and their psychometric characteristics. For a broader review of measures of shame and guilt in the context of PTSD, the reader is directed to Robins, Noftle, and Tracy (2007).

The Trauma-Related Guilt Inventory (TRGI; Kubany et al., 1996) is a 32-item questionnaire designed to specifically measure guilt associated with a traumatic event. Using a 5-point Likert scale, respondents rate how true each statement is for them, ranging from extremely true to not at all true. The TRGI assesses three domains of trauma-related guilt, including hindsight bias/responsibility (e.g., I blame myself for something I did, thought, or felt), violation of personal standards (e.g., I did something that went against my values), the lack of justification (e.g., scoring low on the item If I knew today only what I knew when the event occurred, I would do exactly the same thing), and a general distress factor (e.g., What happened causes me emotional pain). In initial psychometric evaluations the TRGI showed strong evidence of internal consistency and temporal stability and subsequently demonstrated strong convergent validity among combat veterans and domestic violence survivors (Kubany et al., 1996). The TRGI is a widely used measure of trauma-related guilt cognitions.

The Internalized Shame Scale (ISS; Cook, 1987, 1994, 2001) is a widely used, 30-item self-report inventory of trait shame designed for use in both clinical and research settings. Twenty-four items measure trait shame (or internalized shame), and 6 items measure general self-esteem, which is believed to negatively correlate with shame. The measure has demonstrated strong internal consistency and high temporal stability (del Rosario & White, 2006; Rybak & Brown, 1996). The ISS originated in the field of treatment for alcohol use problems but since has expanded broadly and been used in a wide range of clinical samples including individuals with trauma experiences and PTSD (e.g., Beck et al., 2011; Crocker et al., 2016).

The Trauma-Related Shame Inventory (TRSI; Øktedalen et al., 2014) is another contemporary measure of dispositional shame, specifically organized around the experience of a trauma. The 24-item measure includes two subscales distinguishing between internal shame, wherein the shame derives from the self, and external shame, in which the shame is experienced as coming from another. Respondents indicate how true each statement is for them on a 4-point Likert scale ranging from not true of me to completely true of me. Example items include I am ashamed of myself because of what happened to me (internal shame) and If others knew what happened to me, they would be disgusted with me (external shame)." Initial validation efforts demonstrated strong construct validity and convergent validity (Øktedalen et al., 2014), suggesting that the TRSI may be a promising measure for further evaluation and for the assessment of trauma-specific shame experiences.

The Tests of Self-Conscious Affect (TOSCA; Tangney, Wagner, & Gramzow, 1989) are a battery of self-report questionnaires for assessing dimensions of self-conscious emotions, including guilt, shame, blame, and pride. Now in the third iteration (TOSCA-3; Tangney et al., 2000), the format is similar to its original conception: respondents read a series of brief scenarios that might occur as part of one’s daily life and then rate on a 5-point scale how likely it is that they would react in the manner given, with the aim of determining the frequency or proneness of experiencing the given emotion. The original TOSCA was designed for use with adults, but additional versions have been developed for use with children aged 8–12 (TOSCA-C; Tangney, Wagner, Burggraf, Gramzow, & Fletcher, 1990) and adolescents aged 12–20 (TOSCA-A; Tangney, Wagner, Gavlas, & Gramzow, 1991). Psychometric evaluation of the TOSCA supports the distinction between shame and guilt as separate constructs with clinically relevant implications (e.g., Luyten, Fontaine, & Corveleyn, 2002; Watson, Gomez, & Gullone, 2016).

Sadness

As the cardinal emotion associated with depressive disorders, sadness is an important emotion to consider in the context of PTSD. Epidemiological research suggests that the rate of co-occurring major depressive disorder (MDD) among individuals with PTSD is high, with 42.8% of those diagnosed with PTSD also meeting criteria for comorbid MDD in the National Comorbidity Survey Replication (Rojas, Bujarski, Babson, Dutton, & Feldner, 2014). In a nationally representative sample of adolescents, there was a substantial gender difference, with 47.3% of boys with PTSD and 70.6% of girls with PTSD also meeting criteria for co-occurring MDD (Kilpatrick et al., 2003). Although sadness is a prominent affect in MDD, it is not necessary or sufficient to warrant a diagnosis. Thus an assessment of MDD symptoms may not provide the clinician or researcher with a clear sense of the respondent’s experience of sadness itself. Sadness is important to assess in the context of PTSD, as it may be particularly prominent when the traumatic event involved a significant loss (Dalgleish & Power, 2004). Many measures of depression include questions querying sadness (e.g., the Beck Depression Inventory, revised; Beck, Steer, & Brown, 1996), but scales of basic emotions would provide a more efficient way to assess this affective experience if that is the goal.

Sadness is sometimes assessed during trauma script-driven imagery tasks that investigate brain regions that correspond to different emotional experiences (Liberzon & Martis, 2006 provide a review). The PANAS (Watson et al., 1988) has been published in three versions. The original PANAS is a 20-item measure where each item specifies a distinct emotion and respondents are asked to indicate the extent to which they have felt that emotion in the past week. While both positively valenced (e.g., interested, alert, excited, and proud) and negatively valenced (e.g., distressed, upset, guilty, and irritable) emotions are included, there is not an item specifying sad on the original version of the PANAS nor on the 10-item PANAS-Short Form (Thompson, 2007). The expanded, 60-item version of the PANAS (PANAS-X; Watson & Clark, 1999), however, includes a scale assessing sadness that is composed of 5 items (i.e., sad, blue, downhearted, alone, and lonely). There are 11 scales on this version of the PANAS that cover 4 negative emotions (fear, hostility, and guilt, in addition to sadness) and 3 positive emotions (joviality, self-assurance, and attentiveness). There are also four other scales assessing shyness, fatigue, serenity, and surprise (Watson & Clark, 1999). While the PANAS and PANAS-SF will provide scores of general negative affect, they will not permit the assessment of sadness in particular; the PANAS-X would be required for this.

Negative and positive affect

The International Affective Picture System (IAPS; Lang, Bradley, & Cuthbert, 1997; Lang, Bradley, & Cuthbert, 2008) offers an alternative way to assess negative affect broadly defined. This assessment method involves presenting participants with emotionally evocative or neutral images and rating their responses on three dimensions: valence, arousal, and dominance (Lang et al., 1997). Participants are asked to view a subset of images for a given amount of time, and their emotional reaction is recorded. The IAPS currently includes 956 images (Lang et al., 2008), each of which is categorized by the emotional valence it is designed to evoke, including positive images (e.g., a woman on a beach; IAPS #4200), neutral images (e.g., a basket; IAPS #7010), and negative images (e.g., a burn victim; IAPS #3100; Lang & Bradley, 2007). Responses to the images have been normed in samples of college students in the United States (Lang et al., 2008), children (aged 7–9, 10–12, and 13–14; Lang et al., 1997), and older adults (Grühn and Scheibe, 2008) and internationally (e.g., Deák, Csenki, & Révész, 2010; Lasaitis, Ribeiro, & Bueno, 2008). There are several methods available for evaluating participants’ reactions to the IAPS, the most common being the Self-Assessment Manikin (SAM; Bradley & Lang, 1994), which allows individuals to rate the valence of their emotion, their arousal, and the dominance of their emotion using a series of figures. Alternatively, researchers have also used facial electromyography, skin conductance, and heart rate to evaluate emotionality, arousal, and attention. Still, others have measured reactions using fMRI (e.g., McLaughlin et al., 2014; van Rooij et al., 2015; van Rooij, Kennis, Vink, & Geuze, 2016). Several studies using the IAPS have found that, in response to emotionally evocative stimuli, individuals with PTSD demonstrate greater negative emotionality and blunted positive emotionality when compared with controls (e.g., Amdur, Larsen, & Liberzon, 2000; Wolf, Miller, & McKinney, 2009).

The IAPS uniquely offers a method of experimentally eliciting emotions to assess a wide range of emotion-related constructs. Within the PTSD literature alone, the IAPS has been used to assess a number of emotion-related constructs believed to be central to the conceptualization of PTSD. Specifically, some studies have assessed numbing and heightened negative emotional reactivity, whereas others have used the IAPS to evaluate the neural correlates of positive and negative emotional responses in individuals with PTSD (e.g., McLaughlin et al., 2014; van Rooij et al., 2015, 2016). Still, others have used the images to elicit particular negative emotions to evaluate emotion regulation (Shepherd and Wild, 2014). Some researchers have even used the IAPS as a trauma analogue in healthy controls (e.g., Krans, Reinecke, Jong, Näring, & Becker, 2012; Oulton, Takarangi, & Strange, 2016). Overall the IAPS offers an experimental assessment method that may provide qualitatively different information relative to self-report measures for a variety of constructs.

In addition to the array of negatively valenced affective states we have described and that are often associated with PTSD, a disorder that loads heavily on measures of negative affect, it may also be important in some contexts to assess the experience of positive affect in individuals with PTSD. Research has suggested that positive affect and negative affect do not necessarily reflect opposite ends of the same spectrum. Rather, they seem to be orthogonal bipolar dimensions on which meaningful variability may be observed (Tellegen, Watson, & Clark, 1999). Research suggests the capacity for positive emotion is hindered in major depressive disorder (MDD) to a greater extent than in PTSD. Individuals with co-occurring PTSD and MDD show similar levels of negative affect to those with PTSD alone but lower levels of positive affect, suggesting that negative affect may be a shared factor between the two diagnoses, while suppressed positive affect may be more unique to MDD (Post, Zoellner, Youngstrom, & Feeny, 2011). The capacity for positive affect seems to relate to reward function, or one’s ability to derive enjoyment from activities or experiences, the flip side of anhedonia (Nawijn et al., 2015), and anhedonia may be one of the most deleterious aspects of PTSD. In the absence of rewarding activities to motivate behavior, a person with PTSD may have little incentive to overcome avoidance and isolation. Thus, in addition to ratings of negative affective states and of anhedonia specifically, there may be value in measuring one’s capacity for positive emotion. The various forms of the PANAS each offer a broad scale reflecting positive affect. Depending on the level of granularity desired, the short form offers a quick method to assess a few aspects of positive emotion, whereas the PANAS-X includes three separate component scales loading on the broad positive emotion factor (Watson & Clark, 1999).

Emotion-related processes

In addition to the assessment of key affective dimensions that are related to PTSD, researchers and clinicians have found benefit in assessing several emotion-related processes that also have relevance to PTSD. These largely reflect constructs that are thought to function as trait-like individual difference variables that may influence vulnerability to PTSD following exposure to a traumatic event. In each case, we provide a brief description of the construct and recommend assessment instruments that have been supported by the literature. A summary of measures assessing these emotion-related processes appears in Table 2.

Table 2

Alexithymia

Alexithymia is an emotional deficit made up of four primary features: difficulty identifying, naming, describing, and/or expressing emotions and feelings; difficulty distinguishing between emotions or feelings and bodily or physical sensations; difficulty with symbolism that manifests as an inability to experience, describe, or express fantasies and dreams; and a marked focus on external events as opposed to internal events or an inclination toward thinking externally as opposed to internally (Taylor, 1984). These deficits are known to interfere with treatment. The loss of introspection can result in reduced engagement for the client and difficulty for the clinician, while the confusion of feelings for physical symptoms can result in medical help seeking instead of psychological (Taylor, 1984). In the context of PTSD, posttraumatic alexithymia has specifically been defined as difficulty identifying, expressing, or regulating one’s responses to traumatic events, resulting in either not knowing what one is feeling or not feeling anything at all (Frewen, Pain, Dozois, & Lanius, 2006).

Most of the literature regarding alexithymia has evaluated this construct using the 20-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994; Bagby, Taylor, & Parker, 1994). This self-report scale includes items rated on a 5-point scale (i.e., 1 = strongly disagree and 5 = strongly agree) that can be factored into three subscales: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking, all key elements of alexithymia. Psychometric evaluations of the TAS-20 have demonstrated adequate internal consistency and test-retest reliability for the overall measure and subscales (Bagby, Parker, & Taylor, 1994). With regard to construct validity, there is evidence of convergent, discriminant, and concurrent validity (Bagby, Taylor, & Parker, 1994). As evidence of convergent validity, the TAS-20 has been found to be negatively related to openness to experience (in particular, openness to feelings; r = −  0.49) and positively related to negative affect (r = 0.27). With regard to discriminant validity, the TAS-20 has been found to be unrelated to personality traits such as agreeableness (r = −  0.09), conscientiousness (r = 0.21), or sensation-seeking (r = 0.07). Evidence of concurrent validity was evaluated by comparing scores with clinician ratings based on two subscales of the 17-item interviewer-rated Beth Israel Hospital Psychosomatic Questionnaire (BIQ; Sifneos, 1973): affect awareness (r = 0.53) and operatory thinking (r = 0.48). Total and subscale scores on the TAS-20 were significantly correlated to clinician ratings on both BIQ subscales. Note, however, that Marchesi, Ossola, Tonna, and De Panfilis (2014) found evidence that scores on the TAS-20 are highly sensitive to an individual’s current level of distress, which may indicate that it is a measure of negative affect rather than alexithymia. Given the dearth of alternative measures of alexithymia, however, the TAS-20 is recommended for use with caution and awareness of this limitation.

Anhedonia/numbing

In the era of DSM-IV, PTSD diagnoses included an avoidance and numbing symptom cluster, which included items that specifically targeted both effortful avoidance and emotional numbing (conceptualized as a dampening of emotional responsiveness). In DSM-5, these criteria were restructured such that effortful avoidance appears as an independent criterion, and three items regarding emotional numbing (i.e., markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and persistent inability to experience positive emotions) are now included as part of the negative alterations in cognition and mood symptom cluster. This cluster also includes items referring to a broad range of emotions, including shame, guilt, fear, anger, and horror.

Of the emotional numbing symptoms, anhedonia is particularly important to assess. It reflects a loss of interest in activities that one previously enjoyed and/or a loss of pleasure derived from those activities. Although this is not unique to PTSD (anhedonia plays a large role in depressive disorders as well), it appears to be a particularly deleterious aspect of PTSD and has been linked to the social isolation that goes along with PTSD (Nawijn et al., 2015). The converse of anhedonia has been described as reward function, a construct that has only received attention in the context of PTSD in recent years.

A recent article by Nawijn et al. (2015) provided an exhaustive review of measures of reward function or anhedonia that have been used in the context of PTSD, including both self-report and lab-based measures. Additionally, a review by Rizvi, Pizzagalli, Sproule, and Kennedy (2016) evaluated measures of anhedonia in the context of depression. Both of these reviews recommended the Snaith-Hamilton Pleasure Scale (SHAPS; Snaith et al., 1995) as the gold standard for assessing anhedonia. The SHAPS is a 14-item questionnaire with item responses ranging from strongly agree to strongly disagree. The original scoring rubric entailed assigning scores of 1 for item responses of disagree or strongly disagree and values of 0 for agree and strongly agree (Snaith et al., 1995), with total scores ranging from 0 to 14. However, in some research, authors report scoring items on a 4-point scale from 1 to 4 with definitely agree rated 1 and definitely disagree rated 4 (e.g., Franken, Rassin, & Muris, 2007; Langvik & Borgen Austad, 2019). In both scoring scenarios, higher scores are suggestive of a greater degree of anhedonia. Psychometric analyses suggest that the SHAPS is a reliable and valid measure of anhedonia, showing a pattern of correlations suggestive of convergence with measures of anhedonia and depression and discrimination from measures of positive affect and life satisfaction (Franken et al., 2007). Interestingly, however, the magnitude of all of these correlations was fairly modest. In a sample of smokers, the SHAPS showed statistically significant positive correlations with each facet of PTSD, but somewhat surprisingly the correlation with emotional numbing (r = 0.25; P < .01) was in the same range as the correlations between the SHAPS and other symptom clusters (Mathew, Cook, Japuntich, & Leventhal, 2015). In a sample of combat-exposed veterans, those who met criteria for PTSD had a significantly higher mean score on the SHAPS relative to combat-exposed controls (Yuan et al., 2018). The psychometric properties of the SHAPS have not been explored in samples of individuals with PTSD, but have been found to be strong in samples of individuals with depression and nonclinical samples (Franken et al., 2007; Langvik & Borgen Austad, 2019).

Frewen et al. (2012) speculated that anhedonia in PTSD may reflect a more complex emotional process than has typically been observed and conceptualized. They identified negative affective interference as a construct that occurs in individuals with PTSD, wherein not only the experience of positive emotion is blunted (i.e., a hedonic deficit) but also negative emotional states are elicited by ostensibly positive stimuli and the negative emotion preempts the positive affective state. These authors developed a measure that attempts to capture this complex combination of emotional states. The Hedonic Deficit and Interference Scale (HDIS; Frewen et al., 2012) includes 21 items rated on an 11-point scale. Five of the items assess positive emotionality, 5 assess hedonic deficits (difficulty experiencing positive emotions), and 11 items assess interference of negative affect in the context of positive events. The HDIS subscales showed good evidence of internal consistency in the PTSD group (α ranged from 0.85 to 0.93 for the three subscales). Interestingly, in the non-PTSD group, the internal consistency for negative affect interference was weak (α = 0.56) although the other two subscales appeared to show adequate internal consistency (α = 0.84 and 0.85). Regarding validity, the HDIS showed a pattern of correlations demonstrating convergence with other self-report measures of anhedonia. In fMRI analyses the three subscales of the HDIS showed differential correlations with neural activity, suggesting that negative affective interference may reflect a different neurological substrate than hedonic deficits (Frewen et al., 2012).

Anxiety sensitivity

Anxiety sensitivity has received considerable attention in the literature on anxiety disorders and trauma-related disorders. Anxiety sensitivity is conceptualized as a fear of anxiety-related symptoms due to catastrophic expectations and is thought to contribute to the development and maintenance of anxiety disorders (Reiss, 1991) and PTSD (Marshall, Miles, & Stewart, 2010). Specifically, numerous studies have demonstrated the relevance of anxiety sensitivity to PTSD across a variety of populations (see Olatunji & Wolitzky-Taylor, 2009) Anxiety sensitivity is conceptualized as a dimensional variable with three components: fear of somatic concerns, cognitive dyscontrol, and fear of socially observable symptoms (Wheaton, Deacon, McGrath, Berman, & Abramowitz, 2012). In a sample of trauma-exposed patients with substance use disorders, anxiety sensitivity was correlated with PTSD severity. This study used the trauma script-driven paradigm and found that anxiety sensitivity was correlated with postscript negative affect ratings but not with postscript ratings of cravings for substances (McHugh, Gratz, & Tull, 2017), suggesting that anxiety sensitivity may play a role in the amplitude of fear and anxiety responses exhibited by individuals with PTSD in response to trauma-related