An examination of the potential core symptoms of posttraumatic stress disorder: What is integral after removing general psychopathology & distress?

Many confirmatory factor analyses (CFA) have examined the structure of posttraumatic stress disorder (PTSD) with some suggesting increased complexity (i.e., 6+ factors), while others suggesting a more refined structure (i.e., 2-factors). These competing PTSD structures may be due to conflation of non-trauma specific symptoms that have been added overtime. However, none of these studies examined if all symptoms being examined are specific to PTSD or potentially more related to general distress and psychopathology. The current study re-evaluated the structure of PTSD using bifactor exploratory factor analysis (EFA) to identify the construct's core symptoms. Data for EFA models were taken from a sample of Veterans (N = 694) attending outpatient therapy for PTSD and were cross-validated using CFA in a sample of 297 Veterans attending residential treatment. Clinician Administered PTSD Scale for DSM-5 (CAPS-5) at pre-treatment was used across sample. Factor analyses resulted in a 2-factor, bifactor model comprised of eight total items. Model fit was robust, RMSEA = 0 [0.000, 0.036]; robust CFI = 1; robust TLI = 1.017. The bifactor analytic approach captured what might be the core structure of PTSD, which were pathognomonic symptoms of PTSD (Factor one). A distinct second factor related to depression was also found. In identifying this structure, the model eliminates redundancies and lesser performing items and differentiates depressive reactions as potentially distinct and separate. Overall, these findings may assist in future research of PTSD by determining the unique elements of the construct within a veteran sample versus associated features, general psychological distress, and comorbid psychopathology.

Shame as a Mediator in the Association Between Emotion Dysregulation and Posttraumatic Stress Disorder Symptom Reductions Among Combat Veterans in a Residential Treatment Program.

Emotion dysregulation (ED) can be defined as one's inability to effectively respond to and manage internal experiences and the expression of emotion. ED has been linked to the development and maintenance of posttraumatic stress disorder (PTSD), with recent research suggesting that reductions in ED may predict improved treatment outcomes among both civilian and veteran populations. However, few studies have examined how changes in ED may predict treatment outcomes among veterans with PTSD and whether certain core features of PTSD, such as shame, may act as potential mediators in the association between ED and PTSD symptom reductions. The present study sought to explore facets of ED, feelings of shame, and PTSD symptoms among 43 combat veterans upon their admission and discharge to a residential PTSD program. The results demonstrated that all variables of interest significantly decreased from admission to discharge, ds = 0.75-1.84. Correlations indicated that reductions in ED, R2 = .184, and shame, R2 = .228, were associated with reductions in PTSD symptoms. However, the association between reductions in ED and PTSD was significantly mediated by reductions in shame. Overall, these results suggest that higher levels of emotion regulation may partially affect PTSD symptoms through reductions in shame. This may explain the efficacy of frontline PTSD treatments, as they explicitly focus on the processing of one's traumatic experience by reducing PTSD symptoms through regulation techniques that target emotional-behavioral cycles, which may include the shame-withdraw cycle.

An experimental examination of interpersonal problem-solving in nonsuicidal self-injury: A pilot study.

Nonsuicidal self-injury (NSSI) typically occurs in the presence of negative emotions. Prior research has emphasized interpersonal stress as a specific context that may elevate negative emotions in this population and even increase the likelihood of NSSI behavior. However, the factors that contribute to the relationship between interpersonal stress and NSSI have received relatively limited attention. The current pilot study aimed to experimentally examine interpersonal problem-solving as a potential moderator of the interpersonal stress - NSSI risk relationship among those with a NSSI history. Eighty-six participants (52.3% with NSSI history) were randomly assigned to one of three mood induction conditions (interpersonal negative, general negative, interpersonal neutral), after which they completed an interpersonal problem-solving task and a laboratory analogue of self-injurious behavior. Results indicated that NSSI history was associated with poorer interpersonal effectiveness. Further, individuals with a history of NSSI who experienced an interpersonally-focused negative mood and produced less effective interpersonal solutions were more self-harming on a laboratory analogue of self-injurious behavior. While the present findings are preliminary in nature, they offer guidance for research moving forward and, if replicated, suggest interpersonal problem-solving as a potential treatment target among individuals engaging in NSSI.

Shame as a Moderator between Emotion Dysregulation and Posttraumatic Stress Disorder Severity among Combat Veterans Seeking Residential Treatment.

BACKGROUND: Growing evidence suggests that emotion dysregulation may be predictive of posttraumatic stress disorder (PTSD) severity, with emotional non-acceptance, lack of counter strategies, impulse control deficits, and lack of emotional awareness all being positive predictors. However, findings have been mixed. This may be due to no previous study examining the association between emotion dysregulation and PTSD severity with shame, a maintaining factor of PTSD, as a potential moderator. METHODS: The present study examined the relationship between emotion dysregulation, shame, and PTSD severity among 78 male combat veterans (mean age = 42.19) upon their admission to a residential combat PTSD program. RESULTS: Results demonstrated that shame and all facets of emotion dysregulation (except lack of emotional awareness & clarity) were positively associated with PTSD severity. Shame moderated the relationship between lack of emotional awareness and strategies. Among those at or below the sample mean on shame, lack of access to strategies was a positive predictor of PTSD severity. Comparatively, among those with high levels of shame, emotional awareness predicted greater PTSD severity, while among those with low levels of shame, emotional awareness predicted lower PTSD severity. LIMITATIONS: Limitations included reliance on self-report questionnaires and an all-male sample. CONCLUSIONS: Thus, emotion dysregulation may only predict PTSD severity among those reporting lower levels of shame, suggesting the importance of addressing shame as well as emotion dysregulation deficits among those with PTSD. Moreover, emotional awareness may be either a risk or protective factor depending on levels of shame.

Relationships between Non-Suicidal Self-Injury and Other Maladaptive Behaviors: Beyond Difficulties in Emotion Regulation.

Non-suicidal self-injury (NSSI) co-occurs with both other maladaptive behaviors (e.g., aggression) and emotion dysregulation. However, the extent to which these maladaptive behaviors are linked to NSSI independent of emotion dysregulation is unclear. The present study examined relationships between NSSI and six other maladaptive behaviors among university undergraduates. When controlling for demographic variables, emotion dysregulation, and other maladaptive behaviors, binge eating, purging, illicit drug use, and physical aggression were each related to lifetime NSSI history and/or severity. No maladaptive behaviors were significantly related to the presence of current diagnostic-level NSSI in these multivariate analyses. Results suggest that some maladaptive behaviors may relate uniquely to NSSI risk independent of emotion dysregulation, highlighting the importance of considering such behaviors in self-injury assessment and treatment.

The relationship between physiological reactivity to provocation and emotion dysregulation with proactive and reactive aggression.

Biological theories of aggression propose that autonomic nervous system (ANS) hypo-reactivity may be more specific to proactive aggression, whereas ANS hyper-reactivity may be specific to reactive aggression. However, the research findings in this area are mixed. Furthermore, no study to date has examined whether emotion dysregulation moderates the aggression - ANS relationship. The present study examined electrodermal activity (EDA), respiratory sinus arrhythmia (RSA) and heart rate (HR) reactivity in 76-undergraduate participants (29 men, mean age = 21.49) in response to a provocation task relative to baseline. Results showed that blunted HR reactivity was associated with increased proactive aggression. RSA augmentation and blunted EDA reactivity were both associated with increased proactive and reactive aggression, but only among those above the sample mean on emotion dysregulation. Thus, emotion dysregulation may play a key role in the relationship between ANS reactivity and both reactive and proactive aggression.

History of childhood abuse and alcohol use disorder: Relationship with intermittent explosive disorder and intoxicated aggression frequency.

Intermittent Explosive Disorder (IED), the only psychiatric diagnosis for which affective aggression is the cardinal symptom, is uniquely associated with both a history of childhood abuse and a diagnosis of an alcohol use disorder (AUD). Moreover, both childhood abuse and AUD are associated with increased general aggression and aggression while intoxicated. Yet, no study to date has examined the relative contributions of childhood abuse and AUD to IED, nor their effects on overall and intoxicated aggression among those with and without IED. The following study aimed to fill these gaps. Participants were 493 individuals (68% female; Age M = 26.65) either with (n = 265) or without (psychiatric control group; n = 228) IED. All participants completed a clinical interview to (a) diagnose AUD, IED, and other comorbid psychiatric disorders; (b) assess childhood abuse history; and (c) determine lifetime frequency of overall and intoxicated aggression. Results indicated that a history of childhood abuse, but not AUD status, was uniquely predictive of IED status. With regard to aggression frequency, IED, AUD and childhood abuse were all independently associated with overall aggression, although only those with IED showed increased intoxicated aggression as a function of AUD severity. Overall, these results suggest that a history of childhood abuse may increase the chances of engaging in overall aggression and developing IED, which in turn may increase the association between AUD severity and intoxicated aggression.

Age and Gender Effects in Recent Violence Perpetration.

Although we know much about the effects of violence on victims, we know less about individuals who perpetrate violence. In the present study, we used a large, nationally representative sample of adults (National Comorbidity Study-Replication; n = 9,282) to examine demographics (i.e., age and gender) and social, occupational, and cognitive functioning among perpetrators of recent violence. We found that recent violence was more prevalent among younger individuals and males (i.e., these groups were more likely to engage in at least one act of violence). Among those who did engage in violence, there was no effect of age or gender on violence frequency (i.e., number of violent acts engaged in over the past year). Furthermore, gender moderated the effect of age on recent violence prevalence, but not violence frequency. Finally, those reporting violence over the past year showed greater impairment in all examined domains of functioning, but there was no association between impairment and frequency of violence. This study represents one of the first attempts to utilize 12-month prevalence data to explore the lifetime trajectory of violence among those who perpetrate it, which seems to peak in young adulthood and then decrease across the life span. Furthermore, although males are more likely to engage in violence than females, adults who engage in at least one act of violence demonstrate no difference in frequency of yearly violent acts, regardless of gender. Finally, it is apparent that merely engaging in any acts of violence over the past year is associated with functioning problems. Overall, most significant differences emerged between those who do and do not engage in violence, which is key for informing violence risk assessment and prevention.

Emotion processing in intermittent explosive disorder.

Intermittent explosive disorder (IED), a disorder characterized by outbursts of affective aggression, is associated with deficits in regulating emotions. However, less is known about specific deficits in understanding and processing emotions in IED. This study sought to fill that gap by examining components of emotion processing (rumination, alexithymia, and empathy) in those with IED. Participants completed diagnostic interviews and self-report measures, and were categorized into three diagnostic groups: IED (n = 177), Psychiatric Control (PC; n = 171), and Healthy Volunteer (HV; n = 144). Those with IED reported more anger rumination and greater difficulty identifying their feelings than PC or HV participants. Interestingly, those with IED reported higher affective empathy scores than those in the HV group, with no other group differences on measures of empathy. Amongst those with IED, increased anger rumination and decreased sadness rumination predicted greater lifetime aggression, while increased sadness rumination predicted poorer quality of life. These findings suggest that although those with IED have a harder time recognizing their emotions, once they identify feeling angry, they spend more time focused this emotion than those with other disorders. These findings also suggest that cognitive intervention techniques may be beneficial for those with IED.

Negative urgency and reward/punishment sensitivity in intermittent explosive disorder.

UNLABELLED: Intermittent explosive disorder (IED) is the sole psychiatric diagnosis in which affective aggression is the cardinal symptom. Previous research has been equivocal with regard to the relationship between IED and impulsivity. This inconsistency may reflect the varied facets of impulsivity, with some aspects of impulsivity (e.g. negative urgency) as well as some overlapping, albeit distinct constructs (e.g. reward and punishment sensitivity) yet to be studied. METHODS: The present study compared individuals diagnosed with IED (n=81) with psychiatric controls (PCs; n=52) and healthy volunteers (HVs; n=58) on the impulsivity domains of negative and positive urgency, perseverance, sensation seeking, and premeditation, as well as on reward and punishment sensitivity. We hypothesized that individuals with IED would show greater negative and positive urgency, reward sensitivity, punishment sensitivity, with negative urgency independently predicting IED status. We also hypothesized that negative urgency would predict levels of anger, aggression, and aggression control among those with IED. RESULTS: The IED participants reported greater negative urgency than both comparison groups, and greater levels of positive urgency, reward sensitivity, and punishment sensitivity compared to HVs. Further, heightened negative urgency was the sole predictor an IED diagnosis. Within the IED group negative urgency uniquely predicted decreased aggression control and increased trait anger. LIMITATIONS: Limitations included reliance on self-report measures to assess RS/PS, impulsivity, and aggression. CONCLUSIONS: These findings suggest that negative urgency is a key factor associated with IED and is associated with dampened control of aggression within those with IED.

Defense styles in Intermittent Explosive Disorder.

The overreliance on immature and/or neurotic defense mechanisms, as opposed to more mature defensive functioning has been linked to several psychiatric disorders. However, to date, the role of defense styles among individuals with Intermittent Explosive Disorder (IED) has not been examined. Given that individuals with IED display difficulties controlling their anger and aggression, one might expect these individuals to exhibit more immature and less mature defense styles. The current study compared participants with IED to a personality disorder (PD) comparison group, as well as to healthy volunteers (HV) on the Defense Style Questionnaire, a self-report measure that assesses the extent to which individuals endorse using mature, immature, and neurotic defense styles. Subjects with IED had significantly higher scores than both comparison groups on immature defense styles and exhibited lower scores on mature defense mechanisms. Hierarchical regression of significant defense style subscales showed that higher levels of acting out and lower levels of sublimation uniquely discriminated participants with IED from the PD and HV comparison groups.