Positive emotion in posttraumatic stress disorder: A global or context-specific problem?

Problems with positive emotion are an important component of posttraumatic stress disorder (PTSD), with competing perspectives as to why. The global model suggests that people with PTSD experience a relatively permanent shift in their capacity for positive emotion regardless of context, whereas the context-specific model posits access to the full repertoire of positive emotion that only becomes reduced during exposure to trauma reminders. We tested the global versus context-specific models using ecological momentary assessment (EMA). Trauma-exposed adult community members (N = 80) with (n = 39) and without diagnosed PTSD completed 3 days of EMA (n = 2,158 observations). Participants with PTSD reported lower average momentary levels of positive emotion, B = -0.947, 95% CI [-1.35, -0.54], p < .001, and positive situations, B = -0.607, 95% CI [-1.16, -0.05], p = .032, and more thinking about trauma reminders, B = 0.360, 95% CI [0.21, 0.51], p < .001. There was no between-group difference in positive emotion reactivity (degree of positive emotion derived from positive situations), B = 0.03, 95% CI [-0.09, 0.14], p = .635. Increased thinking about trauma reminders predicted lower momentary levels of positive emotion, B = -0.55, 95% CI [-0.83, -0.26], p < .001, but not reactivity, B = 0.02, 95% CI [-0.35, 0.40], p = .906, irrespective of PTSD status. Findings supported the global model and were inconsistent with the context-specific model. This study helps clarify positive emotional functioning in trauma-exposed adults and highlights future directions to better understand problems with positive emotion in PTSD.

Effects of trauma-focused rumination among trauma-exposed individuals with and without posttraumatic stress disorder: An experiment.

Rumination, or thinking repetitively about one's distress, is a risk factor for posttraumatic stress disorder (PTSD). Current theories suggest that rumination contributes to PTSD symptoms directly, by increasing negative reactions to trauma cues (i.e., symptom exacerbation), or represents a form of cognitive avoidance, if verbal ruminations are less distressing than trauma imagery. The goal of this study was to test the symptom exacerbation and cognitive avoidance accounts of trauma-focused rumination. We recruited 135 trauma-exposed participants (n = 60 diagnosed with PTSD) and randomly assigned them to ruminate about their trauma, distract themselves, or engage in trauma imagery. For individuals with and without PTSD, rumination led to larger increases in subjective distress (i.e., negative affect, fear, sadness, subjective arousal, valence) than distraction, ηp 2 s = .04-.13, but there were no differences between rumination and imagery ηp 2 s = .001-.02. We found no evidence that rumination or imagery elicited physiological arousal, ds = 0.01-0.19, but did find that distraction reduced general physiological arousal, as measured by heart rate, relative to baseline, d = 0.84, which may be due to increases in parasympathetic nervous system activity (i.e., respiratory sinus arrhythmia), d = 0.33. These findings offer no support for the avoidant function of rumination in PTSD. Instead, the findings were consistent with symptom exacerbation, indicating that rumination leads directly to emotional reactivity to trauma reminders and may be a fruitful target in PTSD intervention.

Understanding internalizing and externalizing symptoms in trauma exposed community members.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is highly comorbid with internalizing and externalizing symptoms, but few studies have examined risk factors that can account for these comorbidities. The primary aim of this study is to investigate the role of blame attribution (i.e., self-blame and other blame) and impulsivity dimensions (i.e., negative and positive urgency) in predicting internalizing (i.e., social anxiety, depression, and worry) and externalizing symptoms (i.e., aggression, risky thrill-seeking, risky substance use, and sexual risk-taking) when statistically controlling for PTSD. METHOD: Participants were 63 trauma-exposed community members (47.6% diagnosed with PTSD; Mage = 27.17, 84.1% female) interviewed using the Clinician-Administered PTSD Scale-5. We hypothesized that self- and other blame would predict internalizing symptoms and that self-blame, negative urgency, and positive urgency would predict externalizing symptoms after controlling for PTSD. RESULTS: Findings showed that self-blame was associated with all three internalizing symptoms and risky sex and that negative urgency predicted risky aggression. CONCLUSION: This study provides evidence that self-blame is an important risk factor for a broad range of internalizing symptoms and for at least one type of externalizing symptom and that the effects of self-blame are not fully explained by PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Posttraumatic stress disorder-related anhedonia as a predictor of psychosocial functional impairment among United States veterans.

Prior research suggests that anhedonia symptoms related to posttraumatic stress disorder (PTSD; i.e., diminished interest, detachment from others, and difficulty experiencing positive emotions) are consistently associated with a higher degree of impairment in psychosocial functioning beyond that associated with other PTSD symptoms. Unfortunately, much of this research has used cross-sectional study designs; relied upon outdated DSM diagnostic criteria; and failed to control for potentially confounding variables, such as the presence of co-occurring depression. This study used data from Waves 2 and 4 (n = 1,649) of the Veterans' After-Discharge Longitudinal Registry (Project VALOR), a longitudinal dataset of U.S. Army and Marine veterans. As measured using the Inventory of Psychosocial Functioning, Wave 4 psychosocial functioning was regressed on seven PTSD symptom factors at Wave 2 (i.e., intrusions, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal) and potential Wave 2 confounds. The Anhedonia factor, ß = .123, most strongly predicted later psychosocial functional impairment beyond the impact of other PTSD symptom factors, ßs = -.076-.046. Clinical implications of these findings are also discussed.

Reward Processing and Decision-Making in Posttraumatic Stress Disorder.

Theory suggests that, in those with posttraumatic stress disorder (PTSD), positive emotion is likely dampened due to reexperiencing of trauma-related stimuli. Prior research has extended positive emotion experiencing to reward processing research but has not yet examined how trauma cues affect reward processing (i.e., the anticipation of and satisfaction with reward) and decision-making in individuals with PTSD. We compared 24 individuals diagnosed with PTSD to 29 trauma-exposed controls in passive and decision-making phases of a wheel-of-fortune task, following both neutral and trauma inductions. Three types of spinners were used in the task: spinners that were obviously advantageous spinners, obviously disadvantageous spinners, and ambiguously advantageous spinners with outcomes averaging to a net gain. We hypothesized that the PTSD group would report lower reward expectation and lower outcome satisfaction and make less advantageous decisions, differences that would be exacerbated following a trauma prime. The PTSD group reported lower reward expectation than controls for the ambiguous spinners only, suggesting that the reduced anticipation of reward associated with PTSD may be specific to ambiguous stimuli. Reward expectation was not affected by the type of prime. Outcome satisfaction was not affected by PTSD or type of prime. Although only marginally significant, the PTSD group played the ambiguous spinners less often than controls, and played the obviously disadvantageous spinners significantly less often than controls, suggesting that those with PTSD are more aversive to loss. Our findings suggest that PTSD-related deficits are more robust for reward expectation than outcome satisfaction, and support future research examining the role of reward-related decision-making in PTSD.

Moral injury in U.S. combat veterans: Results from the national health and resilience in veterans study.

BACKGROUND: Combat exposure is associated with increased risk of mental disorders and suicidality. Moral injury, or persistent effects of perpetrating or witnessing acts that violate one's moral code, may contribute to mental health problems following military service. The pervasiveness of potentially morally injurious events (PMIEs) among U.S. combat veterans, and what factors are associated with PMIEs in this population remains unknown. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary and nationally representative survey of a population-based sample of U.S. veterans, including 564 combat veterans, collected September-October 2013. Types of PMIEs (transgressions by self, transgressions by others, and betrayal) were assessed using the Moral Injury Events Scale. Psychiatric and functional outcomes were assessed using established measures. RESULTS: A total of 10.8% of combat veterans acknowledged transgressions by self, 25.5% endorsed transgressions by others, and 25.5% endorsed betrayal. PMIEs were moderately positively associated with combat severity (ß = .23, P < .001) and negatively associated with white race, college education, and higher income (ßs = .11-.16, Ps < .05). Transgressions by self were associated with current mental disorders (OR = 1.65, P < .001) and suicidal ideation (OR = 1.67, P < .001); betrayal was associated with postdeployment suicide attempts (OR = 1.99, P < .05), even after conservative adjustment for covariates, including combat severity. CONCLUSIONS: A significant minority of U.S combat veterans report PMIEs related to their military service. PMIEs are associated with risk for mental disorders and suicidality, even after adjustment for sociodemographic variables, trauma and combat exposure histories, and past psychiatric disorders.

Defining trauma: How level of exposure and proximity affect risk for posttraumatic stress disorder.

OBJECTIVE: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes significant changes to Criterion A for posttraumatic stress disorder (PTSD), the criterion that defines which events qualify as "traumatic." This systematic review explores the fundamental question of how to define a trauma by reviewing the difference between direct and indirect trauma exposure and the risk for PTSD associated with both exposure types. Direct exposure includes experiencing a trauma firsthand or witnessing a trauma as it occurs to others. In contrast, indirect exposure may occur by learning about the violent or accidental death of a close associate, through secondary narrative accounts (e.g., in service-related professions), or through work-related media reports. This review examines whether indirect trauma exposure can lead to PTSD and the role of proximity in symptom development. METHOD: We conducted a systematic review of the research assessing changes to PTSD Criterion A in DSM-5, various levels of traumatic exposure, and proximity as a risk factor for PTSD. RESULTS: Our review indicates that indirect exposure can lead to PTSD, although the probability of developing the disorder from indirect exposure is lower than that from direct exposure. Proximity to a trauma also increases risk, but this may be limited to direct exposure. CONCLUSIONS: Knowledge of the impact of level of exposure (direct vs. indirect) and proximity will help to better define what events meet PTSD Criterion A. Future research is needed to examine DSM-5's requirement that exposure through media must be related to one's work.