Positive Emotion Dysregulation in Posttraumatic Stress Disorder

Highlights

• PTSD patients show more dampening of positive emotions than healthy controls (HC).

• PTSD patients show less rumination in response to positive emotions than HC.

• Dysregulation of positive emotions is associated with PTSD symptom severity.

Abstract

Although PTSD is associated with both emotion regulation (ER) difficulties and persistent difficulties experiencing positive emotions, research concerning positive ER in PTSD is still scarce. We aimed to clarify whether PTSD patients show dysfunctional responses to positive emotions and whether positive ER is associated with PTSD symptom severity.

PTSD patients (N = 59) were compared to healthy controls (HC, N = 58) with respect to their self-reported regulation of positive and negative emotions. We used the Responses to Positive Affect Questionnaire to assess positive ER and the Difficulties in Emotion Regulation Scale and Response Styles Questionnaire to assess negative ER.

PTSD patients showed deficient negative as well as deficient positive ER as compared to HC. Both dampening of positive emotions as well as positive rumination were associated with self-reported symptom severity. Furthermore, dampening contributed to the prediction of PTSD symptom severity beyond depressive symptoms and negative rumination.

This study supports and expands previous findings of dysfunctional positive ER in PTSD. Further research is needed to clarify whether deficits in positive ER contribute to the onset and maintenance of PTSD. If so, therapeutic approaches should aim to help PTSD patients build up adequate skills to handle positive emotions in PTSD.

Introduction

In recent years, research in the context of Posttraumatic Stress Disorder (PTSD) has increasingly focused on emotion regulation (ER), i.e., individuals’ ability to influence what emotions they have, when they have them, and how they experience and express these emotions (Gross, 2014). ER difficulties have been discussed as a risk factor for the development and maintenance of PTSD (Badour and Feldner, 2013, Bardeen et al., 2013, Guerra and Calhoun, 2011). Research suggests that the ways in which trauma-exposed individuals handle challenging emotions may predict PTSD symptom severity even better than the trauma itself (Barlow, Goldsmith Turow, & Gerhart, 2017). For example, non-acceptance and suppression of negative emotions (Ehring & Quack, 2010), as well as a lack of effective strategies to regulate negative emotions (Tull, Barrett, McMillan, & Roemer, 2007), have been linked to the severity of PTSD symptoms. Furthermore, rumination, i.e., the tendency to repetitively think about negative experiences, their causes, and their consequences (Nolen-Hoeksema, 1991), has repeatedly been associated with PTSD symptoms (Ehring et al., 2008, Michael et al., 2007). Interestingly, a recent study found that negative rumination fully accounts for the relationship between other ER difficulties and PTSD (Pugach, Campbell, & Wisco, 2020). Pugach et al. (2020) suggest that trauma-exposed individuals engage in rumination to resolve and understand the distress they experience because they have difficulties regulating their emotional responses otherwise. Overall, these findings suggest that ER may be a relevant mechanism that potentially increases vulnerability for PTSD symptoms. In accordance with this assumption, it has been shown that an improvement in ER ability is associated with symptom reduction during PTSD treatment (Cloitre et al., 2002, Price et al., 2006).

However, research to date has focused almost exclusively on the regulation of negative emotions (Seligowski, Lee, Bardeen, & Orcutt, 2015). Short, Boffa, Clancy, and Schmidt (2018) remark that this may be due to the fact that “psychopathology such as PTSD is characterized by persistent negative emotions” (p. 77). Yet the DSM-5 also emphasizes a persistent difficulty experiencing positive emotions in the symptom profile of PTSD (American Psychiatric Association, 2013). Furthermore, there is growing evidence that a PTSD diagnosis and symptom severity are linked with diminished positive affect and emotional numbing (Etter et al., 2013, Feeny et al., 2000, Hopper et al., 2008, Kashdan et al., 2006). Accordingly, neuroimaging studies have revealed alterations in the processing of positive emotions in PTSD patients, including abnormal functioning of reward neurocircuitry. These alterations might reflect neuronal correlates of posttraumatic emotional numbing (Fonzo, 2018, Frewen et al., 2010, Jatzko et al., 2006). Moreover, diminished positive affect in PTSD is associated with poor clinical outcomes, for example, more severe symptoms (Feeny et al., 2000), poorer quality of life (Forbes et al., 2019), increased suicidal ideation (Guerra & Calhoun, 2011), and less response to cognitive-behavioral treatment (Taylor et al., 2001). Thus, a better understanding of positive ER in PTSD is needed.

Although numerous studies have indicated that difficulties with negative ER as well as positive ER constitute a risk factor for emotional disorders in general, hardly any studies have investigated positive ER in the context of PTSD (Buhk et al., 2020, Carl et al., 2013, Gruber, 2011, Raes et al., 2012). Studies that do exist in this context have examined associations between positive ER and different clinical outcomes in trauma-exposed individuals; however, these individuals were not diagnosed with PTSD. For example, Weiss, Dixon-Gordon, Peasant, and Sullivan (2018) reported that higher levels of non-acceptance of positive emotions as well as difficulties engaging in goal-directed behavior and controlling impulsive behavior when experiencing positive emotions are associated with more severe PTSD symptoms in general and DSM-IV symptom clusters in particular (re-experiencing, avoidance/emotional numbing, and hyperarousal). These relations were not accounted for by the variance of difficulties regulating negative emotions (Weiss, Nelson, Contractor, & Sullivan, 2019). Furthermore, traumatized individuals who have greater difficulties regulating positive and negative emotions show higher levels of depressive symptoms and alcohol/drug misuse than individuals displaying fewer ER difficulties. Again, this was not accounted for by difficulties regulating negative emotions only (Weiss et al., 2020, Weiss et al., 2018). Several different theories could explain the associations between positive emotion dysregulation and PTSD symptoms. Firstly, it has been suggested that positive emotions might be aversive for some individuals with PTSD due to the arousal associated with these emotions. Arousal may function as a trauma-related trigger (Weiss et al., 2018, Weiss et al., 2020) and might therefore be avoided, leading to maladaptive positive ER. Secondly, the contrast avoidance model of worry proposes that individuals with generalized anxiety disorder fear negative emotional contrasts, i.e., experiencing unpleasant affective states following pleasant affective states (Newman & Llera, 2011). Thus, they engage in ER strategies that maintain negative affect to avoid experiencing sharp increases in negative emotions. Recent research suggests that the mechanisms highlighted by this model may also be applied to other affective and anxiety disorders (e.g., Rashtbari & Saed, 2020). Hence, trauma-exposed individuals may engage in dysfunctional positive ER to avoid negative emotional contrasts and sudden symptom increases, thereby gaining control over their symptoms. A third explanation for positive emotion dysregulation in PTSD could be the regulatory goal that determines ER direction, for example, experiencing affective states that are familiar and that verify the sense of self. Research on depression has shown that depressed individuals tend to maintain unpleasant feelings by using ER strategies that are congruent with their current negative affect and that validate pessimistic thoughts as part of their identity (Millgram et al., 2015, Vanderlind et al., 2020). Similarly, individuals suffering from PTSD may be less motivated to increase positive mood and might aim to maintain unpleasant but familiar and self-confirming affective states. In sum, following these theories, one would expect patients with PTSD to attempt to down-regulate positive emotions and to avoid up-regulating positive emotions (e.g., by engaging less in ruminative thoughts about positive experiences). However, these assumptions have not yet been tested in PTSD samples.

Taken together, earlier studies support the assumption that positive ER is impaired in PTSD. However, research specifically investigating responses to positive emotions in patients diagnosed with PTSD is still lacking. The main goal of this study was to gain a better understanding of how individuals with PTSD handle positive emotions as compared to healthy controls. We hypothesized that patients suffering from PTSD show more down-regulation of positive emotions, i.e., dampening, and less up-regulation of positive emotions, i.e., positive rumination, as compared to healthy controls. In line with previous findings, we also assumed that PTSD patients show more deviant regulation of negative emotions as compared to healthy controls. The current study further aimed to explore whether PTSD symptom severity is associated with deviations in positive ER – both for the overall PTSD symptom severity as well as for the symptom clusters according to DSM-5. Lastly, we explored whether dampening of positive emotions and positive rumination contribute to the prediction of PTSD symptom severity beyond two of the best-known predictors of PTSD symptom severity, namely, depressive symptoms and negative rumination (Panagioti et al., 2012, Pugach et al., 2020, Rytwinski et al., 2013).