# Motivation and emotion/Book/2024/Post-traumatic stress disorder and emotion

* Multimedia presentation (3 min)

## Overview

* Figure 1. Prevalence and Intensity of PTSD flashback symptom
* Case study
* Harman, a 32 year old flight medic, completed two tours in Iraq and two in Yemen. After the honeymoon phase of returning home, he began experiencing increasing concentration difficulties, which resulted in heightened irritability, anger and frequent aggressive outbursts. Over time, these episodes worsened rendering him homebound, significantly sleep deprived which adversely affected his marriage. His wife is now insisting on therapy or considering divorce if he chooses not to pursue it.
This chapter examines the neurobiological, cognitive and behavioural mechanisms through which PTSD affects emotions. Illustrating how trauma disrupts emotional regulation and heightens emotional reactivity[grammar?]. The primary focus is on understanding how trauma impairs emotional control. To address these complexities, we must first understand the effect of PTSD-related trauma on the impacted brain regions and its influence on emotional processing.
* Focus questions
* What is Post Traumatic Stress Disorder?
* How does PTSD influence emotional regulation?
* How does PTSD influence cognitive changes that contribute to emotional dysregulation?
* What are the functions and changes in the brain associated with trauma and emotional regulation?

## What is post-traumatic stress disorder?

Post Traumatic Stress Disorder is a multifaceted psychiatric condition that is developed following exposure to traumatic events. These sorts of events involve exposure to actual or threatened death, serious injury or sexual violence eliciting intense emotions such as fear, helplessness or horror (Keane et al., 2006). PTSD is characterised by a broad spectrum of symptoms that influence cognitive function, behavioural mechanisms and physical sensations, often leading to chronic impairments and increased risk of re-occurring disorders, including a heightened vulnerability towards suicide (Mann et al., 2024).
According to the DSM-5 criteria, trauma is a fundamental component of PTSD. However, not all individuals exposed to trauma will experience the lasting mental health effects. For those with PTSD, trauma includes directly experiencing the event, witnessing it occur to someone else, or learning that someone close to them was affected by the traumatic event (Hyland et al., 2018)

## What is emotional regulation? =

Emotional regulation is an adaptive ability that manages and adjusts emotional responses to life's ongoing demands in a socially acceptable way. It involves flexibility, allowing for immediate emotional reactions or the ability to delay reactions when appropriate . Substantial evidence from human and animalistic studies support the idea that emotional dysfunction is a key factor leading to the development and maintenance of PTSD (Monsom et al., 2004). Failure in emotional regulation increases psychosocial and and emotional dysfunction caused by traumatic experiences due to the inability to regulate emotions.

## Linking PTSD and emotional regulation

The initial responses of trauma survivors are complex and highly influenced by the personal experiences of the individual[factual?]. Following a distressing event, engagement in various strategies to manage overwhelming negative emotions are common. These coping strategies allow individuals to modify the emotional experience of the stimulus and how it affects their cognitive performance (Hayes et al., 2012). Immediate emotional responses include exhaustion, confusion, anxiety, disassociation, hyperarousal and blunted effect[factual?]. Many of these distressing reactions are considered socially acceptable, psychologically adaptive and often self limiting (CSAT, 2014).
However, trauma can prolong responses increasing the severity[improve clarity]. Which often includes persistent distress with limited periods of calmness, severe dissociative symptoms and intrusive memories or flashbacks that persist despite the individual being in a safe environment (CSAT, 2014)[grammar?]. Severe responses may significantly disrupt an individual's cognitive functioning, impairing their ability to concentrate, make decisions or process information effectively. Often resulting in long-term emotional dysregulation, enabling emotions such as fear, anxiety and depressive symptoms difficult to manage[grammar?].
The detrimental impact of trauma is multifaceted, as it encompasses emotional regulation and cognitive functioning such as memory, attention and executive functioning. Trauma alters the brain processing of emotions and stress[grammar?]. Often resulting into chronic mental health conditions such as PTSD, anxiety and depressive disorders. The challenges commonly faced with emotional dysregulation due to trauma is mood instability, heightened sensitivity to perceived threats or difficulty in calming down after a distressing event[grammar?].[factual?]

## Cognitive mechanisms of PTSD

Table 1. DSM-5 PTSD Diagnostic Criteria. American Psychiatric Association, 5th Edition
| Criterion A | Criterion B | Criterion C | Criterion D | Criterion E | Criterion F | Criterion G | Criterion H |
| Stressor (one required) | Intrusion symptoms | Avoidance (one required( | Negative alterations in cognitions and mood (two required) | Alterations in arousal and reacitivity[spelling?] | Duration (required) | Functional significance (required) | Exclusion (required) |
| Exposed to death, threatened death/injury, actual/threatened sexual violence. | Traumatic event is persistently re-experienced. | Avoidance of trauma related stimuli after the trauma. | Negative thoughts or feelings began/worsened after the trauma. | Trauma-related arousal and reactivity that began/worsened the trauma. | Symptoms last for more than 1 month | Symptoms create distress or functional impairment | Symptoms are not due to medication, substance use or other illness |
| - Direct exposure - Witnessing the trauma - Learning a relative/close friend exposed to trauma -Indirect exposure to aversive details of the trauma | - Intrusive upsetting memories -Nightmares -Flashbacks -Emotional distress after exposure to traumatic reminders - Physical reactivity after exposure to traumatic reminders | - Trauma related thoughts or feelings - Trauma related external reminders | - Inability to recall key features of the trauma - Overly negative thoughts and assumptions about oneself or the world Exaggerated blame of self or others for causing the trauma -Negative affect - Decreased interest in activities - Feeling isolated - Difficulty experiencing positive affect | - Irritability or aggression - Risky/ destructive behaviour - Hyper-vigilance - Heightened startle reaction -Difficulty concentrating -Difficulty sleeping | | - Social impairment - Occupational impairment | |
The dual representation theory by Brewin et al. (1986) is a commonly used framework in understanding the cognitive mechanisms of PTSD. It acknowledges the influence of sensory input on the conscious and unconscious mind encompassing informational processing and social cognitive theories. Emotional processing involves activating the unconscious memories and consciously seeking meaning to reconcile past beliefs with the trauma's reality (Johnson, 2009). When negative emotions subside, individuals restore security and regain control over their environment.
The theory identified two types of emotional responses:
* Primary emotional conditioning: occurs during the traumatic experience associated with fear or anger alongside the re-experienced sensory and physiological information
* Secondary emotions: results from the emotional consequences and implications of the traumatic experience event such as fear, anger, guilt and shame.
* Case study
* Harman exhibits primary emotional conditioning during his traumatic experiences, marked by intense fear and anger. His sedentary lifestyle exacerbated his difficulties with concentration and triggered secondary emotions such as guilt and irritability. These challenges manifested into intrusive memories and heightened emotional responses. Severely impacting his daily function and relationships[grammar?]. His ability to recall specific details is deteriorating while negative emotional content became more prominent and consistent with cognitive models of PTSD[say what?].

### Explicit memory

Cognitive models of PTSD suggest that patients remember emotional content better due to a bias toward or difficulty engaging from threat related information (Chemtob et al., 1998). Behavioural and neuroimaging studies found PTSD individuals tend to recall emotional information better than neutral details compared to healthy or trauma-exposed controls (Hayes et al., 2012). Suggesting a memory advantage for negative threat related information (Golier et al., 2002) and significant improvement in recalling emotional words compared to neutral words[grammar?].
PTSD impacts explicit memory by enhancing the recall of general negative information whilst reducing the ability to remember specific details and content (Hayes et al., 2012). This occurs due to cognitive resources primarily focusing on processing threat related information, often resulting to decrease in memory for neutral or non-threatening events. Additionally, false memories are likely to be associated with trauma specific information (Hayes et al., 2011). As heightened negative arousal alters information encoding and recall[grammar?].

### Implicit memory

Implicit memory refers to information that is expressed unconsciously or automatically (Schacter, 1987) it involves storing and recalling information[grammar?]. Implicit memory consists of perceptual priming,[grammar?] this involves the prior exposure to a stimulus improving the ability to recognise or perceive it later. Whereas, intrusive memories within the context of PTSD, are often caused by sensory cues that individuals experience before or during their traumatic event (Hayes et al., 2012). This suggests why individuals with PTSD display heightened perceptual priming for specific cues.
To assess enhanced perceptual priming towards trauma cues, earlier studies (Mcnally & Amir, 1996; Michael et al., 2005) who [grammar?] utilised word stem tasks resulted with inconsistent results[improve clarity]. However, recent studies (Ehlers et al.. 2006; Michael & Ehlhers, 2007) using perceptual stimuli such as blurred images revealed PTSD individuals exhibit an enhanced implicit memory response towards trauma-related stimuli. Resulting to heightened sensory perception, increased anxiety and difficulty managing symptoms[grammar?].

### Attentional bias and working memory

PTSD individuals often experience intrusive, trauma related memories that are challenging to ignore[factual?]. The persistent nature of such memories can significantly disrupt daily responsibilities and emotional wellbeing[factual?]. Hayes et al. (2012) stated that attentional bias in PTSD is characterised by difficulty engaging from or heightened engagement with threat related stimuli, often resulting to [grammar?] increased hypervigiliance[spelling?] symptoms and attentional avoidance strategies (Bar-Haim et al., 2007).
Working memory refers to the temporary storage and manipulation of information (Baddeley, 1992). It consists of limited capacity, meaning individuals can only manage a specific amount of information at once. This limitation implies that distracting stimuli can interfere with daily performance, particularly for PTSD individuals due to the persistent nature of intrusive thoughts and trauma recalled memories[factual?]. Such interferences contribute to concentration difficulties, a hallmark symptom of PTSD (Hayes et al., 2012).
A study conducted by Schweizer and Dalgeish (2011),[grammar?] found that PTSD individuals performed poorer than trauma-exposed controls on verbal memory tasks. Finding the recall of words presented after trauma related sentences were more challenging than those following neutral sentences[grammar?]. This supports previous findings[factual?] that PTSD patients exhibit deficits in working memory for both verbal and visual stimuli, evident in individuals with current diagnoses and those with a lifetime history of PTSD.

### Quiz
## Neurobiological mechanisms of PTSD

* Case study
* Following an adequate course of therapy, Harman was recommended a neurological evaluation. Neuroimaging results revealed reduced hippocampal volume, contributing to his difficulties in emotional regulation and stress response. Furthermore, the prolonged exposure to stress heightened activity in the amygdala resulting in further impairment of fear acquisition.
The emotional processing theory (EPT) developed by Foa and Kozak (1986),[grammar?] explains how pathological trauma related responses can be altered to initiate adaptive changes in cognitive, emotional, behavioural and physiological domains. EPT suggests that anxiety and trauma related psychopathology stem from a pathological network of stimuli, response elements (cognitive, emotional, behavioural and physiological) and their meaning (Alptert et al., 2021). When this network is activated, introducing incompatible information encourages the formation of more adaptive associations and responses (Alpert, 2021).
Firstly, it is essential to understand how trauma affects neurobiological mechanisms related to memory, attention and their influence on emotional regulation. Brain imaging methods have been utilised to detect distinctive alterations in brain structure and function amongst individuals. Impacted brain regions consists of the hippocampus, amygdala and various cortical regions specifically the cingulate gyrus, insula and orbitofrontal cortex (Raunch et al, 2006)[grammar?]. These areas interact to form a neural circuit that mediates the adaption of stress and fear conditioning (Sherin & Nemeroff, 2011). Research revealed consistent changes in these circuits are directly linked to the development of PTSD (Raunch et al., 2006).
The hippocampus regulates emotional responses, declarative memory, learning and contextual fear conditioning (Anand & Dhikav, 2012). Within PTSD individuals, reduced hippocampal volume is common[factual?]. Due to the prolonged stress exposure, resulting in the decrease of dendritic branching, reduction in dendritic spines and impairment in neurogenesis (Sherin & Nemeroff, 2011)[grammar?]. Magnetic resonance imaging studies of Vietnam Veterns[spelling?] and abuse related PTSD participants revealed smaller hippocampal volumes compared to the controls, due to the association of trauma severity and memory impairments (Raunch et al., 2006). The hippocampus is vital for short and long term memory, driving awareness of the environment. A reduced volume may contribute to chronic PTSD after treatment (Rubin et al ., 2016) and can exacerbate stress responses, hinder its termination, impair the extinction of conditioned fear and the ability to distinguish safe from unsafe environments (Pitman et al., 2002).
Bremner (2006) outlines that the amygdala is essential for encoding the emotional capability of events and is integral to the acquisition of fear responses. The medial prefrontal cortex including the cingulate gyrus, subcallosal gyrus and orbitofrontal cortex modulates emotional responsiveness by inhibiting amygdala function. Hyperactivity in the amygdala is common within PTSD individuals and it occurs due to a deficiency of the top-down modulation by the prefrontal cortex (Simmons et al., 2011). Functional imaging studies revealed hyper-responsiveness in PTSD individuals when exposed to stressful cues and trauma reminders (Shin et al., 2006). In these individuals, the amygdala was found to be sensitised to subliminally threatening stimuli and exhibits activation during acquisition in conditioning experiments (Hender et al., 2003). Damage to the amygdala may result in flattening emotional responses, reducing positive and negative emotional experiences, it may interfere with the ability to form or recall emotional memories[factual?]. Whilst increasing hyperarousal, insomnia and exaggerated startle responses[grammar?]. Research indicates that conditioned fear responses weaken following repeated exposure to the conditioned stimulus without the unconditioned stimulus (McCullough and Ressler, 2016), a process mediated by the prefrontal cortex inhibition of amygdala activity.

### Quiz
## Conclusion

Humans naturally possess the ability to amplify, sustain or diminish negative and positive emotions through unconscious (implicit memory) and conscious (explicit memory) mechanisms. This has the ability to aid or hinder the achievement of behavioural objectives. Emotions are one of the crucial psychopathological processes which help people adapt to the environment and achieve their goals (Einsenberg, 2000). Post traumatic stress disorder is a complex psychiatric condition, characterised by a diverse range of symptoms stemming directly from trauma. The complex interplay of trauma and its impact on cognitive disruptions suggest that individuals experience profound challenges related to memory impairments and attentional biases, which contribute to persistent distress and difficulties managing emotional regulation, ultimately resulting in daily dysfunction.
Neurobiological studies highlight the effect of trauma on the hippocampus, amygdala and prefrontal cortex, all of which are essential elements for regulating fear, stress and emotional responses. Alterations in these brain regions can exacerbate symptoms of PTSD as the hippocampus is integral to memory processing, the amygdala is vital for emotional responses and the prefrontal cortex plays a key role in executive functions such as emotional regulation and appropriate decision making. Consequently, disruptions within these neural systems can result in overwhelming stress and anxiety even in the absence of real danger. Due to this dysregulation, hyperarousal and heightened alertness may manifest often resulting to individuals exhibiting avoidance behaviours and maladaptive coping strategies[grammar?]. Understanding the intricate relationship between trauma, emotional dysregulation and brain function is essential for developing therapeutic interventions that target emotional healing and resilience within individuals diagnosed with PTSD.
* Key takeaways
* Effective emotional regulation serves as a protective factor against mental illness by enabling individuals to identify and modulate intense emotions, which helps prevent episodes of overwhelming and intense feelings. This process reduces the risk of emotional spiraling that can lead to the onset of mental health issues and equips individuals with essential tools to cope with stress and adversity.
* Take time to reflect on your emotions daily.
* Identify which emotional regulation strategies work best for you.
* Develop a personalised toolkit of emotional regulation techniques such as mindfulness meditation or cognitive reframing.