# Emotion, anxiety, and post-traumatic stress disorder

* Multimedia presentation (5 min)

## Introduction

Sergeant Bill Bloggs woke up in a cold sweat for the fourth night in a row. His heart was pounding at a hundred miles an hour and the bed linen was all over the floor.
The nightmares began about three weeks after he returned from an operational deployment to Afghanistan with the Special Forces Task Group, and have increased in intensity and regularity. As a Sergeant he was employed as a Section Commander with a Commando Company from the 2nd Commando Regiment, this was his second tour of Afghanistan and he had also deployed to East Timor with the 3rd Battalion, The Royal Australian Regiment ten years earlier. However, the nightmares are centred around an incident during his first deployment to Afghanistan three years ago. He was a Corporal at the time and Second in Command of his Section, one of his soldiers was killed during a contact in the Hajag Provence.
Sergeant Bloggs was standing beside Johno when he was shot, indeed the projectile narrowly missed Sgt Bloggs before entering his mate's chest and exiting through his back, taking a fair chunk of his spine with it. The wound was horrific and Sgt Bloggs remembers the ear piercing scream from his mate as if it was only yesterday. Johno's death was painful but relatively quick, however for Sgt Bloggs the screaming from Johno seemed to last forever.
Sgt Bloggs witnessed his mate's demise from start to finish. Since the nightmares started he has been having emotion laden flash-backs, has been haunted by a massive amount of guilt and has commenced drinking heavily in an attempt to reduce his symptoms and assist with falling asleep. He has also been extremely irritable and incredibly angry, often flying off the handle at the most minor incidents, especially with his children. Their noise in particular drives him into an uncontrollable and intense rage.
Sgt Bloggs' sudden rage is also fuelled by traffic incidents, especially when he perceives another driver as driving erratically or dangerously. He becomes increasingly angry and harbours this anger for hours after each incident. He has begun avoiding crowds and feels very uncomfortable in public places such as at the local shops and the picture theatre. He has become a recluse and hermit, withdrawing to the safety and comfort of his own home. Sgt Bloggs has been on an emotional roller coaster, experiencing immense highs and extreme lows, his feelings are extremely intense and seem to encompass his entire being.
Although the narrative about Sgt Bill Bloggs is fictional it sets the preconditions for gaining an understanding of how anxiety affects emotion. Anecdotal evidence suggests that the current number of Australian War Veterans suffering with Post Traumatic Stress Disorder (PTSD) has not been at such levels since the Vietnam era. As such the veteran dynamic is changing and having a direct impact upon Defence and community health infrastructure. The signs and symptoms of PTSD and other anxiety disorders do not affect the sufferer in isolation. There is also a direct impact upon the individual's immediate family (Foa, Zoellner, Feeny, & Alvarez-Conrad; 2002). Indeed, there are additional and subsequent spin-off affects[for example?] on extended family members and society in general.
The initial segment of the chapter will introduce readers to a general understanding of emotion and to the wider signs and symptoms of anxiety. Secondly, the chapter will look closely at the affects of anxiety on emotion. The third component will focus on a particular anxiety disorder, namely Post Traumatic Stress Disorder. The chapter content will be supported by contemporary research and literature and will incorporate interviews, quizzes, interactive activities, images and links to other relevant websites and reference material.

### Objectives

The objectives of this chapter are as follows:
* To gain a general understanding of emotion,
* To attain an insight into anxiety,
* To identify how anxiety effects emotion, in terms of;
** the psychological affects, and
** the physiological affects,
* To acquire a familiarisation of Post Traumatic Stress Disorder.

### Purpose

The purpose of this chapter is to enable psychology students to understand how the physiological, psychological and social elements of anxiety affect emotion. This is particularly important for students who intend to pursue a career as a clinician but also for students who are interested in a research profession.

## Part one: Emotion and Anxiety
### Emotion

The study of emotion is a complex and multi-faceted topic, indeed emotion has been widely debated since antiquity, as such there are several theories associated with emotion resulting in several different definitions. There is even a large debate with regard to the exact number of core or basic emotions (Solomon, 2002).
This section will provide readers with a general understanding of emotion, however a comprehensive analysis of the core emotions is at Basic/Core Emotions: Ekman. Emotions are defined as "intense, short-lived subjective feelings that initiate action and influence behaviour" (Solomon, 2002). An initial analysis of this definition identifies three key points. Firstly, emotions are intense. Van Boven, White and Huber (2009) state that current emotions have a stronger impact than emotions which have occurred in the past, the explanation for this is that current emotions are more salient and therefore appear to be stronger in intensity. Secondly, emotions are short-lived, lasting up to a maximum of four seconds (Ekman, 1984 as cited in Deckers 2010 & McMakin, Santiago & Shirk, 2009). Finally, emotions guide action and behaviour (Srivastava, McGonigal, Gross, Tamir & John, 2009). Early studies have identified that the core emotions are aligned with specific facial expressions (Ekman & Freisen, 1971; & Ekman & Freisen, 1978). Facial expressions are reported to be innate and are identical around the globe, thus they are not bound by race, religion or culture. Interestingly people who are blind from birth still convey facial expressions in the same manner as individuals with full sight (Fernandez-Dols, Carrera, De Mendoza & Oceja, 2007; & Miyamoto, Ellsworth & Uchida, 2010). A detailed and thorough analysis of the significance of facial expressions with regard to emotion is at Emotion and Facial Expressions.
* Emotions are intense, short-lived subjective feelings that initiate action and influence behaviour (Solomon, 2002).

#### Basic Emotions and Moods

Emotions are considered to be manifested through experiences, observations and biological determinants (Borelli, David, Anderson, Mayes, Crowley & Sbarra, 2010). As discussed in the aforementioned section, there are a number of models which detail the number and type of core or basic emotions. For example, in their work on emotions and bereavement Coifman & Bonanno make use of eight core emotions: fear, guilt, distress, sadness, happiness, enjoyment, relief and amusement. However, for the sake of conformity, this section will focus on the work of Dr Paul Ekman as described at the Ekman link above. His early research identified six core emotions: anger, Fear, disgust, happiness, sadness and surprise. Ekman hypothesised that the core emotions have evolutionary links which are required for survival, the characteristics he used to guide his formation of emotions are at Basic/Core Emotions: Ekman. His later research identified the additional emotions of contempt, guilt, shame, interest, embarrassment, awe and excitement (Ekman, 1992). He further increased his findings by classifying sensory emotions, namely relief, wonder, ecstasy and bliss (Ekman, 2003). Moods are differentiated from emotions by intensity and temporal measurement. Moods are less intense than emotions but are longer lasting (Velasquez as cited in Canamero, 1998). Emotions have a short life span of seconds where as moods may last for hours. Ekman has not identified anxiety as a core emotion, however it could be regarded as a mood but the evidence to support this is not clear. Primary emotions are regarded as innate and are a response to an internal or external stimulus, whereas secondary emotions are defined as "the product of cognitive processing" (Becker & Wachsmuth as cited in Reichardt, Levi & Meyer, 2006, p.31). Given the definition for emotion, one would draw the conclusion that anxiety is definitely not a primary emotion but may be considered as a secondary emotion. As the next section will identify, anxiety is a disorder that affects cognitive processing.
* Core Emotions
* Anger
* Fear
* Disgust
* Happiness
* Sadness
* Surprise
* (Ekman & Freisen, 1971).

#### Action and Behaviour

Emotion serves as a catalyst to energise motives and thus guide behaviour (Srivastava, McGonigal, Gross, Tamir & John, 2009). In this sense emotions prime 'action readiness'. By way of example, fear energises the fight or flight response in individuals. The motivation of fear is to remove oneself from a dangerous situation, the resulting action may result in avoidance, freezing or escaping behaviours. Additionally, the facial expression of sadness signals distress to others and is a non-verbal request for assistance (Trachsel, Gurtner, von Kanel & Grosse Holtforth, 2010).

#### Section Recap

Emotions are short-lived, intense subjective feelings that initiate action and influence behaviour. The difference between emotions and moods are characterised by intensity and temporal measurement, moods are less intense and may last for hours. Emotions serve to prime the body for action and thus guide behaviour.

### Anxiety

In general terms, anxiety is defined as "a state of uneasiness, accompanied by dysphoria and somatic signs and symptoms of tension, focussed on apprehension of possible failure, misfortune, or danger" (Colman, 2006, p.46). Although this definition is overly simplistic it does provide an excellent introduction into the realm of anxiety disorders. The Diagnostic and Statistical Manual of Mental Disorders categorises anxiety disorders into specific sub-groups (DSM-IV-TR, 2009). The sub-groups include Panic Disorder, Phobias or Social Anxiety, Obsessive Compulsive Disorder, Stress Disorders, and Generalised Anxiety Disorder.
* Anxiety A state of uneasiness, accompanied by disphoria and somatic signs and symptoms of tension, focussed on apprehension of possible failure, misfortune, or danger (Colman, 2006, p.46).
* Watch a 5 min film: Do you have an anxiety disorder?

#### Anxiety Sub-groups

The following definitions of the anxiety sub groups are from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (2009). They provide a simplified understanding of the characteristics of each disorder. "A Panic Disorder is a discrete period in which there is a sudden onset of intense apprehension, fearfulness, or terror often associated with feelings of impending doom. Phobias or social anxiety are characterised by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidant behaviour. Obsessive Compulsive Disorder is characterised by obsessions which cause marked anxiety or distress and/or by compulsions which serve to neutralise anxiety. The Stress Disorders such as PTSD and Acute Stress Disorder (ASD) are characterised by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma. Generalised Anxiety Disorder (GAD) is characterised by at least six months of persistent and excessive anxiety and worry" (DSM-IV-TR, 2009, p.429).
* Watch a 2 min. interview with Sandra who is 17 and lives with anxiety

#### Effects of Anxiety

The psychological effects of anxiety comprise excessive worry, restlessness, irritability and difficulty concentrating (DSM-IV-TR, 2009). The physiological symptoms comprise muscle tension, shaking, trembling and muscle aches, soreness and insomnia (DSM-IV-TR). Anxiety influences general health and well-being and has a notable impact upon sleeping patterns (Boden & Prigerson, 2007). Hamilton, Nelson, Stevens and Kitzman (2007) emphasise the importance of sleep hygiene for general well-being and cognitive function. A comprehensive analysis of sleep and emotion is at Emotion and Sleep. In addition, many sufferers experience somatic symptoms such as sweating, nausea and diarrhea combined with elements of autonomic hyperarousal encompassing increased heart rate, shortness of breath and dizziness (DSM-IV-TR). Anxiety also affects specific parts of the brain such as the amygdala with PTSD, the hypothalamus with panic disorder, the hippocampus in women with PTSD, the prefrontal cortex with phobias and the mid brain tectum with panic disorder. Cortisol levels are also heightened in people with anxiety (Kalueff & Nutt, 2007). The next section will identify how anxiety impacts upon emotions.

#### Section Recap

Anxiety is a disorder that causes extreme worry and uneasiness, it is a complex disorder that is divided into five sub-groups: GAD, stress disorders, phobias, obsessive compulsive disorder and panic disorders. Anxiety manifests in a number of ways including somatic symptoms such as sweating and nausea and general symptoms such as insomnia, accelerated heart rate and muscle tension.

#### Quick Quiz: Emotion & Anxiety

* Name three emotions.
* In your own words, define emotion.
* In your own words define anxiety.
* Name the five anxiety disorders (sub-groups).

## Part two: The Effect of Anxiety on Emotion

* Watch a 5 min film: How anxiety affects the body

### Impacts

It has been established that emotions initiate action and guide our behaviour and that anxiety is a disorder that has psychological and physiological impacts upon the body. This section will address how anxiety effects emotion. Many people living with an anxiety disorder often report that their emotions are influenced dramatically. In particular, the negative emotions are exacerbated, for instance fear and anger are increased (Marshall, Doron-Lamarca, Niles, Taft, Martin & Warfield, 2010). Increased fear with GAD and the stress disorders often results in an excessive startled response and constant feeling of uneasiness. People with OCD will adopt 'religious' compulsions such as excessive washing or constant checking to mask the effects of their obsessions (DSM-IV-TR, 2009). However, the majority of individuals with anxiety disorders will regularly adopt avoidance strategies in order to minimise the effects of their respective disorder. For example, people with phobias actively avoid the specific element or situation that fuels the phobia such as confined spaces, spiders or heights. Adopting avoidance strategies is maladaptive and evidence suggests that individuals who actively avoid expressing emotions actually hinder coping skills and task performance (Trachsel, Gurtner, von Kanel, & Grosse-Holtforth, 2010). When individuals avoid expressing emotions they will not benefit from the essential outputs of emotion such as guiding behaviour and initiating action (Trachsel et al). For example, being primed to escape from danger.

### Early Development

Research suggests that emotion regulation is an extremely important component of childhood development (Davis, Levine, Quas, & Lench, 2010). Psychopathology such as anxiety has been identified in young children and infants. The effect of anxiety inhibits attachment and therefore effects a child's ability to establish peer relationships (Davis et al). In addition, it has been identified that poor attachment and anxiety in children effects emotion regulation and as such hinders performance at school and thus results in learning difficulties (Borelli, David, Anderson, Mayes, Crowley & Sbarra, 2010).

### Decision Making and Task Performance

Contemporary research states that emotion plays a significant role in human decision making as emotions are considered to influence subjective evaluations (Heilman, Crisan, Miclea, Miu & Houser, 2010). Anxiety disorders directly effect emotions and cognitions, and as such have been identified to hinder decision making and working memory (Heilman et al & Moon & Lord, 2006). Therefore poor emotion regulation directly impacts upon decision making which often transfers to poor task performance in the workplace, as a parent or as a driver of a motor vehicle (Heilman et al).

### Section Recap

The impacts of anxiety on emotion effect individuals in a number of ways. Difficulty with attachment has been identified with infants during early development and anxiety has been reported to inhibit the establishment of social relationships and interaction with strangers (Coifman & Bonanno, 2010). In addition, decision making and working memory is also effected, which translates into poor work or task performance and functioning in general.

### Quick Quiz: Effect of Anxiety on Emotion

* Name two psychological effects of anxiety.
* Name three physiological effects of anxiety.
* Identify two ways in which anxiety effects emotion.
* Identify an area of the brain effected by anxiety.
* Is mindfulness an effective treatment for anxiety?

## Part Three: Post Traumatic Stress Disorder (PTSD)

* Watch a 5 min film of Todd, an Aus soldier with PTSD
Post Traumatic Stress Disorder is not a new concept with regard to exposure to traumatic life events, the signs of PTSD have been mentioned in ancient scripts and medieval texts. In more recent times such as World War I individuals presenting with the signs and symptoms of PTSD were diagnosed with shell shock as there was a correlation between sufferers and exposure to intense artillery bombardments.
* Post Traumatic Stress Disorder (PTSD): An anxiety disorder arising as a delayed and protracted response after experiencing or witnessing a traumatic event involving actual or threatened death or serious injury to self or others (Colman, 2006, p.589).
During World War II, the term shell shock was replaced with the diagnosis of battle fatigue. The contemporary term of PTSD came in to prominence after the Vietnam War as there were a significant number of veterans presenting with the condition. However, it is important to note that anyone can be diagnosed with this disorder whether exposed to assault, sexual assault or in motor vehicle accidents for example (DSM-IV-TR, 2009; & Foa, Zoellner, Feeny, Hembree & Alvarez-Conrad, 2002).

### Signs and Symptoms of PTSD

The signs and symptoms of PTSD are varied among different individuals, however the most common symptoms reported are flashbacks, hypervigilance, sleep disturbance, nightmares, intrusive thoughts, anhedonia, feeling flat, avoiding activities and thoughts, irritability, outbursts of anger and poor memory (DSM-IV-TR, 2009; & Wilcox, 2010). A full list of signs and symptoms is in the text box below. An additional list of signs and symptoms specific to military PTSD are at Department of Veteran's Affairs and Veterans and Veterans Families Counselling Service. The most common comorbidities associated with PTSD are alcohol dependence, smoking, illicit drug use and problem gambling (Cook, Jakupcak, Rosenheck, Fontana, & McFall, 2009; & DSM-IV-TR). In addition the sufferer also inevitably is diagnosed with general anxiety symptoms and depression (DSM-IV-TR).

### Effects of PTSD on Emotion

Individuals report that the effects of PTSD upon emotion are significant, such as increased levels of fear and anger (Marshall, Doron-Lamarca, Niles, Taft, Martin & Warfield, 2010). Increased fear often results in an excessive startled response which translates into hypervigilance. Hypervigilance is defined as "an increased state or condition of being excessively alert and overly attentive" (Colman, 2006, p. 801). Sufferers report sitting near exits when in public and occupying seats with their backs to the wall to ensure that they have a full view of the room. They also report feeling excessively uneasy when in crowds are public places such as shopping malls and sporting arenas . Anger is especially exaggerated and out of proportion whenever an individual feels uneasy or threatened. Sufferers describe their anger 'fuse' as almost non-existent and launching into an uncontrollable rage (Marshall et al, 2010).
* Hypervigilance: An increased state or condition of being excessively alert and overly attentive (Colman, 2006, p.801).

### Biopsychosocial Effects

The physiological effects on the individual include hypertension or high blood pressure which increases the sufferers risk of developing heart disease. Excessive alcohol consumption and extensive use of prescription medication can also impair the liver (Magruder & Yeager, 2009). The brain is also directly affected, serotonin is produced in small amounts and therefore is required to be substituted by pharmaceuticals and the amygdala is also impaired. The impaired amygdala is responsible for the increased level of fear and uncontrollable anger experienced by individuals with PTSD. The psychological effects have been previously mentioned, namely depression, general anxiety, suicide ideation and in certain cases homicidal ideation (DSM-IV-TR, 2009). The social effects include an indirect impact upon the community health infrastructure and a significant financial burden on the state and federal governments.
* Flashback: A recurrence of a memory, or the experience of reliving an episode from the past (Colman, 2006, p.287).
The effects of PTSD are not isolated to the individual, immediate family members such as spouses and children often present with similar symptoms to PTSD and are often diagnosed with secondary PTSD (Wilcox, 2010). The Veterans and Veterans Families Counselling Service is an organisation that provides specific PTSD management for Defence members and their families. The VVCS website is at Veterans and Veterans Families Counselling Service. The organisation provides face to face counselling for individuals and their families, and conducts group courses for veterans such as managing anxiety, anger management and relationship work shops.

### Section Recap

PTSD is an anxiety disorder that is manifested by witnessing or experiencing traumatic events where life is directly or perceived to be threatened. Although PTSD is usually associated with war veterans as portrayed in contemporary media, any individual within society may be susceptible to the condition. For example, individuals who are victim to a violent assault or sexual assault. People who have been in horrific motor vehicle, train or plane accidents may also develop PTSD. The signs and symptoms are extensive, including irritability, hypervigilance, poor memory and flashbacks. Comorbidities include alcohol abuse, smoking, illicit drug use, gambling, general anxiety and depression. The impacts of PTSD effect the individual directly which subsequently translates to the sufferers immediate and extended family and society in general.

### Quick Quiz: PTSD

* Name three symptoms of PTSD.
* Name a comorbidity.
* PTSD is a mood disorder. True / False
* PTSD only affects soldiers in combat. True / False
* PTSD was formerly known as shell shock or _________________ .

## Conclusion

Emotions are regarded as intense, short-lived subjective feelings that initiate action and guide behaviour (Solomon, 2002) and are manifested through experiences, observations and biological factors (Borelli, David, Anderson, Mayes, Crowley & Sbarra, 2010). Dr Paul Ekman identified six core emotions: anger, Fear, disgust, happiness, sadness and surprise and hypothesised that emotions have evolutionary links. His later research identified the additional core emotions and sensory emotions as follows: contempt, guilt, shame, interest, embarrassment, awe and excitement (Ekman, 1992) and relief, wonder, ecstasy and bliss (Ekman, 2003). Moods are differentiated from emotions by intensity and temporal measurement. Moods are less intense than emotions but are longer lasting (Velasquez as cited in Canamero, 1998). Primary emotions are regarded as innate and are a response to an internal or external stimulus, whereas secondary emotions are defined as "the product of cognitive processing" (Becker & Wachsmuth as cited in Reichardt, Levi & Meyer, 2006, p.31). Given the definition for emotion, one would draw the conclusion that anxiety is definitely not a primary emotion but may be considered as a secondary emotion.
In general terms, anxiety is defined as "a state of uneasiness, accompanied by disphoria and somatic signs and symptoms of tension, focussed on apprehension of possible failure, misfortune, or danger" (Colman, 2006, p.46). It is a disorder that causes extreme worry and uneasiness, and is divided into five sub-groups: GAD, stress disorders, phobias, obsessive compulsive disorder and panic disorders. Anxiety manifests in a number of ways including somatic symptoms such as sweating and nausea and general symptoms such as insomnia, accelerated heart rate and muscle tension. Many people living with an anxiety disorder often report that their emotions are influenced dramatically and effects them in a number of ways. Difficulty with attachment has been identified with infants during early development and anxiety has been reported to inhibit the establishment of social relationships and interaction with strangers (Coifman & Bonanno, 2010). Adopting avoidant strategies to minimise the effects of the disorder or implementing compulsions to mask obsessions. In addition, decision making and working memory is also effected, which translates into poor work or task performance.
PTSD is an anxiety disorder that is manifested by witnessing or experiencing traumatic events where life is directly or perceived to be threatened. Although PTSD is usually associated with war veterans as portrayed in contemporary media, any individual within society may be susceptible to the condition. For example, individuals who are victim to a violent assault or sexual assault. People who have been in horrific motor vehicle, train or plane accidents may also develop PTSD. The signs and symptoms are extensive, including irritability, hypervigilance, poor memory and flashbacks. Comorbidities include alcohol abuse, smoking, illicit drug use, gambling, general anxiety and depression. The impacts of PTSD effect the individual directly which subsequently translates to the sufferers immediate and extended family and society in general.

## Activities
### Activity 1

Can you identify someone's emotion from looking at their facial expression in a photograph in the newspaper or on TV? Give it a try.

### Activity 2

Have you ever felt incredibly anxious? If so, did this heightened level of anxiety effect your emotions?
In what way? Please describe in a few sentences.

### Activity 3

Talk to a friend about an event you went to on the weekend. BUT, you are not able to use words containing the letters i or o. For example you can't use I, it must be substituted with we or my. You cant use road, maybe you could substitute track or trail. This will be frustrating to say the least. Try to identify what effect this will have on your emotions.

## Glossary

Acute Stress Disorder (ASD): A transient anxiety disorder following exposure to a traumatic event, with a similar pattern of symptoms to PTSD (see below) plus dissociation but occurring within four weeks of the traumatic event.
Anxiety: A state of uneasiness, accompanied by disphoria and somatic signs and symptoms of tension, focussed on apprehension of possible failure, misfortune, or danger (Colman, 2006, p.46).
Depression: A mood (1) state of sadness, gloom, and pessimistic ideation, with loss of interest or pleasure in normally enjoyable activities, accompanied in severe cases by anorexia and consequent weight loss (Colman, 2006, p.2020).
DSM-IV TR: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.
DVA: Department of Veterans' Affairs.
Emotion: Any short term evaluative, affective, intentional, psychological state, including happiness, sadness, disgust and other inner feelings (Colman, 2006, p.248).
Flashback: A recurrence of a memory, or the experience of reliving an episode from the past (Colman, 2006, p.287).
Hypervigilance: An increased state or condition of being excessively alert and overly attentive (Colman, 2006, p.801).
Post Traumatic Stress Disorder (PTSD): An anxiety disorder arising as a delayed and protracted response after experiencing or witnessing a traumatic event involving actual or threatened death or serious injury to self or others (Colman, 2006, p.589).
RSL: Returned and Services League
Sgt/SGT: Military rank, Sergeant
VVCS: Veterans and Veterans Families Counselling Service (formerly- Vietnam Veterans Counselling Service)
VVF: Vietnam Veterans Federation