MENTAL HEALTH INFO RESOURCES
An enduring legacy of trauma for those who manifest the chronic symptoms of Post-Traumatic Stress Disorder (PTSD) is profoundly disrupted emotion. Persons with PTSD can be strikingly sensitive to the most subtle of social stimuli and respond with a torrent of uncontrollable affect on the one hand, and on the other hand they may report feeling emotionally unresponsive to events that they recognize would otherwise elicit emotion. Whereas individuals who are better adjusted regard painful or intense emotions as understandable and controllable states that can be effectively coped with via a number of strategies such as self-talk and seeking social support or validation, persons with PTSD are likely to respond to emotional situations in a limited and inflexible manner. Clinicians and researchers have described PTSD patients as limited in the ability to tolerate strong emotion and further propose that this deficit thwarts the recovery process (1). Instead of allowing emotions to run their course and provide information to the individual about their experience of themselves and their environment, persons with PTSD often avoid the early warning signs of emotion placing themselves at risk for being overwhelmed by subsequent intense reactions. In others instances they may be excessively vigilant and hypersensitive of the precursors to emotion and initiate any number of avoidance behaviors, some subtle, others extreme. As van der Kolk and Ducey (p. 267) (2) suggested, "persons with severe PTSD are incapable of modulated affective experience; they either respond to affective stimuli with an intensity which is appropriate only to the traumatic situation or they barely react at all."
The range of emotional functioning difficulties associated with PTSD is acknowledged in the current nosology within each of the three major symptom clusters or categories (e.g., emotional reactivity associated with re-experiencing, restricted range of affect and detachment associated with emotional numbing, and irritability associated with hyperarousal) (3). However, the mechanisms underlying these divergent symptoms are not well appreciated in current theories of PTSD nor have researchers sufficiently examined them empirically (4-5). The present paper describes one aspect of a program of research we have initiated to explore emotional dysregulation in PTSD. We outline the construct of meta-mood, or beliefs about feeling, and discuss its applicability to the study of emotional-processing deficits in PTSD.
An examination of the underlying mechanisms associated with emotional functioning in PTSD is of particular relevance in the context of the clinical situation. Clinicians who treat PTSD patients spend a good deal of time helping them take a different stance about their emotional experience. Regardless of theoretical orientation, all therapists assist PTSD patients in identifying, acknowledging, explaining, accepting, and integrating emotions related to traumatic events and their aftereffects. In fact, working with traumatic material at any but the most superficial level requires a degree of willingness to experience, and competence in dealing with emotional experience that many persons with PTSD may lack. Our research addresses the following questions that have direct relevance to emotion-focused clinical work with PTSD patients: (a) Are there generalized attitudes and beliefs about feeling that are unique to PTSD? (b) are thoughts and feelings about feeling (meta-cognitions) related to the manner in which threatening trauma-related material is processed emotionally, and (c) might these overarching beliefs about feeling be appropriate targets in treatment?
Several specific aspects of existing theories of PTSD (6-8), and limited empirical evidence (2) suggest that the difficulties in affect regulation evidenced by individuals with PTSD may in part be due to what cognitive psychologists call top-down, conceptual, or executive cognitive processes that serve to organize and modulate affective experience. To date, the specific roles that such processes may play in the etiology and persistence of PTSD have not been adequately examined.
Recently, Litz (5) attempted to explicate the cognitive mechanisms underlying the emotional dysregulation associated with PTSD. Drawing upon Levanthal's perceptual-motor theory of emotion, Litz proposed that the capacity to experience emotions at the expressive-motor or physiological level is not impaired in PTSD. Instead, emotional dysregulation in PTSD is proposed to be a result of a series information-processing events. Conditioned emotional reactions and other re-experiencing symptoms are considered primary manifestations of PTSD that serve to automatically trigger other secondary conditioned emotion routines (e.g., anger, sadness, shame). In addition, conceptual-level, meta-cognitive processes (i.e., top-down rules about experiencing and expressing emotions) have a two-part influence on emotional behavior in PTSD. First, the conceptual rules that govern emotional behavior during states of hyper-reactivity and hyperarousal in PTSD patients are likely to be fairly primitive and are chiefly focused on coping through cognitive and/or behavioral avoidance. Second, over time, PTSD patients become predisposed to respond to a variety of emotional situations in restricted, inflexible, or excessive ways. These limitations are based on rigidly held attitudes and beliefs about emotion and the consequences of experiencing and expressing emotion (i.e., meta-mood processes). Such higher-order cognitive processes in PTSD affect emotional behavior by cueing the activation of emotional routines (e.g., using anger as a means of obtaining control and creating interpersonal distance) as well as shape expressive-motor behavior (e.g., the extent to which someone smiles in the presence of a friend).
How might thoughts and beliefs about emotion or meta-mood play a role in the development of PTSD? Attitudes and feelings about emotion, especially in adults, are typically well formed prior to exposure to trauma and are likely to play a role in the experience of trauma and in recovery from it. Meta-cognitive processes related to emotion may play an etiological role in the development of PTSD by facilitating or impeding the processing of the emotions and memories associated with the event. For example, a soldier who enters the war-zone with particular cognitive rules about emotion, such as the belief that feelings like grief and fear are unacceptable and uncontrollable, at the first thought or image of his lieutenant who had his legs blown off, might say to himself "dwelling on this will cause me to become very upset which is unacceptable and dangerous. I might start to cry and completely lose all control of myself." A belief such as this would likely interfere with this soldier's capacity to process and integrate the traumatic event into his awareness and understanding of himself and the world. Alternatively, beliefs about emotion might develop out of a traumatic situation. A survivor of incest, for instance might have complex beliefs about the potential for tender and positive feelings to lead to very destructive outcomes. Although researchers in the past had not specifically examined how persons with PTSD think about their feelings, cognitive rules about emotion have been explored in non-clinical populations.
Researchers in the area of social-cognition conducting empirical research on higher-level cognitive processes utilizing non-clinical populations have described several constructs that have proven to be relevant to the study of emotional functioning in PTSD. One such construct is the "Meta-experience of emotion" or "Meta-mood", describing one's thoughts and feelings about emotions and emotional experience. Salovey and Mayer developed the meta-mood construct in an effort to quantify aspects of emotional intelligence, or "...the subset of social intelligence that involves the ability to monitor one's own feelings and emotions, to discriminate among them and use this information to guide one's thinking and actions" (p. 189) (9).
Mayer and his colleagues have identified both evaluative and regulatory dimensions of meta-mood (10-11). Evaluative dimensions of meta-mood reflect individual differences in global attitudes and beliefs about feeling while the regulatory dimension refers to repertoires of behaviors and defenses that individuals possess to cope with the experience of emotion. The evaluative dimensions include the following: (a) acceptance (the extent to which a person allows themselves to experience feelings), (b) clarity (how well a person feels they can distinguish what their mood is) and (c) influence (the extent to which a person believes that their judgments are affected by their feelings). The regulatory dimensions of meta-mood include: (a) attempts to repair mood, (b) maintenance of current mood, and (c) dampening of positive moods.
A number of empirical studies have shown an association between various indices of meta-mood and psychopathology. Of particular interest in the context of PTSD is the finding of a negative relationship between clarity and acceptance, as measured by two sub-scales of the State Meta-mood Scale (SMMS) and alexithymia (11). Alexithymia is defined as the inability to articulate emotions verbally and has been implicated in the etiology and maintenance of PTSD (1). The meta-mood sub-constructs, influence and repair were shown to be positively related to the severity of Borderline Personality Disorder symptomatology (11). Mayer and Stevens also found a negative relationship between dampening and borderline symptomatology. The etiological, phenomenological, and symptom-level overlap between PTSD and Borderline Personality Disorder has been extensively documented (e.g. 12-13). Finally, Salovey and his colleagues have demonstrated that the clarity meta-mood dimension is related to recovery from a laboratory stressor (14). It appears that the greater clarity with which a person reports experiencing the emotional impact of events the better able they are to manage stress.
Mayer and his colleagues have also developed a measure of moment-to-moment meta-cognitions regarding emotional experience that are particularly relevant in the study of PTSD (15). This measure includes items such as "fight the feeling" and "remain open." These items are valuable in assessing openness or willingness to engage in emotional processing and as such are likely to be useful in a variety of clinical and research contexts.
In the following section we briefly summarize the findings of a research project we conducted examining the relationship between combat-related PTSD and the construct of meta-mood. There were two main questions that we attempted to explore in this research. First, what are the meta-mood qualities or traits of Vietnam combat veterans with PTSD that distinguish them from Vietnam combat veterans who do not have PTSD? Second, when PTSD patients are in an emotionally reactive state in the laboratory, are there meta-mood variables that distinguish PTSD subjects from controls in terms of the manner in which they attempt to actively cope with such hyper-reactivity?
In our study of meta-mood in Vietnam combat veterans with and without PTSD, we found PTSD to be uniquely associated with dysfunctional attitudes about emotion (16). As expected, PTSD veterans reported significantly more problems with affect tolerance and affect regulation than subjects without the disorder. The PTSD veterans in our study reported perceiving themselves as less clear about the emotional states they experience and overall reported less acceptance of their emotions. Yet, PTSD veterans also reported that their emotions exert greater influence over their thoughts and behavior than well-adjusted combat veterans. In addition, PTSD veterans' report being less likely to attempt to repair negative emotional states, less likely to maintain positive states, and a greater tendency to dampen or suppress positive emotional states.
To see how individuals with PTSD cognitively respond to intense emotional demands, we examined state changes in meta-mood after veterans viewed a videotape of combat-related experiences (a trauma prime) and compared these results with a condition where veterans viewed a neutral videotape. The PTSD group reported greater decreases in their openness to their emotional reactions to the trauma-prime (relative to the neutral condition) in comparison to the well-adjusted group. Additionally, PTSD veterans reported fewer efforts to repair their mood under the trauma-prime condition as compared to the neutral prime, whereas non-PTSD veterans reported an increase in their efforts to repair negative affect. These data suggest that individuals with PTSD "shut down" or dismiss their emotional responses and abandon constructive efforts at mood repair during states of hyper-reactivity. Interestingly, individuals with PTSD reported greater clarity about what they were feeling under the trauma prime as compared with the neutral condition, whereas individuals without PTSD manifested the opposite effect. A reasonable explanation of this finding might be that veterans with PTSD would be more familiar with the feelings associated with trauma reminders, due to their tendency to re-experience aspects of the trauma regularly through their symptoms. For well-adjusted combat veterans, immersion in the Vietnam experience is likely to be less familiar.
Overall, the results of our study are consistent with the notion that PTSD is associated with emotional dysregulation (1, 2, 5, 6). Although our questionnaire data cannot assist us in determining the causal connection between meta-mood factors and PTSD, the results of our study suggest that emotional-processing deficits in PTSD may be related, in part, to top-down rules, attitudes, and beliefs about emotions reflecting a lack of acceptance of emotional experience as valuable, controllable and comprehensible.
Incorporating meta-mood into our understanding of affective functioning in PTSD has implications for both primary prevention efforts and treatment. Attitudes and beliefs about emotions may affect the degree to which survivors of a traumatic event engage in processing and integrating the cognitive and emotional aspects of the experience. If we assume that emotional processing and integration of traumatic events is necessary to avoid the development of post-traumatic symptomatology (e.g., 17-18) than assessing the degree to which attitudes about and cognitive responses to emotion facilitate or impede emotional processing may be important in predicting risk of symptom formation. It would also follow that intervening at the conceptual level of beliefs about, and responses to, intense emotion might be an important part of triage and psycho-educational efforts aimed at preventing the adoption of maladaptive responses such as cognitive and behavioral avoidance.
With regard to the treatment of patients diagnosed with PTSD, it may be that beliefs about experiencing emotion must be addressed in some cases before patients can engage in emotionally intensive and demanding trauma-focused psychotherapy. It may be prudent to consider providing a series of didactics combined with experiential opportunities with the express purpose of teaching patients to modify their meta-mood, that is, to develop a new understanding and appreciation of emotion. In essence, PTSD patients would benefit from training in the language and methods of "emotional-processing" (see 19). The goal in "emotional-processing" training is to get PTSD patients to experience and express in "real-time" their emotional reactions to personally significant experiences, utilizing in-the-moment recognition, acceptance, ownership, and sharing of emotional experience, both positive and negative (see 20-21). Once patients become more accepting and open about their emotional experience they are more likely to benefit from exposure treatment when there is a premium on allowing emotions to be experienced and expressed more freely.
Specifically targeting beliefs about emotions in the treatment of PTSD may be potentially therapeutic in of itself. For example, PTSD patients often present with shame about the experience and expression of emotion that serves to exacerbate such problems as emotional numbing. Studies of emotional "acceptance" (see Wilson et al, this issue) have demonstrated the importance of this dimension of experience to the process of recovery. When meta-mood issues are targeted in treatment it may lead to greater acceptance of emotional experience which is likely to lead to considerable collateral positive change. In fact, assessing meta-mood may be an important step in quantifying progress in treatment.
We would argue that patients need to take a different stance about their emotions if therapy is to have a long term impact on their overall functioning and quality of life. If clinicians systematically understand and address what PTSD patients think and believe about feeling, and use various strategies to assist them in increasing their capacity to feel and express emotions, patients should be less likely to relapse after treatment. Such an approach would enhance patientsí abilities to respond to future stressors and demands with an open attitude about feelings, enabling more effective coping and more responsive and growth-promoting interpersonal relationships.
1. Krystal, H. (1988). Integration and self-healing: Affect, trauma, alexithymia. New Jersey: Lawrence Erlbaum Associates.
2. van der Kolk, B. A. & Ducey, C. P. (1989). The psychological processing of traumatic experience: Rorschach patterns in PTSD. Journal of Traumatic Stress, 2 (3), 259-274.
3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, (4th edition.). Washington, DC: American Psychiatric Association.
4. Davidson, J. R. & Foa, E. B. (1991)Diagnostic issues in post-traumatic stress disorder: Considerations for the DSM-IV. Journal of Abnormal Psychology, 100 (3), 346-355.
5. Litz, B. T. (1992). Emotional numbing in combat-related post-traumatic stress disorder: A critical review and reformulation. Clinical Psychology Review, 12, 417-432.
6. Foa, E. B., Steketee, G., & Olasov-Rothbaum, B. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder. Behavior Therapy, 20, 155-176.
7. Horowitz, M. J. (1986). Stress-response syndromes (2nd edition). Northvale, New Jersey: Jason Aronson Inc.
8. van der Kolk, B. A., Greenburg, M., Boyd, H. & Krystal, J. (1985). Inescapable shock, neurotransmitters, and addiction to trauma: Toward a psychobiology of Post-traumatic stress. Biological Psychiatry, 20, 314-325.
9. Salovey, P., & Mayer, J. D. (1990). Emotional intelligence. Imagination, cognition, and Personality, 9, 185-211.
10. Mayer, J. D., & Gaschke, Y. N. (1988). The experience and meta-experience of mood. Journal of Personality and Social Psychology, 55, 102-111.
11. Mayer , J. D. & Stevens, A. A. (1994). An emerging understanding of the reflective (meta-) experience of mood. Journal of Research in Personality, 28, 351-373.
12. Gunderson, J. G. & Sabo, A. N. The phenomenological and conceptual interface between borderline personality disorder and PTSD. American Journal of Psychiatry, 150 (1), 19-27.
13. Herman, J., Perry, J. & van der Kolk, B. (1989). Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 22, 231-237.
14. Salovey, P., Mayer, J. D., Goldman, S. L., Turvey, C. & Palfai, T.P. (In press) Emotion attention, clarity, and repair: Exploring emotional intelligence using the Trait Meta-Mood Scale. In J. Pennebaker (Ed.) Emotion, disclosure, and health. Washington, D.C.: American Psychological Association.
15. Mayer, J. D., & Salovey, P., Gomberg-Kaufman, S., & Blainey, K. (1991). A broader conception of mood experience. Journal of Personality and Social Psychology, 60, 100-111.
16. Ansorge, S. Orsillo, S. M. Litz, B. T.& Bergman, E. D. Feelings about feelings: The meta-experience of emotion in PTSD. Paper presented at the 10th Annual Meeting of the International Society for Traumatic Stress Studies, Chicago, 1994.
17. Foa , E. B., & Kozack, M. J. (1986). Emotional processing of fear: Exposure to corrective information, Psychological Bulletin, 99, 20-35.
18. Rachman, S. (1980). Emotional processing. Behavioral Research and Therapy, 18, 51-61.
19. Hyer, L.A., Woods, M.G., & Boudewyns, P.A. (1991). PTSD and alexithymia: Importance of emotional clarification in treatment. Special Issue: Psychotherapy with victims. Psychotherapy, 28, 129-139.
20. Greenberg, L. S. & Safran, J. D. (1987). Emotion in psychotherapy. New York: The Guilford Press.
21. Linehan, M.M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York.: The Guilford Press.