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SPECIFICITY OF EMOTIONAL PROCESSING IN POSTTRAUMATIC STRESS DISORDER


Dana Cristina Her? a1, Doina Cosman1, 2
Abstract: Posttraumatic stress disorder (PTSD) represents, from a clinical perspective, an entity characterized by a complex psychopathological pattern of symptoms triggered by the exposure to a traumatic event, while from a phenomenological perspective it entails a specific, dysfunctional pattern of maladjustive affective, cognitive and behavioral reactions to a specific type of events. If an interpretation of real or potential life threat, paired with helplessness and intense negative affect of fear or horror, is provided to negative or even neutral events, trauma related stimuli may elicit an operant conditioning through which the complex clinical features pf PTSD develop. The current study is an overview of specific isuues of emotional processing in PTSD emerged from current research, with an emphasis on the phenomenology of this disorder, due to the fact that PTSD dynamic is conditioned by specific life events, a specific family, sociocultural and developmental context and, mostly, by the presence of individual vulnerability expressed by rigid, dysfunctional, maladjustive and context inappropriate affective, behavioral and cognitive reaction patterns. Keywords: posttraumatic stress disorder, emotional processing, phenomenology, vulnerability. Rezumat: Tulburarea de stres posttraumatic (PTSD) reprezint, din perspectiv clinic, o entitate caracterizat printr-un tablou simptomatologic complex, declan?at de expunerea la un eveniment traumatizant, iar din perspectiv fenomenologic, un tipar specific, disfunc? ional, de reac?ie dezadaptativ afectiv, cognitiv ?i comportamental la o anumit categorie de evenimente. Dac evenimentelor negative sau chiar neutre li se furnizeaz o interpretare implicnd risc vital real sau poten? ial asociat cu neputin? ?i reac? ii afective intense de teroare sau spaim, stimulii rela? iona? i cu evenimentul incriminat pot genera un proces de condi? ionare operant prin intermediul cruia s se constituie tabloul psihopatologic complex al PTSD. Studiul de fa? trece n revist aspectele specifice ale prelucrrii emo? iilor n PTSD eviden? iate de studiile recente, cu accent pe latura fenomenologic a genezei acestei tulburri, avnd n vedere c dinamica PTSD este condi? ionat de un anumit tip de evenimente de via? , un anumit context familial, socio-cultural ?i de dezvoltare ?i, mai ales, de prezen? a vulnerabilit? ii individuale sub raportul tiparelor afective, comportamentale ?i cognitive rigide, disfunc? ionale, neadecvate la context ?i dezadaptative. Cuvinte cheie: tulburarea de stres posttraumatic, procesare emo? ional, fenomenologie, vulnerabilitate. in this respect the role of the dimensional variables valence (positive, negative) and arousal, specific to emotional experience and neurophysiological activity. Affect, as a complex of phyisiological and motivational factors (1), refers to mood (lasting affective state, flexible and adaptive reflection of inner feelings to environmental context) and feelings (intense, transient, positively or negatively polarized affective states generated by specific experiences), and additionally to appraisals, attitudes and preferences (2). Emotions differ from basal mood through duration (brief for emotions, sustained for mood), intensity (high emotions, and low mood), and presence (in emotions) or absence (in mood) of a specific target, respectively (14). The plasticity of emotional processing throughout development, and the origin of its individual and inter-individual variations can be partly explained through the involvement of distinctive neural mechanisms in different aspects of emotional expression (15). It is noteworthy that emotional generation and/or regulation based on individual stimulus expectancies is

Some authors regard basic emotions as the building blocks of emotional life, leading to more elaborate emotional processes through recombination (1). A range of basic emotions, universally true and with a socioculturally modulated expression, were identified anger, disgust, fear, happiness, sadness and surprise (2), generated by stimuli with positive or negative valence. However, there is no consensus yet regarding the number and type of basic emotions, due to the diversity of distinctive definition criteria (1). Thus, basic emotions have been identified by a unique neural pattern (3), unique appraisal pattern (4), unique response tendency (5), unique pattern of physiological response (6), unique facial expression (7), or unique experiential trait (8). Other studies dwell on the hypothesis that emotional life is based on a limited set of sub-emotional variables. Thus, six appraisal variables have been postulated (novelty, valence, relevance, congruence of the purpose, coping potential, instrumental traits) (9), structured as dimensional (10) or discrete variables (11, 12), hence the infinity of complex specific emotions generated by their combinations. Russell (13) emphasizes
1

rd Department of Clinical Psychology, University of Medicine and Pharmacy Iuliu Ha? ieganu Cluj-Napoca. Contact data: 3 Psychiatric Clinic ClujNapoca, Str. V. Babe? 43, Pavilion III, 400012, Romania; Tel/fax 0264590576; email: dana_cristina75@yahoo.com 2 rd 3 Psychiatric Clinic, Cluj County Emergency Hospital Received October 03, 2011, Revised January 09, 2012, Accepted February 02, 2012.

Dana Cristina Her? a, Doina Cosman: Specificity Of Emotional Processing In Posttraumatic Stress Disorder

emotions or the explicit purpose of their regulation (16), in the absence of explicit instructions concerning these processes (11, 17). On the other hand, it was demonstrated that the pathway and timing of key periods for the development of the affective functions depend on behavioral and expressive context. Increased insight into the genetic, neural, developmental context and individual affective experience allows a better understanding of the development of the emotion recognition process, but also of the manner emotional processing is integrated in interpersonal relationships and group-specific social behaviors (18), as the role of emotions cannot be separated from the context of interpersonal relationships (19). Thus, the ability to recognize and share emotions represents the core of empathy and prosocial behaviors, facilitates social learning that is, the ability of the human being to learn and build knowledge by observing emotional reactions of others and, last but not least, elicits moral and ethical behaviors (18). INVOLVEMENT OF EMOTIONAL PROCESSING IN THE DYNAMICS OF POSTTRAUMATIC STRESS DISORDER The cingulate striatal thalamic cingulate circuit, formed by subgenual neurons in the anterior cingulate cortex projecting to nucleus accumbens (20), is involved in complex issues related to emotional processing: assessment of the intensity of emotions, syncronicity between emotions and the functioning of the autonomous nervous system, anticipatory reaction to an event with aversive emotional undertones, management of emotional conflicts (21). Neurophysiology and neuroimagistics studies suggest that specific cortical areas, such as amygdala, insular and ventromedial prefrontal cortex, are crucial for emotional processing and integrating emotions with superior cognitive skills, with the purpose of adequate interpersonal functioning (22); however, other regions of the central nervous system (cerebellum, ventral striatum) also have an input (23 25). Amygdala plays a key role in the perception of specific, emotionally-charged stimuli, and in pairing aversive stimuli with context appropriate emotional response ex. fear (26). Insular cortex, on the other hand, monitors somatic visceral states (27). It was shown that dysfunctions in these areas lead to impaired reasoning and decision making, with repercussions on social functioning (22). Recent imagistic studies emphasized that reaction patterns generated in the amygdala are related to dopamine D2 receptor activity (28). Dopamine mediation in the amygdala has been involved both in emotional processing, and in the control of emotionelicited behaviors (29, 30). On the other hand, D2 dopamine receptors and the DRD2 gene have been linked with the explicit emotion processing and emotion regulation supported by the prefrontal dorsolateral cortex (31). These data lead to the hypothesis that D2 receptor dopamine mediation shares a common genotype background, but with different, structure and functionspecific phenotype expressions, considering that amygdala is involved in emotion perception, while 2

the prefrontal dorsolateral cortex is responsible of conscious, explicit appraisal of emotions (32). Emotional appraisal, regulation and experiencing are intricately liked with the activation patterns of the prefrontal dorsomedial cortex and rostral area of the dorsal cingulate cortex (17, 21, 22). Operant conditioning theory provides an explanation to the pattern of association between the traumatic event (unconditional stimulus) generating unconditional emotional response (fear, horror, helplessness) and specific trauma-context stimuli, which may elicit intense conditioned emotional response by subsequent repeating after the event. Avoidance behaviors develop in this context in order to decrease the anxiety related to conditional stimuli. Cognitive processing of an unexpected or severe event and management of its impact are impaired in subjects developing PTSD, while traumatic experience, incompletely or ineffectively assimilated, lingers in the field of consciousness in the shape of intrusive recollections (33). Dysfunctional conditional response pattern to fear in PTSD is reinforced through increased glutamate neurotransmission in amygdala, in the absence of ventromedial prefrontal cortex inhibition (20), while emotional processing in this context is modulated by a plethora of pretraumatic, traumatic (fragmented representations of trauma memories somatic states, stimuli, feelings and cognitions reflecting intense fear, helplessness, discomfort, confusion) and posttraumatic factors (20, 33, 34). Emotions can be conceptualized as reflected and mentally reactivated somatic states, and the association between events and their affective background may influence superior cognitive processes decisionmaking, respectively, mostly in uncertain situation or when the subject has to chose between a great number of alternatives (35). Integration of information that would eventually modify the event appraisal, especially the issues related to danger degree, is required in order to decrease fear and extinguish maladjustive conditional response. Thus, by repeated exposure to a specific conditional stimulus with no negative consequences, ventromedial prefrontal cortex and hippocampus will send afferences to amygdala that will gradually inhibit fear response and decrease its intensity, although affective memory of trauma persists (20) see Figure 1. The emotional processing theory was advanced as a more flexible pattern of understanding the mechanisms involved in recovery after trauma, and in PTSD onset, respectively. The core concept of this model is fear, defined as a thriarchial structure stimulus, meaning and response (physiological, behavioral, verbal), and complex interconnections between these elements provide the decisional base of conflict avoidance vs. danger confrontation (34). Sensory input is integrated in the amygdala with ventromedial prefrontal cortex (VMPFC) and hippocampal afferences, thus triggering or suppressing the response to a stimulus appraised as threatening (20). This flexible fear reaction model is adaptive if based on a realistic appraisal of the danger degree and individual resources, but it may become maladjustive in the following contexts (34):

Romanian Journal of Psychiatry, vol. XIV, No.1, 2012 have lower levels of emotional avareness and adaptability during the processing of emotionally charged non-traumatic events, compared to healthy individuals (40, 41). Furthermore, high levels of emotional awareness in controls (ascertained by higher LEAS scores) were positively correlated with the activation of the ventral regions of the anterior cingulate and ventromedial prefrontal cortex, in contrast with PTSD subjects, in which LEAS scores were negatively correlated with the activation levels of the aforementioned areas (38). Also, in the same PTSD sample, the intensity of alexythymia was negatively correlated with the level of emotional awareness, while both negatively correlated with the degree of activation of the rostral area of the cingulate anterior cortex, which requires further clarifications (42). A potential interpretation of this paradox may be that increased emotional awareness paired with low adaptive impact may be linked with an increased level of alexithymia; increased emotional awareness of a response entailing intense negative affect can become maladjustive (38, 42). Another potential explanation may be that individuals with impaired emotional awareness also exhibit impaired recognition of the elements of alexithymia (38), which is supported by the observation that subjects with alexithymia have extreme levels of emotional awareness either very high, or very low (42). Therefore, both emotional awareness level and the adaptive impact of individual emotional response need to be considered in PTSD subjects (41, 42). CLINICAL ISSUES IN POSTTRAUMATIC STRESS DISORDER Posttraumatic stress disorder (PTSD) is a condition triggered by the exposure to a traumatic event which: generates feelings of helplessness, intense fear and horror; involves real or perceived life threat, and poses a threat to the physical integrity of the person or others. Core symptoms of PTSD are: re-experiencing of trauma related issues, avoidance of trauma related stimuli, arousal and numbing, while the time interval from the traumatic event to the onset of the disorder is also a diagnostic criterion (43). PTSD onset involves a specific degree of severity of the event unexpected/violent confrontation with death, severe trauma, threat posed on the integrity of the subject or others, paired with a specific individual reaction to the event intense fear, helplessness, horror (33). As a number of negative life events are experienced by a significant proportion of persons throughout their existence without meeting the criteria of trauma that may potentially trigger PTSD, the definition of the traumatic event has undergone many changes in time, and a conceptual clarification of PTSD, as a complex entity reported to both the event per se, and the individual response to the event, was currently reached (44, 45). Etiopathogeny of PTSD entails complex interactions between the severity of the traumatic life event, individual vulnerability and peritraumatic environmental factors (33). Moreover, recent studies suggest that a heterogeneity of symptom patterns may develop, depending on the nature of the traumatic event (43). PTSD diagnostic criteria include individual symptoms that can be ascertained in a variety of anxiety 3

Figure 1: Patterns of conditional learning and extinction of fear response (20) -Stimulus unrealistically represented and appraised as threat -Physiological and behavioral flight response to neutral stimuli -Too intense/rash response to stimuli, interfering with adaptive behaviors -Unrealistic associations between stimulus and other response components Basically, the specific features of this structure in subjects that develop PTSD are: association of stimuli with erroneous danger appraisal, and connection of exaggerated or dysfunctional response to stimuli with an erroneous appraisal of incompetence and helplessness, respectively (20, 21, 34). The hyerachical developmental model of emotional processing posits that sensations represent basic physiological elements of emotional awareness, through modulation, representation and refining which generates superior levels of conscious cognitive processing specific to individuals endowed with superior emotional intelligence and awareness, along with a degree of complexity of emotional experience that would facilitate affective regulation (36). Operating within this theoretical model, some authors suggested that subjects exposed to trauma and with no subsequent psychiatric disorders may be characterized by a higher degree of emotional awareness, compared to those that develop PTSD (37, 38). Moreover, it was suggested that both individuals that develop PTSD, and those with no subsequent posttraumatic psychopathology present levels of activation in the anterior cingulate cortex and medial prefrontal cortex during exposure to trauma related stimuli, that appear associated with the degree of emotional awareness (38), assessed through the Levels of Emotional Awareness Scale (LEAS) (39). Recent studies confirmed that PTSD subjects

Dana Cristina Her? a, Doina Cosman: Specificity Of Emotional Processing In Posttraumatic Stress Disorder

patterns, irritability, hyperarousal, limited attention span, increased startle response (symptoms indicating the state of arousal), decreased interest for otherwise pleasant activities, aloofness, detached and constricted affect, limited projection in the future (33). What makes this clinical entity specific is the onset of the aforementioned symptoms consecutively to an extraordinary event that involves real or perceived threat to physical integrity, and generates intense negative affect horror, helplessness, fear, thus supporting the classification as a distinctive disorder (46). The importance of co-morbidities in PTSD stems from the following observations: on one hand, increased rates of depression, anxiety disorders and substance-related disorders were found in patients with PTSD, which may involve a common etiological mechanism (47, 48). Moving beyond categorial outlook, it was also observed that subjects with subclinical PTSD can also present with severe functional impairment, high comorbidity rates and even suicide ideation (46, 47). On the other hand, neurophysiological patterns of response are significantly different in PTSD subjects, compared to those diagnosed with the aforementioned disorders, which generates a vast research field i.e. the difference between normal and pathological response to trauma (27, 33, 34). VULNERABILITY AND RESILIENCE IN THE PROCESS OF COPING WITH TRAUMA Individual patterns of cognitive and affective response to trauma play a key role in coining the concept of PTSD (33). The need to include the subjective component of trauma emotional participation (intense negative emotions experienced during the traumatic event) and its individual appraisal in current PTSD research is supported by the finding that these factors influence the development of PTSD clinical features (43), along with the individual perception regarding the degree of controllability of the traumatic event (46), developmental individual vulnerability factors, individual coping styles and posttraumatic social support, prior history of trauma and family history of psychopatology (46, 49). A comprehensive stress-response model was advanced as an overview of biological and sociocultural individual vulnerability factors, as well as resilience and protective ones, capturing a developmental continuum of PTSDspecific symptoms, in stark contrast with the flexibility of adaptive reactions in resilient individuals (49) see figure 2. Thus, in the early stage of acute exposure to the traumatic event, both resilient persons and subjects with individual neurobiological vulnerability will exhibit acute stress response associated with fear and anxiety feelings (33, 49). As far as the emotional impact of traumatic events is concerned, what distinguishes vulnerable subjects is the intensity of arousal and of emotions with negative valence, while negative cognitive appraisals and dissociation create the premises for the onset of PTSD symptoms (49). In vulnerable subjects, recollections of the traumatic event, precipitated by internal or external stimuli resonating with the trauma symbols, may extend to recurring intrusions of the incriminated event in sleep, 4

perceptual (illusions, hallucinations, dissociative flashbacks), emotional (intense feelings with negative valence) and behavioral (exhausting avoidance of all external and internal factors associated with trauma) re-experiencing of trauma, paired with intense physiological arousal (33).

Figure 2: Models of genesis and evolution of stress response (34) Some persons with resilience resources (social support, internal neurobiological factors, effective coping mechanisms) may develop transient or subclinical symptoms from the depression, anxiety or PTSD spectrum in the immediate aftermath of trauma exposure (33, 46, 49). Nevertheless, resilient subjects have a common specific ability to provide a neutral cognitive appraisal to traumatic events (49). Subjects with increased risk for PTSD can be identified based on specific factors, regarded as predictors of clinical severity and evolution of the aforementioned disorder, such as: degree of negative emotional reaction (fear, anger), dissociation and numbing, and also on the level of interpersonal distress inducted by the traumatic event (50). Hyperarousal, superficial sleep and avoidance behaviors triggered by trauma-related stimuli may become necessary and adaptive responses of selfpreservation in the context of a realistically appraised imminent life-threat; constricted affect may be justified if the uncensored expression of anger triggered the event; also, recollections of the event, even obsessive ones, may fit the pattern of a necessary, effective and adaptive process of meaningful reframing and appraising of the terrifying experience, its impact and consequences, in

Romanian Journal of Psychiatry, vol. XIV, No.1, 2012 order for the resilient persons to incorporate those meanings into their history and draw lessons for their developmental future (49). Posttraumatic stress disorder state-of-the-science review of current research status Although data from current neuroimagistic studies unravel relevant research directions in the field of PTSD, some limitations ought to be taken into account. Thus, the respective studies usually employed stimuli with negative emotional valence, while neural activation patterns for positive emotions in PTSD is insufficiently known. Also, standardized emotioneliciting stimuli may have general relevance to some subjects, while others may appraise them as specific for the PTSDgenerating event, given the individual specificity of the traumatic event (51, 52, 53). Some neuroimagistic and functional anomalies observed in PTSD subjects may potentially represent family vulnerability factors, as opposed to consequences of exposure to trauma (33, 34, 41, 49). Repeated exposure to emotionally charged stimuli may generate a decrease in the amygdala activation pattern over time, i.e. a potential toning down of the difference between controls and PTSD subjects with amygdala hyperactivation patterns (53), which emphasizes the importance of the extent of exposure to stimuli with negative emotional valence (49). Regarding research methods, transversal studies cannot ascertain whether the dysfunctional neural activation patterns described in PTSD existed prior to trauma or were generated by it hence the comparative assessment of PTSD samples versus both healthy volunteers, and trauma exposed subjects who did not subsequently develop PTSD (52). Results of veteran studies cannot be extrapolated to civilian populations, i.e. of both sexes and with a heterogenous distribution of age, nature of trauma, and pattern of exposure (55, 56). Last but not least, Axis I and II co-morbid conditions, common in PTSD, may contribute to the neural activation patterns previously described (41, 48, 52, 53); however, excluding individuals with comorbidities is not always an efficient solution, because resulting samples have a low significance from the viewpoint of the characteristics of the general PTSD population (41, 46, 53). Exposure to trauma affectively and cognitively imprints individual and collective destiny, in the current context of globalization and acculturation. A plethora of psychopathological, neurobiological and sociocultural arguments confirm the key role of individual risk and resilience factors, intricated in a kaleidoscopic structure shaped by the subject's developmental dynamics. It matters less how many times one falls, it matters more how many times one stands back up again, therefore the efficiency of this structure is assessed through the appropriateness of context appraisal and the adaptive flexibility of individual response. CONFLICTS OF INTERESTS. The authors do not have any conflicts of interests to report. FUNDING SUPPORT AND ROLE OF THE FUNDING SOURCE. The article is a part of a PhD research co-funded by the Social European Fund through the Operational Structural Programme for the Development of Human Resources (POSDRU) 2007 2013 Invest in people! Doctoral Studies: through science to society, Contract Code 6/1.5/S/3, University Babe Bolyai, ClujNapoca, Romania. REFERENCES
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