In 1988, Bobby McFerrin wrote a hit song based on words of wisdom from Indian mystic Meher Baba; the message was simple, “don’t worry, be happy.” The original music video for the song guest starred Robin Williams and included imagery of suicidal ideation. The fact that Williams committed suicide about 25 years later further underscores the importance of the song’s message. But how does one manage to stop worrying and by happy? Throughout this series of blog posts, I have discussed processes involved in modulating emotion including models of emotion regulation (ER) and specific ER strategies like avoidance and rumination. In this last post, I will briefly discuss how ER can be used to help treat posttraumatic stress disorder (PTSD).
A recent meta-analysis conducted by Seligowski and colleagues (2014) examined the association between different ER strategies and posttraumatic stress symptoms. Their results indicated large effect sizes for overall general emotion dysregulation, as well as rumination, thought suppression, and experiential avoidance; medium effect sizes for expressive suppression, and worry; and non-significant effects for acceptance and reappriasal. These findings suggest that more maladaptive types of ER are strongly associated with posttraumatic stress symptoms than adaptive ER strategies (Seligowski et al., 2014); this may help maintain the symptoms of PTSD (detailed in APA, 2013). Given these results, it makes sense that most psychological treatments for PTSD address emotion dysregulation.
Bisson and colleagues (2013) recently reviewed the current, most popular psychological therapy-based treatments for PTSD in adults: exposure therapy, cognitive therapy, and eye movement desensitization and reprocessing (EMDR). Exposure therapy involves having the patient “relive or re-experience” their trauma using imagery techniques like autobiographical scripts, cues associated with the trauma, or virtual reality simulators (Bisson et al., 2013). This type of therapy is designed to extinguish a classically conditioned fear response and addresses maladaptive avoidance strategies of ER (see Blog Post 2 for more information on classical and operant conditioning in avoidance learning in PTSD).
Cognitive therapy involves having a patient identify their distorted thinking regarding themselves, their trauma, or the world and utilizes ER techniques to challenge and alter these distorted views (Bisson et al., 2013). The four main components of cognitive therapy are psychoeducation, anxiety management, exposure, and cognitive restructuring (Bisson et al., 2013). There are many different types of therapies available that emphasize each of these components to varying degrees (for a recent review of cognitive therapies for PTSD, see Kar, 2011).
EMDR was pioneered by Shapiro (1989) and involves having patients focus on an aspect of their trauma whilst concurrently receiving bilateral stimulation (typically via eye movement by tracking the therapist’s fingers). The efficacy of EMDR has been a controversial topic; especially when a meta an analysis from Davidson and Parker (2001) indicated that EMDR with eye movements was no more effective than EMDR without eye movements suggesting that the unique component of this type of treatment did not contribute to the therapeutic effect. However, a more recent meta analysis has indicated that when the secondary task engages working memory, it can help attenuate trauma-related memories (Lee & Cuijpers, 2013).
All of these psychological treatments have been shown to be more effective than waitlist or usual care, but differences in efficacy between each type of treatment remains unclear (Bisson et al., 2013). Additionally, dropout and nonresponse rates are high for therapy (some estimates are as high as 50%) most likely due to emotional discomfort during treatment and the length of treatment (Schottenbauer et al., 2008). Clearly, more research is needed to improve treatment response rates.
Identifying predictors of treatment response is one way to help improve response rates. Recently, Shin and colleagues (2013) reviewed neuroimaging predictors of treatment response in anxiety disorders including PTSD. Lower pre-treatment activation to masked fearful faces in the amygdala and rACC has been shown to predict treatment response to cognitive therapy (Bryant et al., 2008a). Increased pre-treatment gray matter density in the rACC was demonstrated in responders to cognitive therapy compared to non-responders (Byrant et al., 2008b). Additionally, greater gray matter density in several limbic and prefrontal areas was also seen in responders to EMDR compared to non-responders (Nardo et al., 2010). Shin and associates (2013) suggested that pre-treatment measures of the amygdala and rACC may be the most promising predictors of treatment response, but more research is needed to confirm this theory.
In summary, emotion dysregulation and maladaptive ER strategies are associated with PTSD symptomatology. Fortunately, psychological therapies utilizing more adaptive ER techniques have been developed to treat PTSD. While these therapies can be effective for many individuals, non-response rates and attrition are still problematic. New research aimed at identifying predictors of treatment response is imperative to continue to improve treatment efficacy. Clearly, ER is a critical component of both the symptomatology as well as the treatment of PTSD, hopefully we can continue to use ER to develop better treatment techniques.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. (5th ed.). Arlington, VA: American Psychiatric Association.
Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 12. DOI: 10.1002/14651858.DC003388.pub4.
Bryant, R. A., Felmingham, K., Kemp, A., Das, P., Hughes, G., Peduto, A., & Williams, L. (2008a). Amygdala and ventral anterior cingulate activation predicts treatment response to cognitive behaviour therapy for post-traumatic stress disorder. Psychological Medicine, 38(4):555-61.
Bryant, R. A., Felmingham, K., Whitford, T. J., Kemp, A., Hughes, G., Peduto, A., & Williams, L. M. (2008b). Rostral anterior cingulate volume predicts treatment response to cognitive-behavioural therapy for posttraumatic stress disorder. Journal of Psychiatry and Neuroscience, 33(2):142-6.
Davidson, P. R., & Parker, K. C. H. (2001). Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology, 69: 305-16.
Kar, N. (2011). Cognitive behavioral therapy for the treatment of post-traumatic stress disorder: a review. Neuropsychiatric Disease and Treatment, 7: 167-81.
Lee, C. W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movement in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231-9.
McFerrin, B. (1988). Don’t Worry, Be Happy. On Simple Pleasures [LP]. EMI-Manhattan Records.
Nardo, D., Hogberg, G., Looi, J. C., Larsson, S., Hallstrom, T., & Pagani, M. (2010). Gray matter density in limbic and paralimbic cortices is associated with trauma load and EMDR outcome in PTSD patients. Journal of Psychiatric Research, 44(7):477-85.
Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Gray, S. H. (2008). Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry, 71(2): 134-168.
Seligowski, A. V., Lee, D. J., Bardeen, J. R., & Orcutt, H. K. (2014). Emotion regulation and posttraumatic stress symptoms: a meta-analysis. Cognitive Behaviour Therapy, DOI: 10.1080/16506073.2014.980753.
Shapiro, F. (1989). Eye movement desensitization: a new treatment for post-traumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 20(3):211-7.
Shin, L. M., Davis, F. C., VanElzakker, M. B., Dahlgren, M. K., & Dubois, S. J. (2013). Neuroimaging predictors of treatment response in anxiety disorders. Biology of Mood and Anxiety Disorders, 3(15), DOI: 10.1186/2045-5380-3-15.