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. Author manuscript; available in PMC: 2021 Dec 1.
Published in final edited form as: Traumatology (Tallahass Fla). 2020 Aug 20;26(4):396–404. doi: 10.1037/trm0000279

Distress Tolerance Interacts with Peritraumatic Emotions to Predict Posttraumatic Stress Symptoms Following Sexual Victimization

Caitlyn O Hood 1, Alyssa C Jones 1, Jessica Flores 1, Christal L Badour 1, Matthew T Feldner 2,3
PMCID: PMC7992979  NIHMSID: NIHMS1616855  PMID: 33776596

Abstract

The intensity of peritraumatic emotions occurring at the time of, and in the hours or days immediately following, a traumatic event prospectively predicts posttraumatic stress symptom severity. However, less is known about how the perception of one’s ability to tolerate distressing emotions affects the relation between peritraumatic emotions and posttraumatic stress symptoms. Therefore, the current study investigated how perceived distress tolerance affects the association between peritraumatic emotional intensity and symptoms of posttraumatic stress. Participants included 72 adult women with a history of sexual victimization. Ratings of peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), perceived distress tolerance, and posttraumatic stress symptoms were examined. All analyses controlled for general negative affect. Significant interactions emerged for overall peritraumatic emotional intensity, and specifically for peritraumatic anger, sadness, and shame. The associations between these peritraumatic emotions and posttraumatic stress symptoms were stronger for individuals with lower perceived ability to tolerate distress. Our results suggest that peritraumatic emotional experiences may be particularly relevant to understanding the development and maintenance of posttraumatic stress symptoms among individuals who have difficulty tolerating intense negative emotional states. Future research should examine whether perceived distress tolerance might serve as a potential target for posttraumatic stress prevention efforts.

Keywords: peritraumatic emotion, posttraumatic stress, PTSD, distress tolerance, sexual victimization

Peritraumatic responses to environmental stressors are multifaceted and can include a variety of cognitive, emotional, physiological, and behavioral reactions (Vance et al., 2018). In Bovin and Marx’s (2011) model depicting the interactive components of peritraumatic responses, a person must first appraise an environmental stressor or potentially traumatic event as taxing to their available resources or as a threat to their well-being. Following this initial appraisal, a person may experience a peritraumatic emotional reaction, consisting of subjective emotions, additional cognitions, and physiological responses. Peritraumatic emotions (or negative emotions felt at the time of or in the hours and days following a traumatic event) often include fear, anger, sadness, guilt, and shame. Each emotion is associated with a different appraisal and may prompt a behavioral urge (Power & Dalgleish, 2015). For example, fear is related to the appraisal of immediate danger and a flee or freeze urge; anger is linked to the appraisal of a blocked goal or a crossed boundary and an approach urge; and sadness relates to the appraisal of loss or failure and a withdrawal or retreat urge. Shame and guilt are considered self-conscious emotions in which a person negatively appraises themselves (shame) or their behavior (guilt) as failing to meet a set of standards or goals. Whereas guilt may prompt an individual to change their behavior, shame is associated with the tendency to withdraw or isolate. Peritraumatic emotional responses may initially prompt individuals to engage in behaviors that facilitate survival or safety seeking. However, peritraumatic emotions also have been associated with the development of trauma-related psychopathology, including posttraumatic stress disorder (PTSD) symptoms (Bovin & Marx, 2011; Hathaway et al., 2010; Lancaster et al., 2011; Resick & Miller, 2009).

There is a robust literature on the relation between peritraumatic fear and subsequent PTSD symptoms, which has been proposed to occur largely through the process of fear conditioning (Foa & Kozak, 1986; Keane et al., 1985). Specifically, previously neutral cues (e.g., sights, smells, sounds) associated with a traumatic event acquire the ability to trigger intense fear responses following a trauma, even in the absence of actual or perceived threat of harm. Persistent behavioral escape and avoidance of conditioned stimuli associated with the trauma result in the maintenance of posttraumatic stress reactions. Yet, other peritraumatic emotions have been associated with PTSD symptoms above and beyond experiences of fear. For example, Lancaster and colleagues (2011) found that greater intensity of peritraumatic anger, sadness, guilt, and disgust - but not shame - were associated with more severe PTSD symptoms when controlling for experiences of fear, helplessness, and horror. In other studies, higher intensity of peritraumatic shame has been associated with more severe PTSD symptoms after accounting for fear (Vásquez et al., 2012), particularly for individuals exposed to interpersonal violence (e.g., physical or sexual assault; La Bash & Papa, 2014). Peritraumatic emotions other than fear may relate to PTSD symptoms through a similar conditioning process similar to that described above.

Peritraumatic emotions may occur in isolation or in combination with one another. To explore this idea, Lancaster and Larsen (2016) examined the combined effect of multiple peritraumatic emotions (e.g., fear, helplessness, horror, anger, sadness, guilt, shame, disgust, and confusion) on PTSD symptoms among trauma-exposed undergraduate students using a latent profile analysis. The profiles associated with the most considerable functional impairment were those characterized by high intensity of each peritraumatic emotion, and those characterized by high intensity of anger and guilt but low-to-medium intensity of other emotions. Moreover, the majority of individuals who were categorized into the high overall peritraumatic emotion and the high anger/guilt profiles reported experiencing interpersonal violence (e.g., childhood physical or sexual assault) as their worst or most distressing traumatic experience. Thus, the intensity of specific peritraumatic emotions, as well as the intensity of overall peritraumatic emotional distress, may differentially relate to PTSD symptomology.

Distress tolerance has been proposed as both a risk and a maintenance factor for PTSD (Vujanovic et al., 2015). Distress tolerance is conceptualized as having two components: the perceived ability to, and the behavioral act of, enduring negative emotional, aversive, or frustrating experiences (Leyro et al., 2010). Among trauma-exposed individuals, one’s perceived ability to withstand negative emotions is more relevant for understanding PTSD symptomology than one’s perceived or actual ability to tolerate aversive or frustrating experiences. For instance, Marshall-Berenz and colleagues (2010) compared responses on the Distress Tolerance Scale (DTS; Simons & Gaher, 2005) - the most commonly used measure of a person’s perceived ability to tolerate emotional distress - with self-report (e.g., Discomfort Intolerance Scale; Schmidt et al., 2006) and behavioral (e.g., mirror-tracing task and breath-holding task) indices of a person’s ability to endure physical discomfort or frustration. Of all the measures assessed, only scores on the DTS were negatively related to PTSD symptom severity. Additionally, scores on the DTS have been inversely associated with both global PTSD symptom severity and individual PTSD symptom clusters (Vujanovic et al., 2011; Vujanovic et al., 2017).

In line with the aforementioned model of peritraumatic responses to potentially traumatic events proposed by Bovin and Marx (2011), individuals who perceive that they are less able to tolerate distressing emotional experiences may be more likely to negatively appraise their emotions experienced at the time of, and in the hours or days immediately following, a traumatic event (e.g., “I couldn’t handle it”). Such negative appraisals may also lead individuals to avoid subsequent reminders of the trauma, thus limiting exposure and maintaining conditioned emotional reactions to trauma cues. For example, perceived distress tolerance has been negatively related to the severity of PTSD symptoms among trauma-exposed individuals who demonstrate high, but not low, levels of general negative affect (Vujanovic et al., 2013). However, it is unknown whether perceived distress tolerance moderates the association between peritraumatic emotions and PTSD symptoms.

The current study sought to expand upon extant work by (a) examining the relation between peritraumatic emotional intensity and posttraumatic stress symptom severity among a sample of women with a history of sexual victimization and (b) investigating whether perceived distress tolerance moderated this association. This study included sexually-victimized women, as unwanted sexual experiences have been linked to increased peritraumatic emotional intensity (Amstadter & Vernon, 2008) and the subsequent development of PTSD symptoms (Kilpatrick et al., 2017) to a greater degree than other trauma types. General negative affect was included as a covariate in all models given possible associations with peritraumatic emotion intensity and posttraumatic stress symptom severity. It was hypothesized that higher overall peritraumatic emotional intensity would be associated with more severe posttraumatic stress symptoms (Vance et al., 2018). It was also expected that the relation between overall peritraumatic emotional intensity and posttraumatic stress symptoms would be stronger among individuals with lower levels of perceived distress tolerance (Vujanovic et al., 2013). Given the mixed findings from prior research, exploratory analyses were conducted to examine the relations among the intensity of specific peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), distress tolerance, and posttraumatic stress symptoms.

Method

Participants

The present study was part of a larger investigation involving an experimental investigation of affective responses to trauma cues (Badour & Feldner, 2016). Participants included a sample of 72 community-recruited adult women (Mage = 31.15, SD = 13.17). All participants reported having a history of at least one experience of sexual victimization that satisfied the definition of a Criterion A trauma within the PTSD diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994). Women were excluded from study participation at the initial phone screening or in-person baseline assessment if they: 1) evidenced limited mental competency and the inability to give informed, voluntary, written study consent; 2) demonstrated current suicidal ideation with intent; 3) had a memory of the most distressing (i.e., index) trauma that resulted due to spontaneous or assisted recovery (this criterion pertained to the larger study); or 4) experienced any traumatic event in the month prior to participating in the study. Participants were predominantly white (79.2%), non-Hispanic (93.1%), single (56.8%), and completed at least some college (88.8%).

Participants reported a history of the following types of non-consensual sexual acts: vaginal intercourse (36.1%), anal intercourse (4.2%), oral intercourse (19.5%), exposing of sex organs (22.2%), touching/fondling of sex organs (50.0%), and other (8.3%). The majority of participants (84.7%) reported multiple non-consensual sexual acts. Perpetrators included relatives (38.9%), intimate partners/spouses (8.3%), acquaintances (11.1%), dates (6.9%), friends (9.7%), other known persons (12.5%), and strangers (12.5%). Six percent of women reported multiple perpetrators. The average age at which the index (i.e., worst or most distressing) sexual trauma occurred was 14.00 years (SD = 9.20; range: 1–47). Of the index non-consensual sexual acts reported in the current study, 69.4% occurred before participants were 18 years old. Eighteen percent of participants met full diagnostic criteria for PTSD per the DSM-IV (APA, 1994). An additional 19.4% of participants met criteria for subthreshold PTSD per the scoring criteria outlined in Schnurr (2014).

Measures

Posttraumatic Stress

The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) is the gold standard semi-structured clinical interview for assessing posttraumatic stress symptoms and PTSD diagnostic status per DSM-IV defined criteria. In the present study, the CAPS was used to measure past-month severity of posttraumatic stress symptoms and PTSD diagnosis in relation to participants’ index sexual trauma. A symptom severity score was computed by summing the frequency and intensity scores obtained for the 17 symptoms on the CAPS. Past-month PTSD diagnostic status was calculated for descriptive purposes using the 1–2 scoring rule (Weathers et al., 1999). Subthreshold PTSD was defined as reports of at least one Criterion B, one C, and one D symptom, as well as significant trauma-related distress or impairment (Schnurr, 2014). The CAPS demonstrates strong psychometric properties (Weathers et al., 2001). In the current study, internal consistency for the CAPS was excellent (Cronbach’s α = .92).

Peritraumatic Emotions

The Emotion Questionnaire (EQ; Amstadter & Vernon, 2008) was used to retrospectively measure the intensity of peritraumatic emotions experienced at two time points: during and in the hours or days immediately following the index trauma when participants felt the worst. The EQ measures five peritraumatic emotional experiences, including fear, anger, sadness, guilt, and shame. Participants were instructed to rate 17 emotion adjectives (e.g., “afraid,” “angry,” “blue,” “guilty,” “humiliated,” etc.) using a 5-point scale with response options ranging from 1 (not at all) to 5 (extremely). Scores were averaged for each individual peritraumatic emotion subscale (e.g., fear, anger, sadness, guilt, and shame) across the two time points (i.e., during and immediately following the index trauma) and ranged from 1–5. A total score reflecting overall peritraumatic emotional intensity was computed by summing the individual peritraumatic emotion subscales and ranged from 5–25. In the current study, internal consistency for the emotion scales ranged from good to excellent (Cronbach’s αs = .90 − .96).

Distress Tolerance

Participants’ perceived ability to tolerate emotional distress was measured using the 15-item Distress Tolerance Scale (DTS; Simons & Gaher, 2005). Participants responded to statements such as, “Feeling distress or upset is unbearable to me” and “I’ll do anything to avoid feeling distressed or upset” using a 5-point scale with response options ranging from 1 (strongly agree) to 5 (strongly disagree). Higher scores on the DTS represent a greater perception of one’s ability to tolerate distress. Scores on the DTS evidence good convergent and discriminant validity (Simons & Gaher, 2005). Internal consistency for the DTS was excellent in the present sample (Cronbach’s α = .94).

Negative Affect

The general tendency to experience negative affect was assessed using the 10-item negative affect subscale of the Positive and Negative Affect Schedule (PANAS-NA; Watson et al., 1988). Item responses are on a 5-point Likert-type scale ranging from 1 (very slightly or not at all) to 5 (extremely) and measure the extent to which participants generally feel different negative emotions (e.g., “distressed”). Total scores range from 10–50, and higher scores represent higher levels of general negative affect. The PANAS-NA demonstrates excellent convergent and discriminant validity (Watson et al., 1988). In the present sample, internal consistency was excellent (Cronbach’s α = .91).

Procedure

All study procedures were approved by the university’s Institutional Review Board. Recruitment for the parent study occurred between 2011 and 2012. Participants were recruited via electronic and paper flyers, as well as media advertisements displayed in the community. Women deemed eligible at the initial phone screen were invited to complete an in-person baseline assessment prior to laboratory procedures. During the in-person assessment, all participants provided informed consent before completing the CAPS interview and self-report measures (e.g., the EQ, DTS, and PANAS-NA), as well as additional measures and laboratory procedures that are not relevant to the current investigation (see Badour & Feldner, 2016). Participants were then debriefed on study procedures, given information detailing community-based mental health resources, and compensated $40 for their participation.

Data Analytic Approach

First, zero-order correlations were computed to examine relations among posttraumatic stress symptoms, peritraumatic emotions, distress tolerance, and general negative affect. Second, primary hypotheses were tested via simple moderation regression models using the PROCESS macro for SPSS (Hayes, 2012; Hayes, 2013). In separate analyses, overall peritraumatic emotional intensity and each individual peritraumatic emotion subscale (e.g., fear, anger, sadness, guilt, and shame) were entered as the independent variable, distress tolerance was entered as the moderator, and posttraumatic stress symptom severity was the outcome variable. Continuous variables were mean centered prior to entry in the regression models (Aiken et al., 1991). Each regression model included general negative affect as a covariate. An a priori decision was made to adjust for general negative affect, as it could influence both posttraumatic stress symptom levels and peritraumatic emotional reactivity. However, given well-recognized problems with adjusting for covariates (Kraemer, 2015), results from analyses that did not include general negative affect as a covariate are also reported to make clear the impact this covariate had on the results. Significant interactions in models including general negative affect as a covariate were probed using simple slopes analyses (Cohen et al., 2003). Since recollections of peritraumatic emotions may be subject to recall bias—particularly for women who experienced sexual victimization at very young ages—additional regression models were conducted that included the number of years since index trauma exposure as a covariate along with general negative affect. However, the inclusion of years since index trauma as a covariate did not change the primary results of the regression models described below.

Results

Responses on the EQ were missing for one participant, and data from 71 participants were analyzed. Zero-order correlations (Table 1) revealed significant negative associations between distress tolerance and posttraumatic stress symptoms and general negative affect. Distress tolerance was also negatively correlated with peritraumatic emotional intensity overall and specifically with peritraumatic fear. Posttraumatic stress symptoms were positively associated with general negative affect and peritraumatic emotional intensity overall, as well as with peritraumatic fear and shame. General negative affect was positively associated with peritraumatic emotional intensity overall, as well as peritraumatic fear, guilt, and shame. Peritraumatic emotions were positively correlated with one another with the exception of fear and guilt. Results of the regression models are presented in Table 2.

Table 1.

Descriptive Statistics and Zero-order Correlations Among Primary Study Variables

1 2 3 4 5 6 7 8 9
1. CAPS -- −.61*** .75*** .31** .32** .22 .17 .20 .28*
2. DTS -- −.68*** −.26* −.29* −.14 −.16 −.18 −.23
3. PANAS-NA -- .29* .29* .13 .16 .25* .30*
4. EQ-Total -- .65*** .80*** .87*** .77*** .85***
5. EQ-Fear -- .42*** .47*** .21 .43***
6. EQ-Anger -- .73*** 54*** .53***
7. EQ-Sad -- .59*** .68***
8. EQ-Guilt -- .71***
9. EQ-Shame --
 Mean 32.25 3.40 23.81 15.38 3.32 2.63 3.16 2.89 3.37
 (SD) (19.13) (0.95) (9.24) (5.15) (1.43) (1.16) (1.26) (1.39) (1.30)
 Range 5–91 1.21–5.00 10–47 5.5–25.0 1–5 1–5 1–5 1–5 1–5
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Note. CAPS = Clinician-Administered PTSD Scale; DTS = Distress Tolerance Scale; EQ = Emotion Questionnaire; PANAS-NA = Positive and Negative Affect Schedule - Negative Affect.

*

p < .05,

**

p < .01,

***

p < .001

Table 2.

Distress Tolerance and Peritraumatic Emotional Reactivity in Predicting Posttraumatic Stress Symptoms

Without Covariates With Negative Affect as a Covariate
Model 1A: Distress Tolerance and Peritraumatic Emotions Model 1B: Distress Tolerance and Peritraumatic Emotions
R2 B SE t R2 B SE t
Model Summary 47*** Model Summary .63***
 DTS 4.97 5.66 0.88  DTS 9.27 4.83 1.92
 EQ - Total 4.27 1.24 3.44***  EQ - Total 3.35 1.06 3.17**
 DTS x EQ - Total −1.02 0.33 −3.08**  DTS x EQ - Total −0.84 0.28 −2.98**
 PANAS-NA 1.15 0.22 5.36***
Model 2A: Distress Tolerance and Peritraumatic Fear Model 2B: Distress Tolerance and Peritraumatic Fear
R2 B SE t R2 B SE t
Model Summary .41*** Model Summary .61***
 DTS −10.83 2.01 −5.38***  DTS −2.89 2.17 −1.33
 EQ - Fear 2.80 1.40 2.01*  EQ - Fear −2.04 1.16 1.75
 DTS x EQ - Fear −2.08 1.46 −1.42  DTS x EQ - Fear −2.34 1.21 1.94
 PANAS-NA −1.25 0.22 5.68***
Model 3A: Distress Tolerance and Peritraumatic Anger Model 3B: Distress Tolerance and Peritraumatic Anger
R2 B SE t R2 B SE t
Model Summary 42*** Model Summary .62***
 DTS −11.80 1.90 −6.22***  DTS −3.61 2.10 −1.72
 EQ - Anger 2.16 1.55 1.39  EQ - Anger 1.80 1.27 1.42
 DTS x EQ - Anger −2.71 1.49 −1.82  DTS x EQ - Anger −2.68 1.22 −2.19*
 PANAS-NA 1.25 0.22 5.81***
Model 4A: Distress Tolerance and Peritraumatic Sadness Model 4B: Distress Tolerance and Peritraumatic Sadness
R2 B SE t R2 B SE t
Model Summary .65*** Model Summary .79***
 DTS −11.74 1.77 17.84***  DTS −3.74 2.10 0.44
 EQ - Sadness 1.36 1.42 0.96  EQ - Sadness 0.87 1.18 0.74
 DTS x EQ - Sadness −3.20 1.34 −2.39*  DTS x EQ - Sadness −2.92 1.10 −2.64*
 PANAS-NA 1.23 0.22 5.73***
Model 5A: Distress Tolerance and Peritraumatic Guilt Model 5B: Distress Tolerance and Peritraumatic Guilt
R2 B SE t R2 B SE t
Model Summary .67*** Model Summary .60***
 DTS −11.02 1.88 −5.85***  DTS −4.15 2.14 −1.94
 EQ - Guilt 1.84 1.28 1.44  EQ - Guilt 0.67 1.13 0.59
 DTS x EQ - Guilt −4.05 1.37 −2.94**  DTS x EQ - Guilt −2.43 1.23 −1.98
 PANAS-NA 1.14 0.23 4.92***
Model 6A: Distress Tolerance and Peritraumatic Shame Model 6B: Distress Tolerance and Peritraumatic Shame
R2 B SE t R2 B SE t
Model Summary .71*** Model Summary .79***
 DTS −11.13 1.81 −6.14***  DTS −4.39 2.06 −2.13*
 EQ - Shame 3.23 1.35 2.39*  EQ - Shame 1.81 1.20 1.52
 DTS x EQ - Shame −5.09 1.41 −3.62**  DTS x EQ - Shame −3.78 1.23 −3.06**
 PANAS-NA 1.10 0.23 4.99***
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Note: DTS = Distress Tolerance Scale; EQ = Emotion Questionnaire; PANAS-NA = Positive and Negative Affect Schedule – Negative Affect Subscale.

*

p < .05,

**

p < .01,

***

p < .001

Overall Peritraumatic Emotional Intensity

In both models (Model 1A and 1B), there were significant main effects of overall peritraumatic emotional intensity on posttraumatic stress symptom severity. These effects were qualified by significant interactions between overall peritraumatic emotional intensity and distress tolerance that accounted for a significant proportion of the variance in posttraumatic stress symptom severity (Model 1A: ΔR2 = .07, F[1,67] = 9.46, p = .003; Model 1B: ΔR2 = .05, F[1,66] = 8.88, p = .004). Post-hoc probing (as depicted in Figure 1A) revealed that for those low in distress tolerance (−1 SD), peritraumatic emotional intensity was positively associated with posttraumatic stress symptoms (B = 1.30, SE = 0.44, t = 2.96, p = .004). Peritraumatic emotional intensity was not related to posttraumatic stress symptoms among individuals with high distress tolerance (+1 SD; B = −0.28, SE = 0.36, t = −0.80, p = .43).

Figure 1.

Figure 1.

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Interaction Between Distress Tolerance and Overall Peritraumatic Emotional Intensity (1A) and Peritraumatic Anger (1B), Sadness (1C), and Shame (1D) Predicting Posttraumatic Stress (PTS) Symptom Severity when Controlling for General Negative Affect

Peritraumatic Fear

The main effects of peritraumatic fear and distress tolerance were significantly related to posttraumatic stress symptom severity when general negative affect was not included as a covariate (Model 2A). However, after including general negative affect as a covariate, the main and interactive effects of peritraumatic fear and distress tolerance were no longer associated with posttraumatic stress symptom severity (Model 2B).

Peritraumatic Anger

In the model without covariates (Model 3A), there was a significant negative effect of distress tolerance, but the main effect of peritraumatic anger and the interaction between distress tolerance and peritraumatic anger were not significantly related to posttraumatic stress symptom severity. However, when accounting for general negative affect (Model 3B), the interaction between peritraumatic anger and distress tolerance accounted for a significant proportion of the variance in posttraumatic stress symptom severity (ΔR2 = .03, F[1,66] = 4.83, p = .03). Post-hoc probing of the interaction (Figure 1B) revealed that for those low in distress tolerance (−1 SD), peritraumatic anger was positively associated with posttraumatic stress symptoms (B = 4.34, SE = 1.67, t = 2.60, p = .01). Peritraumatic anger was not related to posttraumatic stress symptoms among individuals with high distress tolerance (+1 SD; B = −0.75, SE = 1.77, t = −0.42, p = .67).

Peritraumatic Sadness

The interaction between peritraumatic sadness and distress tolerance accounted for a significant proportion of the total variance in posttraumatic stress symptom severity in both models (Model 4A: ΔR2 = .05, F[1,67] = 5.72, p = .02; Model 4B: ΔR2 = .04, F[1,66] = 6.98, p = .01). Post-hoc probing (as depicted in Figure 1C) revealed that for those low in distress tolerance (−1 SD), peritraumatic sadness was positively associated with posttraumatic stress symptoms (B = 3.63, SE = 1.61, t = 2.26, p = .03). Peritraumatic sadness was not related to posttraumatic stress symptoms among individuals with high distress tolerance (+1 SD; B = −1.89, SE = 1.54, t = −1.23, p = .22).

Peritraumatic Guilt

In the model without negative affect included as a covariate (Model 5A), there was a significant main effect of distress tolerance on posttraumatic stress symptom severity that was qualified by a significant interaction between peritraumatic guilt and distress tolerance (ΔR2 = .07, F[1,67] = 8.66, p = .005). However, when accounting for general negative affect, neither effect remained significant (Model 5B).

Peritraumatic Shame

In both models (Model 6A and 6B), the interactions between peritraumatic shame and distress tolerance accounted for a significant proportion of the variance in posttraumatic stress symptom severity (Model 6A: ΔR2 = .10, F[1,67] = 13.09, p < .001; Model 6B: ΔR2 = .05, F[1,66] = 9.38, p = .003). Post-hoc probing (as depicted in Figure 1D) revealed that for those low in distress tolerance (−1 SD), peritraumatic shame was positively associated with posttraumatic stress symptoms (B = 8.05, SE = 2.11, t = 3.82, p < .001). Peritraumatic shame was not related to posttraumatic stress symptoms among individuals with high distress tolerance (+1 SD; B = −1.59, SE = 1.66, t = −0.96, p = .34).

Discussion

Peritraumatic emotional reactions have been associated with the development of PTSD symptoms (Bovin & Marx, 2011; Hathaway et al., 2010; Resick & Miller, 2009). Although prior research has emphasized the role of peritraumatic fear, other negative emotions (e.g., anger, sadness, guilt, shame) felt at the time of and in the hours or days immediately following a traumatic event have been linked to increased PTSD symptom severity above and beyond experiences of fear (La Bash & Papa, 2014; Lancaster et al., 2011; Lancaster & Larsen, 2016; Vásquez et al., 2012). Since individuals with difficulty tolerating emotional distress may experience increased PTSD symptoms (Vujanovic et al., 2011, 2013, 2015, 2017), the current study aimed to examine (a) whether overall peritraumatic emotional intensity was related to posttraumatic stress symptoms and (b) if distress tolerance moderated this association. Additional exploratory analyses were conducted to examine the relations among specific peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), distress tolerance, and posttraumatic stress symptom severity.

Consistent with prior research, our results demonstrate strong correlations between posttraumatic stress symptoms, distress intolerance, and general negative affect (Vujanovic et al., 2011, 2013, 2017). Posttraumatic stress symptoms were also positively correlated with overall peritraumatic emotional intensity, and specifically peritraumatic fear and shame. Distress tolerance was negatively related to overall peritraumatic emotional intensity and fear, but no other peritraumatic emotions. Furthermore, general negative affect was positively associated with overall peritraumatic emotional intensity, and specifically fear, guilt, and shame. These findings suggest that fear experienced at the time of or in the hours and days following a traumatic event is significantly related to a person’s tendency to experience and ability to tolerate negative emotions, which accords with models suggesting fear conditioning is involved in the development of PTSD (Foa & Kozak, 1986; Keane et al., 1985).

Overall peritraumatic emotional intensity in response to participants’ index sexual trauma was related to more severe posttraumatic stress symptoms, particularly for women with a lower perceived ability to tolerate distress. Our exploratory analyses revealed that distress tolerance moderated the relation between peritraumatic anger, shame, and sadness - but not fear or guilt- and posttraumatic stress symptom severity. Specifically, the intensity of anger, shame, and sadness experienced at the time of, and in the hours and days immediately following, the index sexual trauma were related to more severe posttraumatic stress symptoms, specifically among women who perceived they were less able to tolerate distressing emotions. Thus, our findings suggest that the interactive effect of overall peritraumatic emotional intensity and distress tolerance on posttraumatic stress symptoms was driven by experiences of anger, shame, and sadness.

Anger experienced during a trauma may facilitate an adaptive response to approach or address the immediate threat of harm (Power & Dalgleish, 2015), and anger experienced in the hours and days following a trauma may stem from reflection upon, or appraisal of, the traumatic event as a boundary violation (Amstadter & Vernon, 2008). Peritraumatic anger has been linked to PTSD symptomology (Hathaway et al., 2010; Lancaster et al., 2011), and prolonged trauma-related anger is included in the updated diagnostic criterion for PTSD (APA, 2013). However, our results suggest that one’s perceived ability to tolerate peritraumatic anger, rather than the intensity of anger alone, may play an important role in the development and maintenance of posttraumatic stress symptoms. Individuals who perceive that they are less able to tolerate emotional distress may be more inclined to feel strong urges to address or act upon trauma-related anger. However, individuals who are not able to act in line with anger urges (i.e., confront the perpetrator) may continue to feel trauma-related anger even after the immediate threat of harm has passed and may subsequently avoid trauma reminders that could trigger intense feelings of anger. It is also possible that the inability to act on anger urges—to protect oneself from harm or betrayal—may result in appraisals of inferiority, weakness, or helplessness, thus eliciting peritraumatic shame and sadness. Although the current study cannot speak directly to this possibility, future work aimed at teasing apart the relations among peritraumatic anger and distress tolerance would further shed light their contribution to posttraumatic stress symptoms.

Shame is considered a self-conscious, appraisal-based emotion (Power & Dalgleish, 2015), and a growing body of research depicts an association between trauma-related shame and PTSD symptoms (Cunningham et al., 2018; Saraiya & Lopez-Castro, 2016). In line with the model presented by Bovin and Marx (2011), traumatic experiences may either produce or exacerbate negative appraisals of the self (e.g., “I deserved what happened to me” or “I am weak for allowing the event to happen”) and result in feelings of peritraumatic shame. Findings from the present study suggest that one’s perceived ability to tolerate distressing emotional experiences may play a role in the development of posttraumatic stress symptomology for individuals who experience shame at the time of or in the hours and days following exposure to sexual trauma. Those with low perceived distress tolerance who feel ashamed after being sexually victimized may avoid coming in contact with trauma reminders due to concerns about being able to tolerate the negative affect elicited by such cues (e.g., “I couldn’t handle it”), thus interfering with the process of cue exposure necessary for normative recovery following trauma exposure. These negative appraisals of the self that stem from trauma-related shame may also maintain posttraumatic stress symptoms by resulting in maladaptive beliefs about the world (e.g., “The world is unsafe”) or future (e.g., “Bad things will always happen to me”; Ehlers & Clark, 2000) that can impair use of social support (Dodson & Beck, 2017). Future research is needed to test the hypothesis that the combination of peritraumatic shame and distress intolerance predict avoidance of trauma cues, or if these two factors may be linked to posttraumatic stress symptoms via another process.

Although the research on peritraumatic sadness is limited, our findings suggest that sadness may be an important variable to study in relation to the development of posttraumatic stress symptoms, particularly for individuals who perceive that they are less able to tolerate distressing emotions. It is possible that peritraumatic sadness may stem from feelings of loss or diminished perceptions of power and safety following sexual victimization (Amstadter & Vernon, 2008), and may prompt individuals who perceive that they are less able to tolerate distressing emotional experiences to withdraw or isolate (Power & Dalgleish, 2015). Similar to the experiences of peritraumatic anger and shame described above, the process of withdrawing or isolating may prevent an individual from exposing themselves to trauma-related cues or seeking social support that could facilitate normative recovery from a traumatic event. Thus, future research should include measures of peritraumatic sadness to understand how this experience affects posttraumatic stress symptoms, particularly among individuals with a lower tolerance for distress.

When general negative affect (i.e., PANAS-NA scores) was included as a covariate in the regression model, the main and interactive effects of peritraumatic fear and distress tolerance were not associated with posttraumatic stress symptoms. However, when general negative affect was not included as a covariate, the main effects of peritraumatic fear and distress tolerance were both independently related to posttraumatic stress symptoms. A surprising and complicated picture emerges when considering the zero-order correlations and regression results in combination. Peritraumatic fear was the only emotion that was significantly correlated with posttraumatic stress symptoms, distress tolerance, and general negative affect at the zero-order level. However, the association between peritraumatic fear and posttraumatic stress symptoms was not significant after accounting for distress tolerance and general negative affect in the regression model. Our results suggest that these constructs may be highly overlapping, and continued research—particularly longitudinal studies—is needed to better understand the interplay between distress tolerance and fear reactions to traumatic events. For example, it is possible that peritraumatic fear and distress tolerance function as overlapping risk factors for PTSD, that one is a proxy for the other, or that one is mediating the effects of the other (Kraemer et al., 2001).

Similarly, the main and interactive effects of peritraumatic guilt and distress tolerance were not significantly related to posttraumatic stress symptoms when general negative affect was included as a covariate in the regression model. However, the interactive effect between peritraumatic guilt and distress tolerance was significantly related to posttraumatic stress symptoms after removing general negative affect as a covariate. Thus, our inclusion of general negative affect in the regression model reduced the interaction between peritraumatic guilt and distress tolerance to non-significance. The scale used to measure general negative affect in the present study is comprised of 10 adjectives that describe high-arousal negative emotions or experiences, including four synonyms for anxiety and one depicting guilt (Diener et al., 2009; Watson et al., 1988). Since peritraumatic fear and guilt were both positively correlated with general levels of negative affect, their association with posttraumatic stress symptoms may have been diminished in the regression model that included general negative affect as a covariate. In addition to using longitudinal research to understand the interplay among these factors over time, reducing the time between traumatic event exposure and assessment of peritraumatic emotional responses will be important to increase confidence in the discriminant validity of trauma-related emotional reactivity measures and general levels of negative affect.

Limitations and Future Directions

The current results must be considered within the context of the study’s limitations. The sample was comprised of predominantly White women with histories of sexual victimization. Thus, the results may not generalize to women of non-White racial backgrounds, other trauma types (e.g., physical assault, combat, non-interpersonal trauma), or genders. Moreover, only a subset of the participants met full diagnostic criteria for PTSD per the DSM-IV defined criteria (18%; APA, 1994) or subclinical PTSD (19%; Schnurr, 2014). The results should be replicated in a clinical sample using the updated conceptualization of PTSD symptoms described in the 5th edition of the DSM (APA, 2013).

Peritraumatic emotional experiences were measured retrospectively via a self-report survey and based on the assumption that participants could differentiate between specific trauma-related emotions. Not only is this assessment strategy vulnerable to recall bias and survey fatigue, but women who have experienced sexual violence may not perceive peritraumatic emotions as distinct or discrete constructs. Moreover, the study’s cross-sectional nature precludes strong inferences regarding how traumatic event exposure and subsequent emotional experiences, distress tolerance, and posttraumatic stress symptoms relate across time. It is possible that the experience of sexual victimization and subsequent development of posttraumatic stress symptoms influenced levels of distress tolerance (Dvir et al., 2014), rather than the reverse (i.e., distress intolerance increased risk for PTSD symptoms following sexual victimization). Therefore, future work seeking to replicate or extend this study should aim to limit reliance on the cross-sectional, retrospective assessment employed here. Future research may also seek to utilize measures that more thoroughly assess specific emotions and rely less on the participants’ ability to know the difference between similar emotions (e.g., shame, guilt, disgust). It is also important for researchers to consider whether being asked about one’s trauma history influences how participants respond to measures of emotional distress. Although out of the scope of the present study’s aims, future research should consider evaluating other confounding or extraneous variables that may help contextualize the association between peritraumatic responses and posttraumatic stress (e.g., social support, comorbid mental and physical health conditions, personality dispositions, etc.).

Despite these limitations, the results of the current study contribute to a burgeoning literature focused on the impact of a range of peritraumatic emotional experiences on the development and maintenance of posttraumatic stress symptoms. In line with prior work, a strength of this study is that we evaluated the effects of both overall peritraumatic emotional intensity and discrete peritraumatic emotions on posttraumatic stress symptoms (Hathaway et al., 2010; Lancaster et al., 2011, 2016). Although our reliance on retrospective reports make such predictions tentative, the results provide the foundation for future studies to assess peritraumatic emotions soon after sexual victimization and then monitor posttraumatic stress symptomology. This assessment strategy would increase confidence in the validity of the measurements of peritraumatic emotional experiences. Evaluating the independent contributions of specific peritraumatic emotions on posttraumatic stress symptoms may provide insight for intervention targets. Furthermore, future research is needed to establish the relation between trauma-related negative emotions and emotion-specific distress tolerance (e.g., anger tolerance; Bernstein & Brantz, 2013).

Conclusions

These results further support the importance of exploring peritraumatic emotions outside of fear and, although this was not a clinical sample, may offer clinical implications. Clinicians may consider assessing for negative emotions experienced at the time of and in the hours and days immediately following traumatic experiences, since peritraumatic emotions appear to be an important factor in the development of PTSD. Assessing peritraumatic emotional responses may also serve to inform prevention and early intervention efforts aimed at reducing the likelihood of PTSD development following a trauma. Given that participants’ perceptions of their ability to tolerate distressing emotions qualified the aforementioned associations, researchers and clinicians aiming to enhance recovery from traumatic event exposure may consider incorporating therapeutic techniques that promote distress tolerance. Such techniques may be a useful target in promoting resilience and healthy recovery.

Acknowledgments

All authors declare they have no conflicts of interest. This research was supported by a National Institute of Mental Health (NIMH) National Research Service Award (F31 MH092994) awarded to Dr. Christal Badour. Effort on this project was supported by the Office of Women’s Health Research, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism (K12 DA035150; T32 DA035200; T32 AA027488) through the National Institutes of Health (NIH). This publication’s contents are solely the responsibility of the authors and do not necessarily represent the official views of NIH.

References

  1. Aiken LS, West SG, & Reno RR (1991). Multiple regression: Testing and interpreting interactions. Sage. [Google Scholar]
  2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Author. [Google Scholar]
  3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author. [Google Scholar]
  4. Amstadter AB, & Vernon LL (2008). Emotional reactions during and after trauma: A comparison of trauma types. Journal of Aggression, Maltreatment & Trauma, 16(4), 391–408. 10.1080/10926770801926492 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Badour CL, & Feldner MT (2016). Disgust and imaginal exposure to memories of sexual trauma: Implications for the treatment of posttraumatic stress. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 267–275. 10.1037/tra0000079 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bernstein A, & Brantz H (2013). Tolerance of Negative Affective States (TNAS): Development and evaluation of a novel construct and measure. Cognitive Therapy and Research, 37(3), 421–433. 10.1007/s10608-012-9471-6 [DOI] [Google Scholar]
  7. Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, & Keane TM (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8(1), 75–90. 10.1002/jts.2490080106. [DOI] [PubMed] [Google Scholar]
  8. Bovin MJ, & Marx BP (2011). The importance of the peritraumatic experience in defining traumatic stress. Psychological Bulletin, 137(1), 47–67. 10.1037/a0021353 [DOI] [PubMed] [Google Scholar]
  9. Cohen J, Cohen P, West SG, & Aiken LS (2003). Applied multiple regression/correlation analysis for the behavioral sciences (3rd ed.). Routledge. [Google Scholar]
  10. Cunningham KC, Davis JL, Wilson SM, & Resick PA (2018). A relative weights comparison of trauma-related shame and guilt as predictors of DSM-5 posttraumatic stress disorder symptom severity among US veterans and military members. British Journal of Clinical Psychology, 57(2), 163–176. 10.1111/bjc.12163 [DOI] [PubMed] [Google Scholar]
  11. Diener E, Wirtz D, Biswas-Diener R, Tov W, Kim-Prieto C, Choi DW, & Oishi S (2009). New measures of well-being. In Diener E (Ed.). Assessing well-being: The collected works of Ed Diener (pp. 247–266). Springer Netherlands. 10.1007/978-90-481-2354-4 [DOI] [Google Scholar]
  12. Dodson TS, & Beck JG (2017). Posttraumatic stress disorder symptoms and attitudes about social support: Does shame matter? Journal of Anxiety Disorders, 47, 106–113. 10.1016/j.janxdis.2017.01.005 [DOI] [PubMed] [Google Scholar]
  13. Dvir Y, Ford JD, Hill M, & Frazier JA (2014). Childhood maltreatment, emotional dysregulation, and psychiatric comorbidities. Harvard Review of Psychiatry, 22(3), 149–161. 10.1097/HRP.0000000000000014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Ehlers A, & Clark DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319–345. 10.1016/S0005-7967(99)00123-0 [DOI] [PubMed] [Google Scholar]
  15. Foa EB, & Kozak MJ (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35. 10.1037/0033-2909.99.1.20 [DOI] [PubMed] [Google Scholar]
  16. Hathaway LM, Boals A, & Banks JB (2010). PTSD symptoms and dominant emotional response to a traumatic event: An examination of DSM-IV Criterion A2. Anxiety, Stress & Coping, 23(1), 119–126. 10.1080/10615800902818771 [DOI] [PubMed] [Google Scholar]
  17. Hayes AF (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling.
  18. Hayes AF (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. Guilford Publications. [Google Scholar]
  19. Keane TM, Zimering RT, & Caddell JM (1985). A behavioral formulation of posttraumatic stress disorder in Vietnam veterans. Behavior Therapist, 8(1), 9–12. [Google Scholar]
  20. Kilpatrick DG, Badour CL, & Resnick HS (2017). Trauma and posttraumatic stress disorder prevalence and sociodemographic characteristics. In Gold S, Cook J, & Dalenberg C (Eds.), APA handbook of trauma psychology: Foundations in knowledge (Vol. 1, pp. 63–85). American Psychological Association (APA) Books. [Google Scholar]
  21. Kraemer HC (2015). A source of false findings in published research studies: Adjusting for covariates. JAMA Psychiatry, 72, 961–962. DOI: 10.1001/jamapsychiatry.2015.1178 [DOI] [PubMed] [Google Scholar]
  22. Kraemer HC, Stice E, Kazdin A, Offord D, & Kupfer D (2001). How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. American Journal of Psychiatry, 158(6), 848–856. [DOI] [PubMed] [Google Scholar]
  23. La Bash H, & Papa A (2014). Shame and PTSD symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 6(2), 159–166. 10.1037/a0032637 DOI: 10.1037/a0032637 [DOI] [Google Scholar]
  24. Lancaster SL, Melka SE, & Rodriguez BF (2011). Emotional predictors of PTSD symptoms. Psychological Trauma: Theory, Research, Practice, and Policy, 3(4), 313–317. 10.1037/a0022751 [DOI] [Google Scholar]
  25. Lancaster SL, & Larsen SE (2016). Profiles of peritraumatic emotions. Journal of Aggression, Maltreatment & Trauma, 25(9), 1006–1018. [Google Scholar]
  26. Leyro TM, Zvolensky MJ, & Bernstein A (2010). Distress tolerance and psychopathological symptoms and disorders: A review of the empirical literature among adults. Psychological Bulletin, 136(4), 576–600. 10.1037/a0019712 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Marshall-Berenz EC, Vujanovic AA, Bonn-Miller MO, Bernstein A, & Zvolensky MJ (2010). Multimethod study of distress tolerance and PTSD symptom severity in a trauma-exposed community sample. Journal of Traumatic Stress, 23(5), 623–630. 10.1002/jts.20568 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Power M, & Dalgleish T (2015). Cognition and emotion: From order to disorder. Psychology Press. [Google Scholar]
  29. Resick PA, & Miller MW (2009). Posttraumatic stress disorder: Anxiety or traumatic stress disorder? Journal of Traumatic Stress, 22(5), 384–390. 10.1002/jts.20437 [DOI] [PubMed] [Google Scholar]
  30. Saraiya T, & Lopez-Castro T (2016). Ashamed and afraid: A scoping review of the role of shame in post-traumatic stress disorder (PTSD). Journal of Clinical Medicine, 5(11), 94. 10.3390/jcm5110094 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Schmidt NB, Richey JA, & Fitzpatrick KK (2006). Discomfort intolerance: Development of a construct and measure relevant to panic disorder. Journal of Anxiety Disorders, 20(3), 263–280. 10.1016/j.janxdis.2005.02.002 [DOI] [PubMed] [Google Scholar]
  32. Schnurr PP (2014). A guide to the literature on partial PTSD. PTSD Research Quarterly, 25(1), 1–3. [Google Scholar]
  33. Simons JS, & Gaher RM (2005). The Distress Tolerance Scale: Development and validation of a self-report measure. Motivation and Emotion, 29(2), 83–102. 10.1007/s11031-005-7955-3 [DOI] [Google Scholar]
  34. Vance MC, Kovachy B, Dong M, & Bui E (2018). Peritraumatic distress: A review and synthesis of 15 years of research. Journal of Clinical Psychology, 74(9), 1457–1484. [DOI] [PubMed] [Google Scholar]
  35. Vásquez DA, de Arellano MA, Reid-Quiñones K, Bridges AJ, Rheingold AA, Stocker RP, & Danielson CK (2012). Peritraumatic dissociation and peritraumatic emotional predictors of PTSD in Latino youth: Results from the Hispanic family study. Journal of Trauma & Dissociation, 13(5), 509–525. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Vujanovic AA, Bonn-Miller MO, Potter CM, Marshall EC, & Zvolensky MJ (2011). An evaluation of the relation between distress tolerance and posttraumatic stress within a trauma-exposed sample. Journal of Psychopathology and Behavioral Assessment, 33(1), 129–135. 10.1007/s10862-010-9209-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Vujanovic AA, Dutcher CD, & Berenz EC (2017). Multimodal examination of distress tolerance and posttraumatic stress disorder symptoms in acute-care psychiatric inpatients. Journal of Anxiety Disorders, 48, 45–53. 10.1016/j.janxdis.2016.08.005 [DOI] [PubMed] [Google Scholar]
  38. Vujanovic AA, Hart AS, Potter CM, Berenz EC, Niles B, & Bernstein A (2013). Main and interactive effects of distress tolerance and negative affect intensity in relation to PTSD symptoms among trauma-exposed adults. Journal of Psychopathology and Behavioral Assessment, 35(2), 235–243. 10.1007/s10862-012-9325-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Vujanovic AA, Litz BT, & Farris SG (2015). Distress tolerance as risk and maintenance factor for PTSD: Empirical and clinical implications. In Martin CR, Preedy VR, & Patel VB (Eds.), Comprehensive guide to posttraumatic stress disorder (pp. 1–13). Springer International Publishing. [Google Scholar]
  40. Watson D, Clark LA, & Tellegen A (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of Personality and Social Psychology, 54(6), 1063. 10.1037/0022-3514.54.6.1063 [DOI] [PubMed] [Google Scholar]
  41. Weathers FW, Keane TM, & Davidson JR (2001). Clinician-Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13(3), 132–156. 10.1002/da.1029 [DOI] [PubMed] [Google Scholar]
  42. Weathers FW, Ruscio A, & Keane TM (1999). Psychometric properties of nine scoring rules for the clinician-administered posttraumatic stress disorder scale. Psychological Assessment, 11, 124–133. doi: 10.1037/1040-3590.11.2.124. 10.1037/1040-3590.11.2.124 [DOI] [Google Scholar]

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