PTSD: Emotional Numbing, Reduced Affect Display (25th Intl. Conference Neurology & Neurophysiology)

Uploaded 4/6/2021, approx. 25 minute read

Thank you very much, and thank you for having me.

Esteemed colleagues, today I would like to discuss some recent developments in the perception and the conception of trauma.

My name is Sam Vaknin, I'm a professor of psychology in Southern Federal University, Rostov-on-Don, and a professor of finance and a professor of psychology in CIAS-CIAPS.

So I would like to start by quoting from two articles. One of them was published almost 20 years ago. It was titled Emotional Numbing in Post-Traumatic Stress Disorder, Current and Future Research Direction, and it was authored by Brett Litz, LITZ and Matt Gray. It was published in the Australian and New Zealand Journal of Psychiatry, April 2002.

The objective of this paper was this, despite being understudied and poorly understood relative to the chronic fear, anxiety and other aversive emotional states that occur in the immediate aftermath of trauma, emotional numbing has become a core defining feature of post-traumatic stress disorder.

The experience of trauma produces very intense emotions, such as overwhelming fear, horror and anxiety, and these reactions can linger for a lifetime.

Many trauma survivors also report restrictions in their emotional experience, a phenomenon most commonly referred to as emotional numbing.

In contrast to previous accounts of post-traumatic emotional functioning, our model posits that individuals with PTSD have difficulty expressing positive emotions as a result of re-experiencing states.

We further argue that patients with PTSD are capable of experiencing and expressing the full range of emotions that were available pre-traumatically.

Our model holds that individuals with PTSD are not, in fact, emotionally numb as a result of traumatic experience, rather PTSD is associated with hyper-responsivity to negatively-balanced emotional stimuli.

Consequently, patients with PTSD require more intense positive stimulation to access the full complement of appetitive or pleasant emotional behavior.

And this article started a new movement to re-conceive of trauma.

I would say that there are two major developments recently.

First of all, the re-conception of trauma of personality disorders is post-traumatic conditions we are beginning to conceive of borderline, narcissism, even to some extent histrionic and maybe psychopathy.

We are beginning to re-conceive of these disorders, schizoid, paranoid, as post-traumatic conditions rather than personality disorders.

That's the first trend. It involves the study of dissociation among many other mechanisms.

The second trend is to understand that there are two types, actually, of PTSD, two types of post-traumatic stress disorder and complex post-traumatic stress disorder, complex trauma.

The first type is the externalizing type. It's when the trauma is actually projected.

And so these people experience flashbacks. They experience emotional dysregulation. They act out. They decompensate. They adopt reckless behaviors, etc. So they externalize their trauma in many ways.

The second type of reaction to trauma is an internalizing reaction where what happens is the trauma kills, destroys the ability to emote. There's emotional numbing. And I will come to it a bit later.

I would like to read to you from an article titled Emotional Reactivity and Antisocial Behavior Relative to Post-Traumatic Stress Symptom Expression, a Latent Profile Analysis. It was authored by Molly Miller and Monica Marcey. It was published in the Journal of Abnormal Child Psychology, volume 47, in 2019.

And it says, the study examined whether emotional reactivity was associated with violent juvenile offending in a sample of detained boys. It predicted that latent profile analysis would reveal a low reactivity group characterized by symptoms of emotional numbing and callous unemotional traits, and a high reactivity group characterized by symptoms of hyperarousal and emotional dysregulation. It was hypothesized that the low reactivity group would have higher rates of violent offending and proactive aggression than the high reactivity group.

Contrary to expectations, results indicated that the presence of both emotional numbing and hyperarousal symptoms, but not hyperarousal symptoms alone, were associated with higher rates of violent offending, CU traits, and proactive aggression.

Results indicate that the risk of serious aggressive behavior and violent offending may be highest among youth who are easily provoked to respond aggressively, hyperarousal symptoms, while simultaneously able to maintain emotional detachment, elevated emotional numbing symptoms, and callous unemotional traits.

So we see that post-traumatic stress disorder can induce the experience of trauma, can induce emotional numbing, can alter, can change the way we express emotions. And this is reminiscent of a disorder called alexithymia. Alexithymia is a personality trait characterized by subclinical inability to identify and describe emotions experienced by oneself and others as well.

The core characteristic of alexithymia is marked dysfunction in emotional awareness, social attachment, interpersonal relation.

Now PTSD produces what is clinically called reduced affect display.

Effect is of course the way we display emotions. Emotion is the internal experience. Effect are the behaviors, the facial expressions, the body language that reflect the emotion that is occurring inside.

So there's an internal aspect, which is the emotion, and an external manifestation of the internal aspect, and that is the effect. Reduced affect display or emotional blunting is a condition of reduced emotional reactivity. It's a failure to express feelings.

Effect display is missing. Verbally, non-verbally, feelings are just not mentioned, not displayed.

And it is especially so when the person discusses issues that would normally be expected to engage the emotions, to arouse and excite and otherwise generate emotions.

In people with reduced affect display, expressive gestures are rare and there is little animation in facial expression or vocal inflection.

Reduced affect is very common in autism, in autism spectrum disorders, in schizophrenia, in depression, post-traumatic stress disorder, depersonalization disorder, which is a form of dissociation, schizoid personality disorder, or of course in the case of brain damage. It's also a side effect of quite a few antipsychotic medications and antidepressants and so on.

But reduced affect is not apathy. It's not indifference. It's a lack of emotion. Anhedonia is a lack of ability to experience pleasure. Apathy is indifference, which could be cognitive indifference, or valence, axiologically indifference.

Reduced affect is when the emotions are missing, when there's no emotional expression.

And we don't know, we can't really tell if the lack of emotional expression reflects a lack of emotion. There's no emotion to display, no emotion to express or some wall, some defense, some firewall separating the underlying emotion, which is experience and the display expression and manifestation of the experienced emotion. We are not sure.

There are several types of blunted emotional expression.

First of all, there is constricted affect. Constricted affect is a reduction in individual's expressive range and the intensity of emotional responses.

Then there is blunted or flat affect. Blunted affect is a lack of affect more severe than restricted or constricted affect, but less severe than flat or flattened affect.

The difference between flat and blunted affect is in degree. A person with flat affect has no or nearly no emotional expression. He or she may not recall at all.

To circumstances that usually evoke, may not react at all, I'm sorry, to circumstances that usually evoke strong emotions in others, a person with blunted affect, on the other hand, has a significantly reduced intensity in emotional expression. And finally, there's shallow affect. Shallow affect is a little like blunted affect.

For example, psychopaths, factor one psychopaths, they have shallow affect. It's one of the attributes of psychopathy.

And a bit later I will review the various disorders and so on. PTSD was long known to cause negative feelings, depressive moods, re-experiencing, hyperarousal, etc.

But it is only recently that psychologists are beginning to realize that PTSD can cause exactly the opposite. Not arousal, blunted affect, decreasing feeling, no experience of positive emotions.

Blunted affect or emotional numbness is a consequence of PTSD because it causes diminished interest in activities that produce pleasure. It leads to anhedonia. It produces detachment from others, attachment style, which is essentially avoidant or insecure. It restricts emotional expression and reduces the tendency to express motions, behaviorally.

Blunted affect is a very difficult outcome of response to PTSD. It's a central symptom in post-traumatic stress disorders.

In PTSD the blunted affect is a psychological response to the trauma, a way to combat overwhelming anxiety that the patient feels.

In blunted affect there are abnormalities also in the brain which are associated with it.

Now blunted, shallow, constricted and restricted affect should be distinguished from inappropriate affect. Inappropriate affect is something a bit different.

Inappropriate affect involves the display of reactions that do not match the situation that one is in or do not match one's internal state.

Generally, emotions, actions, environment, circumstances, they should all be on the same page. They should all reflect and conform. They should all fit in like in a jigsaw puzzle.

But in inappropriate affect, the effect, the expression of the emotion has nothing to do with the event of the circumstance.

For example, someone laughing at a funeral. Inappropriate affect is usually a symptom of some underlying physical or mental condition but it is sometimes considered a disorder in itself. It's been described well over a hundred years ago at least.

We have great studies from the 1950s, Bleuler and others, and so Stelaski referred in 1909, referred to inappropriate affect as intra-psychic ataxia, ataxia.

So intra-psychic ataxia.

And generally, inappropriate affect was studied together with flat affect in schizophrenia.

Schizophrenia was the hunting ground for breakdowns between emotion and effect.

But actually, we can see similar phenomena and even of the same magnitude, for example, among psychopaths in borderline personality disorder when there is a transition or switching to a secondary psychopathic state in narcissism on many occasions.

So it's wrong to think that effect, improper effect, inappropriate affect, blunt affect, etc., they're all schizophrenic, schizophrenic form disorders. They are common also among personality disorders.

We know that this kind of wrong affect is caused by brain damage, neurological dysfunction, schizophrenia, psychotic disorders, medications, but also by psychological factors. And these psychological factors lead simultaneously to a breakdown between experienced emotion and the expression of emotion and modalability, anxiety disorders, depressive disorders, or personality disorders.

The conditions involving inappropriate, shallow, blunt affect are numerous. Major depressive disorder, schizophrenia, schizoid personality disorder, post-traumatic stress disorder, schizoaffective disorder, psychopathy, depersonalization, borderline personality disorder, and a host of neurological conditions, including, of course, dementia.

And here are the symptoms. For example, uncontrollable crying, even when not feeling sad, recognizing that reactions are inappropriate, emotions that do not match the reality of a situation or are opposite to the reality of the situation.

Showing happiness during a tragedy, for example, becoming angry without any outward provocation, flat affect, or not showing expected emotional reactions, but not holding back emotions.

There's simply nothing to show.

So you see inappropriate affect disorders. Let's call them affect disorders.

They are numerous.

Blunted affect is common in schizophrenia, but also, for example, in psychopathy and narcissism, restricted affect, flat affect, they are all very common.

There's also labile affect. Labile affect is when people show rapid changes in emotions that don't seem to relate to any outside situations or inappropriate for the situation.

In labile affect, the person rapidly cycles and shifts between moods and effects non-responsively, not in reaction to anything that's happening outside, not even in reaction to anything that's happening inside, as though their emotions are so dysregulated that they spun centrifugally out of control.

And this appears a lot, for example, in manic episodes during bipolar disorder, in borderline personality disorder, and anxiety disorders of stimulation, fatigueand so on.

Shallow affect is often used to describe the emotional experience of people with psychopathy. A person with shallow affect feels little emotion about situations that would be expected to elicit much stronger, specific feelings.

And this means that things that cause most people to experience negative emotions have no impact on psychopaths.

For example, psychopaths experience no fear. American serial killer Richard Ramirez, known as the Night Stalker, when he heard that he sentenced to death, he said, big deal. Death always went with the territory. See you in Disneyland. Death's shallow or flat affect.

Now, this should be distinguished from emotional numbness, emotional numbing, or emotional numbness. Everyone experiences emotional numming or numbness at some point in life. But when it becomes a way of life, when it becomes the main dimension and determinant of emotional life, it becomes a pathology. It becomes a problem.

So most people experience one emotion at any given time. And most people experience positive emotions two and a half times more often than negative emotions.

Emotions are very critical because they are a form of cognition. They sustain reality testing. They facilitate social interactions and connectivity.

But when one is overwhelmed, when one feels helpless, when one is abused or traumatized, it's very common to turn on emotional numbing. It provides a protective defense. If it is taken to extreme, it might lead, of course, to dissociation. But emotional numbing is one stage before dissociation. It provides relief. It allows to cope with hard feelings.

If these hard feelings were accessible, if the emotional numbing did not set in, these hard feelings could have had very, very long-term, long-lasting consequences. So emotional numbing is a very effective defense against long-term mental health issues.

And so emotional numbness, I want to quote Meira Mendez. She's a licensed psychotherapist and program coordinator at Providence St. John's Child and Family Development Center. And she says, emotional numbing is a mental and emotional process of shutting out feelings and maybe experiences deficits of emotional responses or reactivity. There is a temporary restriction on the capacity to feel, but it's temporary, on the capacity to feel or express emotions.

She continues, while emotional numbing blocks or shuts down negative feelings and experiences, it also shuts down the ability to experience pleasure, engaging positive interactions in social activities and interferes with openness for intimacy, social interests, and problem-solving skills.

So emotional numbing is a price for emotional numbing, obviously. And if emotional numbing becomes a coping tool, it involves avoidance, denial, detachment, dismissal. It blocks the capacity for confronting, processing, problem-solving and managing emotions and experiences. And the symptoms of emotional numbness include losing interest in important ones' positive activities you used to enjoy, feeling distant or detached from other people, failing to access your feelings, feeling flat, both physically and emotionally, experiencing an inability to fully participate in life, having difficulty with experiencing positive feelings, such as happiness, preferring isolation, rather than being with others.

Normally, emotional numbing is a reaction to physical or emotional pain. It's a post-traumatic reaction. The relief is temporary and allows you to move on with your life.

But if this protective shield is deployed all the time, it gets in the way of connecting with other people. It gets in the way of getting in touch with feeling, which are both negative and positive.

So anhedonia sets in and results in anxiety and depression later on.

And so the common causes, like PTSD, grief, overwhelming stress, depression, physical or sexual abuse, especially egregious abuse, mental or emotional abuse, incest, substance abuse, they all lead to a form of emotional numbing.

But for emotional numbing to be considered healthy, it must be temporary. It can be a part of post-traumatic stress disorder, but it must be temporary. If not, then it becomes a psychiatric disorder in response to a traumatic event.

Intense, disturbing, intrusive thoughts and feelings related to the event can last months or even years when the event is over, precisely because the event had not been emotionally processed.

Alternatively, because emotional processing and expression did not take place, sometimes there is very severe dissociation up to the point of dissociative identity disorder.

So post trauma can resolve in ways which are permanently pathological. It can shatter the personality and it is precisely because emotions are not expressed, not processed. The person doesn't get in touch with these emotions.

This kind of pent-up energy which creates what Freud called a reaction.

In order to cope with trauma from an event, avoidance and emotional numbing are common, but we need to encourage the PTSD patient not to avoid thoughts, feelings or conversation about the traumatic event, the places, the people who bring this event to mind as triggers or who had participated in the event.

Individuals diagnosed with anxiety disorders experience emotional numbness as a response to extremely high stress levels, fear reactions or excessive worry. In fact, avoidance of both positive and negative emotions is associated with higher levels of anxiety.

So this is a counterproductive mechanism. People with anxiety become dysregulated, they numb their emotions, they lower them or delete them, they don't express them. This creates higher anxiety.

Mendes points out that depressive episodes may present with decreased attunement to feelings, dulling of emotions and emotional numbing.

She says higher levels of depression and mood dysregulation result in a greater propensity for emotional numbing.

And of course emotional numbing is a part of a larger picture which is emotional detachment or emotional blunting, the inability to connect to others on an emotional level and a positive means of coping with anxiety.

And so emotion focused coping is used by avoiding certain situations that might trigger anxiety. The evasion of emotional connection is one of them.

So by avoiding or evading emotional connections, you don't take a risk of being hurt again. It's a form of pain or hurt aversion. It may be a temporary reaction to a stressful situation or a chronic condition such as depersonalization, derealization, disorder.

In other words, it's closely allied with dissociation.

Emotional blunting is reduced affect display and of course is one of the negative symptoms of schizophrenia.

And so emotional blunting, emotional detachment, they can manifest in numerous ways. In numerous ways, patients diagnosed with emotional detachment have reduced ability to express emotion, to empathize with others, to form powerful emotional connections.

They have anxiety, they have stress disorders, this can create difficulties in maintaining personal relationships, interpersonal relationships.

People move elsewhere in their minds. They appear preoccupied, not entirely there. So it resembles, it mimics ADHD, but it's not. It's very often misdiagnosed as ADHD. People may be fully present, but exhibit purely intellectual behavior when emotional behavior should have been appropriate, more appropriate.

So there are many ways.

Emotional detachment manifests in multifarious ways. They may have a hard time to love a family member. They may avoid activities, places and people associated with past traumas. The dissociation can lead to a lack of attention to memory problems and in extreme cases, amnesia. In some cases, they present an extreme difficulty in giving or receiving empathy, which can be related to the spectrum of narcissistic personality disorder.

In children, the traits of aggression and antisocial behaviors are correlated to emotional detachment. These are actually early signs of emotional detachment.

I would add to this precautious sexuality. It suggests that we need to evaluate children for these traits and behaviors for higher behavioral problems in order to avoid bigger problems, such as emotional detachment in the future.

We don't know for sure what is the brain background, the background in brain abnormalities, but we know that there are behavioral mechanisms that involved in emotional detachment and in experiential avoidance, which is another manifestation.

These people, for example, react very calmly to highly emotional circumstances.

It's a decision to avoid engaging emotional connections. It's not an inability to emote or inability to express emotions, but it's a decision. It's a choice.

There's no difficulty in doing it. It's just they prefer not to for professional, personal, social reasons, or because of past trauma.

Sometimes emotional flat effect or shallow effect is a form of boundary in order to preserve desperately psychic integrity, to avoid undesired impact and pain and hurt by other people, to escape emotional demands because all this had been associated in the past with pain and with trauma.

So detachment does not necessarily mean avoiding empathy. It allows the person to rationally choose whether or not to be overwhelmed or manipulated by such feelings.

So emotional detachment is also related to experiential avoidance. Experiential avoidance is the attempt to avoid thoughts, feelings, memories, physical sensations, and other internal experiences, even when doing so creates harm in the long run. Even when this avoidance is damaging and the person knows it's damaging, the person prefers to avoid.

The process of experiential avoidance is maintained through negative reinforcement. There's a short-term relief of mounting anxiety and discomfort, and this is achieved by avoiding emotions, avoiding experiences, and this increases the likelihood that the behavior will persist.

It is self-reinforcing.

The current conceptualization of experiential avoidance suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties, in particular habitual and persistent unwillingness to experience uncomfortable thoughts, uncomfortable feelings, and associated avoidance and inhibition of these experiences.

This is linked to a whole range of problems, and so experiential avoidance is an integral part of third wave cognitive behavioral theories, such as acceptance and commitment therapy, ACT, ACT.

But the general concept much precedes ACT and third wave or third-generation cognitive behavioral psychology.

We find, for example, the concept of defense mechanisms in psychoanalysis and psychodynamic theories.

Defense mechanisms are intended to avoid unpleasant affect, discomfort, egodystonic, conflicting thoughts or conflicting motivation, dissonances.

So, in a way, defense mechanisms are processes that contribute to the expression of various types of psychopathology.

So, they are forms of avoidance. They are forms of reframing that inhibit affect expression, affect display.

And then we have process experiential therapy, which is essentially Gestalt. The base is Gestalt.

So, Gestalt also deals, and humanistic theory, also deals with issues of emotional inhibition and so on.

In humanistic theory, for example, Carl Rogers wrote, whether the stimulus was the impact of a configuration of form, color or sound in the environment, or the sensory nerves, or a memory trace from the past, or a visceral sensation of fear or pleasure or disgust, the person would be living it, would have it completely available to awareness.

It's an early description of flashback. He is more open to his feelings of fear and discouragement and pain. He is more able to fully to live the experiences of his organism rather than shutting them out of awareness.

So, memory, I mean, emotional detachment, experiential avoidance, emotional blunting, flat affect, they are all defenses. They are all defenses against flashbacks, actually, or emotional dysregulation.

In behavioral therapy, we also know that fears and anxieties are regulated in ways which sometimes involve counter-acting avoidance.

Individuals repeatedly encountering and remaining in contact with what causes them distress and comfort begin to avoid the resulting emotions.

Same in cognitive theory, reappraisals of negative thought patterns and schema, perpetuating distorted beliefs, lead to psychopathology involving flat affect.

So, there are problems associated with flat affect and denial of display and so on.

Distress. Avoidance creates distress. Avoidance reinforces the notion that discomfort, distress and anxiety are bad or dangerous, should be avoided at all costs. Sustaining avoidance requires effort and energy, so it's very depleting. Avoidance limits one's focus at the expense of truly experiencing what's going on in the presence and may get in the way of other important aspects of life.

And so, I will summarize by, I will end by summarizing the various examples.

In major depressive episode, we have isolation, we have suicide. And isolation and suicide are intended to counter feelings of sadness, guilt and loss and worth.

In post-traumatic stress disorder, we have avoiding trauma reminders and triggers. We have hypervigilance and they are intended to fend off, to defend against memories, anxiety and concerns of safety.

In social phobia, we have the avoidance of social situations which is intended to defend against anxiety, concerns of judgment from others. In panic disorder, we avoid situations that induce panic, of course, intended to defend against fear and physiological sensations associated with anxiety and panic disorders.

In agoraphobia, restricting travel outside of home or other safe areas, a constricted life, is defense against anxiety, fear of having symptoms of panic.

In obsessive compulsive disorder, there's a lot of checking of many rituals, repetitive rituals. They are intended to protect against worry of consequences, contamination. In substance use disorders, abusing alcohol and drugs leads to numbing, brownouts, blackouts, coma sometimes. These are intended to compensate for emotions, memories and withdrawal symptoms which are highly egodystonic.

In eating disorders, we restrict food intake, purging. These are forms of avoidance and they're intended to cater to the worry about becoming overweight, fear of losing control, actually, by proxy.

And finally, in borderline personality disorder, we have self-harm, cutting, which is a form of protection against high emotional arousal or, on the contrary, a form of reminding oneself that one is alive.

You see the enormous range, the enormous range of functionality of inappropriate numb, flat and shallow affect. And so it's not limited to schizophrenia by any means and it's helping us to reconceptualize a whole host of hitherto disparate mental health conditions as actually post-trauma, post-traumatic conditions.

This includes, of course, personality disorders.

Thank you for listening.

Hello. Yes. Thank you so much, Dr. Sam, for your wonderful talk. Thank you.

So if anyone having any question, they can ask to Dr. Sam. Anyone want to ask any questions?

Okay, then we will proceed to another talk.

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