Applied Psychology OPUS

The Effect of Post Traumatic Stress Disorder on the Ability to Recognize Facial Expressions

by Coralie Nehme

         More than 13 million Americans will suffer from posttraumatic stress disorder (PTSD) at some point in their lives (Frueh, 2000). The DSM-IV-TR (2000) 4th ed., text rev. criterion for PTSD includes a history of exposure to a traumatic event which must meet two criteria and symptoms from each of the following symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. The duration of symptoms and the functional significance (acute vs. chronic) is also a part of the diagnostic criteria. Symptoms some people with PTSD may experience include: re living the trauma through flashbacks, nightmares, memories or escalating physical manifestations of trauma through increased anger, stress and sleeplessness (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 200). There is no determined time lapse following a traumatic event during which one typically begins experiencing an onset of PTSD symptoms. Symptoms may appear directly after the traumatic event or may be delayed, taking place months or years later. PTSD symptoms are typically so severe that they interfere in the individual’s ability to live daily life as they normally would (Akhter, Nordine & Levinson, 2009). PTSD affects a person’s emotions, and recent research indicates that PTSD affects the ability to recognize facial expressions (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). The inability to recognize facial expressions is significant because factual knowledge that is associated with certain types of facial expressions is lost when the ability to recognize these expressions is diminished (Adolphs, Damasion, Tranel & Damasio, 1996).

        Studies show differences in the ability of individuals with diagnosed PTSD and their ability to recognize different facial expressions, specifically expressions of fear and sadness (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Current research also seems to indicate a difference in PTSD in adults and children and its effects on their ability to recognize facial expressions of emotions (Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Research is conflicted, however, as to the nature of the relationship between PTSD and the ability to recognize facial expressions. Some studies have found that having PTSD inhibits the ability to recognize facial expressions, whereas others have concluded that PTSD increases an individual’s ability to recognize certain emotions in facial expressions, such as sadness and fear. There appears, however, to be a link between PTSD and emotional numbing, but research does not explore this relationship. PTSD has been linked with decreased ability to express emotions, a part of emotional numbing (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Emotional numbing is a form of detachment or dissociation that is part of the avoidance cluster of symptoms that is typical in trauma survivors (Litz et al., 1997).This paper will examine the studies conducted examining the relationship between PTSD and emotional numbing. It will attempt to make connections between these (PTSD and emotional numbing) and the ability to recognize facial expressions. The paper will explore the relationship between having PTSD and the ability to recognize facial expressions, as well as the effect of this phenomenon on the daily lives and interactions of individuals with PTSD. Despite disparities in the literature, this paper will analyze the differential effects of PTSD on the ability to recognize facial expressions in adults and children.

Connections to Post Traumatic Stress Disorder
        According to the DSM-IV-TR (2000), individuals with PTSD suffer three types of symptoms: avoidance/numbing, increased anxiety/emotional arousal, and intrusive memories. PTSD affects one’s emotional wellbeing, perhaps due to the emotional impairment prevalent in those who have experienced trauma (Frueh, 2000). Emotional impairment has been suggested as the pivotal connection, responsible for the difference between the ability or lack of ability to recognize emotions in facial expressions. How does the inability to express emotions lead to inability to recognize those same emotions in the facial expressions of others? Poljac, Montagne and Hann (2010) suggest, “Facial expressions represent strong cues for emotional states and their perception and interpretation is a human ability crucial for establishing normal interpersonal relationships” (Poljac, Montagne, & Haan, 2010, p. 977). This means that facial expressions play a vital role in social networking and relationshipbuilding. Further support for this claim comes from the emotion-type hypothesis proposed by Ross and Monnot’s research on emotions in the right and left hemispheres of the brain, suggesting that these emotional facial expressions allow for cross-cultural communication.

        Emotion-Type Hypothesis that combines the two main hypotheses about the lateralization of emotions, which states: “primary emotions and related displays are processed preferentially by the right hemisphere whereas social emotions and related ‘display rules’ are processed preferentially by the left hemisphere” (Ross and Monnot, 2010, p. 872). The study conducted by Ross and Monnot supports this third hypothesis. This is significant because primary emotions, such as anger, fear, sadness, and happiness are believed to be “genetically hard-wired” and are thus recognized across all cultures. Aging plays a role in this, however, and as one ages, the ability to recognize multiple facial expressions at once (different in the upper and lower halves of the face) diminishes, specifically with sadness and fear (Ross and Monnot, 2010). Similarly, studies have shown that PTSD mainly affects the ability to recognize emotions of fear, sadness and anger. Further research aims to better examine the relationship between PTSD the ability to recognize facial expressions, most notably the study by Poljac, Montagne, & Haan (2010).

        In the research study conducted in 2010 by Poljac, Montagne, & Haan, the researchers selected 20 male war veterans who were diagnosed with PTSD and 20 males matched in age and education level who had no history of mental illness (control group). Results showed that PTSD participants had slightly higher depression scores than the control group. The Benton Facial Recognition Test did not reveal significant differences between the groups. Results of the experiment showed that that group differences existed between the control and experimental group. The PTSD group could only recognize expressions of fear and sadness in more expressive faces, but there were no differences for the emotions of anger, disgust, happiness and surprise (Poljac, Montagne, & Haan, 2010). This finding suggests the negative impact of PTSD on the ability to recognize emotional facial expressions.

        Kirsch and Brunnhuber, (2006) found that individuals with PTSD report diminished restrictions in their capacity to feel (Kirsch & Brunnhuber, 2006). Women with PTSD exhibited higher levels of negative stimulation and expressed more negative emotion words in response to both positive and negative stimuli, whereas no group differences emerged in facial expressivity, suggesting that PTSD affects the type of response across varied stimuli (Kirsch and Brunnhuber, 2006). The data found that there was a difference between the control and experimental groups’ abilities to distinguish and convey facial expressions, but this difference is not enough to be statistically significant. Results of this study, however, found that there were significant differences in anger. Participants with PTSD recognize and experience anger more often than the control group (Kirsch and Brunnhuber, 2006). No significant differences were found between having PTSD and the ability to recognize sadness and fear, directly opposing previous research.

        In an attempt to further understand the relationship between PTSD and the ability to recognize facial expressions, another study compared the severity of PTSD on the ability to recognize masked and unmasked facial expressions of happiness and fear. Researchers monitored activity in the amygdala, which is a key neurological component of emotional processing. Researchers then showed participants with acute and long-standing chronic PTSD images of masked and unmasked facial expressions of fear and happiness (Armony, Corbo, Clement & Brunet, 2005). Amygdala activation increased in masked facial expressions with increased scores of PTSD severity (Armony et al., 2005). This indicates that severity of PTSD has some effect on the ability to recognize expressions of both happiness and fear (Armony et al., 2005).

Children with PTSD
        Studies have shown that PTSD affects a child’s ability to recognize facial expressions differently than it affects an adult’s. Understanding why this difference exists will allow us to further comprehend the effect of PTSD on the ability to recognize facial expressions. Participants were shown “morphed facial emotion identification tasks.” Participants included a mix of maltreated and homeless children (Masten, Guyer, Hodgdon, McClue, Charney et al., 2008). The researchers looked at the patterns of emotional processing in children with PTSD. They tested whether atypical processing of emotions after trauma was related to a PTSD diagnosis. The study focused on fear as the negative emotion of interest because fear suggests the presence of danger in the immediate environment, which is the negative emotion often exhibited by an abuse victim.

        Though there was no difference between the control and experimental groups in the accuracy of recognizing fear, the rate at which this task was executed differed between groups. Specifically, children with PTSD were able to recognize facial expressions of fear much faster than the control children who did not meet diagnostic criteria for PTSD. There were not, however, any differences between the control and PTSD groups in the ability to recognize neutral and happy expressions.

        Children with PTSD recognize facial expressions of fear better than those without PTSD, whereas studies have shown that adults with PTSD are less able to recognize facial expressions of fear and anger. PTSD, therefore, differentially affects the ability to recognize facial expressions in children than it does in adults. The occurrence of such is an interesting phenomenon that merits further research to indicate why such a disparity exists.

Limitations
        There is little research about the link between PTSD and the ability to recognize facial expressions. This is, however, an important topic to research, because the ability to recognize emotional expressions is vital to successful social interactions and effective communication (Masten et al., 2008). Better understanding of the effects of PTSD on the ability to recognize facial expressions and more research on the possible link to emotional numbing will help us develop a better understanding of the brain and the role that recognizing emotions plays in social interactions. Further research should also be done on the severity of PTSD and the ability to recognize emotional expressions. More research on this could allow better motivation for individuals suffering from PTSD to get help immediately, to prevent the effects that long-term chronic PTSD has on emotional processing. The difference between the effect of PTSD in children and adults should also be explored to teach us more about the effects of trauma on brain and emotional development from childhood to adulthood.

Discussion
        The ability to recognize facial expressions is vital to the formation of social and inter-personal relationships. The cross-cultural homogeneity of facial expressions indicates the significance of this ability. Understanding the relationship between PTSD and the ability to recognize facial expressions is also essential to the development of better techniques for treating PTSD. PTSD affects the emotional processing of all those afflicted with it, but the field lacks understanding of how emotional processing is effected, and how to rehabilitate individuals with damaged emotional processing capabilities.

References

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Akhter, M.N., Nordine, G., & Levinson, R.A. (2009). Technology-assisted management of posttraumatic stress disorder in nonmilitary personnel returning from the war zone byfamily practitioners. Journal of National Medical Association, 101(8)

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Armony, J. L., Corbo, V., Clement, M. H., & Brunet, A. (2005). Amygdala response in patients with acute PTSD to masked and unmasked emotional facial expressions. The American Journal of Psychiatry, 162(10), 1961-1963.

Bernsten, D., Rubin, D. C., & Siegler, I. C. (2011). Two versions of life: Emotionally negative and positive life events have different roles in the organization of life story and identity. Emotion, 11(5), 1190-1201. doi: 10.1037/a0024940

Frueh, B.C. (2000). Posttraumatic Stress Disorder. (2000). Encyclopedia of psychology. USA: Oxford University Press.

Kirsch, A., & Brunnhuber, S. (2007). Facial expression and experience of emotions in psychodynamic interviews with patients with PTSD in comparison to healthy subjects. Psychopathology, 40, 296-302. doi: 10.1159/000104779

Lewis, S. F., & Garver, D. L. (1995). Treatment and diagnostic subtype in facial affect recognition in schizophrenia. J. Psychiat, 29(1), 5-11.

Litz, B. T., Schlenger, W. E., Weathers, F. W., Caddell, J. M., Fairbank, J. A., & LaVange, L. M. (1997). Predictors of emotional numbing in posttraumatic stress disorder. Journal of Traumatic Stress, 10(4), 607-618.

Masten, C. L., Guyer, A. E., Hodgdon, H. B., McClure, E. B., Charney, D. S., Ernst, M., et. al. (2007). Recognition of facial emotions among maltreated children with high rates of posttraumatic stress disorder. Child abuse and neglect, 32, 139-153. doi: 10.1016/j.chiabu.2007.09.006

Poljac, E., Montagne, B., & Haan, E. H. F. (2010). Reduced recognition of fear and sadness in post-traumatic stress disorder. Cortex, 47, 974-980. doi: 10.1016/j.cortex.2010.10.002

Ross, E. D., & Monnot, M. (2010). Affective prosody: What do comprehension errors tell us about hemispheric lateralization of emotions, sex, and aging effects, and the role of cognitive appraisal . Neuropsychologia, 49, 866-877. doi: 10.1016/j.neuropsychologia.2010.12.024

Author's Biography

Coralie Nehme is a first-semester senior in Applied Psychology. She is currently the OPUS publicity chair and an editor in-training. Her research interests include trauma, anxiety disorders, and the influences of immigration and culture. She is exploring her interest of the influence of immigration and culture on parenting on Dr. Erin Godfrey's research team looking at the customs that immigrant mothers want their children to adapt. She is also exploring her interest in trauma and anxiety disorders at the Bellevue/NYU Langone Program for Survivors of Torture. After graduation in December, she plans to take a gap year to work before applying to PhD programs in Counseling Psychology.