Introduction
A considerable number of veterans develops PTSD, depression and other psychiatric disorders and the number of psychiatric casualties seems to have increased quite a bit over time (Karstoft, Nielsen & Andersen, 2017) based on self-report. If one uses prescriptions from the Danish registers as a measure for psychiatric disorders almost a quarter of the veterans suffer from disorders post-deployment (Lyk-Jensen, 2022).
This article focuses on a selection of these veterans and asks whether or not the army can learn something from these injured veterans, which can be used to enhance the treatment and diagnoses of this group. Concretely, this study describes and analyzes the prevalence of PTSD and CPTSD in a treatment sample and analyzes the psychological mechanisms involved. We think that this knowledge is important for the people who will assist them in their recovery and will also be valuable for all who are interested in the human consequences of modern warfare, as well as those who are assessing claims in court.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is a common mental disorder in military and veteran populations (Williamson et al., 2018; Wisco et al., 2014). The term “veteran” refers to anyone who has completed at least one operational deployment, regardless of whether he or she is still serving (Forsvarsministeriet, 2016, p. 1). PTSD often becomes a chronic disorder resulting in substantial functional impairment and reduced quality of life (Armenta et al., 2018; Pacella, Hruska, & Delahanty, 2013). 10% of Danish soldiers deployed to Afghanistan, it is estimated, self-reported probable PTSD two and a half years after returning home (Madsen, Andersen, & Karstoft, 2016). Furthermore, the prevalence and severity of PTSD symptoms increased over time; 13.7% reported high levels of PTSD symptoms and another 13% reported moderate to high levels of depression 6.5 years post-deployment (Karstoft et al., 2017; Nielsen, Andersen & Karstoft, 2019). In addition, some of these soldiers exposed to military service-related trauma are at risk of developing complex conditions that require thorough assessment.
The recently published 11th edition of the International Classification of Diseases, ICD-11 (World Health Organization, 2018), divides PTSD into two “sibling disorders” within the section on Disorders Specifically Associated with Stress: PTSD and complex PTSD (CPTSD). The stressor acts as the “gate” that allows consideration of a diagnosis of either PTSD or CPTSD (Maercker et al., 2013). The ICD-11 model of PTSD is conceived as a fear-based reaction to a specific traumatic event and is defined by three symptom clusters that relate to core posttraumatic responses: (1) re-experiencing the traumatic event in the present in the form of nightmares, flashbacks, or vivid intrusive memories typically accompanied by strong emotions like fear or horror; (2) avoidance of reminders of the traumatic events; and (3) persistent perceptions of heightened current threat manifested as increased arousal and hypervigilance. The CPTSD diagnosis includes the symptoms of PTSD as well as persistent and pervasive “disturbances in self-organization” (DSO) that describe three clusters of symptoms: (1) affective dysregulation, i.e., heightened emotional reactivity, dissociative experiences, or emotional numbing; (2) negative self-concept, e.g., feelings of guilt, shame, or worthlessness; and (3) disturbances in relationships, including difficulties sustaining relationships and feeling close to others (WHO, 2018).
The addition of CPTSD to the ICD-11 classifications is based on the evidence that individuals with the disorder have a poorer prognosis and may benefit from different treatments to those individuals with PTSD (Brewin et al., 2017). The types of events associated with higher risk for CPTSD are expected to be sustained, repeated, or multiple forms of traumatic exposure (Cloitre et al., 2013). In addition, several empirical studies have consistently demonstrated that ICD-11 CPTSD is associated with greater comorbidity, significantly worse psychosocial functioning, and reduced quality of life when compared to ICD-11 PTSD, emphasizing that CPTSD is a more severe disorder than PTSD in clinically meaningful ways (Brewin et al., 2017; Elklit, Hyland & Shevlin, 2014; Karatzias et al., 2019; Karatzias et al., 2017; Murphy et al., 2016).
The division of PTSD into two qualitatively different disorders has been largely supported across trauma-exposed populations, and a number of studies find evidence of symptom profiles consistent with PTSD and CPTSD in samples of, respectively, treatment-seeking, heterogeneous, trauma-exposed samples of adult westerners (Böttche et al., 2018; Cloitre et al., 2013; Hyland et al., 2017a; Knefel et al., 2020); bereaved parents after the death of a child, rape victims, and victims of physical assault (Elklit et al., 2014); trauma-exposed young non-Western adults from Northern Uganda (Murphy et al., 2016); adult survivors of sexual abuse, women in shelters, psychiatric outpatients endorsing an ICD-10 diagnosis of PTSD; refugees and torture survivors (Vang et al., 2021); and trauma-exposed university students, pain-patients, and military personnel (Hansen et al., 2017).
Recent studies have evaluated the ICD-11 model of CPTSD in veteran populations (Wolf et al., 2015). A study by Murphy et al. (2020) that aimed to validate the ICD-11 model of PTSD and CPTSD and assess the rates of the two disorders among treatment-seeking British veterans found adequate grounds to distinguish the two diagnoses. Another recently replicated study by Folke, Nielsen & Karstoft (2021) found the distinction in ICD-11 of PTSD and CPTSD clinically relevant in a large sample of Danish treatment-seeking military veterans. Further, their findings implied that veterans who meet the criteria for CPTSD have different types of symptoms, greater severity, higher levels of functional impairment, and are more likely to be single, divorced, or widowed, and more likely to use psychotropic medication, compared to veterans meeting the PTSD-criteria (Folke et al., 2019, 2021).
A study of the prevalence of PTSD and CPTSD in a group of previously deployed treatment-seeking Danish soldiers and veterans found that, in total, 13.0% met the criteria for probable PTSD, whereas 31.4% met the criteria for CPTSD (Folke et al., 2023). The study found that increased risk of CPTSD was related to the length of the exposure to trauma, the experience of war and combat, and being single. Older age and the receipt of sickness benefits were risk factors for both PTSD and CPTSD. The veterans with CPTSD reported higher levels of functional impairment, comorbidity, and more suicide attempts compared to the PTSD group and a group with no trauma disorder (Folke et al., 2023). Despite limited research on CPTSD among veterans, another study involving treatment-seeking Croatian veterans reported an 80.6% prevalence of CPTSD more than 20 years after the war exposure (Letica-Crepulja et al., 2020). This emphasizes the relationship between the severity of posttraumatic distress and functional problems in trauma-exposed veterans.
One central mechanism implicated in the development and prolongation of PTSD symptoms following trauma exposure is emotion regulation (Bardeen, Kumpula & Orcutt, 2013). Gross (1998) defines emotion regulation as the process by which an individual can, either consciously or unconsciously, influence which emotions they experience, the timing of these emotions, and how the individual perceives and expresses these emotions. Two of the emotion-regulation strategies Gross (1998) introduces in his process model are suppression and reappraisal. Suppression is a response-focused strategy that attempts to conceal, reduce, or inhibit emotional expressions. Reappraisal is an antecedent-focused strategy, that attempts to reinterpret an emotional event in a way that changes the emotional impact and meaning. Following a traumatic event, the individual may experience strong emotional responses, intrusive re-experiencing symptoms, and accompanying distress (Seligowski, et al., 2015). Furthermore, trauma exposure frequently leads to heightened emotional distress, which, in turn, places increased demands on the individual to regulate their emotions. However, in the case of PTSD, these efforts to regulate emotions are often disrupted, making it challenging for individuals to modulate their emotional responses effectively (Seligowski et al., 2015).
Gratz and Roemer (2004, p. 52) proposed six dimensions in which difficulties with emotion regulation may occur: (a) lack of Awareness of emotional responses; (b) lack of Clarity of emotional responses; (c) Nonacceptance of emotional responses; (d) limited access to emotion regulation Strategies perceived as effective; (e) difficulties controlling Impulses when experiencing negative emotions; and (f) difficulties engaging in Goal-directed behaviors when experiencing negative emotions. Individuals with greater PTSD symptom severity exhibit elevated emotion dysregulation following trauma exposure (Sippel et al., 2016) and given the associations between several aspects of emotion regulation difficulties and PTSD, trauma-exposed individuals with heightened emotion dysregulation may be less equipped to cope with the distress associated with PTSD symptomology (Raudales et al., 2020).
Emotion dysregulation in veterans exposed to trauma has additionally been linked to compromised interpersonal functioning and heightened risk of posttraumatic psychopathology (Cox et al., 2017); veterans with PTSD have been found to use a greater number of maladaptive strategies (e.g., suppression) to regulate emotions compared to veterans without PTSD (Sippel et al., 2016). Moreover, emotion dysregulation has been found to mediate the relationship between PTSD symptoms and various risky, impulsive behaviors (Weiss et al., 2012).
In addition, a meta-analysis found that approximately 10% of military personnel reported engaging in physical acts of violence in the month following their deployment, and around 20% reported such acts over a longer time period (MacManus et al., 2015). The prevalence rates of overall aggression were 29%–36%, depending on whether verbal aggression was included (MacManus et al., 2015). Anger and aggression in military populations is strongly associated with mental health issues such as PTSD (Gonzalez et al., 2016; Taft et al., 2007) and have been tied to several common physical and behavioral health issues that are commonly observed post-combat deployment, e.g., opioid use, risky driving, and intimate partner violence (Wilk et al., 2015). Specifically, anger and aggression in U.S. veterans have been associated with PTSD hyperarousal (Elbogen et al., 2010), PTSD re-experiencing (Hellmuth et al., 2012) and depression (Taft et al., 2009).
However, no studies to date have, to our best knowledge, investigated whether ICD-11 PTSD and CPTSD symptoms are associated with emotion regulation difficulties and aggression in veterans seeking treatment following military deployment. The present study therefore investigates the relationship between these variables and the severity of posttraumatic symptomatology in this population. The study has two objectives: first, to identify demographic and trauma-related risk factors associated with PTSD and CPTSD; and, second, to explore how much of the variance in ICD-11 posttraumatic symptomatology can be explained by scores in emotional dysregulation and aggressive behavior, when controlled for other factors such as demographics, trauma-related somatization, dissociation, negative affectivity, and perceived social support.
Based on the existing literature of the risk factors for ICD-11 PTSD and CPTSD, we expect a high prevalence of posttraumatic symptoms and distress among the veterans, and severity to be associated with demographics (age, marital status), military action (number of missions, land of deployment, combat exposure), and clinical factors such as alcohol intake and the use of psychotropics (Hyland et al., 2017a; Karatzias et al., 2019; Karatzias et al., 2017). Although not yet examined in relation to ICD-11 PTSD and CPTSD, difficulties in emotion regulation have been shown to increase the risk of posttraumatic distress and have been identified as a critical factor in the development and prolongation of posttraumatic stress symptoms across a variety of samples (Seligowski et al., 2015); therefore, we expected emotion dysregulation to be associated with both PTSD and CPTSD. Finally, based on data from clinical samples (Cox et al., 2017; Cox et al., 2018; Raudales et al., 2020), we expected different aspects of emotion regulation to be associated with the severity of posttraumatic symptomatology.
Methods
Participants
Data for this study were obtained from a sample of Danish war veterans (n = 142) referred to the outpatient service of a highly specialized trauma treatment unit (ATT) in the Region of Southern Denmark between February 2018 and May 2021. At intake, all veterans were invited to fill out a paper-and-pen self-report questionnaire pertaining to their current symptomatology, trauma experience, medication use, and sociodemographic information. For this study, everyone who was referred to ATT and filled out the questionnaire was considered. All patients were informed about the study in detail and gave their informed consent. The study was approved by the University Data Protection Agency (RIO at SDU; No. 16.510) and written informed consent was obtained from all participants after detailed information about the study was provided to them.
Measures
Below are the variables forming the analytical criteria.
Demographics
Variables containing basic information including gender, age, marital and parental status, number of missions, recent country of service and experiences of threat, injury, dread, and debriefing during military deployment. Additionally, information about psychoactive medication, intake of alcohol and recent major life events (e.g., bereavement, illness, divorce, relocation, marriage) was also included. Weekly alcohol intake was recorded in one of three groups (0–14, 15–30, >31 units).
PTSD-symptoms and severity (ITQ)
The International Trauma Questionnaire (ITQ) assesses ICD-11 PTSD and CPTSD (Cloitre et al., 2018). The ITQ is a brief, simply worded measure focusing on the core features of PTSD and CPTSD employing straightforward diagnostic rules. Consistent with the organizing principles of the ICD-11 to maximize clinical utility and international applicability through a focus on a limited but central set of symptoms (Vang et al., 2021), it principally draws on three symptom clusters designated Re-experience, Avoidance, and Sense of Threat, each comprising two items to measure PTSD in the past month. A further three clusters with two items per cluster measures disturbances in self-organization (DSO); these are designated Affective Dysregulation, Negative Self-concept, and Disturbances in Relationships. The participants answered the DSO items in terms of how they typically felt, thought about themselves, and related to others. The three items for each domain (PTSD and DSO) measuring the level of functional impairment were not included in this study. The items were measured on a 5-point scale from 0 (“Not at all”) to 4 (“Extremely”), giving a total of 12 items with a possible total ITQ score in the range of 0 to 60. Following standard practice in trauma research (Elklit & Shevlin, 2007; Karatzias et al., 2017), scores ≥2 (“Moderately”) were used to indicate the presence of a symptom. All analyses were based on these dichotomized items (Cloitre et al., 2018). The ITQ has demonstrated good psychometric properties in several studies (Hyland et al., 2017a; Hyland et al., 2017b). In the current study, the Cronbach’s alpha coefficient for the ITQ was 0.85, PTSD-subscale 0.80, and for the DSO subscale 0.81.
Emotion regulation (DERS)
Prior research indicates difficulties in emotion regulation in populations with high prevalence of complex PTSD and that emotion regulation problems have a significant negative impact on interpersonal relationships and maladaptive behaviors (Gratz & Roemer, 2004). In this study we used Gratz & Roemer’s Difficulties in Emotion Regulation Scale (DERS) to evaluate emotion regulation in the veteran population. The DERS was developed to assess emotion dysregulation more comprehensively than existing measures by reflecting difficulties within six facets of emotion regulation. The 36-item self-report scale inquires how respondents relate to their emotions to produce scores on the following subscales: (a) “Nonacceptance of emotional responses”; (b) “Difficulty engaging in goal-directed behavior”; (c) “Impulse control difficulties”; (d) “Lack of emotional awareness”; (e) “Limited access to emotion regulation strategies”; and (f) “Lack of emotional clarity”. Participants were asked to indicate how often the items apply to themselves, with responses ranging from 1 (“almost never” [0–10%]) to 5 (“almost always” [91–100%]) giving a total score range from 36 to 180 (Gratz & Roemer, 2004).
While there are no standardized clinical cutoffs for this measure, prior research suggests that the clinical range on the DERS total score varies from averages of approximately 80 to 127 (Haynos, Roberto, & Attia, 2015). For the purposes of this study, DERS items were recoded so that higher scores in every case indicated greater emotion dysregulation. The DERS is a widely used self-report measure of subjective emotional functioning with good psychometric properties. The questionnaire has demonstrated strong internal consistency, good test-retest reliability, and satisfactory construct and predictive validity (Gratz & Roemer, 2004; Hallion et al., 2018). In the current study, the Cronbach’s alpha coefficient for DERS was 𝛼 = 0.92, and for the subscales: Non-Acceptance 𝛼 = 0.75, Goals 𝛼 = 0.81, Impulse 𝛼 = 0.86, Awareness 𝛼 = 0.70, Strategies 𝛼 = 0.88, and Clarity = 0.79.
Negative affectivity, somatization, and dissociation (TSC-26)
PTSD often co-occurs with depression, anxiety, somatization, and dissociation (Armenta et al., 2018). In this study, these comorbid variables were measured in the revised 26-item Danish version of the Trauma Symptom Checklist (TSC-26), an instrument measuring the occurrence of psychological symptoms associated with trauma (Krog & Duel, 2003; Chiffre et al., 2024). The TSC-26 questionnaire covers three dimensions (nNgative affectivity, Somatization, and Dissociation) and is scored on a 4-point Likert scale with 1 (“no”), 2 (“yes – sometimes”), 3 (“yes – often”), 4 (“very often”). Possible scores are in the range of 10–40 for Negative affectivity, 11–44 for Somatization, 5–20 for Dissociation, and in total 26–104. In the current study, the alpha values for the subscales were: Negative affectivity 𝛼 = 0.84, Somatization 𝛼 = 0.77, Tissociation 𝛼 = 0.78, and total TCS 𝛼 = 0.90.
Aggressive behavior (aggression scale)
Prior research has revealed heightened aggressive behavior among veterans with PTSD and demonstrated that PTSD diagnosis and PTSD symptoms can be a predictor of high levels of aggression (Taft et al., 2007). To measure the levels of aggression in this study, we used a short, 6-item aggression scale developed by Taft and colleagues at the National Center for PTSD, Boston. The scale assesses the level of aggression ranging from verbal violence and threats of violence (e.g., “was verbally abusive,” “threatened someone with a weapon”) to actual acts of violence (e.g., “had a physical fight with someone,” “used a weapon against someone”). Responses for this measure were referenced to aggressive incidents towards anyone in the 4 months prior to assessment and given on the 7-point scale: 0 (“never”), 1 (“once”), 2 (“3 to 5 times”), 4 (“6 to 10 times”), 5 (“11 to 20 times”), 6 (“more than 20 times”). All items were recoded to reflect the estimated frequency of the behavior: “never” = a score of 0; “once” = a score of 1; “twice” = a score of 2; “3 to 5 times” = a score of 4; “6 to 10 times” = a score of 8; “11 to 20 times” = a score of 15; “more than 20 times” = a score of 25 and summed to compute a total aggression frequency score (Taft et al., 2007). In the current study, the alpha value for total aggression scale was α = 0.65.
Social support (CSS)
Social support is generally recognized as a possible mediator of distress and as a predictor of psychological well-being among survivors of traumatic experiences. The importance of social support following trauma is reflected in many trauma studies (Elklit, Pedersen, & Jind, 2001). For this study, the experience of social support was measured by the Crisis Support Scale (CSS; Joseph, Williams, & Yule, 1992), a 7-item scale for measuring social support after a crisis has occurred. The items include: (1) perceived availability of someone to listen; (2) contact with people in a similar situation; (3) the ability to express oneself; (4) received sympathy and support; (5) practical support; (6) the experience of being let down; and (7) general satisfaction with social support. Answers are scored on a 7-point Likert scale ranging from 1 (“never”) to 7 (“always”) giving a total score range of 7–49. Based on data from several trauma studies, the scale appears to be very robust and demonstrates good reliability, validity, internal consistency, and item discrimination. Elklit et al. (2001) have confirmed the psychometrical reliability and validity of the Danish version. The alpha value for the total CSS score in the present study was 𝛼 = 0.67.
Data Analysis
Descriptive statistics were computed to examine sample demographics and to ascertain sample frequencies/percentages, means, and standard deviations on each study measure. Prevalence rates for PTSD and CPTSD were calculated.
Further analysis progressed in three linked stages.
First, bivariate correlations were computed to examine basic associations between the main study variables (emotion dysregulation, psychological symptoms associated with trauma, social support, and aggression), demographic factors (age, relationship status, parenting, number of missions, location of deployment, combat exposure, recent major life events, use of psychoactive drugs, and alcohol intake) and symptoms of ICD-11 PTSD and CPTSD. Statistical significance was set as p < 05. As only one dependent variable was used (the ITQ score), the alpha level was not adjusted.
Second, t-tests and between-groups ANOVA analyses were computed to explore the impact of demographic variables on ITQ and to assess effect sizes. For testing associations between dichotomous variables (number of children, combat exposure and use of psychoactive drugs) and the ITQ total score, a t-test for independent samples was used.
Third, independent variables, measures, and subscales that had significant associations with ICD-11 PTSD and CPTSD symptoms were subsequently entered in hierarchical multiple linear regression analyses to explore their degree of predictability and explanatory efficacy. These were adjusted for variables found to be constant or significant (age, attending debriefing, and use of psychotropics) to control for possible confounding variables. Based on the ANOVA analysis we decided not to include the remaining demographics in the two models. Collinearity was checked in the multiple regression model by the variance inflation factor (VIF). Data were checked for extreme scores and skewness, and to comply with the few outliers identified, robust methods (bootstrapping) were applied in the analyses. Statistical analyses were performed using SPSS version 28.0.
Results
Descriptive Statistics
Table 1 displays the mean scores and standard deviations of demographic, military, and clinical characteristics. Mean sample age was 42.7 years (SD = 8.49) and the majority were male (97.9%). Based on ITQ data, 20 (14.2%) of the 142 participants did not meet the diagnostic criteria for PTSD, while 42 (29.8%) and 79 (56.0%) met the criteria for probable PTSD and CPTSD respectively. In addition, the participants reported (see Table 2) clinically relevant scores in emotion dysregulation (DERS total: M = 104.89; SD 21.49) and trauma-related psychological symptoms (TSC: Somatization, M = 29.57, SD = 5.60, Dissociation (M = 10.58, SD = 3.44), and Negative affectivity (M = 26.64, SD = 6.22). On average, moderate levels of experienced social support (CSS: M = 28.50, SD = 7.02), and low levels of aggressive behavior (Aggression Scale: M = 10.64, SD = 15.88).
Table 1
Descriptive statistics (n = 142).
| PARTICIPANT CHARACTERISTICS | n/MEAN | PERCENT/SD | RANGE |
|---|---|---|---|
| Demographic | |||
| Age | 42.7 | 8.49 | 22–58 |
| Male | 139 | 97.9% | |
| Female | 3 | 2.1% | |
| Cohabiting/married | 85 | 59.8% | |
| Single/not married | 36 | 25.4% | |
| Divorced/widower | 21 | 14.8% | |
| Childless | 36 | 25.4% | |
| Parent | 103 | 74.1% | |
| Number of children | 1.6 | 1.40 | 1–8 |
| Military | |||
| Number of missions | 2.5 | 2.16 | 1–15 |
| Balkan | 65 | 45.8% | |
| Afghanistan | 50 | 35.2% | |
| Middle East and other | 26 | 18.4% | |
| Experience of mortal danger | 23 | 16.2% | |
| Injury | 45 | 31.7% | |
| Experience of helplessness or intense fear | 49 | 34.5% | |
| Debriefing | 78 | 54.9% | |
| Clinical | |||
| Recent major life events | 2.2 | 2.07 | 1–10 |
| Psychoactive drugs | 77 | 54.2% | |
| Alcohol intake: | |||
| 0–14 units pr. week | 116 | 82.3% | |
| 15–30 units pr. week | 17 | 12.1% | |
| >31 units pr. week | 8 | 5.7% | |
| no PTSD* | 20 | 14.2% | |
| PTSD* | 42 | 29.8% | |
| CPTSD* | 79 | 56.0% |
[i] Note. valid (n = 139–142).
*PTSD symptoms were assessed with the International Trauma Questionnaire (ITQ).
Table 2
Descriptive statistics for study variables.
| SCALES AND SUBSCALES | MEAN | SD | RANGE |
|---|---|---|---|
| ITQ | |||
| Re-experiencing | 6.39 | 3.22 | 0–12 |
| Avoidance | 5.51 | 2.08 | 0–8 |
| Hyperarousal/vigilance | 6.08 | 1.84 | 0–8 |
| PTSD-symptoms (sum) | 17.96 | 5.97 | 2–28 |
| Extrinsic emotion regulation | 13.13 | 3.78 | 2–20 |
| Intrinsic emotion regulation | 12.55 | 4.53 | 1–20 |
| Negative self-concept | 10.09 | 4.63 | 0–16 |
| Disturbance in relations | 7.62 | 3.02 | 1–12 |
| DSO-symptoms (sum) | 43.27 | 13.10 | 12–68 |
| DERS | |||
| Non-acceptance | 19.24 | 6.85 | 6–38 |
| Goals | 17.86 | 4.56 | 5–25 |
| Impulse | 17.34 | 6.05 | 6–30 |
| Awareness | 19.74 | 4.59 | 7–30 |
| Strategies | 24.32 | 7.53 | 8–40 |
| Clarity | 14.90 | 4.59 | 5–25 |
| DERS Total | 104.89 | 21.49 | 0–148 |
| TSC-26 | |||
| Negative affectivity | 26.64 | 6.22 | 12–40 |
| Somatization | 29.57 | 5.60 | 15–44 |
| Dissociation | 10.58 | 3.44 | 5–20 |
| Social Support (CSS) | |||
| Total | 28.50 | 7.02 | 0–46 |
| Aggressive Behavior | |||
| Total | 10.64/4.00* | 15.88 | 0–102 |
[i] Note. DSO = disturbances in self organization, valid (n = 114–141).
* = Median.
Correlations
To identify covariates for subsequent analyses, preliminary analyses were conducted to examine the relationships between independent demographic variables and the severity of traumatic stress. Results demonstrated no significant correlations between ITQ total scores and the following demographic factors: age, number of children, number of missions, and recent major life events (all rs < .16, all ps > .05) and no differences in posttraumatic severity as a function of experience of combat exposure (mortal danger, injury, experience of dread) and alcohol intake (all ts < .81, all ps > .05, two-tailed). However, independent-samples t tests found that 77 participants using psychotropics (M = 29.66; SD = 9.35) compared to the 64 participants not using medication (M = 33.64; SD = 7.34) reported significantly lower PTSD symptoms t(139) = 2.83, p < .01, two-tailed, d = .47). Conversely, the 77 participants who received postcombat debriefing (ITQ M = 32.82; SD = 8.98) compared to the 64 participants who did not (ITQ M = 29.84; SD = 8.11) reported higher levels of PTSD symptomatology t(139) = 2.05, p = .04, two-tailed, d = .35). One-way ANOVA revealed no significant relationship between the ITQ total scores, marital status, and land of deployment (both Fs [2, 138] < 1.89, both ps > .05).
Furthermore, zero-order bivariate correlations were computed between ITQ scores (PTSD and DSO) and all other independent variables to identify factors associated with posttraumatic symptomatology as assessed by the ITQ subscales (see Table 3). Of particular interest, results showed significant and strong correlations between ITQ PTSD scores and TSC Dissociation, TSC Somatization and DERS Non-Acceptance and DERS Impulse scales. Similar significant correlations were observed between DERS Impulse and ITQ DSO symptoms, which were further supported by the moderate, significant relation between DERS Impulse and aggressive behavior. Correlations analyses also indicates that, except for DERS awareness, all other DERS subscales are associated with trauma symptomatology showing moderate to strong significant correlations between ITQ DSO scores, and DERS Non-Acceptance, DERS Goals, DERS Strategies, DERS Clarity, TSC Somatization, TSC Dissociation and TSC Negative affectivity. This further suggests that greater severity of posttraumatic symptoms is associated with overall difficulties in emotion regulation.
Table 3
Bivariate associations (Pearson correlations) between study variables.
| VARIABLE | 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. | 11. | 12. | 13. | 14. | 15. | 16. | 17. | 18. | 19. |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1. PTSD-symptomsa | (.80) | ||||||||||||||||||
| 2. Re-experiencing | .86** | — | |||||||||||||||||
| 3. Avoidance | .79** | .52** | — | ||||||||||||||||
| 4. Hypervigilance | .74** | .49** | .36** | — | |||||||||||||||
| 5. DSO-symptomsa | .46** | .37** | .30** | .45** | (.81) | ||||||||||||||
| 6. Affective dysreg. | .37** | .30** | 25** | .36** | .73** | — | |||||||||||||
| 7. Neg. self-concept | .34** | .27** | .18* | .37** | .84** | .38** | — | ||||||||||||
| 8. Dist. In relationships | .41** | .33** | .31** | .35** | .82* | .50** | .51** | — | |||||||||||
| 9. Non-accept | .41** | .36** | .31** | .31** | .50** | .32** | .48** | .40** | (.75) | ||||||||||
| 10. Goals | .34** | .23** | .31** | .30** | .44** | .28** | .43** | .32** | .61** | (.81) | |||||||||
| 11. Impulse | .48** | .43** | .35** | .35** | .49** | .38** | .43** | .37** | .47** | .64** | (.86) | ||||||||
| 12. Awareness | .07 | .02 | .02 | .15 | .21* | .15 | .16 | .19* | .25** | .17** | .14 | (.70) | |||||||
| 13. Strategies | .26* | .19* | .20* | .23** | .61** | .40** | .56** | .46** | .57** | .72** | .60** | .13 | (.88) | ||||||
| 14. Clarity | .27** | .28** | .10 | .25** | .44** | .30** | .37** | .39** | .43** | .40** | .37** | .47** | .34** | (.79) | |||||
| 15. Neg. affectivity | .44** | .37** | .25** | .43** | .73** | .51** | .64** | .59** | .42** | .39** | .50** | .17 | .56** | .38** | (.84) | ||||
| 16. Somatization | .55** | .49** | .27** | .57** | .49** | .34** | .39** | .45** | .25** | 25** | .34** | .11 | .29** | .33** | .64** | (.77) | |||
| 17. Dissociation | .59** | .63** | .36** | .40** | .49** | .38** | .37** | .44** | .39** | .27** | .46** | .23** | .30** | .46** | .53** | .59** | (.78) | ||
| 18. Aggressive behavior | .23** | .23** | .13 | .18* | .29** | .30** | .14 | .30** | .09 | .13 | .39** | .06 | .14 | .04 | .43** | .37** | .41** | (.65) | |
| 19. Social support | –.11 | –.08 | –.11 | –.08 | –.31 | –.20* | –.19* | –.38** | –.16 | –.13 | –.14 | –.18* | –.20* | –.20* | –.25** | –.16 | –.16 | –.09 | (.67) |
| Mean | 15.48 | 3.90 | 5.51 | 6.08 | 16.02 | 5.64 | 4.82 | 5.56 | 19.24 | 17.86 | 17.34 | 19.74 | 24.32 | 14.90 | 26.64 | 29.57 | 10.58 | 4.36 | 28.50 |
| SD | 5.08 | 2.39 | 2.08 | 1.84 | 5.10 | 1.76 | 2.63 | 1.95 | 6.85 | 4.56 | 6.05 | 4.59 | 7.53 | 4.59 | 6.33 | 5.60 | 3.44 | 4.82 | 7.02 |
[i] **. – correlation is significant at the 0.01 level (Pearson, 2-tailed) *. = correlation is significant at the 0.05 level (Pearson, 2-tailed). Coefficient alphas appear in parentheses. aSum of ICD-11 PTSD and DSO symptoms respectively, measured with ITQ-scale.
Furthermore, the overall relationship between trauma symptomatology and Aggression was significant, although showing weak correlations coefficients between ITQ PTSD and DSO symptoms respectively. Finally, a moderate negative correlation between ITQ DSO symptoms and total CSS scores was found, indicating higher levels of posttraumatic severity to be associated with lower levels of perceived social support.
Regression analysis
Two overall models of hierarchical multiple regression analyses were used to assess the ability of the independent measures (DERS, TSC, Aggression, and CSS) to predict levels of posttraumatic severity (perceived ITQ PTSD and DSO symptoms respectively) after controlling for the influence of demographic factors age, debriefing, and use of psychoactive medication. Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity, multicollinearity, and homoscedasticity. Multicollinearity was checked in both models by the variance inflation factor (VIF). All VIF values were < 3.09; collinearity tolerance values were all < .32.
Model I
The first step consisted of age, debriefing, and the use of psychotropics, explaining 5% of the variance in perceived PTSD symptoms. In the second step, five emotion regulation factors (DERS: Non-acceptance, Goals, Impulse, Strategies, and Clarity) were entered, explaining a further 27% of the variance. Three emotion regulation factors (DERS: Non-acceptance, Impulse and Strategies) were entered, explaining 28% of the variance. In the third step we included aggressive behavior factors (Aggression Scale) and aspects of social support, explaining an additional 4% of the variance. After the entry of the three TSC sub-scales (Somatization, Dissociation, and Negative affectivity) in the fourth step, the final model included ten variables, which in all explained 52% of the ITQ-PTSD score (Table 4). The use of psychotropics was only significant in the first step. The variables with the strongest individual contribution to the level of perceived PTSD symptoms were, in order, aspects of emotion regulation (Impulse, Non-acceptance, and Strategies) and Somatization.
Table 4
Model I · Hierarchical regression analyses for variables predicting ITQ-PTSD symptoms.
| STEPS | VARIABLE | B | STD. E | ß | SIG. | F | DF | SIG. | R2 | ADJ. R2 |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 3.41 | 3,131 | .02 | .07 | .05 | |||||
| Age | –.01 | .06 | –.01 | .92 | ||||||
| Attended debriefing | –1.50 | 1.07 | –.13 | .16 | ||||||
| Use of psychotropics | 2.93 | 1.03 | –.24 | .005 | ||||||
| 2. | 7.89 | 8,107 | <.001 | .37 | .32 | |||||
| Age | .04 | .04 | .07 | .35 | ||||||
| Attended debriefing | –.75 | .72 | –.07 | .30 | ||||||
| Use of psychotropics | 1.21 | .71 | .12 | .09 | ||||||
| DERS non-accept | .22 | .09 | .25 | .02 | ||||||
| DERS goals | .00 | .17 | .00 | .98 | ||||||
| DERS impulse | .43 | .10 | .44 | <.001 | ||||||
| DERS strategies | –.13 | .10 | –.16 | .19 | ||||||
| DERS clarity | .16 | .12 | .12 | .19 | ||||||
| 3. | 6.90 | 10,97 | <.001 | .42 | .36 | |||||
| Age | .04 | .06 | .06 | .51 | ||||||
| Attended debriefing | .54 | 1.01 | .05 | .59 | ||||||
| Use of psychotropics | 1.22 | .98 | .10 | .22 | ||||||
| DERS non-accept | .28 | .09 | .32 | .00 | ||||||
| DERS goals | .01 | .17 | .01 | .96 | ||||||
| DERS impulse | .42 | .12 | .42 | <.001 | ||||||
| DERS strategies | –.18 | .10 | –.23 | .07 | ||||||
| DERS clarity | .15 | .13 | .12 | .21 | ||||||
| Aggressive behavior | .13 | .11 | .11 | .22 | ||||||
| CSS social support | .00 | .07 | .01 | .98 | ||||||
| 4. | 9.58 | 13,92 | <.001 | .58 | .52 | |||||
| Age | –.03 | .06 | –.05 | .56 | ||||||
| Attended debriefing | .86 | .92 | –07 | .35 | ||||||
| Use of psychotropics | 1.20 | .87 | .10 | .17 | ||||||
| DERS non-accept | .17 | .09 | .20 | .05 | ||||||
| DERS goals | .17 | .15 | .13 | .27 | ||||||
| DERS impulse | .32 | .11 | .32 | .005 | ||||||
| DERS strategies | –.23 | .09 | –.29 | .02 | ||||||
| DERS clarity | –.09 | .12 | –.07 | .47 | ||||||
| Aggressive behavior | –.17 | .11 | –.15 | .12 | ||||||
| CSS social support | .02 | .06 | .02 | .76 | ||||||
| TSC somatization | .18 | .07 | .20 | .02 | ||||||
| TSC dissociation | .08 | .14 | .06 | .56 | ||||||
| TSC negative affectivity | .06 | .11 | .06 | .61 |
Model II
Like the first model, the first step consisted of age, debriefing, and the use of psychotropics, explaining 1% of the variance in perceived DSO-symptoms. In the second step, five emotion regulation factors (DERS: Non-acceptance, Goals, Impulse, Strategies, and Clarity) were entered, explaining a further 42% of the variance. The third step, consisting of aggressive behavior and social support, explained a further 5% of the variance. In the fourth and final step, trauma symptoms (TSC Somatization, Dissociation, and Negative affectivity) were included, explaining another 14% of the variance. Thus, the final model included 10 factors, which in all explained 62% of the ITQ-PTSD score (see Table 5). Neither age, debriefing, nor the use of psychotropics were significant in the first step. Three emotion regulation subscales were significant in the second step (Strategies, Non-acceptance, and Impulse), but only strategies remained significant in the final model. The Impulse subscale lost significance when aggression was introduced into the model. However, when Negative affectivity was entered in the final stage, aggression was no longer significant.
Table 5
Model II · Hierarchical regression analyses for variables predicting ITQ-DSO symptoms.
| STEPS | VARIABLE | B | STD. E | ß | SIG. | F | DF | SIG. | R2 | ADJ. R2 |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. | 1.42 | 3,102 | .21 | .04 | .01 | |||||
| Age | –.06 | .06 | –.09 | .37 | ||||||
| Attended debriefing | –1.87 | 1.07 | –.18 | .08 | ||||||
| Use of psychotropics | 1.25 | 1.07 | .12 | .23 | ||||||
| 2. | 10.93 | 8,97 | <.001 | .47 | .43 | |||||
| Age | –.00 | .05 | –.00 | .99 | ||||||
| Attended debriefing | –.40 | .83 | –.04 | .63 | ||||||
| Use of psychotropics | .52 | .81 | .05 | .52 | ||||||
| DERS non-accept | .16 | .08 | .22 | .04 | ||||||
| DERS strategies | .33 | .08 | .48 | <.001 | ||||||
| DERS Impulse | .18 | .09 | .20 | .05 | ||||||
| DERS Clarity | .17 | .10 | .14 | .11 | ||||||
| DERS Goals | –.28 | .14 | –.26 | .04 | ||||||
| 3. | 10.61 | 10,95 | <.001 | .53 | .48 | |||||
| Age | .04 | .05 | .06 | .43 | ||||||
| Attended debriefing | –.13 | .81 | –.01 | .87 | ||||||
| Use of psychotropics | .79 | .78 | –.08 | .31 | ||||||
| DERS non-accept | .16 | .08 | .21 | .04 | ||||||
| DERS strategies | .33 | .08 | .49 | <.001 | ||||||
| DERS Impulse | .07 | .10 | .08 | .48 | ||||||
| DERS Clarity | .15 | .10 | .13 | .14 | ||||||
| DERS Goals | –.24 | .13 | –.22 | .08 | ||||||
| Aggressive behavior | .23 | .09 | .22 | .01 | ||||||
| CSS social support | –.10 | .05 | –.14 | .08 | ||||||
| 4. | Age | –.02 | .04 | –.03 | .66 | 14.03 | 10,116 | <.001 | .67 | .62 |
| Attended debriefing | –.92 | .72 | –.09 | .20 | ||||||
| Use of psychotropics | 1.09 | .68 | .10 | .11 | ||||||
| DERS non-accept | .07 | .07 | .09 | .34 | ||||||
| DERS strategies | .20 | .07 | .28 | .01 | ||||||
| DERS Impulse | –.02 | .08 | –.02 | .81 | ||||||
| DERS Clarity | .06 | .09 | .05 | .50 | ||||||
| DERS Goals | –.10 | .12 | –.09 | .38 | ||||||
| Aggressive behavior | .01 | .09 | .01 | .92 | ||||||
| CSS social support | –.05 | .05 | –.06 | .34 | ||||||
| TSC somatization | –.05 | .08 | –.05 | .61 | ||||||
| TSC dissociation | .17 | .14 | .12 | .22 | ||||||
| TSC negative affectivity | .4 | .09 | .53 | <001 |
Discussion
This study sought to investigate the associations between emotion regulation difficulties, aggression, and the severity of posttraumatic symptomatology in a sample of treatment-seeking military veterans. It further aimed to examine the occurring ICD-11 PTSD and CPTSD symptom distribution in a treatment-seeking population. Based on previous studies, it was hypothesized that there was a high prevalence of both PTSD and CPTSD symptoms consistent with the ICD-11 specifications in this patient group. The findings in this study contribute to the existing literature by revealing a notably high prevalence of CPTSD among Danish treatment-seeking veterans. The study identified that 29.8% of the treatment-seeking veterans met the criteria for PTSD, while 56.0% met the criteria for CPTSD. The high prevalence of CPTSD amongst the Danish treatment-seeking veterans is not surprising given that active participation in war increases the likelihood of being exposed to interpersonal traumatic stressors, further increasing the risk for developing CPTSD. The high prevalence of both PTSD and CPTSD makes it more important to investigate the occurrence of emotion regulation difficulties and aggression in this population.
The study also sought to identify the demographic- and trauma-related risk factors associated with ICD-11 PTSD and CPTSD. Contrary to expectations, the study did not uncover a significant relationship between the severity of posttraumatic symptoms and demographic or military-related factors. The study only revealed that the use of psychotropic medication was linked to significantly reduced PTSD symptoms, and post-combat debriefing was associated with elevated levels of CPTSD symptomatology. However, both effects disappear in the hierarchical regression analyses as soon as the DERS factors are introduced. This suggests that emotion regulation factors are influential in predicting PTSD and CPTSD symptoms.
Contrary to existing research, the study did not find a relationship between age and CPTSD. Prior studies by Folke et al. (2019, 2021, 2023) found that older age was a risk factor for CPTSD. In contrast, Murphy et al. (2020) found that younger age was a risk factor for CPTSD. The notion of older age as a potential risk factor may be attributed to prolonged military service, potentially exposing veterans to a greater number of traumatic events. This increased exposure may create a cumulative effect, as sustained or repeated trauma heightens the likelihood of developing CPTSD (Cloitre et al., 2013).
Further, this study investigated whether various experiences during military deployment, such as threat, injury, fear/helplessness, and debriefing, could heighten the risk of developing PTSD and CPTSD. Surprisingly, no significant correlations were found. Folke et al. (2023) identified that exposure to war and combat significantly increased the likelihood of developing CPTSD among military personnel. Similarly, Murphy et al. (2020) found that personnel in combat roles were three times more likely to have probable CPTSD. However, the discrepancy between these findings might be linked to the limited sample size or the limited range of experiences, as everyone was in treatment in the current study. The inclusion of threats and fear/helplessness encountered during military deployment in this study is based upon existing knowledge from related fields. Existing research indicates that threats and fear/helplessness can result in severe posttraumatic symptomology despite the absence of visible physical injuries (Elklit, 1993). Injuries can often serve as tangible evidence of the perceived danger of an experienced traumatic event, both to oneself and to others (Elklit, 1993). Additionally, the severity of the traumatic event tends to correlate with increased support from the social network (Elklit, 1993). Consequently, the lack of visible damage may fail to convey the individual’s experiences in a manner readily recognizable by those around them, possibly resulting in decreased social support.
The existing literature identifies negative social support as a risk factor for PTSD (Robinaugh et al., 2011). However, contrary to earlier beliefs, recent studies do not find the absence of adequate social support to be a strong predictor for PTSD (Robinaugh et al., 2011). Consistent with these findings, our study concludes that positive social support is not a predictor for PTSD. Conversely, while the absence of social support is associated with CPTSD when introduced in the hierarchical model, it loses its strength as soon as negative affectivity is entered. Therefore, difficulties in interpersonal relations, a symptom of CPTSD, may not be alleviated by the presence of positive social support. This is in line with the study from Kaniasty & Norris (2008), who found that social deterioration (such as occurs when greater PTSD leading to decreased social support) accounted for the support-to-distress relationship years after the traumatic events.
The relationship between emotional dysregulation and the onset and persistence of posttraumatic stress symptoms was likewise investigated. After a traumatic event, individuals may encounter heightened emotional reactions, intrusive recollections, and distress associated with reliving the experience (Seligowski et al., 2015). Is it possible to identify specific aspects of emotional regulation associated to both PTSD and CPTSD? This study confirmed that different aspects of emotion dysregulation are associated with the severity of posttraumatic symptomatology. The results demonstrate a significant connection between PTSD and the DERS subscales of Non-Acceptance, Impulsivity, and lack of emotion-regulation Strategies. These findings suggest that these specific emotional reactions are closely linked to PTSD and may impact the regulation of emotion and the capacity to remain in control of one’s behavior when experiencing negative emotions.
Non-Acceptance refers to the rejection or dismissal of negative emotions and reactions to distress. The Impulse subscale reflects difficulties remaining in control when experiencing negative emotions. The Strategy subscale assesses the belief that effective emotion regulation strategies are unavailable or ineffective when upset or distressed. In the final step of the PTSD model, TSC Somatization weakened the impact of Non-Acceptance and Impulse but allowed Strategies to remain as a significant emotional factor. However, Strategies present a negative contribution to PTSD, i.e., a strong belief that the person cannot regulate emotions when upset, means that PTSD is less severe. This looks like a paradox: how can having strategies to mitigate the symptoms of PTSD contribute to the condition itself? The simple answer could be that the strategies are not efficient. This problem is discussed below in criticism of the DERS model. Emotional regulation difficulties seem more prevalent in PTSD than in CPTSD, perhaps reflecting a less chronic condition. The endorsement of the three emotion regulation variables might be an indicator of the veteran being in a volatile state, having a hard time with emotion regulation due to ineffective strategies. The difficulties appear to co-occur with somatization symptoms that are manifested in the body as psychosomatic symptoms and pains that are less pronounced than in CPTSD.
However, one would expect the impact of emotion regulation variables to be more pronounced in CPTSD where affect regulation is a central symptom cluster that includes both a hyper- and a hypo-emotional response.
Among veterans with CPTSD, access to emotion regulation strategies appear more limited than with PTSD. However, the significance of the DERS subscales almost disappeared at Step 4, when Negative affectivity was added to the model, where only the (lack of) subscale Strategies remained significant and positively associated with CPTSD. Negative affectivity exhibited a very strong beta value that heavily weakens the beta values of all the DERS variables, suggesting that a mindset of anxiousness and anhedonia has become prominent in the veterans. This is in stark contrast to the PTSD regression model where the difficulties of emotional regulation contributed relatively more to PTSD. With CPTSD, the activated strategies involved maybe futile attempts to manage the severe symptoms of the disorder, which includes aggression behavior and lack of social support and/or negative support.
The DERS subscales, rooted in Gratz and Roemer’s conceptualization, emphasizes domains involved in adaptive emotion regulation. The model explains that deficits in the six DERS domains result in maladaptive reactions to emotions. Unfortunately, the DERS model exhibits some limitations and operationalization-related issues. Differentiating the distinct domains is challenging due to a lack of clarity in the model. This complexity impedes a clear understanding of the domains, thus complicating the discussion of results based on this conceptualization. In contrast, Gross’s process model is easier to grasp and offers greater conceptual clarity, drawing upon well-established concepts like reappraisal and suppression. This model focuses on the modification of emotional experiences, providing insight into the effectiveness of specific emotion regulation strategies across different phases of an emotional situation.
Building upon this framework, Gross and Jazaieri (2014) categorize two forms of emotional dysregulation: emotion-regulation failures, characterized by improper timing in emotion regulation, and emotion misregulation, involving the failure to employ an appropriate emotion regulation strategy given the specific context. Drawing from Gross’s model in the antecedent-focused section, emotional dysregulation signifies a failure to employ reappraisal in relation to the given situation, cognition, or attention, leading to subsequent negative emotions. In the response-focused section of the model, unsuccessful attempts to suppress emerging negative emotions may yield negative experiential, behavioral, and physiological responses.
This phenomenon may explain the significant predictive roles of somatization and negative affectivity in PTSD and CPTSD within the hierarchical analyses. Notably, the introduction of somatization and negative affectivity into the analyses diminishes the significance of several of the DERS domains. This pattern suggests that both emotion regulation difficulties and, paradoxically, possibly excessive or maladaptive regulation efforts may contribute to the manifestation of somatization and negative affectivity in individuals with PTSD and CPTSD.
Based on the existing research finding a relationship between veterans and aggression (MacManus et al., 2015; Gonzalez et al., 2016; Taft et al., 2007) and the literature highlighting the connection between PTSD, heightened emotional intensity, and reactivity (Sippel et al., 2016), we posited that treatment-seeking veterans would exhibit aggression issues. However, contrary to prior research that found a strong association between aggression and PTSD, our current study reveals a statistically significant but weak/moderate correlation between PTSD and CPTSD symptomatology and aggression. This association is weakened when entered in the hierarchical analysis for both PTSD and CPTSD.
The potential use of emotional suppression as a regulation strategy among veterans may account for the observed lack of any significant impact of aggression in the final prediction of PTSD and CPTSD. This finding challenges common understandings about veterans’ aggression issues in that, given the absence of noticeable effects, aggression does not appear to be a prominent symptom within the subgroup of treatment-seeking veterans. In the hierarchical analyses for CPTSD, the significance of DERS Strategies diminishes with the introduction of negative affectivity. This may indicate that veterans with CPTSD have a firm belief that nothing can be done to control and regulate their emotions when they become “ignited”. Their impulses are, rather, suppressed and absorbed in a chronic state of negative affectivity.
Clinical Implications
While this study utilizes a single-time-point sampling method with limited variables, it may offer potential insights of clinical relevance. The results emphasize that the veterans referred to the specialized outpatient trauma service (ATT) are notably distressed. A significant proportion of these individuals exhibit complex symptoms and psychological difficulties. Analysis of the findings reveals that the treatment-seeking veterans face challenges such as dissociation, somatization, absence of social support, and difficulties in emotion regulation (ER). Emotion regulation emerges as a complex clinical concern, encompassing multifaceted aspects. The study indicates that some aspects of ER are more prominent within the target group than others. Particularly, the lack of strategies for emotion regulation appears to be more pronounced in veterans with CPTSD, while those with PTSD demonstrate notable deficiencies in impulse control and the non-acceptance of emotions while, paradoxically, possessing strategies that might, however, be ineffective. Further examination to determine the qualitative nature of these constructs could be of clinical interest. In addition, one possible implication of the findings is that treatment-seeking veterans should be offered training in emotion regulation skills along the lines of well-established approaches such as Dialectical Behaviour Therapy. Numerous clinical studies confirm that skills deficiency, a well-known risk factor for ER difficulties, can be mitigated through treatment.
Conclusion
This study supports the existing literature in finding that treatment-seeking veterans experience substantial challenges, with a higher prevalence of CPTSD compared to PTSD. Unexpectedly, the study did not find significant aggression issues in the sample. However, in line with expectations, it revealed emotion regulation difficulties to be significant risks, with a more pronounced impact on PTSD than CPTSD. Notably, the study suggests that challenges in emotion regulation, or overly affective regulation, may contribute to somatization.
Data Accessibility Statement
The data are available on reasonable request.
Notes
[4] The ICD-11 classifications are the 11th iteration of WHO’s International Classification of Diseases. See https://icd.who.int/en/.
Acknowledgements
We want to thank ATT for their contribution with collection of data and MSc Henrik Thorndal Machon who contributed to an early draft.
Competing Interests
The authors have no competing interests to declare.