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. Author manuscript; available in PMC: 2026 Mar 12.
Published before final editing as: J Interpers Violence. 2026 Jan 24:8862605251414433. doi: 10.1177/08862605251414433

Posttraumatic Stress Disorder and Aggression: The Role of Emotion Regulation

Miracle R Potter 1, Danielle M Morabito 2, Norman B Schmidt 1
PMCID: PMC12977976  NIHMSID: NIHMS2146890  PMID: 41580429

Abstract

Posttraumatic stress disorder (PTSD) is a debilitating mental disorder that has been associated with increased aggressive behavior. Extant literature demonstrates that emotion regulation (ER) difficulties occur in both PTSD and aggression; however, two models (information processing and I3) of this relationship suggest oppositional roles of ER. The purpose of this study is to examine the relationship between PTSD symptoms, ER, and aggression in a trauma-exposed civilian sample through the lens of the information processing and I3 models and extend this examination to consider gender and the type of traumatic experience endorsed. Moderation and mediation analyses were used to determine the interactive and indirect effects of trauma and ER on aggression. Alternative mediators and moderators were used to determine the specificity of the model and the direction of the relationship. Findings indicate that, despite the significant relationship between PTSD symptoms and aggression, this relationship was not moderated by ER, inconsistent with the I3 model. However, ER fully mediated the relationship between PTSD and aggression, supporting the information processing model. These results held constant when interchanging the predictor and mediator. Neither trauma type nor gender influenced the indirect effect of ER on PTSD and aggression. ER difficulties do not influence the proclivity to aggress among trauma-exposed individuals, but could act as a link to explain the association between PTSD and aggression. Thus, ER may be a potential treatment target for both PTSD and aggression independently and comorbidly.

Keywords: trauma, PTSD, emotion regulation, aggression

Introduction

Posttraumatic stress disorder (PTSD) is a mental illness characterized by the onset of symptoms such as avoidance, intrusions, hyperarousal, and negative alterations in cognition and mood following a traumatic event such as threatened or actual death or assault (American Psychiatric Association, 2013). The presence and severity of such symptoms impose significant distress and impair the ability to function in major life areas. This disorder affects approximately 8% of the population in the United States, with prevalence magnified in populations that are exposed to higher rates of potentially traumatic events (e.g., first responders, military) and those who experience greater severity and chronicity of events (Kessler et al., 2012; Van Eerd et al., 2021). The long-term sequelae of PTSD can include significant functional impairment in mobility, self-care, and interpersonal interactions and relationships (Jellestad et al., 2021). Moreover, specific symptoms of PTSD have been associated with increased negative affect, including anger and hostility, posing specific challenges to interpersonal interactions and overall social functioning (Beck et al., 2009; Mathes et al., 2020; Taft et al., 2017).

Aggression, defined as behavior intended to cause harm to an individual, has been associated with PTSD across the lifespan (Anderson & Bushman, 2002). Observed and self-reported aggressive behavior of individuals with PTSD ranges from verbal altercations to more perilous forms of aggression, including physical aggression and violence with weapons (Taft et al., 2017). For example, a small sample of combat veterans who screened subthreshold or positive for PTSD were significantly more likely to endorse aggressive behavior, such as threatening physical violence or having a physical fight, relative to veterans who did not screen positive for PTSD (Jakupcak et al., 2007). The relationship between PTSD and aggression has also been demonstrated in civilian women, with meta-analytic data demonstrating the significant association between exposure to potentially traumatic events, PTSD symptomology, and subsequent aggression (Augsburger & Maercker, 2020). This pattern of findings is mirrored in studies using laboratory measures of aggression, such as the point-subtraction aggression paradigm, in which participants can choose to deliver an aversive stimulus to their competitors (Kivisto et al., 2009). Because of the strength of this relationship, aggression and related correlates have been investigated as potential treatment targets and considered when examining PTSD treatment efficacy (Krauss et al., 2023; Miles et al., 2020).

One factor that is related to both PTSD and aggression and commonly targeted in cognitive-behavioral treatments is emotion regulation (ER; Cloitre et al., 2002; Cohen et al., 2016). ER is the process of managing what, how, and when emotions are experienced, and importantly, how emotions are expressed (Gross, 1998). Extant literature posits broad features of ER, including emotional awareness, acceptance of emotions, impulse and behavior control, and the ability to engage in regulatory strategies to reduce distress (Gratz & Roemer, 2004). Effective ER allows an individual to appropriately recognize the emotional experiences, accept them, and act in accordance with their goal in a given context (Gross & Muñoz, 1995). When ER is disrupted, an individual can experience significant difficulty managing emotions as indicated by impaired ability to appropriately engage in the aforementioned facets, increasing distress. As such, ER has been identified as a transdiagnostic risk and maintenance factor across the spectrum of psychopathology (Aldao et al., 2016). Consistent with this idea, impaired ER has been posited as a critical factor in the development and maintenance of posttraumatic stress symptoms, with meta-analytic findings demonstrating significant associations between PTSD symptom severity and general emotional dysregulation (Seligowski et al., 2015). For example, longitudinal work in this area has shown ER difficulties prior to a traumatic event as predictive of the development of PTSD symptoms following an acute trauma. In addition, ER difficulties following an acute traumatic event predict PTSD symptoms 8 months later (Bardeen et al., 2013).

Relatedly, individual differences in ER may influence the likelihood of engaging in aggressive behaviors (Davidson et al., 2000). For example, Tull found that experiential avoidance, characterized by avoidance of thoughts and feelings, and emotional inexpressivity, characterized by the failure to display emotions, predicted aggression while controlling for trait anger (Tull et al., 2007). Furthermore, Roberton found that maladaptive ER was associated with a life history of aggression in an adult offending sample (Roberton et al., 2014). ER has also been examined in the context of intimate partner violence (IPV) such that deficits in ER have been associated with physical and psychological IPV (Neilson et al., 2023). Most notably, ER has been examined in the context of personality pathology such that ER difficulties fully accounted for the indirect relationship between Borderline Personality Disorder symptoms and subsequent aggression in a mixed clinical and community sample (Scott et al., 2014).

The relationships between PTSD, ER, and aggression have been established, but how they are related are still unclear. One model used to conceptualize cognitive and emotional processes in PTSD is the information processing model. This model suggests that information about emotional stimuli, their meaning, and responses is processed together and stored in memory networks (Lang, 1994). In the context of PTSD, response information can include verbal, behavioral, and physiological reactions (e.g., running, hyperarousal) when confronted with emotional stimuli. When aroused, an individual may lose the ability to monitor their thoughts and emotions, subsequently reducing the ability to regulate physiological arousal and behaviors when exposed to threatening emotional stimuli (Chemtob et al., 1988). Thus, such response information can engender a need to protect oneself, which could include aggressive responding (Beckham et al., 2000). This theoretical model has been used to examine interpersonal hostility and violence in combat veterans, suggesting that deficits in regulatory ability may explain the connection between hyperarousal and subsequent behaviors (Beckham et al., 2000). Consistent with this model, ER may represent the link that explains how PTSD relates to aggressive behaviors (Miles et al., 2015, 2016).

While the information processing model suggests an indirect relationship between PTSD and aggression through regulatory abilities, the I3 model posits that PTSD differentially influences the likelihood of engaging in aggressive behaviors based on the level of ER. The I3 model suggests that there are three processes that influence the likelihood of aggression when encountering a precipitating event—instigation, impellance, and inhibition (Finkel & Hall, 2018). Instigation refers to the capacity of the current environment for aggressive behavior (e.g., provocation, social rejection). Impellance refers to the strength of the situational or dispositional factors that have on the instigation (e.g., trait anger, possession of a weapon). Inhibition represents the conflict between the proclivity to aggress and restraint in favor of nonaggressive responding (e.g., self-control; Birkley & Eckhardt, 2015; Lau et al., 1995). As such, this model posits that aggression is most likely when the intensity of the instigation and impellance is strong, and inhibition is weak. The I3 model has often been used to conceptualize aggression in the form of IPV and has recently been used to conceptualize the relationship between anger and aggression in PTSD (Birkley & Eckhardt, 2019; Finkel et al., 2012; Massa et al., 2020; Taft et al., 2017). For example, aspects of ER have moderated the relationship between PTSD and aggressive behaviors in an incarcerated population such that at high levels of PTSD, participants with greater acceptance of emotional responses, greater impulsive control difficulties, and less access to ER strategies reported greater levels of aggression perpetration (Wahlstrom et al., 2015). The influential impact of ER on PTSD and aggression has also been seen in the IPV literature (Caiozzo et al., 2016; Price et al., 2014). To our knowledge, no research to date has examined these models concurrently.

Despite the cogency of both the information processing and I3 models, these models fail to account for specific trauma-related and demographic factors that may be influential. Prior literature suggests that variability in the type of trauma one is exposed to can have differential effects on PTSD symptom presentation (Chung & Breslau, 2008; Smith et al., 2016). For example, Kelley et al. (2009) found that sexual assault survivors exhibited greater flashbacks, intrusive thoughts, nightmares, and distress at reminders when compared to the symptom profiles of motor vehicle accident survivors and those who experienced a sudden loss of a loved one (Kelley et al., 2009). In addition, prior literature suggests that there may be gender differences in the experience and expression of negative affect in PTSD, with men exhibiting a greater expression of negative affect in the form of violence or aggression than women despite women reporting a greater internal experience of negative affect (Butterfield et al., 2000; Castillo et al., 2002; Jakupcak & Tull, 2005). However, research has yet to examine how trauma type and gender may influence the relations among PTSD, ER, and aggression.

Given the lack of consensus on how PTSD and ER are related to aggression, the present study seeks to compare the two models empirically. The I3 model would predict that PTSD symptoms are more strongly related to increased aggression among participants with greater ER difficulties compared to participants with lower ER difficulties. We aim to test this hypothesis by examining whether the level of ER difficulties moderates the relationship between PTSD symptoms and aggression. On the other hand, the informational processing model would predict that PTSD symptoms lead to greater ER difficulties, which are associated with increased aggressive behaviors. We aim to test this hypothesis by examining whether ER difficulties mediate the relationship between PTSD symptoms and aggression. For each model, we consider additional potentially relevant factors such as trauma exposure type and gender.

Method

Participants

Participants (N = 98; Mage = 18.87, SD = 1.14) were undergraduate students recruited from a psychology department subject pool, as part of a larger experimental study examining self-reported and behavioral indicators of threat responding. Inclusion criteria included exposure to at least one potentially traumatic event, and exclusion criteria included conditions that may interfere with participation in experimental tasks (e.g., uncorrected visual impairment; lower body paralysis). The present study utilizes baseline self-report measures only. The sample age ranged from 18 to 23 and predominantly identified as female (75.5%) and White (91.8%). Demographic information is listed in Table 1.

Table 1.

Participant Demographics.

Variable N (%)
Age M =18.87, SD =1.14
Gender
 Male 23 (23.5%)
 Female 74 (75.5%)
 Other 1 (1%)
Race
 White/Caucasian 90 (91.8%)
 Black/African American 5 (5.1%)
 Asian 3 (3.1%)
 Other 1 (1%)
Sexual orientation
 Heterosexual 85 (86.7%)
 Homosexual 1 (1%)
 Bisexual 10 (10.2%)
 Other 2 (2%)
Trauma type
 Interpersonal 24 (24.5%)
 Non-interpersonal 74 (75.5%)
Exposure type
 Direct 45 (46%)
 Witnessed 39 (40.0%)
 Learned about 24 (24.5%)
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Measures

Demographics.

Participants completed demographic information, including age, gender, race, ethnicity, and sexual orientation. These items were used to characterize the sample.

Posttraumatic Diagnostic Scale.

The Posttraumatic Diagnostic Scale (PDS) is a well-validated self-report questionnaire assessing exposure to a variety of traumatic events as well as presence and severity of posttraumatic stress symptoms (Foa et al., 1997). In the current study, Part I of the PDS, which asked participants to identify whether they have lived through or witnessed any of 12 types of traumatic events, was used to determine eligibility.

Life Events Checklist for DSM-5.

The Life Events Checklist for DSM-5 was used to assess the number and type of potentially traumatic experiences (Weathers, Blake, et al., 2013). Participants indicated whether they directly experienced, witnessed, or learned about 17 different types of traumatic events. In addition, participants were asked to briefly describe the worst event, how long ago it happened, how it was experienced (i.e., directly, witnessed, learned about, repeated exposure to aversive details), and whether there was a life threat, serious injury or death, and/or sexual violence to determine whether the event met Criterion A for DSM-5 PTSD.

Posttraumatic Stress Checklist for DSM-5.

The Posttraumatic Stress Checklist for DSM-5 (PCL-5) is a 20-item self-report measure used to assess PTSD symptoms (Weathers, Litz, et al., 2013). Participants were asked to rate their PTSD symptoms during the past month on a five-point scale from 0 (not at all) to 4 (extremely). The PCL-5 has a score range of 0 to 80, with higher scores indicating higher symptom severity, and a cutoff score of 33 indicating probable PTSD (Blevins et al., 2015). The PCL-5 has demonstrated strong psychometric properties (Bovin et al., 2016). The PCL-5 demonstrated good internal consistency in the current study (α = .94).

Difficulties in Emotion Regulation Scale 16-Item.

The DERS-16 is a 16-item self-report measure used to assess difficulties in emotion regulation, derived from the original 36-item difficulties in emotion regulation scale (DERS; Bjureberg et al., 2016; Gratz & Roemer, 2004). Participants are asked to rate items on a five-point scale from 1 (almost never) to 5 (almost always). The DERS-16 has a score range of 16 to 80, with higher scores indicating more difficulty with emotion regulation. The DERS-16 has demonstrated strong psychometric properties (Bjureberg et al., 2016) and showed good internal consistency in the current study (α = .92).

Buss-Perry Aggression Questionnaire.

The Buss-Perry Aggression Questionnaire (BPAQ) is a 29-item self-report measure of aggression-related feelings and behaviors (Buss & Perry, 1992). Participants are asked to rate items on a five-point scale from 1 (extremely uncharacteristic of me) to 5 (extremely characteristic of me). The BPAQ has a score range of 29 to 145, with higher scores indicating higher levels of aggression-related feelings and behaviors. Previous research has demonstrated good reliability and validity (Buss & Perry, 1992). The BPAQ total demonstrated good internal consistency in the current study (α = .85).

Procedure

Participants read and signed an informed consent document and later completed self-report measures detailed above. All study procedures were carried out by research staff and graduate students and approved by the University Institutional Review Board.

Data Analytic Plan

First, data were examined for outliers, skewness, and kurtosis. Means, standard deviations, and bivariate correlations were examined for all continuous variables of interest. Post hoc power analyses were conducted to determine power to detect direct and indirect effects in the current sample using the Monte Carlo Power Analysis for Indirect Effects Shiny App (Schoemann et al., 2017). Next, a moderation analysis was run to examine the moderating effect of ER difficulties on the relationship between PTSD symptoms and aggression while accounting for gender and trauma type. Participants who identified as nonbinary were excluded from the data so that gender could be examined as binary for interpretability. To determine moderation, a series of multiple linear regression analyses was conducted. The PTSD symptom and ER variables were multiplied to create an interaction term after both were centered at 0. To assess whether ER difficulties mediated the relationship between PTSD symptoms and aggression while including gender and trauma type as covariates, an indirect effects analysis was conducted using the R mediation package (version 4.5.0; Tingley et al., 2014). Trauma type was distinguished and coded by mode of contact (0 = non-interpersonal, 1 = interpersonal). Specifically, the effect of PTSD symptoms was denoted by a; b denoted the path of ER difficulties to aggression. The indirect effect of (ab) is a product of a and b. Finally, path c′ denoted the direct effect of PTSD symptoms to aggression after including ER difficulties into the model. To examine the specificity of the direction of the model, the PTSD symptom and DERS variables were interchanged, such that the effect of DERS was denoted by a; b denoted the path of PTSD symptoms to aggression. The indirect effect of (ab) is a product of a and b. Finally, path c′ denoted the direct effect of ER difficulties on aggression after including PTSD symptoms into the model. The bootstrapping procedure (10,000 bootstrapped samples) was used to construct 95% confidence intervals and test the overall mediation effect.

Results

Preliminary Analyses

The data had no outliers, were not heavily skewed or kurtotic, and met assumptions of linearity, multicollinearity, homoscedasticity, and normality. Post hoc power analyses indicated sufficient power (0.82) to detect a medium indirect effect of ER difficulties on aggression with PTSD symptoms as the predictor. See Table 2 for descriptive statistics and zero-order correlations.

Table 2.

Descriptive Statistics and Zero-Order Correlations of Main Study Variables.

Variable M SD Range Skewness Kurtosis 1 2
1. PCL5_total 18.76 15.88 74 0.88 0.19
2. AQ_total 65.97 16.51 76 0.77 0.35 .37** [0.19, 0.53]
3. DERS_Total 36.02 12.46 59 0.85 0.77 .59** [0.44, 0.70] .43** [0.25, 0.58]
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Note. M and SD are used to represent mean and standard deviation, respectively. Values in square brackets indicate the 95% confidence interval for each correlation. The confidence interval is a plausible range of population correlations that could have caused the sample correlation (Cumming, 2014). PCL-5 = Posttraumatic Stress Checklist for DSM-5; AQ = Aggression Questionnaire; DERS = Difficulties in Emotional Regulation Scale.

**

indicates p < .01.

Primary Analyses

For moderation analyses, there was a significant and positive main effect between ER difficulties (β = .49, SE = 0.15, p < .01) and aggression, and a nonsignificant main effect of PTSD symptoms on aggression (β = .24, SE = 0.13, p = .068), when accounting for gender and trauma type. The interaction between ER difficulties and PTSD symptoms in relation to aggression was not significant (β = .001, SE = 0.05, p = .476), indicating that the relationship between PTSD symptoms and aggression is not moderated by ER difficulties.

Table 3 summarizes the results of all mediation analyses. In Step 1 of the model, PTSD symptoms were significantly and positively associated with aggression (β = .47, SE = 0.11, p < .001), with a notable effect size (sr2 = .15). In Step 2, PTSD symptoms were significantly and positively associated with ER difficulties (β = .45, SE = 0.08, p < .001), with a notable effect size (sr2 = .34). In Step 3, ER difficulties (β = .50, SE = 0.15, p < .001) but not PTSD symptoms (PTSD symptoms; β = .25, SE = 0.13, p = .053) were significantly and positively associated with aggression, with a small effect size (sr2 = .13). Next, using the 10,000 samples to estimate confidence intervals for the indirect relation was also significant (see Figure 1). Results showed that the indirect relation between PTSD symptoms and aggression through ER difficulties was statistically significant (ab = 0.45*0.50 = 0.22, 95% CI [0.07, 0.47]). The direct effect of PTSD symptoms on aggression, when accounting for ER difficulties, gender, and trauma type, was not significant (β = .25, p = .174, 95%CI [0.00, 0.50]). The proportion mediated, or the effect size, is sr2 = .13.

Table 3.

Regression Analyses of PTSD and Aggression Mediated by ER Difficulties and the Direction Specificity Model.

β SE 95% CI T Adjusted R2 sr 2
Step 1: Outcome: total aggression .16
 PCL-5 .47*** 0.11 [0.24, 0.70] 4.15 .15
 Gender −8.31* 3.72 [−15.70, −0.91] −2.23
 Trauma Type −2.94 4.18 [−11.23, 5.36] −0.70
Step 2: Outcome: ER difficulties .34
 PCL-5 .45*** 0.08 [0.30, 0.60] 5.90 .34
 Gender 4.36 2.49 [−0.58, 9.30] 1.75
 Trauma type −0.83 2.79 [−6.37, 4.71] −0.30
Step 3: Outcome: total aggression .19
 ER difficulties .50*** 0.15 [0.21, 0.79] 3.40 .18
 PCL-5 .25 0.13 [0.00, 0.50] 1.96 .13
 Gender −10.49** 3.59 [−17.61, −3.36] −2.92
 Trauma type −2.52 3.96 [−10.39, 5.35] −0.64
Direction specificity model
 Step 1: Outcome: total aggression .23
  ER difficulties .65*** 0.13 [0.40, 0.91] 5.14 .14
  Gender −9.75 3.48 [−16.66, −2.94] −2.80
  Trauma type .50 3.59 [−6.64, 7.64] .14
 Step 2: Outcome: PTSD .34
  ER difficulties .61*** 0.10 [0.41, 0.82] 5.94 .34
  Gender .31 2.82 [−5.29, 5.90] .11
  Trauma type 13.38*** 2.91 [7.60, 19.16] 4.60
 Step 3: Outcome: total aggression .25
  ER difficulties .50*** 0.15 [0.21, 0.79] 3.41 .18
  PCL-5 .25 0.13 [0.00, 0.50] 2.00 .13
  Gender −9.82** 3.43 [−16.63, −3.02] −2.87
  Trauma type −2.86 3.92 [−10.63, 4.92] −0.73
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Note. β indicates the standardized regression weights. SE indicates standard error. CI indicates 95% confidence interval. sr2 represents the semi-partial correlation squared. PTSD = posttraumatic stress disorder; ER = emotion regulation; PCL-5 = Posttraumatic Stress Checklist for DSM-5.

*

indicates p < .05.

**

indicates p < .01.

***

indicates p < .001.

Figure 1.

Figure 1.

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ER Difficulties Mediating PTSD and Aggression, Covarying for Gender and Trauma Type.

Note. c = total effect, c′ = direct effect, a = a path, b = b path, [,] = 95% confidence interval.

To determine the specific direction of the mediated relationship between PTSD symptoms, ER difficulties, and aggression, the PTSD symptom and DERS variables were interchanged, and the mediation model was run again. Results showed that the indirect relation between ER difficulties and aggression through PTSD symptoms was not statistically significant (ab = 0.61*0.25 = 0.15, 95% CI [0.00, 0.00], sr2 = .00). However, there was a significant direct effect of ER difficulties on aggression when accounting for PTSD symptoms, gender, and trauma type (β = .50, p < .001, [0.21, 0.79]). These results indicate that while there is a unique relationship between ER difficulties and aggression, the path by which PTSD symptoms and aggression are related through ER difficulties is specific to the model, indicating that PTSD symptoms are indirectly related to aggression through ER difficulties.

Discussion

The current study concurrently examines the relationship between PTSD symptoms, ER, and aggression through the lens of two models that propose different roles of ER difficulties in the relationship between PTSD and aggression. Inconsistent with the I3 model and some of the prior research in this area, the degree of ER difficulties did not influence the proclivity to aggress as it relates to PTSD, failing to support our first hypothesis. One potential explanation for this discrepancy is that the influence of ER as an impelling factor is stronger in specific at-risk populations. For example, Wahlstrom et al. found that components of ER, specifically nonacceptance of emotional responses, impulse control difficulties, and limited access to emotional regulation strategies, significantly moderated the relationship between PTSD severity and aggression in incarcerated methamphetamine users (Wahlstrom et al., 2015). Thus, future research should examine additional elements of risk (e.g., impulsivity) relevant to this relationship, using the I3 framework. Theoretically, arguments could be made for the strength of the relationship between ER and aggression to be influenced by PTSD symptoms. ER has been directly and indirectly associated with aggressive behavior, and the strength of this relationship could be a function of PTSD symptom severity, specific symptom clusters, or trauma exposure (Neilson et al., 2023; Roberton et al., 2014). Given this, future research could explore how PTSD broadly or trauma exposure impacts the relationship between ER and aggression.

Contrastingly, there was a significant indirect effect of PTSD symptoms and aggression via ER difficulties, but no significant indirect effect in the model interchanging the PTSD symptom and ER difficulties variables, providing support for the information processing account of PTSD. This is consistent with prior literature examining the processes underlying aggressive behaviors in individuals with PTSD. Neurobiological studies of PTSD show reduced activation of brain regions involved in emotion regulation and altered functioning in areas associated with information and emotional processing (Morey & Brown, 2012). Deficits in such regulatory abilities and altered processing of external stimuli could be associated with engaging in aggressive behavior (Miles et al., 2017; Taft et al., 2015). Taken together, this further suggests that ER may be a unique explanatory factor by which PTSD relates to aggression rather than a factor that increases or decreases the proclivity to aggress (Miles et al., 2017).

Trauma type had a nonsignificant main effect on aggression in both models, which seems to be inconsistent with prior literature. Although limited, some studies have identified interpersonal or intentional trauma as a risk factor for committing violent acts in both adolescence and adulthood (Bynion et al., 2018; Molina-Coloma et al., 2022). Gender having a main effect on aggression is consistent with prior literature (Miles et al., 2016) and may be indicative of the social and/or culturally defined gender roles of “appropriate” expressions of anger (Chaplin, 2015). Thus, it could be that gender may act as a dispositional factor that, when paired with PTSD, increases the likelihood of aggressive behavior.

Many evidence-based therapies for both PTSD and aggression include some aspects of ER skill development within the treatment. For example, the Skills Training in Affect and Interpersonal Regulation (STAIR) treatment for PTSD includes an ER module that provides skills to increase awareness of emotions and develop skills to cope with difficult emotions and distress (Cloitre et al., 2020). When paired with Prolonged Exposure (PE), STAIR has been shown to reduce anger expression (Cloitre et al., 2002). Acceptance and Commitment Therapy (ACT), another treatment for PTSD, includes emotion regulation strategies and acceptance skills to facilitate acceptance of difficult thoughts, feelings, and emotions, rather than avoid them (Hayes et al., 2011). A randomized control trial indicated that engagement in ACT resulted in greater declines in psychological and physical aggression compared to a support and discussion control group (Zarling et al., 2015). Prior literature and the current study findings suggest that ER as a treatment target provides promise for cases of PTSD with aggression. In addition, traditional trauma-focused therapies such as Cognitive Processing Therapy (CPT) and PE have demonstrated improvements in ER indirectly (Coyne et al., 2024; Shnaider et al., 2022). In CPT, increasing emotional awareness and addressing maladaptive beliefs lead to greater emotional stability (Resick et al., 2016). In PE, repeated practice of tolerating negative emotions encourages emotional processing and increases the capacity to self-regulate (McLean & Foa, 2011). While these traditional trauma-focused therapies influence ER, additional research is needed to assess the impact of CPT and PE on aggression.

The findings of this study should be interpreted considering its limitations. First, the data used in this study were cross-sectional, limiting our ability to make causal inferences. Considering that the hypotheses of this study are time-dependent and true mediation usually involves measurement of constructs at different time points, future research should utilize longitudinal data to examine whether PTSD leads to increased ER difficulties that subsequently cause aggressive behavior. Second, though all participants were trauma-exposed, only 22% of the sample had scores on the PCL-5 indicative of a probable PTSD diagnosis, thus our results reflect ER as a mediator of the relationship between PTSD symptoms and aggression rather than the syndrome. Future research could investigate factors influencing conditional risk for aggressive behavior among those with and without PTSD. Moreover, the sample used in the study is largely homogenous by race, gender, and educational status and thus may not be representative of the general population. Prior literature suggests disparities in the prevalence of trauma exposure and aggressive behavior with men endorsing greater exposure and aggression, and people of color endorsing greater trauma exposure (Frans et al., 2005; Roberts et al., 2011). Thus, future research would benefit from more diverse samples representative of the population. Further, assessment of aggressive behavior was based on self-report, which could be biased by gender (e.g., males endorsing more aggressive behaviors, females endorsing less aggressive behaviors). Future research could use behavioral measures of aggression to obtain a more accurate assessment of aggressive behavior.

Despite these limitations, the current study represents a novel comparison between different models that attempt to account for PTSD, ER, and aggression. ER does not appear to alter the proclivity to aggress among trauma-exposed individuals with varying levels of PTSD symptoms but could act as a link to explain the connection between PTSD symptoms to aggressive behavior. Importantly, ER may be an important treatment target for individuals with PTSD symptoms who are at risk for exhibiting aggressive behavior or could aid in the prevention of subsequent aggressive behavior.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This research was supported by T32 MH093311–14 (MRP).

Author Biographies

Miracle R. Potter, MS, is a fourth-year clinical psychology doctoral student at Florida State University. She received a Bachelor of Science degree in psychology from Florida Agricultural and Mechanical University. Her primary research interests are focused on examining risk factors for trauma-related psychopathology, behavioral outcomes of trauma-related psychopathology, and the role of culture as a protective factor in prevention and treatment.

Danielle M. Morabito, PhD, is an assistant professor of clinical psychology at the University of Nevada, Las Vegas. Her research includes examining risk factors for the development of trauma-related psychopathology, the impact of trauma on psychosocial functioning, and interventions for prevention and treatment.

Norman B. Schmidt, PhD, is a distinguished research professor and a director of the Anxiety and Behavioral Health Clinic at Florida State University. His research focuses on the prevention and treatment of anxiety pathology, biobehavioral parameters, and their relationship with physical health. He has completed numerous clinical trials focused on treatment and has received funding from a range of national organizations.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Ethical Considerations

The study received ethical approval from the Florida State University IRB (STUDY500000446) on June 2019.

Consent to Participate

Written informed consent for inclusion in this study was obtained prior to participation.

Data Availability Statement

Data will be made available upon reasonable request.*

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