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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Psychol Trauma. 2021 Sep 9;14(4):688–695. doi: 10.1037/tra0001118

Examining Indirect Effects of Emotion Dysregulation between PTSD Symptom Clusters and Reckless/Self-Destructive Behaviors

Ling Jin a, Fallon S Keegan b, Nicole H Weiss c, Ahmad M Alghraibeh d, Suliman S Aljomaa d, Amjad R Almuhayshir d, Ateka A Contractor b,*
PMCID: PMC8904644  NIHMSID: NIHMS1738560  PMID: 34498900

Abstract

Objectives.

Emotion dysregulation theoretically and empirically explains the link between posttraumatic stress disorder (PTSD) and post-trauma reckless and self-destructive behaviors (RSDBs).

Method.

The current study uniquely examined the role of emotion dysregulation in the association between the four heterogeneous PTSD clusters (intrusions, avoidance, negative alterations in cognition and mood [NACM], and alterations in arousal and reactivity [AAR]) and an overall measure of post-trauma RSDBs. Trauma-exposed participants (n=411) completed self-report measures assessing PTSD symptoms (PTSD Checklist for DSM-5), emotion dysregulation (Difficulties in Emotion Regulation Scale-16), and engagement in RSDBs (Posttrauma Risky Behaviors Questionnaire).

Results.

Direct and indirect effects were examined using PROCESS Model 4. The bias-corrected bootstrap revealed a significant indirect effect of emotion dysregulation in post-trauma RSDBs’ relation with PTSD’s intrusions (B = −.13, SE = .04, 95% CI [−.23, −.06]), avoidance (B =.15, SE =.07, 95% CI [.04, .33]), NACM (B =.17, SE =.05, 95% CI [.09, .27]), and AAR (B =.14, SE =.05, 95% CI [.05, .27]).

Conclusions.

Emotion dysregulation explained associations between the severity of each PTSD symptom cluster and overall post-trauma RSDBs. PTSD treatments targeting emotion dysregulation may help to reduce post-trauma RSDBs for trauma-exposed individuals.

Posttraumatic stress disorder (PTSD) symptoms are etiologically linked to the experience of a traumatic event (American Psychiatric Association [APA], 2013), and occur in ~1 in 12 individuals in the United States general population (Kilpatrick et al., 2013). Descriptively, the construct of PTSD, according to the latest Diagnostic and Statistical Manual edition (5th ed.; DSM-5; American Psychiatric Association, 2013), is comprised of four symptom clusters: intrusions (e.g., intrusive thoughts, flashbacks, and nightmares of the trauma); avoidance of trauma reminders; negative alterations in cognitions and mood (NACM; e.g., negative affect, maladaptive beliefs); and alterations in arousal and reactivity (AAR; e.g., hypervigilance).

Extensive research links PTSD to reckless and self-destructive behaviors (RSDBs; see Tull et al., 2015), such as hazardous substance use (Weiss et al., 2019a), risky sexual behaviors (Weiss et al., 2019b), non-suicidal self-injury (Raudales et al., 2020b), and violent acts (Semiatin et al., 2017). In fact, 41% of individuals with PTSD endorse RSDBs during their lifetime (Miller, 2013). A growing body of literature suggests that trauma-exposed individuals engage in RSDBs due to deficits in emotion regulation (Weiss et al., 2012; 2014; 2015b). Tull and Aldao (2015a) differentiated between ability and strategy models of emotion regulation. Ability models refer to the dispositional ways in which individuals understand, regard, and respond to their emotional experience (Gratz & Roemer, 2004). On the other hand, strategy models are defined by specific tactics individuals use to influence the experience and expression of emotion (Gross, 2015). Emotion regulation abilities are theorized to be a higher order process that determines the nature and success of emotion regulation strategies (Tull & Aldao, 2015). The experience of PTSD symptoms may rapidly deplete emotion regulation abilities (Weiss et al., 2012), consequently increasing RSDBs (Inzlicht & Schmeichel, 2012). In support of this proposition, emotion dysregulation has been found to underlie the association between PTSD severity and overall RSDBs (Weiss et al., 2012; 2015b) as well as several RSDBs such as alcohol and drug use (Weiss et al., 2019a), aggression (Miles et al., 2016), self-harm (Raudales et al., in press), risky sexual behaviors (Weiss et al., 2019b), and disordered eating (Echeverri-Alvarado et al., 2020). Given this evidence, this study explores emotion regulation abilities in the PTSD-RSDB relation.

However, there are critical gaps in the existing literature. First, no studies to our knowledge have accounted for PTSD symptom heterogeneity when examining the role of emotion dysregulation in the PTSD-RSDB relationship. Indeed, PTSD symptom clusters have found to differentially associate with clinical outcomes (Contractor et al., 2014, 2018) including different RSDBs (e.g., Weiss et al., 2019a; 2019b) and facets of emotion dysregulation (O’Bryan et al., 2015; Short et al., 2016). Thus, research on the potential role of emotion dysregulation in the relations between nuanced PTSD symptom clusters and post-trauma RSDBs could inform trauma treatment, as emotion dysregulation is likely to cause and/or maintain PTSD symptomatology and may differentially associate to each PTSD symptom cluster (Short et al., 2016). Second, most studies that have examined the link between emotion dysregulation and an overall measure of post-trauma RSDBs have been limited to clinical samples characterized by substance use disorder (SUD; Raudales et al., 2020a). In fact, research using data from more heterogenous community samples would illuminate whether these findings are generalizable to the wider population of trauma-exposed individuals with PTSD symptoms.

Addressing these limitations, we examined the role of emotion dysregulation in associations between the four heterogeneous PTSD symptom clusters (intrusions, avoidance, NACM, AAR) and an overall measure of post-trauma RSDBs in a trauma-exposed community sample. We hypothesized that all PTSD symptom cluster severities would be significantly and positively associated with emotion dysregulation (Paulus et al., 2019; Short et al., 2016) and post-trauma RSDBs (Semiatin et al., 2017). Further, we expected that emotion dysregulation would be significantly and positively associated with post-trauma RSDBs (Weiss et al., 2019a). Lastly, we hypothesized that each PTSD symptom cluster severity would indirectly associate with post-trauma RSDBs through emotion dysregulation, in accordance with the emotion dysregulation model linking PTSD and RSDBs (Weiss et al., 2012; 2014; 2015a; 2015b).

Methods

Procedure and Participants

The current study was approved by University of North Texas Institutional Review Board. Participants were recruited from Amazon’s Mechanical Turk (MTurk) platform. MTurk generates reliable data (Shapiro et al., 2013), MTurk’s subject pool is diverse (Buhrmester et al., 2011), and MTurk has demonstrated utility for trauma research (Engle et al., 2020). The current study was described as a 45–60-minute survey aimed to develop a measure of post-trauma RSDBs. Eligible participants (a) were >/= 18 years old, (b) had a working knowledge of English, (c) lived in North America, and (d) experienced traumatic experience(s) as screened with the Primary Care PTSD Screen for DSM-5 (Prins et al., 2016). Eligible participants who provided informed consent, finished the survey in entirety, and passed all validity checks were compensated $1.25. Of note, our compensation amount is consistent with other studies (Litman et al., 2015), and evidence suggests that MTurk participants are internally motivated, wherein the amount of monetary compensation does not affect the data quality (Buhrmester et al., 2011).

Measures

Life Event Checklist for DSM-5

(LEC-5; Weathers et al., 2013a). The LEC-5 is a 17-item self-report measure that assesses traumatic experiences. Participants respond to each item with the options “Happened to me,” “Witnessed it,” “Learned about it,” “Part of my job,” “Not sure,” or “Doesn’t apply.” Those who selected one of the first four response options on any of the 16 LEC-5 items (Item 17 examined any other extremely stressful event) were considered to have experienced a traumatic event, consistent with PTSD’s DSM-5 Criterion A (American Psychiatric Association, 2013). Although there is no psychometric information on the LEC-5, the LEC for DSM-IV demonstrates good psychometric properties including convergent/discriminant validity and test-retest reliability (Bae et al., 2008; Gray et al., 2004).

PTSD Checklist for DSM-5

(PCL-5; Weathers et al., 2013b). The PCL-5 is a 20-item self-report measure that assesses PTSD severity during the past month. Response options range from 0 (not at all) to 4 (extremely). Total score of ≥31 indicates probable PTSD (Bovin et al., 2016). Participants completed the PCL-5 referencing the most distressing trauma endorsed on the LEC-5 (Weathers et al., 2013a). The PCL-5 demonstrates excellent psychometrics (Bovin et al., 2016). Cronbach’s alpha in the current study were: overall = .96; intrusions = .91; avoidance = .87; NACM = .92; AAR = .86. In the current study, PCL-5 Item #16 assessing RSDBs was not included in the computation of the AAR subscale score.

Difficulties in Emotion Regulation Scale-16

(DERS-16; Bjureberg et al., 2015). The DERS-16 is a 16-item self-report measure of five emotion dysregulation domains: difficulty regulating impulsive behaviors when distressed; difficulty accepting negative emotions; inability to engage in goal-directed behaviors under distress; lack of effective emotion regulation strategies; and lack of emotional clarity. Response options range from 1 (almost never) to 5 (almost always); higher scores indicate more difficulty regulating emotions. It demonstrates good psychometrics (Bjureberg et al., 2015); Cronbach’s alpha in the current study = .97.

Posttrauma Risky Behaviors Questionnaire

(PRBQ; Contractor et al., 2020a). The PRBQ is a 16-item self-report measure of the extent of participation in specific post-trauma RSDBs over the past month. On the initial 14 items, participants rate the frequency of engaging in RSDBs on a scale ranging from 0 (never) to 4 (very frequently). The last 2 items assess functional impairment due to RSDBs and the relation of the RSDB frequency to the onset of the worst trauma. The PRBQ demonstrates good psychometrics (Contractor et al., 2020a, b, 2021); Cronbach’s alpha in the current study = .92.

Alcohol Use and Disorders Identification Test Alcohol Consumption Questions

(AUDIT-C; Bush et al., 1998). The AUDIT-C is a 3-item self-report measure that assesses heavy drinking and active alcohol use disorders. Participants respond to a 5-point Likert scale (Item 1: 0 [never] to 4 [daily or more times a week]; Item 2: 0 [1 or 2] to 4 [10 or more]; Item 3: 0 [Never] to 4 [daily/almost daily]). The AUDIT-C has good psychometrics, and a cutoff score of ≥4 indicates probable alcohol abuse/dependence (Bush et al., 1998). Cronbach’s alpha in the current study= .74.

Drug Abuse Screening Test-10

(DAST-10; Skinner, 1982). The DAST-10 is a 10-item self-report measure of drug misuse, including occupational/relational problems, illegal activities, or regret using 1 (yes) and 0 (no) response options. The DAST has adequate psychometric properties, and a cutoff score of ≥3 indicates probable problematic drug use (Carey et al., 2003). Cronbach’s alpha in the current study = .83.

Exclusions, Missing Data, and Sample Characteristics

See Supplemental Figure 1 for a graphical description of participant exclusion criteria. From an initial 891 total survey attempts, the final sample included 411 participants averaging 35.90 years in age (SD = 11.19); the majority were female (n = 235; 57.20%). Most participants (85.20%) identified as non-Hispanic. Further, 76.90% of the sample (n = 316) identified as White, 9.50% of the sample (n = 39) identified as African-American/Black, 10.70% of the sample (n = 44) identified as Asian/Asian-American, 4.60% of the sample (n = 19) identified as American Indian or Alaskan Native, and 0.70% of our sample (n = 3) identified as Native Hawaiian/other Pacific Islander. Of note, 49.88% of the sample had probable clinical levels of RSDBs (≥ 3.5; Contractor et al., 2021), and 37.70% of the sample had probable PTSD (≥ 31; Bovin et al., 2016). The most frequently endorsed index trauma types were transportation accident (16.30%), natural disaster (13.40%), and sexual assault (13.10%). RSDBs with the highest levels of engagement included problematic technology use (M = 0.90, SD = 1.13), eating behaviors (M = 0.82, SD = 1.13), and alcohol use (M = 0.72, SD = 1.09). See Supplemental Table 1 for description of sample characteristics. Missing data was minimal (i.e., 1 item of the DERS-16 had missing data), and data was missing completely at random (Little’s χ2[49] = 38.56, p = .858; Schafer & Graham, 2002). Missing data was estimated with Expectation Maximization (Schafer & Graham, 2002).

Data Analyses

Data were normally distributed using the benchmarks of skewness < 2 and kurtosis < 7 (Curran et al., 1996). Indirect effect analyses were conducted using PROCESS Model 4 (Hayes, 2013). Here, we conceptualized each of four PTSD symptom clusters as the predictors (X), post-trauma RSDBs as the dependent variable (Y), and emotion dysregulation as an explanatory factor (M). We ran four independent mediation models, one for each of the four PTSD symptom clusters. In each model, we controlled the effects of the other three PTSD symptom clusters. Direct effects included the relationship between (1) each of the PTSD symptom clusters and post-trauma RSDBs; (2) each of the PTSD symptom clusters and emotion dysregulation; and (3) emotion dysregulation and post-trauma RSDBs. Indirect effects included paths from each of the four PTSD symptom clusters (separately) to post-trauma RSDBs accounting for emotion dysregulation. The significant indirect effects were investigated by utilizing a bias-corrected bootstrap with 10,000 samples (Shrout & Bolger, 2002). See Figure 1 for the conceptual models.

Figure 1.

Figure 1.

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Conceptual Diagram for Proposed Mediation Model.

Note. RSDBs is post-trauma reckless and self-destructive behaviors; NACM is negative alterations in cognitions and mood; AAR is alterations in arousal and reactivity; In each model, we controlled for the effects of the other three PTSD symptom clusters.

Results

Scores on intrusions symptoms, avoidance symptoms, NACM symptoms, AAR symptoms, emotion dysregulation, and post-trauma RSDB averaged 6.62 (SD = 5.47), 2.98 (SD = 2.54), 9.51 (SD = 8.71), 5.09 (SD = 4.50), 34.85 (SD = 16.01), and 6.89 (SD = 9.50), respectively. All four PTSD symptom clusters had significant positive correlations with emotion dysregulation and post-trauma RSDBs, and emotion dysregulation had a significant positive correlation with post-trauma RSDBs (Supplemental Table 2).

See Table 1 for results of the primary analyses; each model accounted for 37.15% of variance in post-trauma RSDBs (p < .001). For intrusions, results indicated that emotion dysregulation significantly accounted for the relationship between intrusions symptom severity and post-trauma RSDBs (B = −.13, 95% confidence interval, CI [−.23, −.06]). Results indicated significant direct effects between intrusions symptoms and emotion dysregulation (B = −.72, p < .001), between emotion dysregulation and post-trauma RSDBs (B = .17, p < .001), and between intrusions symptoms and post-trauma RSDBs (B = .30, p = .021).

Table 1.

Direct and Indirect Effect Statistics

B SE β p LLCI ULCI
Intrusions
Direct Effects
 Intrusions on emotion dysregulation −.72 .21 −.25 < .001 −1.13 −.32
 Emotion dysregulation on RSDBs .17 .03 .29 < .001 .11 .23
 Intrusions on RSDBs .30 .13 .17 .021 .05 .55
Indirect Effect −.13 .04 −.07 -- −.23 −.06
Avoidance
Direct Effects
 Avoidance on emotion dysregulation .88 .38 .14 .010 .14 1.63
 Emotion dysregulation on RSDBs .17 .03 .29 < .001 .11 .23
 Avoidance on RSDBs −.66 .23 −.18 .005 −1.12 −.20
Indirect Effect .15 .07 .04 -- .04 .33
NACM
Direct Effects
 NACM on emotion dysregulation .97 .14 .53 < .001 .69 1.26
 Emotion dysregulation on RSDBs .17 .03 .29 < .001 .11 .23
 NACM on RSDBs .29 .09 .27 .002 .11 .47
Indirect Effect .17 .05 .15 -- .09 .27
AAR
Direct Effects
 AAR on emotion dysregulation .78 .24 .22 .001 .30 1.26
 Emotion dysregulation on RSDBs .17 .03 .29 < .001 .11 .23
 AAR on RSDBs .25 .15 .12 =.099 −.05 .54
Indirect Effect .14 .05 .06 -- .05 .27
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Note. RSDBs is post-trauma reckless and self-destructive behaviors; NACM is negative alterations in cognitions and mood; AAR is alterations in arousal and reactivity; p value of indirect effect is not available from PROCESS (Hayes, 2013); B is unstandardized coefficients; SE is standard error; β is standardized coefficients; LLCI = Lower limit 95% confidence interval of unstandardized coefficients; ULCI = Upper limit 95% confidence interval of unstandardized coefficients; In each model, we controlled for the effects of the other three PTSD symptom clusters.

For avoidance, results indicated that emotion dysregulation significantly accounted for the relationship between avoidance symptom severity and post-trauma RSDBs (B = .15, CI [.04, .33]). Results indicated significant direct effects between avoidance symptoms and emotion dysregulation (B = .88, p = .010), between emotion dysregulation and post-trauma RSDBs (B = .17, p < .001), and between avoidance symptoms and post-trauma RSDBs (B = −.66, p = .005).

For NACM, results indicated that emotion dysregulation significantly accounted for the relationship between NACM symptom severity and post-trauma RSDBs (B = .17, CI [.09, .27]). Results indicated significant direct effects between NACM symptoms and emotion dysregulation (B = .97, p < .001), between emotion dysregulation and post-trauma RSDBs (B = .17, p < .001), and between NACM symptoms and post-trauma RSDBs (B = .29, p = .002).

For AAR, results indicated that emotion dysregulation significantly accounted for the relationship between AAR symptom severity and post-trauma RSDBs (B = .14, CI [.05,.27]). Results indicated significant direct effects between AAR symptoms and emotion dysregulation (B = .78, p = .001) and between emotion dysregulation and post-trauma RSDBs (B = .17, p < .001).

Supplemental analyses were conducted on a subsample with probable SUD (n = 173), given the frequent comorbidity of PTSD and SUD (Weiss et al., 2019a). Probable SUD was conceptualized as ≥3 on DAST-10 (Carey et al., 2003) or ≥4 on AUDIT-C (Bush et al., 1998). Results in this subsample similarly showed that emotion dysregulation significantly accounted for the relationships between intrusions symptom severity and post-trauma RSDBs, between avoidance symptom severity and post-trauma RSDBs, between NACM symptom severity and post-trauma RSDBs, but not for AAR symptom severity.

Discussion

Current study results indicated significant associations between (1) the four PTSD symptom clusters and emotion dysregulation, (2) the three PTSD symptom clusters (except for AAR) and post-trauma RSDBs, and (3) emotion dysregulation and post-trauma RSDBs. Results are consistent with research supporting relations of PTSD symptom clusters with emotion dysregulation (Tripp & McDevitt-Murphy, 2015) as well as with post-trauma RSDBs (Weiss et al., 2019a; 2019b). In terms of indirect effects, emotion dysregulation explained the relationship between all four PTSD symptom clusters and post-trauma RSDBs. Theoretical and clinical implications are elaborated below.

As hypothesized, trauma-exposed individuals with greater avoidance symptoms, NACM symptoms, and AAR symptoms were more likely to report emotion dysregulation, which increased the possibility of endorsing post-trauma RSDBs. Broadly, our results are consistent with the emotion dysregulation model potentially linking PTSD and post-trauma RSDBs (Weiss et al., 2012; 2014; 2015b), as well as empirical evidence linking PTSD with emotion dysregulation (Tull et at., 2007; Weiss et al., 2013) and emotion dysregulation to post-trauma RSDBs (Weiss et al., 2019a; 2019b). The experience of PTSD symptoms is associated with intense and distressing emotions (e.g., fear; Foa & Riggs, 1993). In turn, this may deplete regulatory capactities (Weiss et al., 2012), consequently increasing RSDBs (Inzlicht & Schmeichel, 2012). Alternatively, engagement in RSDBs, as a maladaptive coping strategy, may serve to temporarily down-regulate trauma-related negative emotions (Raudales et al., 2020b) and hence, may be reinforced (Briere et al., 2010), especially given that trauma-exposed individuals demonstrate fewer effective emotion regulation strategies (Hannan & Orcutt, 2020). Critically, maladaptive coping strategies such as engagement in RSDBs can paradoxically maintain or even exacerbate PTSD severity in the long-run (Tull et al., 2007).

Notably, emotion dysregulation explained the association between all four nuanced PTSD symptom clusters and post-trauma RSDBs. First, emotion dysregulation accounted for associations between intrusions symptoms and post-trauma RSDBs. The model of dialectical reactions to trauma (Harned & Linehan, 2008) suggests that trauma-exposed individuals can experience opposite reactions, shifting from one extreme to another via overcontrol (emotional numbing, rigid control of behavior) and undercontrol (e.g., emotional flooding, reckless disinhibition of behaviors). Perhaps, intrusions symptoms such as flashbacks and nightmares may trigger excessive control over emotional experiences, in turn leading to more risk-aversive reactions including rigid control over and inhibition of one’s behaviors, excessive planning, and increased caution before acting (Linehan, 1993; Ritschel et al., 2015).

Further, emotion dysregulation explained associations between avoidance symptoms and post-trauma RSDBs, despite the weakest correlations between avoidance symptoms and post-trauma RSDBs. Avoidance of trauma cues may alleviate distressing emotions in the short-term, however, paradoxically, it may also elicit intense, reactive, and long-lasting negative emotions (e.g., fear) – and related difficulties regulating these emotions – when encountering trauma-associated stimuli in the long-term (Foa & Riggs, 1993; Jin et al., 2020), consistent with the concept of experiential avoidance (Hayes et al., 1996). Such affect processes may contribute to engaging in post-trauma RSDBs.

Also, emotion dysregulation explained associations between NACM symptoms and post-trauma RSDBs. Perhaps, among trauma-exposed individuals, NACM symptoms such as greater negative thoughts and emotions as well as less interest in and reduced capacity for experiencing positive emotions may be overwhelming and may contribute to ineffective emotion regulation strategies (Jin et al., 2020; Short et al., 2016). Further, these individuals with greater NACM symptoms and emotion dysregulation may not carefully plan goal-directed and adaptive behaviors (Raudales et al., 2020b); all such processes may increase the likelihood of engaging in post-trauma RSDBs for temporal relief (Roemer et al., 2001). Broadly, this explanation reflects the emotion dysregulation viewpoint of the PTSD-RSDB link (Weiss et al., 2012; 2014; 2015b).

Lastly, emotion dysregulation explained associations between AAR symptoms and post-trauma RSDBs. Consistent with the disinhibition theory (Casada & Roache, 2005) and the cognitive model (Ben-Zur & Zeider, 2009), inhibitory dysfunction, restriction in information processing, and a lack of focused attention on goal-directed activities are associated with AAR symptoms among trauma-exposed individuals (e.g., failure to inhibit fear responses when encountering safety cues; Jovanovic & Ressler, 2010). These behavioral patterns may increase the likelihood that trauma-exposed individuals may react impulsively to experienced emotional distress (vs. impulse control; Jin et al., 2020; Short et al., 2016) and may not inhibit and manage unwanted thoughts, emotions, and behaviors effectively, contributing to post-trauma RSDBs (Ben-Zur & Zeider, 2009; Casada & Roache, 2005). This finding, however, was not replicated with a subsample with probable SUD. Perhaps, mechanisms underlying PTSD-RSDB relations in a SUD sample may be different; this should be examined.

Limitations, Future Directions, and Implications

This study has some limitations to consider when interpreting results. All questionnaires were self-report measures; obtained responses may be subjected to desirability bias, and some behaviors may be underreported. Relatedly, the standard, self-report LEC-5 may be limited in assessing Criterion A traumatic events given the absence of probing and clarification by an experimenter/clinician; future research may consider using the interview version of the LEC-5 administered by trained experimenters or clinicians. Next, given the cross-sectional and correlational nature of the study, we cannot ascertain directionality and causality. Also, there is controversy in the existing literature on whether NACM symptoms represent and are related to general vs. PTSD-specific distress (Contractor et al., 2014; 2018). Taken together, examining the potentially alternate or bi-directional relations between emotion dysregulation and NACM symptoms or distress via a longitudinal design is worthy of future investigations. Further, the current study did not examine the dysregulation of positive emotions which is related to both PTSD and post-trauma RSDBs (Raudales et al., 2020b); as well as the role of additional moderators/mediators such as depression, rumination, and social support (McKinney et al., 2017; Neyshabouri et al., 2020) in the PTSD-RSDBs link. In addition, we utilized data from a non-clinical trauma-exposed sample, which may limit the applicability of findings to other diverse and clinical populations (e.g., samples seeking mental health treatment in outpatient or inpatient facilities). Relatedly, results should be interpreted cautiously, given that most of the referenced theories are contextualized within clinical settings. Finally, given that the emotion regulation facets differentially relate to PTSD symptom clusters (Ehring & Quack, 2010) and post-trauma RSDBs (Tripp & McDevitt-Murphy, 2015; Weiss et al., 2019a; 2019b), future investigations can examine facets of emotion dysregulation using the current study’s research framework.

This study presents both theoretical and clinical implications. Previous literature has noted that various post-trauma health outcomes may be driven by common risk factors (Contractor et al., 2020a; Shaw et al., 1992); we advance this literature by suggesting that emotion dysregulation may be one such common mechanism underlying both PTSD and post-trauma RSDBs. Relatedly, this research supports the importance of targeting emotion dysregulation in trauma treatments given its central role in enhancing/maintaining post-trauma RSDBs among individuals with varied PTSD symptoms (Ehring & Quack, 2010). Hereby, by using evidence-based emotion dysregulation focused treatments, such as Dialectical Behavioral Therapy Prolonged Exposure (DBT PE; Harned & Linehan, 2008), DBT (Linehan, 1993) and emotion regulation group therapy (Gratz et al., 2014), clinicians may help trauma-exposed individuals with PTSD symptoms reduce engagement in post-trauma RSDBs. In this regard, distress tolerance and emotion regulation techniques to down-regulate negative emotions (e.g., taking opposite action; Harned & Linehan, 2008), up-regulate positive emotions (e.g., mindfulness; Harned & Linehan, 2008), and endure intense negative emotions (e.g., Linehan, 1993) through individual or group therapy may influence post-trauma RSDB engagement among individuals with PTSD symptoms. Further, clinicians may benefit from a comprehensive assessment of emotion dysregulation to inform case conceptualization, accurate prognosis assessments, and treatment plan development to address post-trauma RSDBs. Finally, our results add to the several theories (e.g., Emotional Processing Theory, Perceptual-Motor Theory of Emotion, Foa & Riggs, 1993; Litz, 1992) and therapeutic techniques (e.g., DBT PE; Harned & Linehan, 2008) that emphasize affect processes in the onset/maintenance of PTSD symptoms and post-trauma RSDBs. Thus, our study was the first to comprehensively delineate the role of emotion dysregulation between each of the four nuanced PTSD symptom clusters and varied post-trauma RSDBs.

In conclusion, our findings extend the previous literature on the interrelations among heterogenous PTSD symptoms clusters, emotion dysregulation, and post-trauma RSDBs. Primarily, our findings suggest that emotion dysregulation underlies associations between all four heterogenous PTSD symptom cluster severities and post-trauma RSDBs. These findings suggest the potential utility of addressing emotion dysregulation in trauma treatments as a means of preventing or reducing post-trauma RSDBs. Clinical trial and experimental research can further examine longitudinal and daily-level relations between PTSD, emotion dysregulation, and post-trauma RSDBs, including effects of potentially relevant moderators such as impulsivity and trauma type in the examined relations.

Supplementary Material

Supplemental Material

Clinical Impact Statement:

This research suggests that trauma-exposed individuals with greater posttraumatic stress disorder (PTSD) symptoms of avoidance, negative cognition and mood, and arousal, as well as fewer symptoms of intrusions are more likely to experience difficulties regulating emotions, which may increase engagement in reckless/self-destructive behaviors. Trauma treatments that improve emotion regulation skills may prevent or reduce reckless/self-destructive behaviors.

Acknowledgement:

The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding this work through research group No (RG-1439–012)

Funding: This work was supported, in part, by a grant from the National Institutes of Health (K23DA039327 and P20GM125507) awarded to the N.H.W; and by funding from the Deanship of Scientific Research at King Saud University research group (RG-1439–012) awarded to A.M.A., S.S.A., and A.R.A..

Footnotes

Declarations of interest: none.

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