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Emotion Dysregulation Prospectively Predicts PTSD Symptom Severity 3-Months after Traumatic Exposure

Courtney N. Forbes, Matthew T. Tull, Daniel Rapport, Hong Xie, Brian Kaminski, Xin Wang

June 25, 2020

Why study emotion dysregulation as a predictor of PTSD symptom trajectories?

As many as one-third of individuals who have experienced a traumatic event develop posttraumatic stress disorder (PTSD; Pietrzak et al., 2011), a psychiatric condition characterized by intrusive recollections of the traumatic event, avoidance of reminders of the traumatic event, alterations in cognition and mood, increased arousal and reactivity, and clinically significant distress and/or impairment (APA, 2013). Previous research has identified multiple risk factors for the development of PTSD, including (younger) age, (female) gender, and experiencing an interpersonal traumatic event (Brewin et al., 2000). However, less is known about risk factors that can be modified following a traumatic event. By understanding processes contributing to the development of PTSD, we can target these processes early-on using evidence-based interventions to help individuals recover from traumatic experiences and protect against (or mitigate) long-term psychiatric problems.

One promising process is emotion dysregulation, defined as deficits in one or more of the following domains: (a) awareness, understanding, and acceptance of emotions; (b) ability to control impulsive behaviors and engage in goal-directed behaviors when experiencing negative emotions; (c) flexible use of non-avoidant, situationally-appropriate strategies to modulate emotional responses to meet goals and situational demands; and (d) willingness to experience negative emotions in pursuing a meaningful life (Gratz & Roemer, 2004).

Why is emotion dysregulation relevant to PTSD symptom trajectories? A traumatic event can result in more intense and frequent negative emotions (APA, 2013). The experience of these emotions can be difficult to accept and modulate, as well as interfere with quality of life and the pursuit of goals. As a result, individuals may begin to avoid reminders of the traumatic event that bring up unpleasant emotions. Others may engage in risky and/or self-destructive behaviors (e.g., substance use) to cope with painful emotions. Although these strategies might bring about temporary relief, they can prolong distress and lead to more avoidance and isolation, increasing risk for the development of severe PTSD symptoms (Foa & Kozack, 1986).

Emotion dysregulation has been identified as a core component of PTSD, and research provides strong support for associations between emotion dysregulation and PTSD symptoms (Seligowski et al., 2015). However, only one study has examined if emotion dysregulation predicts the PTSD development following a traumatic event (Bardeen et al., 2013). Therefore, our study aimed to examine if emotion dysregulation in the aftermath of a traumatic event predicts PTSD symptoms 3 months later, even when considering other risk factors for PTSD.

Participants and procedure

Eighty-five individuals were recruited from two hospital emergency departments (EDs) in Toledo, Ohio. The sample was predominantly Black/African-American (56.3%) and White (40.0%). The most common traumatic events experienced were motor vehicle accident (54.2%) and interpersonal violence (41.9%). Participants initially completed assessments of PTSD symptoms (Posttraumatic Stress Disorder Checklist; Weathers et al., 2013), emotion dysregulation (Difficulties in Emotion Regulation Scale; Gratz & Roemer, 2004), lifetime trauma history (Brief Trauma Questionnaire; Schnurr et al., 1999), and adverse childhood experiences (Childhood Trauma Questionnaire; Bernstein et al., 2003). Approximately three months later, PTSD symptoms stemming from the event that brought them to the ED were again assessed.

To address our study’s aim, a hierarchical linear regression analysis was conducted with age, gender, race, ethnicity, type of traumatic event, childhood adversity, lifetime trauma history, and baseline PTSD symptoms entered on the first step. Emotion dysregulation was entered on the second step. Three-month PTSD symptoms was the dependent variable.


PTSD risk factors in the first step of the model accounted for significant variance (43%) in 3-month PTSD symptom severity, ΔF (8, 58) = 5.46, p < .001. Including emotion dysregulation significantly improved the model, accounting for significant unique variance (4%) in 3-month PTSD symptom severity, ΔF (1,57) = 4.35, p = .042.


Greater emotion dysregulation in the aftermath of a traumatic event predicted more severe 3-month PTSD symptoms in a recently traumatized sample recruited from hospital EDs, even when accounting for other well-established PTSD risk factors. Results extend past research showing cross-sectional associations between emotion dysregulation and PTSD by demonstrating that emotion dysregulation predicts PTSD symptom development over 3 months. Findings highlight the need for ongoing research on emotion dysregulation in PTSD development. If results are replicated in other samples, emotion dysregulation could be a promising target for evidence-based early post-traumatic interventions to prevent and/or mitigate the development of PTSD.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.

Bardeen, J. R., Kumpula, M. J., & Orcutt, H. K. (2013). Emotion regulation difficulties as a prospective predictor of posttraumatic stress symptoms following a mass shooting. Journal of Anxiety Disorders27, 188-196.

Bernstein, D. P., & Fink, L. (1998). Childhood Trauma Questionnaire: A retrospective self-report (CTQ). San Antonio, TX: NCS Pearson.

Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology68, 748.

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin99, 20-35.

Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41–54.

Pietrzak, R. H., Goldstein, R. B., Southwick, S. M., & Grant, B. F. (2011). Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Anxiety Disorders, 25, 456-465.

Schnurr, P., Vielhauer, M., Weathers, F., & Findler, M. (1999). The Brief Trauma Questionnaire. White River Junction, VT: National Center for PTSD.

Seligowski, A. V., Lee, D. J., Bardeen, J. R., & Orcutt, H. K. (2015). Emotion regulation and posttraumatic stress symptoms: a meta-analysis. Cognitive Behaviour Therapy44, 87-102.

Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5) [Measurement instrument]. Available from

Reference Article

Forbes, C. N., Tull, M. T., Xie, H., Rapport, D., Kaminski, B., & Wang, X. (in press). Emotion dysregulation prospectively predicts PTSD symptom severity 3-months after traumatic exposure. Journal of Traumatic Stress.

Questions for Discussion

  1. How could strategies for assessing and treating posttraumatic emotion dysregulation be incorporated into clinical practice?
  2. Could assessing emotion dysregulation after a traumatic event help identify individuals who may be at high risk for developing PTSD?
  3. How might brief, emotion-focused interventions delivered during or shortly after an ED visit be useful in preventing the development of PTSD?

About the Authors

Courtney N. Forbes is a doctoral candidate in clinical psychology at the University of Toledo. Her research and clinical interests center on integrating basic research on biobehavioral processes underlying mood, anxiety, and trauma-related disorders into the development and dissemination of evidence-based interventions.
Matthew T. Tull is a professor in the Department of Psychology at the University of Toledo. His research interests are focused on emotion-related factors in the anxiety disorders and posttraumatic stress disorder, particularly in regard to the role of emotion dysregulation in substance use and other risky behaviors.
Hong Xie is a research assistant professor in the Department of Neurosciences at the University of Toledo Medical Center. Her research employs structural and functional MRI techniques to examine human brain plasticity in low-stress and high-stress settings.
Daniel Rapport is a professor in the Department of Psychiatry at the University of Toledo Medical Center. His research interests include the assessment and management of treatment-resistant depression and bipolar disorder.
Brian Kaminski is an emergency medicine physician and medical director of the Emergency Department at ProMedica Toledo Hospital. He also serves as the vice president of Quality and Patient Safety and Patient Safety Officer at ProMedica Toledo Hospital.
Xin Wang is an associate professor in the Department of Psychiatry at the University of Toledo Medical Center. His research is focused on early structural and functional brain alterations that predict the development of posttraumatic stress disorder in the aftermath of a traumatic event.