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Emotion Regulation Difficulties in Trauma Survivors: The Role of Trauma Type

and PTSD Symptom Severity

Article  in  Behavior Therapy · December 2010

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Behavior Therapy 41 (2010) 587 – 598

www.elsevier.com/locate/bt

Emotion Regulation Difficulties in Trauma Survivors:

The Role of Trauma Type and PTSD Symptom Severity
Thomas Ehring
University of Amsterdam

Dorothea Quack
University of Bielefeld

ALTHOUGH POSTTRAUMATIC STRESS DISORDER (PTSD) is

Two different hypotheses regarding the relationship be-
tween emotion regulation and PTSD are described in the
literature. First, it has been suggested that emotion
regulation difficulties are part of the complex sequelae of
early-onset chronic interpersonal trauma and less common
following late-onset or single-event traumas. Second, PTSD
in general has been suggested to be related to emotion
regulation difficulties. Bringing these two lines of research
together, the current study aimed to investigate the role of
trauma type and PTSD symptom severity on emotion
regulation difficulties in a large sample of trauma survivors
(N = 616). In line with the hypotheses, PTSD symptom
severity was significantly associated with all variables
assessing emotion regulation difficulties. In addition,
survivors of early-onset chronic interpersonal trauma
showed higher scores on these measures than survivors of
single-event and/or late-onset traumas. However, when
controlling for PTSD symptom severity, the group differ-
ences only remained significant for 2 out of 9 variables. The
most robust findings were found for the variable “lack of
clarity of emotions.” Implications for future research,
theoretical models of trauma-related disorders, and their
treatment will be discussed.
We are grateful to the numerous self-help organizations, mailing
lists owners, and website hosts for their invaluable help with
recruitment for this study. In addition, we would like to thank
Christian Glass for his help with recruitment and data management.
Address correspondence to Thomas Ehring, Ph.D., Department of
Clinical Psychology, University of Amsterdam, Roetersstraat 15,
1018 WB Amsterdam, The Netherlands; e-mail: t.w.a.ehring@uva.nl.
0005-7894/10/587–598/$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.
mostly regarded as a reliable, valid, and clinically
useful diagnostic category (Nemeroff et al., 2006),
some aspects of the diagnosis nevertheless remain
controversial (e.g., McHugh & Treisman, 2007;
McNally, 2004). Most importantly, a number of
authors have argued that it is too much focused on
the sequelae of single-event traumas, but does not
adequately capture the more complex problems
experienced by adult survivors of childhood inter-
personal trauma, especially if the traumatic events
have occurred repeatedly or chronically (Briere &
Spinazzola, 2005; Cloitre, Miranda, Stovall-
McClough, & Han, 2005; Herman, 1992a, 1992b;
van der Kolk, 2005; van der Kolk, Roth, Pelcovitz,
Sunday, & Spinazzola, 2005). A number of addi-
tional trauma-related diagnoses for this specific
subgroup have therefore been suggested, including
complex PTSD (Herman, 1992b), disorder of
extreme stress not otherwise specified (DESNOS;
van der Kolk et al., 2005), and, more recently,
developmental trauma disorder (van der Kolk,
2005). Other authors have described groups of
symptoms that are thought to be typical sequelae of
early-onset interpersonal trauma without suggesting
a separate diagnostic category (Briere, Kaltman, &
Green, 2008; Briere & Spinazzola, 2005; Cloitre et
al., 2005). Although the different conceptualizations
of complex trauma sequelae show considerable
differences, they also agree on a number of key
symptoms, including emotion regulation difficulties.
The suggestion that exposure to chronic inter-
personal trauma early in life should lead to emotion
regulation difficulties is based on findings from
developmental psychology. Research has shown
 Author's personal copy
588 ehring & quack
that adaptive emotion regulation is learned in
interaction with primary caregivers (Calkins &
Hill, 2007; Cole, Michel, & Teti, 1994). On the one
hand, caregivers' own emotion regulation behavior
serves as a model for the developing child as to how
to deal with emotional states. In addition, care-
givers guide the child in understanding and labeling
his/her own emotions and ultimately regulating
them in a way to achieve his/her goals. In addition,
there is evidence that compromised attachment is
associated with emotion regulation deficits (Cloitre,
Stovall-McClough, Zorbas, & Charuvastra, 2008),
which supports the idea that the interpersonal
context is important for the development of
emotion regulation. On a theoretical level, it is
therefore conceivable that the experience of chronic
interpersonal trauma in early developmental stages
should disrupt the development of adaptive emo-
tion regulation, especially when the perpetrator is
one of the key caregivers (Cloitre et al., 2005, 2008;
Ford, 2009; van der Kolk et al., 1996); however, to
our knowledge no prospective studies testing this
hypothesis have been conducted to date. On the
basis of the theoretical assumptions regarding the
effects of trauma on the development of emotion
regulation, a number of authors suggest that
emotion regulation difficulties are one of the
complex symptoms that specifically develop after
early-onset chronic interpersonal trauma (e.g.,
Cloitre et al., 2005; van der Kolk et al., 2005).
The suggestion that survivors of early-onset inter-
personal trauma typically show pronounced emo-
tion regulation difficulties also forms the rationale
for treatment approaches specifically developed for
this group that include strategies to build up
emotion regulation skills (Cloitre, Koenen, Cohen,
& Han, 2002; Wolfsdorf & Zlotnick, 2001).
A review of evidence supporting this view is
complicated by the fact that emotion regulation is a
broad concept that has been defined in different
ways (see Gross & Thompson, 2007; Kring &
Werner, 2004). The current study is based on Gratz
and Roemer's (2004) integrative conceptualization,
which suggests four key dimensions of emotion
regulation: (a) awareness and understanding of
one's emotions, (b) acceptance of negative emo-
tions, (c) the ability to successfully engage in goal-
directed behavior and control impulsive behavior
when experiencing negative emotions, and (d) the
ability to use situationally appropriate emotion
regulation strategies. On the basis of this concep-
tualization, Gratz and Roemer developed the
Difficulties in Emotion Regulation Scale (DERS).
Results of factor analyses support a six-factor
solution for the DERS, whereby the first and third
dimension suggested by the authors are represented
by two factors each (Dimension 1: Lack of
Emotional Awareness and Lack of Emotional
Clarity; Dimension 3: Difficulties Engaging in
Goal-Directed Behavior and Impulse Control
Difficulties).
Evidence for the idea that survivors of early-
onset interpersonal trauma suffer from alterations
in emotion regulation comes from three groups
of studies. First, survivors of early-onset inter-
personal trauma were found to report higher
levels of alexithymia than nontraumatized con-
trols (Cloitre, Scarvalone, & Difede, 1997;
McLean, Toner, Jackson, Desrocher, & Stuckless,
2006; Zlotnick et al., 1996). Alexithymia is
defined as difficulty with identifying and labeling
one's own emotional state and corresponds to the
first dimension of Gratz and Roemer's (2004)
conceptualization. Second, a number of studies
have investigated acceptance of negative emotions.
When compared to nontraumatized controls, sur-
vivors of early-onset interpersonal trauma were
found to report more difficulties tolerating and
regulating negative emotions (Briere & Rickards,
2007), higher levels of fear of emotions (Tull,
Jakupcak, McFadden, & Roemer, 2007), and
higher experiential avoidance, defined as an un-
willingness to experience negative thoughts and
feelings and high efforts to escape from them
(Batten, Follette, & Aban, 2001; Marx & Sloan,
2002). Furthermore, studies conducted as part of
the DSM-IV field trial showed that a majority of
survivors of early-onset interpersonal trauma
reported difficulties appropriately regulating their
emotions (e.g., fear, anger) or impulses (e.g., self-
destructive behavior, sexual involvement; Pelcovitz
et al., 1997; van der Kolk et al., 1996). Finally, a
recent study found self-reported emotion regulation
problems to be strongly associated with functional
impairment beyond PTSD symptom severity in
treatment-seeking women who had experienced
early-onset interpersonal trauma (Cloitre et al.,
2005).
Taken together, earlier findings support the view
that psychological problems following early-onset
interpersonal trauma include emotion regulation
difficulties. However, to our knowledge, no pro-
spective studies have been conducted to date
investigating the suggested temporal precedence of
traumatic events leading to emotion regulation
difficulties. In addition, it is less clear whether
these difficulties are indeed specific for survivors of
this type of events or whether they are also present
in individuals with PTSD who have experienced
traumas later in life and/or only once. In line with
the latter view, it is interesting to note that the
DSM-IV diagnosis of PTSD includes symptoms that
 Author's personal copy
emotion regulation in trauma survivors
may directly reflect difficulties in emotion regula-
tion, with emotional hyperreactivity to trauma-
related cues on the one hand and hyporeactivity
in the form of emotional numbing on the other
hand (see Frewen & Lanius, 2006; Litz, Orsillo,
Kaloupek, & Weathers, 2000). A number of studies
have shown that PTSD in general, even following
adult-onset traumas, is related to alterations in
emotion regulation. Specifically, PTSD has been
found to be related to (a) alexithymia (Frewen,
Dozois, Neufeld, & Lanius, 2008); (b) a negative
attitude towards emotional expression and a
tendency to suppress and/or withhold negative
emotions (Lowery & Stokes, 2005; Moore, Zoellner,
& Mollenholt, 2008; Nightingale & Williams, 2000;
Roemer, Litz, Orsillo, & Wagner, 2001), as well as
high levels of experiential avoidance (Kashdan,
Morina, & Priebe, 2009; Marx & Sloan, 2005;
Morina, Stangier, & Risch, 2008; Plumb, Orsillo, &
Luterek, 2004); and (c) self-reported problems
regulating one's emotions (Tull, Barrett, McMillan,
& Roemer, 2007). Taken together, these findings
show an association of emotion regulation difficul-
ties with PTSD following late-onset single-event
traumas, which may call into question the wide-
spread assumption that they are a specific charac-
teristic of early-onset chronic interpersonal trauma.
An alternative hypothesis would be that emotion
regulation difficulties are simply related to the
severity of PTSD symptoms irrespective of the type
of traumatic event experienced.
We suggest that studies testing these two
hypotheses against each other need to fulfill two
requirements. First, they need to directly compare
survivors of early-onset interpersonal traumas with
survivors of late-onset and/or noninterpersonal
traumas regarding characteristics of emotion regu-
lation that are thought to be implicated in trauma-
related disturbances. Secondly, PTSD symptom
severity needs to be controlled for in order to
ensure that possible differences between different
types of trauma survivors are not just due to
differences in the severity of PTSD symptoms
experienced. To our knowledge, there is no
published study that fulfills both requirements.
However, a small number of studies have directly
compared different types of trauma survivors
regarding characteristics of emotion regulation.
Results showed that survivors of early-onset
interpersonal trauma report higher levels of alex-
ithymia (Cloitre et al., 1997), more difficulties
tolerating and regulating negative emotions (Briere
& Rickards, 2007), and more problems with the
regulation of anger as well as more self-destructive
behavior (Pelcovitz et al., 1997; Scoboria, Ford,
Lin, & Frisman, 2008; van der Kolk et al., 1996)
589
when compared to survivors of late-onset interper-
sonal trauma and/or noninterpersonal trauma (but
see also Ford, Stockton, Kaltman, & Green, 2006,
who failed to find differences in emotion regulation
between different types of trauma survivors). Thus,
results of most studies directly comparing different
types of trauma survivors support the view that
emotion regulation difficulties are more pro-
nounced in survivors of early-onset interpersonal
than late-onset or single-event traumas. However,
as none of the existing studies has controlled for
levels of PTSD, it is unclear whether the emotion
regulation difficulties observed are indeed due to
the type of event experienced or simply due to
higher levels of PTSD in the early-onset group.
In addition, past studies differ considerably
regarding their definition of the different trauma
types that were compared. Whereas some studies
compared survivors of early-onset versus late-onset
interpersonal trauma regardless of the number of
events experienced (e.g., Cloitre et al., 1997;
Pelcovitz et al., 1997; van der Kolk et al., 2005),
others distinguished between single incidents vs.
ongoing/chronic traumatization within the group of
early-onset interpersonal traumas (e.g., Ford et al.,
2006; Roth, Newman, Pelcovitz, van der Kolk, &
Mandel, 1997). Most studies used the age of 14 as
the cutoff to distinguish between early vs. late
traumas. However, some studies chose the higher
cutoff of 18 years of age (e.g., Cloitre et al., 1997).
In the current study, self-reported characteristics
of emotion regulation were assessed in a large
group of trauma survivors via a web-based survey.
The assessment battery for emotion regulation was
compiled with the aim to assess all four groups of
emotion regulation variables suggested by Gratz
and Roemer (2004), with at least two measures per
group. In addition, emotion suppression and
cognitive reappraisal were assessed as two specific
emotion regulation strategies that have been found
in earlier research to be significantly related to
PTSD symptomatology (Moore et al., 2008) as well
as other types of emotional problems (e.g., Gross &
John, 2003). As emotion suppression can be
assumed to be related to low acceptance of negative
emotions, it was included in the group of variables
assessing emotion acceptance. Reappraisal, on the
other hand, was added to the fourth group of
variables assessing the functional and flexible use of
emotion regulation strategies. In line with most
earlier studies (e.g., Pelcovitz et al., 1997; van der
Kolk et al., 2005), early-onset interpersonal trauma
was defined as sexual or physical violence experi-
enced before the age of 14. We also distinguished
whether the trauma was “chronic” (i.e., for the
duration of at least 1 year) or not, as done in earlier
 Author's personal copy

590 ehring & quack

studies (e.g., Roth et al., 1997). Based on the
developmental literature, we expected chronic
interpersonal trauma experienced at an early age
to be specifically associated with emotion regula-
tion deficits.
The hypotheses were as follows:
1. Emotion regulation difficulties are significantly
related to levels of PTSD symptoms.
2. Survivors of early-onset chronic interpersonal
trauma report higher levels of emotion regu-
lation difficulties than survivors of late-onset,
early-onset single/repeated and noninterper-
sonal traumas.
3. The differences in emotion regulation be-
tween the different types of trauma survivors
remain significant when controlling for PTSD
symptoms.
Method
participants
The study was conducted as a web-based survey. In
this way it was hoped to reach a larger and more
diverse sample of trauma survivors than when
recruiting participants via clinical services. Past
studies directly comparing web-based versus
paper-and-pencil surveys found both types of
research to be equally reliable (e.g., Fortson, Scotti,
Del Ben, & Chen, 2006; Nosek, Banaji, &
Greenwald, 2002). The final sample consisted of
616 participants (see Table 1 for demographic
information). Recruitment took place in two ways.
First, information about the study and a link to the
online questionnaire were posted on 15 websites,
which were either websites advertising web-based
studies in general or websites providing informa-
tion about trauma-related and/or other emotional
disorders. Second, self-help organizations, mailing
lists, and online communities for trauma survivors
were contacted and asked to distribute study
information and the link to the online question-
naire among their members. The online question-
naire was active between July 2006 and February
2007. A total of 2,423 individuals accessed the
welcome page providing information about the
study: 2,022 individuals agreed to take part in the
survey and started filling in the questionnaire, 772
of which provided complete data. For all events
reported in the Trauma History Questionnaire (see
below), we checked whether these events met
DSM-IV trauma criterion A1 (experiencing, wit-
nessing, or being confronted with an event that
involved actual or threatened death or serious
injury, or a threat to the physical integrity of self or

Table 1
Demographic Variables and PTSD Symptom Severity by Trauma Type
Total sample Non- Late Early single Early chronic Statistic
(N = 616)1 interpersonal interpersonal interpersonal interpersonal
(n = 135)2 (n = 211)3 (n = 101)4 (n = 169)5
Age: M (SD) 32.03 (11.16) 34.86 (13.52) 31.24 (10.49) 30.67 (12.01) 32.31 (9.97) F(3, 417) = 2.02, p = .11
Sex
Female 82.9% 63.8% 85.2% 77.6% 92.2% χ2 (3, N = 463) = 29.49,
Male 17.1% 36.2% 14.8% 22.4% 7.8% p b .001

Marital Status
Single 65% 69.6% 62.6% 70.6% 62.3% χ2 (6, N = 463) = 6.21,
Married 27.2% 27.5% 30.3% 21.2% 27.3% p = .40
Divorced/ widowed 7.8% 2.9% 7.1% 8.2% 10.4%

Employment Status
Not working 46.2% 47.8% 45.2% 43.5% 48.1% χ2 (6, N = 463) = 5.49,
Employed 44.7% 43.5% 7.1% 15.3% 44.2% p = .48
Self-employed 9.1% 8.7% 47.7% 41.2% 7.8%

IES-R
Mean score 2.55 (0.84) 1.94 (.68)1 2.46 (.83)2 2.59 (.75)2 3.11 (.63)3 F(3, 615) = 64.74, p b .001
Sum score 56.1 (18.48) 42.68 (14.96) 54.12 (18.26) 56.98 (16.5) 68.42 (13.86)
Note. Different superscripts denote differences between groups at p b .05.
1
Age: n = 421; Sex/Marital Status/Employment: n = 463.
2
Age: n = 63; Sex/Marital Status/Employment: n = 66.
3
Age: n = 140; Sex/Marital Status/Employment: n = 155.
4
Age: n = 78; Sex/Marital Status/Employment: n = 85.
5
Age: n = 140; Sex/Marital Status/Employment: n = 154.
 Author's personal copy
emotion regulation in trauma survivors
others). Participants who did not report any
traumatic event according to this definition were
excluded from the analyses (n = 156). The final
sample therefore consisted of 616 participants.
Participants did not receive a compensation for
their participation.
Based on participants' answers to the Trauma
History Questionnaire (Green, 1996) including
their descriptions of the traumatic events, the
sample was divided into four trauma groups: (1)
survivors of noninterpersonal traumas (e.g., acci-
dents, fire, observed traumatic events in others;
n = 135); (2) survivors of late-onset (age ≥ 14)
interpersonal traumas (n = 211; 51.7% physical
assault, 19.5% sexual assault, 28.8% physical and
sexual assault); (3) survivors of early-onset
(age b 14) single or repeated interpersonal traumas
that lasted for less than 1 year (n = 101; 59.8%
physical assault, 21.8% sexual assault, 17.8%
physical and sexual assault); (4) survivors of early-
onset (age b 14) chronic interpersonal traumas that
lasted for at least 1 year (n = 169; 30.2% physical
abuse, 33.1% sexual abuse, 36.7% physical and
sexual abuse). To classify participants who had
experienced several traumatic events that belonged
to different categories, a hierarchy was used with
“early-onset chronic interpersonal trauma” at the
top, followed by “early-onset single or repeated
interpersonal trauma,” “late-onset interpersonal
trauma,” and finally “noninterpersonal trauma.”
For example, a participant who had experienced a
single sexual assault at the age of 10 and a hurricane
at the age of 35 was assigned to the “early-onset
single or repeated interpersonal trauma” group.
questionnaires
Trauma History
Participants' trauma history was assessed with the
Trauma History Questionnaire (THQ; Green,
1996), which inquires about 24 different traumatic
events. For each event, participants are asked to
indicate whether they have experienced it, and if so,
the number of times and approximate age(s) of
occurrence. In addition, they are asked to write
down a brief description of the event that has
happened to them.
PTSD Symptom Severity
The Impact of Event Scale−Revised (IES-R; Weiss
& Marmar, 1997) was used to assess the severity of
PTSD symptoms. Participants are asked to rate 22
items representing trauma-related symptoms (e.g.,
“Pictures about it popped into my mind”; “I had
trouble falling asleep”) on a scale from 0 (not at all)
to 4 (extremely). The IES-R has extensively been
used in clinical and nonclinical populations and
591
shows good psychometric properties (Creamer,
Bell, & Failla, 2003; Weiss, 2004). Based on an
explicit decision by the test authors (see Weiss,
2004), no norms or clinical cutoff scores are
available for the IES-R. However, the test authors
suggest comparing mean scores to the anchor
points of the response scale (e.g., 0 = not at all;
2 = moderate; 4 = extremely) when interpreting the
IES-R results.
Characteristics of Emotion Regulation
A number of questionnaires were used to assess
characteristics of emotion regulation.
Self-reported emotion regulation difficulties were
assessed with the Difficulties in Emotion Regulation
Scale (DERS; Gratz & Roemer, 2004). Six subscale
scores can be computed from the 36 items:
Nonacceptance of Emotions (6 items; e.g., “When
I'm upset, I feel guilty for feeling that way”; α = .90);
Difficulties Engaging in Goal-Directed Behavior
When Distressed (5 items; e.g., “When I'm upset, I
have difficulty getting work done”; α = .91); Im-
pulse Control Difficulties (6 items; e.g., “When I'm
upset, I become out of control”; α = .91); Lack of
Emotional Awareness (6 items; e.g., “I pay atten-
tion to how I feel” [reversed]; α = .82); Limited
Access to Emotion Regulation Strategies' (8 items;
“When I'm upset, I believe that there is nothing I
can do to make myself feel better.”; α = .93); and
Lack of Emotional Clarity (5 items; “I am confused
about how I feel”; α = .90). Participants rate each
item on a scale from 1 (almost never, 0 − 10%) to 5
(almost always, 91 − 100%). Earlier research has
shown good psychometric properties for the scale
(Gratz & Roemer, 2004).
In addition, participants filled in the Emotion
Regulation Questionnaire (ERQ; Gross & John,
2003). The ERQ assesses the typical use of emotion
suppression (4 items, e.g., “I keep my emotions to
myself”) and reappraisal (6 items, e.g., “When I
want to feel less negative emotion, I change the way
I'm thinking about the situation”). Each item is
rated on a scale from 1 (strongly disagree) to 7
(strongly agree). The scale has been shown to
possess good psychometric properties (Gross &
John, 2003). Internal consistencies in the current
study were good (emotion suppression: α = .81;
reappraisal: α = .87). There is correlational as well
as experimental evidence supporting the classifica-
tion of emotion suppression as a primarily dys-
functional emotion regulation strategy and
reappraisal as a primarily functional one (Gross,
2002; Gross & John, 2003).
Experiential avoidance was assessed with the
Acceptance and Action Questionnaire (AAQ;
Hayes et al., 2004). The 9-item self-report
 Author's personal copy
592 ehring & quack
questionnaire measures the tendency to negatively
evaluate unpleasant feelings, thoughts and sensa-
tions, and unwillingness to tolerate these private
events and attempts to suppress or escape them
(example items: “Anxiety is bad”; “If I could
magically remove all the painful experiences I've
had in my life, I would do so”). Participants are
asked to rate each item on a scale from 1 (never
true) to 7 (always true). Acceptable to good
psychometric properties have been found in earlier
research using the measure (Hayes et al., 2004; α in
this sample: .71).
procedure
The study was conducted by means of a web-based,
secured and encrypted survey, using the Unipark
platform (www.unipark.com). When following the
link to the study, participants accessed a welcome
page. On this page, respondents were briefed about
the survey (Title: “Dealing with Emotions”). They
were told that the study aimed to investigate how
people deal with their emotions and how this is
related to negative life experiences. They were
informed that part of the questionnaire would be
about traumatic experiences they may have had, and
it was emphasized that participation was voluntary,
that they could stop filling in the survey at any point
and that the data would remain anonymous. At the
end of the welcome page, participants were explicitly
asked to indicate whether they wanted to participate
in the study or not. Participants could give their
informed consent by clicking on “yes.”
The questionnaires were then presented in the
following order: AAQ, DERS, ERQ, THQ, IES-R,
and a questionnaire asking participants to provide
demographic data. The closing page of the survey
thanked participants and gave them the opportunity
to leave a comment for the investigators. In addition,
the first author's contact details were provided in
case participants had further questions or comments
related to the study or felt distressed by it.
statistical analyses
The emotion regulation variables assessed were
divided into four groups, following Gratz and
Roemer's (2004) model: (a) awareness and clarity
(DERS subscales: Lack of Emotional Awareness
and Lack of Clarity); (b) acceptance (DERS
subscale: Nonacceptance; AAQ total score; ERQ
subscale: Emotion Suppression); (c) difficulties with
goal-directed behavior and impulse control (DERS
subscales: Difficulties Engaging in Goal-Directed
Behavior and Impulse Control Difficulties); and (d)
strategy use (DERS subscale: Limited Access to
Strategies; ERQ subscale: Reappraisal).
Associations between emotion regulation difficul-
ties and PTSD symptom severity (Hypothesis 1) were
assessed using Pearson product-moment correlations.
In order to test differences in emotion regulation
between the different trauma groups (Hypothesis 2),
separate MANOVAs were carried out for each of the
four groups of emotion regulation variables. Signif-
icant main effects of trauma type were then followed
up by separate ANOVAs for each variable and
planned simple contrasts comparing each trauma
group with the early chronic interpersonal group.
Similarly, MANCOVAs with the IES-R score as the
covariate were conducted to test Hypothesis 3,
followed by ANCOVAs and simple contrasts.
Power analyses for the MANOVAs and follow-
up ANOVAs based on α = .05 and N = 616 partici-
pants revealed high power (N.99) to detect a
moderate effect size (f 2 = .25).
Results
preliminary analysis: group differences on
demographic variables
Before testing the hypotheses, we first checked
whether the groups differed on any demographic
variables. As shown in Table 1, no difference in age,
marital status, or employment between the groups
emerged. However, the rate of female participants
was higher in the interpersonal trauma groups than
the noninterpersonal trauma group. As would be
expected, the groups also differed regarding the
severity of PTSD symptoms assessed with the IES-
R. Survivors of early chronic interpersonal trauma
showed the highest IES-R mean scores (between
anchor points quite a bit and extremely), followed
by early single interpersonal and late interpersonal
trauma survivors (between anchor points moder-
ately and quite a bit), and noninterpersonal trauma
survivors showed the lowest scores (between
anchor points a little bit and moderately).
hypothesis 1: relationship between
emotion regulation difficulties and
ptsd symptom severity
Correlations between the different emotion regula-
tion scores and PTSD symptom severity are shown
in Table 2. In line with Hypothesis 1, IES-R scores
showed significant correlations with all indices of
emotion regulation difficulties in the expected
direction.
hypothesis 2: differences in emotion
regulation according to trauma type
As shown in Table 3, results of MANOVAs showed
significant main effects of trauma type for all four
groups of emotion regulation variables. Follow-up
 Author's personal copy

emotion regulation in trauma survivors 593

Table 2
Pearson Correlations between PTSD Symptom Severity and Characteristics of Emotion Regulation
Variable 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
1. IES-R −

Awareness and Clarity

2. DERS − lack of awareness .34⁎⁎ −
3. DERS − lack of clarity .48⁎⁎ .55⁎⁎ −

Acceptance
4. DERS − non-acceptance .48⁎⁎ .40⁎⁎ .61⁎⁎ −
5. AAQ − experiential avoidance .49⁎⁎ .41⁎⁎ .62⁎⁎ .61⁎⁎ −
6. ERQ − emotion suppression .36⁎⁎ .46⁎⁎ .46⁎⁎ .44⁎⁎ .35⁎⁎ − -

Difficulties with goal-directed behavior and impulse control

6. DERS − goal-directed behavior .49⁎⁎ .34⁎ .59⁎⁎ .57⁎⁎ .70⁎⁎ .33⁎⁎ −
7. DERS − impulse control difficulties .49⁎⁎ .36⁎⁎ .60⁎⁎ .58⁎⁎ .65⁎⁎ .28⁎⁎ .76⁎⁎ −

Strategy Use
8. DERS − limited access to strategies .52⁎⁎ .42⁎⁎ .66⁎⁎ .72⁎⁎ .74⁎⁎ .42⁎⁎ .77⁎⁎ .74⁎⁎ −
10. ERQ − reappraisal -.23⁎⁎ -.38⁎⁎ -.39⁎⁎ -.25⁎⁎ -.45⁎⁎ -.15⁎⁎ -.44⁎⁎ -.42⁎⁎ -.50⁎⁎ −
Note. IES-R = Impact of Event Scale−Revised; DERS = Difficulties in Emotion Regulation Scale; ERQ = Emotion Regulation Questionnaire;
AAQ = Acceptance and Action Questionnaire.
⁎ p b .01.
⁎⁎ p b .001.

Table 3
Characteristics of Emotion Regulation by Trauma Type
Non- Late Early single Early chronic (M)ANOVA (M)ANCOVA
interpersonal interpersonal interpersonal interpersonal
F(6, 1224)a η2 F(10, 1530)a η2
(n = 135) (n = 211) (n = 101) (n = 169)
or F(3, 612) or F(5, 766)
M (SD) M (SD) M (SD) M (SD)
Awareness and Clarity 16.23⁎⁎ .07 3.93⁎⁎ .02
DERS − lack of awareness 16.33 (4.50)c 17.32 (5.20)c 17.51 (5.49)c 19.53 (5.54) 10.53⁎⁎ .05 1.19 .01
DERS − lack of clarity 11.40 (4.79)b 13.52 (5.18)b 13.99 (5.12)b 17.24 (5.16) 35.08⁎⁎ .15 7.69⁎⁎ .04

Acceptance 8.82⁎⁎ .04 1.21 .01

DERS − non-acceptance 13.78 (5.88)c 16.76 (6.66)c 17.31 (6.65)c 19.83 (6.51) 22.21⁎⁎ .10 N/A
AAQ − experiential avoidance 35.60 (7.74)c 37.96 (8.63)c 39.43 (7.82)c 42.54 (7.72) 20.10⁎⁎ .09 N/A
ERQ − emotion suppression 13.24 (5.69)c 14.33 (6.34)c 14.40 (6.75)c 16.57 (6.20) 7.86⁎⁎ .04 N/A

Difficulties with goal-directed behavior and impulse control 14.03⁎⁎ .06 2.29⁎ .01
DERS − goal-directed behavior 13.72 (5.13)b 15.35 (5.61)b 16.98 (5.03)c 18.75 (4.96) 26.08⁎⁎ .11 4.09⁎ .02
DERS − impulse control difficulties 12.65 (5.56)c 14.98 (6.20)c 16.05 (6.22)c 18.67 (6.85) 24.41⁎⁎ .11 2.51 .01

Strategy Use 13.19⁎⁎ .06 2.09 .01

DERS − limited access 18.81 (8.31)c 23.05 (8.75)c 25.35 (9.29)c 27.43 (7.37) 28.11⁎⁎ .12 N/A
to strategies
ERQ − reappraisal 25.86 (7.37)c 24.24 (8.07)c 23.14 (8.23) 22.04 (8.30) 6.14⁎ .03 N/A
PANAS = Positive and Negative Affect Schedule; DERS = Difficulties in Emotion Regulation Scale; AAQ = Acceptance and Action
Questionnaire; ERQ = Emotion Regulation Questionnaire.
a
Pillai's Trace; N/A: ANCOVA not computed because of nonsignificant MANCOVA.
b
Significant contrast between this group and early-onset chronic interpersonal trauma group in both ANOVA and ANCOVA controlling for
IES-R scores.
c
Significant contrast between this group and early-onset chronic interpersonal trauma group in ANOVA, but not significant in ANCOVA
controlling for IES-R scores.
⁎ p b .01.
⁎⁎ p b .001.
 Author's personal copy
594 ehring & quack
ANOVAs revealed significant main effects of
trauma type on all emotion regulation variables.
In line with Hypothesis 2, simple contrasts com-
paring all groups to the last one showed that
survivors of early-onset chronic interpersonal
trauma reported significantly higher emotion regu-
lation difficulties than all other groups for almost
all variables. Only one contrast was nonsignificant,
showing that survivors of early-onset chronic
interpersonal trauma did not differ from survivors
of early-onset single interpersonal traumas regard-
ing their reappraisal scores.
hypothesis 3: group differences when
controlling for ptsd symptom severity
According to Hypothesis 3, we expected that
survivors of early-onset interpersonal trauma would
still show higher scores on measures of emotion
regulation difficulties when PTSD symptom severity
is controlled for. In contrast to the hypothesis, two of
the four MANCOVAs conducted were nonsignifi-
cant, indicating that the different groups of trauma
survivors did not differ regarding their acceptance of
negative emotions as well as strategy use when
symptom levels of PTSD were controlled. However,
significant main effects remained in the MANOVAs
for Awareness and Clarity and Difficulties With
Goal-Directed Behavior and Impulse Control. Fol-
low-up ANCOVAs showed that the DERS subscale
Lack of Clarity was the only emotion regulation
variable for which survivors of early chronic
interpersonal trauma remained to show higher scores
than all other trauma groups. On the DERS subscale
Difficulties Engaging in Goal-Directed Behavior,
survivors of early chronic interpersonal trauma still
reported higher levels than survivors of noninterper-
sonal and late-onset interpersonal traumas, but did
not differ from early-onset single interpersonal
trauma survivors.
testing the robustness of the findings
In order to test the robustness of the findings, we
repeated the analyses with slight variations. First,
we combined all survivors of early-onset interper-
sonal trauma to one group, regardless of whether
the event met criteria for chronic trauma or not.
This did not change the results.
Second, as the proportion of females was
significantly higher for the early-onset groups
than the late-onset groups, we reran all analyses
for female participants only. 1 All correlations
1
The number of male participants in our sample was rather low.
Therefore, controlling for sex by entering this as an additional factor
in the analyses would have resulted in too small a sample size.
between emotion regulation variables and PTSD
symptom severity remained significant. In addition,
the same pattern of group differences were found as
in the total sample, although some simple contrasts
failed to reach significance. As the trauma groups
still significantly differed regarding their IES-R
scores, the (M)ANCOVAs controlling for PTSD
symptom severity were also repeated for female
participants only. When controlling for IES-R
scores, Clarity of Negative Emotions was the only
remaining variable for which significant group
differences were found.
dropout analysis
A set of t tests was conducted comparing partici-
pants with complete data (n = 616) with those who
did not complete the whole online questionnaire.
Data for the latter group were available for the
AAQ (n = 800), the DERS (396 b n b 745 for the
different subscales) and the ERQ (n = 308). Partici-
pants with complete data reported significantly
higher emotion regulation difficulties on the AAQ
and the DERS than participants who dropped out,
all t's N 2.3, all p's b .01. No significant difference
emerged for the ERQ subscales, both t's b 1.7, both
p's b .09.
Discussion
The aim of the current study was to investigate the
role of trauma type and PTSD symptom severity in
emotion regulation difficulties experienced by
trauma survivors. In line with the first hypothesis,
significant correlations between all emotion regu-
lation variables and PTSD symptom severity were
found. Symptom levels of PTSD were related to (a)
reduced levels of clarity and awareness of emotion;
(b) low levels of acceptance of negative emotions,
higher levels of experiential avoidance, and higher
levels of emotion suppression; (c) difficulties
engaging in goal-directed behavior when distressed
and high levels of impulse control difficulties; and
(d) impaired use of functional emotion regulation
strategies, including low levels of reappraisal. These
findings were found to be robust and still held when
looking at female participants only. The results
replicate a series of earlier findings (e.g., Morina et
al., 2008; Moore et al., 2008; Tull, Barrett, et al.,
2007) and are consistent with the view that
successful recovery from trauma requires adaptive
emotion regulation and that therefore difficulties in
emotion regulation are a risk factor for the
development and/or maintenance of the disorder.
However, in the absence of prospective studies,
the causal nature of the association remains unclear
as self-reported difficulties to regulate one's
 Author's personal copy
emotion regulation in trauma survivors
emotions could also be the consequence of having
the disorder.
It has been suggested that emotion regulation
difficulties are particularly prominent in survivors
of early-onset chronic interpersonal trauma, such as
childhood sexual or physical abuse by caregivers.
The second aim of this study was to test this
hypothesis by comparing survivors of early-onset
chronic interpersonal trauma with survivors of late-
onset, noninterpersonal and/or nonchronic
traumas. In line with our second hypothesis,
significant group differences emerged for all vari-
ables assessing characteristics of emotion regula-
tion. Simple contrasts confirmed the expected
pattern of group differences for all variables.
Survivors of early-onset chronic interpersonal
trauma did not only report higher emotion regula-
tion difficulties than nontraumatized controls, but
also higher difficulties than survivors of late-onset
traumas, early-onset noninterpersonal traumas,
and nonchronic early-onset interpersonal traumas.
This finding is in line with a small number of earlier
studies (Briere & Rickards, 2007; Cloitre et al.,
1997; van der Kolk et al., 1996). It can be seen as
support for the idea that high levels of emotion
regulation difficulties are specific for survivors of
early-onset chronic interpersonal trauma and are
part of the complex pattern of posttrauma sequelae
found in this population (see Cloitre et al., 2005;
van der Kolk, 2005; van der Kolk et al., 1996).
However, because of the strong association be-
tween PTSD symptom severity and emotion regu-
lation difficulties, this finding could also simply be
due to higher levels of PTSD in survivors of early-
onset chronic interpersonal trauma. It therefore
appears important to test whether the group
differences hold when controlling for symptom
levels of PTSD. Our results showed that the
expected group differences only remained signifi-
cant for two variables: Lack of Emotional Clarity
and Difficulties Engaging in Goal-Directed Behav-
ior. However, group differences for the latter
variable ceased to be significant when looking at
female participants only.
The finding that group differences disappeared
for most emotion regulation variables when con-
trolling for levels of PTSD may be interpreted as
evidence against the idea that emotion regulation
difficulties are a specific feature of early-onset
chronic interpersonal trauma. According to this
interpretation, the fact that survivors of early-onset
chronic interpersonal trauma showed higher scores
on emotion regulation variables than survivors of
other types of traumatic events could be seen as
primarily the consequence of higher levels of PTSD
in this group. The two variables ‘lack of emotional
595
clarity' and ‘difficulties engaging in goal-directed
behavior' form an interesting exception as survivors
early-onset chronic interpersonal trauma showed
heightened scores on these variables independent of
levels of PTSD.
However, alternative explanations for this pat-
tern of findings are also conceivable. First, if early
chronic interpersonal trauma leads to impaired
emotion regulation and if emotion regulation
difficulties in turn are a risk factor for PTSD, one
would expect PTSD symptom severity as well as
emotion regulation difficulties to be highest in the
early chronic interpersonal trauma group as found
in the current study. A strong association between
all three variables may then conceal a true
association between trauma type and emotion
regulation difficulties when controlling for PTSD.
Second, there may be some construct overlap
between the measures of PTSD symptom severity
and emotion regulation difficulties, such as avoid-
ance of negative affect and lack of ability to self-
soothe, which may have artificially increased the
effect of the IES-R as a covariate. Third, the results
may suggest that rather than being part of a
syndrome of complex PTSD, emotion regulation
difficulties could be a common feature of PTSD
following any type of traumatic event.
The design of the current study does not allow a
decision between these alternative explanations.
However, the findings suggest a number of
promising avenues for future research. First, the
simultaneous consideration of trauma type and
PTSD symptom severity are a strength of the
current study. Our results suggest that it is
necessary to also measure PTSD symptom severity
when investigating the influence of trauma type on
emotion regulation and vice versa. Using groups
matched by PTSD symptom severity or, ideally, a
prospective longitudinal design could then help to
directly test the different ideas presented above.
Second, emotion regulation is a very broad
concept and has been operationalized in very
different ways in past research. Results of the
current study, in which different facets of the
concept were assessed, showed that PTSD symptom
severity was broadly related to all emotion regula-
tion variables and this remained significant when
controlling for type of trauma. On the other hand, a
specific association between early-onset chronic
interpersonal trauma and emotion regulation was
only found for emotional clarity and difficulties
engaging in goal-directed behavior when control-
ling for levels of PTSD. In future research, theory-
driven predictions should be tested as to which
specific aspects of emotion regulation are expected
to be impaired as a consequence of early-onset
 Author's personal copy
596 ehring & quack
chronic interpersonal trauma rather than treating
emotion regulation as a unitary phenomenon. As in
most earlier research, only self-report measures of
emotion regulation were included in the current
study, which is a clear limitation. Future research
should include more objective measures of emotion
regulation and/or experimental designs.
Third, the strong and robust association with
PTSD symptom severity raises the question as to
whether emotion regulation difficulties reported by
trauma survivors should best be conceptualized as
broad deficits of regulating negative emotional
states in general or as specific deficits in regulating
negative emotions triggered by trauma reminders as
reflected in the PTSD diagnostic criteria. These
alternative hypotheses could best be tested in
experimental designs using emotion-eliciting stim-
uli that differ regarding their trauma-relatedness.
Fourth, it is unclear whether different types of
early-onset chronic interpersonal trauma are differ-
ently associated with emotion regulation difficul-
ties. Future research investigating this issue should
not only focus on physical and sexual abuse but
also include emotional abuse and neglect, which
were not assessed in the current study but have been
found to be related to emotion regulation difficul-
ties and symptom levels of PTSD in recent research
(e.g., Briere & Rickards, 2007).
Fifth, the relationship between type of trauma,
PTSD, and emotion regulation difficulties is not
only of theoretical interest, but may also have
important clinical implications if replicated in future
research. Based on the view that pronounced
emotion regulation difficulties are a specific feature
of complex symptoms that develop after early-onset
chronic interpersonal trauma, a number of authors
have suggested that these emotion regulation
difficulties should be addressed in treatment before
using trauma-focused strategies such as prolonged
imaginal exposure (Cloitre et al., 2002; Wolfsdorf
& Zlotnick, 2001). However, it remains controver-
sial whether this phase-based approach is indeed
necessary (for a discussion of this issue, see Cahill,
Zoellner, Feeny, & Riggs, 2004; Cloitre, Stovall-
McClough, & Levitt, 2004). The design of the
current study does not allow drawing conclusions
regarding this issue. Instead, research directly
examining the effects of skilled-based versus trau-
ma-focused techniques on emotion regulation and
PTSD symptom severity in survivors of early-onset
chronic interpersonal trauma is needed to resolve
this controversy. In addition, future research should
also test the idea that emotion regulation difficulties
may be a feature of PTSD in general and that
individuals with this disorder following all types of
traumatic events may benefit from the integration of
emotion regulation interventions into standard
treatment.
Finally, a number of methodological limitations of
the current study bear noting. Some of these limita-
tions are related to the fact that all measures were
assessed via a web-based survey. Web-based studies
are related to reduced control over who participates
and how participants fill in the measures. However, it
is reassuring that studies directly comparing web-
based versus paper-and-pencil surveys found both
types of research to be equally reliable (Fortson et al.,
2006; Nosek et al., 2002). Nevertheless, the high
number of participants not completing the survey is
an important challenge in web-based research. Given
the population and topic of the current study, a high
dropout rate was predictable. Only 40% of partici-
pants agreeing to take part completed all question-
naires and results of dropout analyses showed that
completers showed higher levels of emotion regula-
tion difficulties than noncompleters. As the high
dropout may limit the generalizability of the findings,
future studies should take measures aiming to reduce
dropout and should ideally test representative samples
of trauma survivors.
An additional limitation of the current study
concerns the fact that a nonclinical sample was
tested and we did not assess how many participants
were in need of treatment for their symptoms and/
or had already received treatment. Furthermore,
PTSD was assessed with a self-report questionnaire
only, which did not allow establishing a diagnosis
of PTSD. In addition, comorbid symptoms or
diagnoses were not measured. The characterization
of the current sample in terms of symptom severity
is complicated by the fact that no norms or clinical
cutoff scores are available for the IES-R (Weiss,
2004). However, IES-R scores for survivors of late-
onset trauma are comparable to earlier studies
testing community samples of Type-I trauma
survivors (e.g., Beck et al., 2008; Creamer et al.,
2003; King et al., 2009). Similarly, IES-R scores for
survivors of early-onset interpersonal trauma are
comparable to those reported in earlier studies on
adult survivors of childhood abuse (e.g., Paivio,
Holowaty, & Hall, 2004; Shakespeare-Finch & de
Dassel, 2009). Nevertheless, future research is
needed to investigate whether the findings can be
replicated in clinical samples with diagnoses estab-
lished by structured clinical interviews.
Despite these limitations, the results of the current
study emphasize the need to simultaneously consid-
er type of trauma and PTSD symptom severity when
investigating emotion regulation in trauma survi-
vors. The findings support a strong association
between PTSD and emotion regulation difficulties
and suggest new avenues for future research into
 Author's personal copy
emotion regulation in trauma survivors
emotion regulation deficits as specific sequelae of
early-onset chronic interpersonal trauma.
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R E C E I V E D : September 12, 2009
A C C E P T E D : April 13, 2010
Available online 30 June 2010