Shared Pathogeneses of Posttrauma Pathologies: Attachment,

Emotion Regulation, and Cognitions

Michelle M. Lilly and Ban Hong (Phylice) Lim
Northern Illinois University DeKalb, IL
Objective: To demonstrate how intrapersonal functioning variables related to attachment, cogni-
tion, and emotion are implicated in mental health outcomes for two samples of interpersonal trauma
survivors, including undergraduates and women from the community. Method: Two samples of
survivors of interpersonal trauma were included: undergraduates (n = 290, 60% female) and intimate
partner violence survivors from the community (n = 114). Participants completed self-report measures
that assessed psychopathology, emotion dysregulation, attachment processes, and cognitions about
the world, self, and others. Results: Emotion dysregulation was strongly linked to symptoms
of depression, posttraumatic stress disorder, and somatization in both samples. Cognitions also ac-
counted for unique variance in predicting symptoms of depression and somatization in both samples.
Conclusions: Results suggest that disruption in the ability to regulate emotions is the most consis-
tent predictor of mental health in survivors of interpersonal trauma, followed by cognitions regarding
the world, self, and others. Treatment implications are discussed.  C 2012 Wiley Periodicals, Inc. J.

Clin. Psychol. 69:737–748, 2013.

Keywords: interpersonal trauma; psychopathology; emotion; attachment; cognition

Interpersonal trauma exposure, or trauma that is induced by other individuals such as childhood
abuse or intimate partner violence (IPV), has been linked to disrupted functioning in survivors’
attachment style (Flanagan & Furman, 2000; Koss, Dinero, Seibel, & Cox, 1998; Muller, Sicoli, &
Lemieux, 2000; Roche, Runtz, & Hunter, 1999), emotion regulation (Cloitre, Miranda, Stovall-
McClough, & Han, 2005), and cognitions (Janoff-Bulman, 1992; Resick & Schnicke, 2006).
Further, disruptions in these areas of intrapersonal functioning have been shown to increase
risk for posttrauma psychopathology (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Bifulco,
Moran, & Lillie, 2002; Waldinger, Schulz, Barsky, & Ahern, 2006), thus they can be considered
posttrauma pathogeneses. The present study examines the relations between these areas of
functioning and common posttrauma mental health symptoms in undergraduate interpersonal
trauma survivors and survivors of IPV.
The theory of attachment (Bowlby, 1969/1982) describes an innate behavioral system that
motivates humans to develop a strong emotional bond with their primary caregiver for security
and protection. The relationship that develops between infant and caregiver results in an internal
working model of self and others that guides the growing infant in subsequent interpersonal
interactions. Early exposure to interpersonal trauma, however, can result in disrupted attachment
processes. Adult survivors of sexual abuse, for example, tend to be insecure in their attachment
to romantic partners (Flanagan & Furman, 2000; Koss, Dinero, Seibel, & Cox, 1998) and
survivors of interpersonal trauma, whether exposure occurred in childhood or adulthood, have
been shown to display an impaired attachment style (Muller, Sicoli, & Lemieux, 2000; Roche,
Runtz, & Hunter, 1999).
Another area of intrapersonal functioning that has been implicated in posttrauma reactions
is emotion regulation, which involves coping with and modulating negative emotions. Labile
emotional arousal experienced during and immediately following a traumatic experience can
compromise one’s ability to regulate emotional reactions, resulting in a tendency to respond with

Please address correspondence to: Michelle M. Lilly, Northern Illinois University, DeKalb, IL 60115. E-mail:
mlilly1@niu.edu

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 69(7), 737–748 (2013) 

C 2012 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.21934

738 Journal of Clinical Psychology, July 2013

inappropriate emotions during normal circumstances (Cloitre, Miranda, Stovall-McClough, &

Han, 2005). Interpersonally, emotion dysregulation can take the form of anger and/or hostility,
including intimate partner aggression (Jakupcak & Tull, 2005), and even engagement in de-
liberate self-harm as a maladaptive emotion regulatory technique (Yates, Carlson, & Egeland,
2008).
Cognitions have also garnered significant attention because of their role in posttrauma re-
actions. Exposure to interpersonal trauma has been found to engender profound disruptions
in one’s fundamental, cognitive assumptions of the world, the self, and others. Assumptive
worldviews–that the world is benevolent and meaningful, and that misfortune is least likely to
strike moral and worthy people, including themselves–are intended to help us navigate social
interactions with a sense of agency and security (Janoff-Bulman, 1992). However, this “illu-
sion of invulnerability” can be shattered when one is confronted by trauma at the hands of
another person, making survivors question the cognitive framework they previously held. Many
interpersonal trauma survivors develop negative worldviews, believing that the world is cruel
and meaningless, that others are malevolent, and that the self is to blame for adversity (Janoff-
Bulman, 1992).
Though the association between exposure to interpersonal trauma and each of the pathogene-
ses has been amply documented, research has also highlighted the strong interrelations between
attachment, emotion regulation, and cognitions. Secure attachment, for example, is theorized
to foster growth in the areas of emotion regulation, cognition, behavior, and personality, all of
which are important in determining one’s mental health and wellbeing (Bowlby, 1969/1982). In
addition, a unified view of emotional and cognitive processes has been postulated in integrative
information processing models of functioning (e.g., Lang, 1983), as well as seminal trauma-
related treatment paradigms that were developed based on emotional (Foa & Kozak, 1986) and
cognitive (Resick & Schnicke, 1992) theories.
As such, that each of these pathogeneses is implicated in postinterpersonal trauma psy-
chopathologies, including symptoms of posttraumatic stress, depression, and somatization, is
unsurprising. Given that mental representations of self and others strongly determine one’s
subsequent mental health, attachment disruption is likely a common mechanism through which
trauma exposure affects the development of posttrauma psychopathologies (Massie & Sza-
jnberg, 2006). Having an insecure attachment has been found to increase considerably one’s
lifelong risk for symptoms of depression (Bifulco, Moran, & Lillie, 2002), posttraumatic stress
(Stovall-McClough & Cloitre, 2006), and somatization (Waldinger, Schulz, Barsky, & Ahern,
2006). Meta-analytic reviews have also found a large effect size for the implication of emotion
dysregulation in psychological disorders, including depressive and posttraumatic stress symp-
toms (Aldao, Nolen-Hoeksema, & Schweizer, 2010; Frewen, Dozois, Neufeld, & Lanius, 2008).
Emotion dysregulation has also been implicated in the development of somatic disorders (Waller
& Scheidt, 2006). Likewise, cognitive distortions are said to underlie most psychopathologies,
rendering this entity among the most common focus for psychotherapeutic intervention (e.g.,
Ellis, 1962). While posttraumatic stress symptoms remain the most widespread outcome for
interpersonal trauma survivors who experience cognitive distortions (Brewin & Holmes, 2003;
Ehlers & Clark, 2000), cognitive distortions are also highly associated with depressive symptoms
(Coyne & Gotlib, 1983) and somatization symptoms (Rief, Hiller, & Margraf, 1998).
Considering that the development of these disorders can be attributed to disruptions in at-
tachment, emotion regulation, and cognitions, they may each be considered the pathogeneses
through which the etiological agent of interpersonal trauma exposure leads to psychopathology
across several diagnostic categories. The presence of comorbidity among these psychopatholo-
gies is also highly prevalent (McLean & Gallop, 2003). An epidemiology study found that 88.3%
of men and 79% of women who have a history of posttraumatic stress also met criteria for at least
one additional mental disorder (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Arousal,
reactivity, and avoidance are key symptoms not only in posttraumatic stress, but also in several
other disorders prevalent in trauma survivors, including depression (Keane, Wolfe, & Taylor,
1987), questioning whether separate diagnostic labels are truly necessary. Collectively, this indi-
cates that the pathologies may not be entirely distinct from one another and share underlying
vulnerabilities that may be captured by the pathogeneses outlined. Nevertheless, related research
 Posttrauma Pathogeneses 739

has been scant because extant literature on etiology and treatment outcomes has focused pre-
dominantly on one area of functioning (e.g., emotion dysregulation) and/or one mental health
outcome (e.g., posttraumatic stress), failing to consider the high interrelatedness between the
pathogeneses and between the categories of psychopathology. If the onset and prognosis of
depression, somatization, and posttraumatic stress symptomatology can indeed be attributed
to shared, underlying vulnerabilities, these psychopathologies may be better constructed as a
general traumatic stress sequalae with implications for intervention.
Correspondingly, this study aims to identify areas of impaired functioning following in-
terpersonal trauma exposure (i.e., attachment difficulties, emotion dysregulation, and world
assumptions) and how they relate to pathological symptoms. The following hypotheses were
proposed: (a) the various areas of intrapersonal functioning (i.e., attachment, emotion regula-
tion, and world assumptions) will be correlated; (b) the mental health outcomes associated with
trauma exposure (i.e., posttraumatic stress, depression, and somatization symptoms) will be cor-
related; (c) and, last, disruptions in attachment, emotion regulation, and world assumptions will
independently predict symptoms of posttraumatic stress, depression, and somatization. These
hypotheses are tested using two subsamples of interpersonal trauma survivors (undergraduates
and IPV survivors) that differ significantly in age, ethnicity, and extent of interpersonal trauma
exposure.

Methods
Participants and Procedure
Participants included an undergraduate subsample and an IPV survivors subsample from the
community. The undergraduate sample was recruited from a mid-sized university (approxi-
mately 17,000 undergraduate students) in the Midwest region of the United States, while the
IPV survivors were recruited from the local community surrounding the same university. Under-
graduates completed the survey online and received credit toward an introductory psychology
course. Informed consent was presented electronically at the start of the survey and participants
were provided with an electronic debriefing form at the completion of the survey. The debriefing
form provided basic information regarding the purpose of the study and a list of affordable com-
munity resources in the event that they experienced lingering distress. Survey completion took
approximately 45 to 60 minutes. For the purposes of this study, only participants that endorsed
having experienced at least one interpersonal trauma in their lifetime were included in analyses.
IPV survivors were recruited from the community using newspaper advertisements, fliers at
local grocery stores and laundromats, and local domestic violence and homeless shelters. IPV
participants were asked to complete an onsite interview. The first half of the interview involved
completion of self-report measures, while the second half included a qualitative interview. An
informed consent document was presented prior to completion of the self-report measures and
a debriefing form was provided upon completion of the qualitative interview. The debriefing
form provided information regarding the aims of the study and a list of affordable community
resources. Only responses from the self-report questionnaires were used for the purposes of this
study. Participants were paid $50 for their time and transportation and childcare were provided
if needed. No adverse events were reported during data collection with either the undergraduate
or IPV subsamples.
The undergraduate subsample (n = 290) had an average age of 19.77 (standard deviation
[SD] = 3.61) and was majority female (n = 174, 60.0%). The majority of the students were in
their first (freshman) or second year (sophomore) of college (n = 243, 83.8%) and self-identified
as European American (n = 187, 64.5%). Of the remaining undergraduates, 15.5% (n = 45)
self-identified as African American, 5.5% (n = 16) as Hispanic, 4.5% (n = 13) as Asian or Asian
American, 5.5% (n = 16) as biracial, and 6.6% (n = 16) selected either “other” or “skip this
question.” The IPV survivors (n = 114) had an average age of 29.57 (SD = 9.95) and were all
female. The majority of IPV survivors were African American (n = 68, 60.2%), followed by
European American (n = 30, 26.5%), biracial (n = 10, 8.8%), Hispanic (n = 3, 2.7%), and other
(n = 2, 1.8%). The majority of the IPV survivors had a high school degree and/or some college
740 Journal of Clinical Psychology, July 2013

(n = 82, 71.9%), though some participants had less than a high school degree (n = 15, 13.2%) or
a college or graduate school degree (n = 17, 14.9%). The IPV survivors had an average income of
$1,282 (SD = 4375) in the month preceding the interview. The IPV survivors in the sample were
significantly older than the undergraduates, t(399) = 14.48, p < .001, and a larger proportion of
IPV survivors identified as ethnic minority, χ2 (2) = 48.46, p < .001.

Measures
Demographics. Participants completed a short questionnaire that assessed basic demo-
graphic information such as age, ethnicity, gender (for the undergraduate sample only), and level
of education.

Attachment. The Experiences in Close Relationships Scale-Revised (ECR-R; Fraley,

Waller, & Brennan, 2000) was used to assess attachment problems. The ECR-R is a 36-item
measure that results in two scales: Anxious attachment and Avoidant attachment. Scores are
generated by averaging the responses of the 18 items per subscale. Respondents are asked to
answer the questions using a 7 point scale ranging from 1 (Not at all) to 7 (Extremely). Sample
items include “I’m afraid that I will lose my partner’s love” (anxious attachment) and “I prefer
not to show a partner how I feel deep down” (avoidant attachment). Research by Sibley and Liu
(2004) found that the ECR-R demonstrated strong test-retest reliability over a 6-week period.
The authors also used confirmatory factor analyses to support the presence of two constructs
(avoidance and anxiety) in an adult sample. Internal consistency for the anxious attachment
subscale was α = .93 for undergraduates and α = .89 for IPV survivors. Internal consistency for
the avoidant attachment subscale was α = .94 for undergraduates and α = .87 for IPV survivors.

Emotion regulation difficulties. The Difficulties in Emotion Regulation Scale (DERS;

Gratz & Roemer, 2004) is a 36-item scale that was used to evaluate emotion dysregulation.
Response options for the scale include Almost never (0–10%), Sometimes (11–35%), About half
the time (36–65%), Most of the time (66–90%), and Almost always (91–100%). A total emotion
regulation difficulties score was generated by reverse scoring specified items and summing all item
responses. Higher scores reflect greater deficits in the ability to regulate emotions. Sample items
include “I experience my emotions as overwhelming and out of control” and “I am clear about
my feelings” (reverse coded). In the original sample, Gratz and Roemer (2004) reported high
internal consistency (α = .93) and intra-subscale internal consistency that was in the acceptable
range (greater than .80). For undergraduates, the internal consistency was α = .88. For IPV
survivors, the internal consistency was α = .92.

World Assumptions scale (WAS). The WAS is a 32-item scale that measures partici-
pants’ assumptions about the meaningfulness of the world, the benevolence of the world, and
self-worth (Janoff-Bulman, 1989). Response options are on a 6-point scale from 1 (Strongly
disagree) to 6 (Strongly agree). Sample items include “There is more good than evil in the
world” and “People are naturally unfriendly and unkind.” A total score was generated by re-
verse scoring specified items and summing all responses. In the original sample, discriminant
analyses showed that responses discriminated between trauma survivors and those without a
trauma history. Research showed that the WAS accounted for 12% of the variability in fear of
intimacy scores, 4% of the variability in depression scores, and 41% of the variability in trauma
scores among undergraduate students (Harris & Valentiner, 2002). Internal consistency for the
undergraduates was α = .80 and α = .77 for IPV survivors in the present study.

Somatization. The somatization (SOM) subscale of the Symptom Checklist 90 – Revised

(SCL-90-R; Derogatis, 1994) was used to assess somatic complaints. The scale includes twelve
items that query respondents as to whether they have been bothered by somatization symptoms
in the previous week such as headaches, nausea, and muscle soreness. Response options are on a
5-point scale ranging from 0 (Not at all) to 4 (Extremely). The SOM subscale score is generated
by averaging the responses to the 12 subscale items. Higher scores reflect greater somatization.
 Posttrauma Pathogeneses 741

In previous research, the subscale has shown strong test-retest reliability (α = .85) and has
converged with other measures of somatization (Derogatis, 1994). Internal consistency for the
somatization subscale in this sample was α = .92 for the undergraduates and α = .91 for IPV
survivors.

Depression. The depression (DEP) subscale of the Symptom Checklist 90 – Revised (SCL-
90-R; Derogatis, 1994) was used to assess for the presence of depressive symptoms in the week
preceding data collection. The DEP subscale contains 13 items, and scores are generated by
averaging item responses. Response options are on a 5-point scale from 0 (Not at all) to 4
(Extremely). The DEP subscale demonstrated strong internal consistency (.90) and adequate
test-retest reliability (.75) across 10 weeks in symptomatic volunteers and strong internal con-
sistency (.90) and test-retest reliability (.82) across 1 week in psychiatric outpatients (Derogatis,
1994). The subscale has also converged with other measures of depressive symptoms. Internal
consistency for the undergraduates was α = .92 and α = .92 for IPV survivors.

Posttraumatic Stress Diagnostic (PDS) scale symptoms. The PDS (Foa, 1995) was
used to assess severity of posttraumatic stress symptoms in the last month. The scale asks
respondents to identify an index traumatic event that was considered the “worst” or one that
has “stuck with them.” Respondents are then asked whether they experienced symptoms of
posttraumatic stress in response to that event in the last month with response options of 0 (Not
at all or only one time), 1 (Once a week or less/once in awhile), 2 (2–4 times a week/half the
time), and 3 (5 or more times a week/almost always). A symptom score was created by tallying
the 17 symptom items, with higher scores indicating more posttraumatic stress symptoms.
The instrument has shown acceptable test-retest reliability for symptom severity score (83%)
and reliability for the measure was originally reported at .92. The internal consistency of the
symptom score for the undergraduates was α = .93 and α = .92 for IPV survivors.

Trauma exposure. The Traumatic Life Events Questionnaire (TLEQ; Kubany, 2004) as-
sessed respondents’ exposure to any of 23 different potentially traumatic events. Response
options include 0 (Never), 1 (Once), 2 (Twice), 3 (Three times), 4 (Four times), 5 (Five times),
and 6 (More than five times). In the present study, a total interpersonal trauma score was gen-
erated by tallying the responses to TLEQ items that assessed exposure to the following items:
robbed or present during a robbery (item 8), hit or beaten by a stranger or someone not known
very well (item 9), threatened to be killed or caused serious physical harm (item 11), physically
punished in a way growing up that resulted in bruises, etc. (item 12), slapped, punched, kicked
or beaten up by a partner (item 14), childhood sexual assault by person at least 5 years older
(item 15), childhood sexual assault by person approximately the same age (item 16), adolescent
sexual assault (item 17), adult sexual assault (item 18), and stalked (item 20). Items were chosen
because they represented events in which an individual experienced directly an assault from an-
other person, rather than events that had happened to others. Participants in the undergraduate
sample were only included in the present analysis if they reported exposure to at least one of the
above interpersonal traumatic events. Because IPV is considered an interpersonal trauma, all
participants in the IPV subsample were automatically included in the analyses. Kubany (2004)
showed the TLEQ to have strong test-retest reliability and convergent validity with measures of
PTSD.

Results
Participants in both samples had experienced a broad range of exposure to interpersonal trauma
(Table 1). In the undergraduate sample, participants reported having experienced an average of
5.07 (SD = 6.13) potentially traumatizing interpersonal experiences. Notably, however, 33.4%
(n = 97) of the undergraduate participants reported having experienced only one such event and
just over half of the subsample (50.3%, n = 146) reported having experienced two or fewer. As
expected, the number was much higher in IPV survivors, where the average number of potentially
traumatizing interpersonal events endorsed was 15.88 (SD = 11.93) and 50.9% (n = 58) of the
742 Journal of Clinical Psychology, July 2013

Table 1
Interpersonal Trauma Exposure for the Undergraduate (n = 290) and IPV (n = 114) Subsamples

Undergraduates (%) IPV (%)

Percent exposed Percent exposed
M (SD) M (SD)

Robbed or been present during a robbery where the robber 13.1% 24.3%
used or displayed a weapon
.17 (.52) .33 (.72)
Hit or beaten up and badly hurt by a stranger or by 13.8% 20.6%
someone you didn’t know very well
.20 (.66) .26 (.57)
Anyone threatened to kill you or cause serious physical harm 38.3% 46.7%
.66 (1.14) 1.46 (2.01)
While growing up were you physically punished in a way 20.3% 40.2%
that resulted in bruises, burns, cuts or broken bones
.61 (1.43) 1.86 (2.59)
Been slapped, punched, kicked, beaten up or otherwise 26.6% 100%
physically hurt by your spouse (or former spouse),
boyfriend/girlfriend, or some other intimate partner
.56 (1.22) 3.61 (2.11)
Before your 13th birthday did anyone – who was at least 5 11.0% 34.9%
years older than you – touch or fondle your body in a
sexual way or make you touch or fondle their body in a
sexual way
.32(1.01) 1.45 (2.34)
Before your 13th birthday did anyone close your age touch 15.9% 13.2%
sexual parts of your body or make you touch sexual parts
of their body against your will or without your consent
.23 (.83) .41 (1.26)
After your 13th birthday and before your 18th birthday did 13.8% 21%
anyone close your age touch sexual parts of your body or
make you touch sexual parts of their body against your
will or without your consent
.35 (1.04) .65 (1.56)
After your 18th birthday did anyone close your age touch 13.8% 19.8%
sexual parts of your body or make you touch sexual parts
of their body against your will or without your consent
.28 (.92) .44 (1.20)
Has anyone ever stalked you 22.8% 48.6%
.36 (.85) 1.34 (1.96)

Note. IPV = intimate partner violence; SD = standard deviation; M = mean.

sample reported having experienced at least 15 such events. As such, the extent of interpersonal
trauma exposure across groups can be considered quite disparate and was statistically significant
(t (401) = 12.16, p < .001). Table 2 reveals the mean and standard deviation for the variables of
interest in the study for both subsamples. Given the extent of trauma exposure in survivors of
IPV, it was not surprising that the IPV subsample reported significantly greater impairment in
regards to intrapersonal functioning and mental health than undergraduates across all variables,
with the exception of world assumptions. Contrary to expectations, IPV survivors in this study
reported world assumptions that were significantly more positive than undergraduate students.
To test the first two study hypotheses, that intrapersonal functioning variables and mental
health outcomes would be significantly related, correlation analyses were performed (Table 3).
As predicted, in the undergraduate sample, significant correlations were observed between all
intrapersonal functioning variables. World assumptions showed strong inverse correlations with
both anxious and avoidant attachment, suggesting that greater attachment difficulties were
associated with more negative assumptions about the world. A significant inverse correlation
was also observed between world assumptions and emotion regulation difficulties in the under-
graduate sample. A similar, though slightly different pattern emerged for IPV survivors. Like the
undergraduates, a strong positive relationship was observed between greater anxious attachment
 Posttrauma Pathogeneses 743

Table 2
Descriptive Information for Variables of Interest for Undergraduates (N = 290) and IPV Survivors
(N = 114)

Undergraduates IPV survivors

M SD M SD t, p

Anxious attachment 2.17 2.03 3.78 1.27 7.86, <.001

Avoidant attachment 1.88 1.79 3.88 1.11 11.10, <.001
Emotion regulation difficulties 50.00 42.03 72.51 20.54 8.27, <.001
World assumptions 77.91 63.43 121.86 16.14 7.30, <.001
Depressive symptoms .62 .83 1.17 .93 5.85, <.001
Posttraumatic stress symptoms 7.32 9.07 12.24 11.13 4.59, <.001
Somatization symptoms .48 .72 .93 .89 5.26, <.001

Note. IPV = intimate partner violence; SD = standard deviation; M = mean.

Table 3
Correlations Between Intrapersonal Functioning Variables and Mental Health Outcomes for
Undergraduates (N = 290) and IPV Survivors (N = 114)

1 2 3 4 5 6 7

1. Anxious attachment - .59*** .49*** −.38*** .54*** .18** .41***

2. Avoidant attachment .31** - .20** −.26*** .31*** .13* .28***
3. Emotion regulation difficulties .47*** .00 - −.13* .58*** .25*** .50***
4. World assumptions −.38*** −.33*** −.08 - −.30*** −.11 −.23***
5. Depression symptoms .52*** .18 .62*** −.33*** - .37*** .71***
6. Posttraumatic stress symptoms .39*** .05 .38*** −.09 .35*** - .38***
7. Somatization symptoms .42*** .10 .62*** −.25*** .79*** .37*** -

Note. IPV = intimate partner violence.

Undergraduates are represented in the top right of the matrix and IPV survivors are represented in the
bottom left of the matrix.
* p < .05. ** p < .01. *** p < .001.

and emotion regulation difficulties, while a strong inverse relationship was noted between world
assumptions and both anxious and avoidant attachment difficulties. Contrary to predictions,
emotion regulation difficulties were not significantly related to avoidant attachment or world
assumptions in IPV survivors.
As predicted, there were significant, positive correlations between trauma-related mental
health outcomes for both undergraduates and IPV survivors. These correlations ranged from r =
.37 (between posttraumatic stress and depression symptoms) and r = .71 (between depression and
somatization symptoms) for the undergraduates, and between r = .35 (between posttraumatic
stress and depression symptoms) and r = .79 (between depression and somatization symptoms)
for the IPV survivors. In fact, the correlations between depression and somatization symptoms
were so strong that the distinct nature of these disorders should be questioned. Though, given
that the items were different subscale on the same measure (SCL-90-R), it is possible that the
unusually high correlations could be due to shared response set variance.
A series of regression analyses were performed to examine the predictive ability of intrap-
ersonal functioning variables on mental health outcomes. In terms of depression symptoms
(Table 4), a similar pattern was observed for both undergraduates and IPV survivors, namely,
greater anxious attachment, greater emotion regulation difficulties, and more negative assump-
tions about the world each uniquely predicted variance in depressive symptoms. These results
suggest that various areas of intrapersonal functioning are implicated in the presence of depres-
sive symptoms, and that these results are similar across quite different trauma exposed samples.
744 Journal of Clinical Psychology, July 2013

Table 4
Intrapersonal Functioning Variables Predicting Depression, Posttraumatic Stress, and Somatiza-
tion Symptom Scores in Undergraduates (N = 290) and IPV survivors (N = 114)

Undergraduates IPV survivors

Adj R2 B (SE β) p Adj R2 B (SE β) p

Depression .43 .47

Anxious attachment .17 (.04) .00*** .14 (.06) .03*
Avoidant attachment .03 (.04) .44 .04 (.06) .49
Emotion dysregulation .02 (.00) .00*** .02 (.00) .00***
World assumptions −.01 (.00) .00** −.01 (.00) .01*
Posttraumatic stress .06 .17
Anxious attachment .03 (.52) .95 2.54 (.96) .01**
Avoidant attachment .43 (.47) .36 −.27 (.94) .78
Emotion dysregulation .12 (.04) .00** .13 (.05) .01*
World assumptions −.04 (.04) .31 .02 (.07) .73
Somatization .30 .41
Anxious attachment .06 (.04) .18 .05 (.07) .40
Avoidant attachment .07 (.04) .06 .01 (.06) .87
Emotion dysregulation .02 (.00) .00*** .02 (.00) .00***
World assumptions −.01 (.00) .04* −.01 (.00) .03*

Note. SE = standard error; IPV = intimate partner violence.

* p < .05. ** p < .01. *** p < .001.

Conversely, greater posttraumatic stress symptoms were predicted only by greater emotion reg-
ulation difficulties in undergraduates, and greater emotion regulation difficulties and greater
anxious attachment in IPV survivors (Table 4). Finally, somatization symptoms also showed
a similar pattern across the samples, namely, both greater emotion regulation difficulties and
more negative cognitions about the world were associated with greater somatization symptoms
for both undergraduates and IPV survivors (Table 4).

Discussion
Research has shown that exposure to trauma at the hands of another person can be particularly
detrimental to various areas of intrapersonal functioning, spanning fundamental functioning in
attachment processes, emotion regulation, and cognitive assumptions about the world, self, and
others. Further, these various processes are interrelated. The results support previous research
that suggests that attachment, emotion, and cognition are significantly interrelated and, in this
case, across two quite different samples of interpersonal trauma survivors. The only exception
was that emotion regulation difficulties were not significantly related to world assumptions,
though only for the IPV survivors. In total, the IPV survivors’ scores on both the DERS and
the WAS were notably very high. It is possible that a ceiling effect occurred when examining the
relationship between these variables, and that a lack of variability in the constructs led to Type
II error.
The results of the study provide replication of previous research that has found significant
comorbidity in symptoms of psychopathology posttrauma (Kessler et al., 1995; McLean &
Gallop, 2003). For both undergraduates and IPV survivors, moderate to strong correlations were
observed between symptoms of all three mental health outcomes of depression, posttraumatic
stress, and somatization symptoms. Though the correlations were not so high as to suggest that
the disorders were likely tapping in to the exact same phenomenon, it does suggest that it may
be unlikely for interpersonal trauma survivors to present for treatment with symptomatology
that neatly fits into just one category. These results reinforce not only previous empirical work
 Posttrauma Pathogeneses 745

on this topic, but also support the observations that clinicians working with trauma survivors
have made for decades.
Further, intrapersonal variables were significantly related to mental health outcomes across
both subsamples with only a few exceptions. Surprisingly, world assumptions were not signifi-
cantly related to symptoms of PTSD for either undergraduates or IPV survivors. These results
contradict previous research that has shown a correlation between more negative world assump-
tions and higher posttraumatic stress symptomatology in trauma survivors (Lilly & Pierce, 2012;
Magwaza, 1999). Additionally, avoidant attachment was not significantly related to any of the
mental health outcomes, though this was only true for IPV survivors. However, this may again
be related to a ceiling effect as the scores for anxious attachment in IPV survivors was quite
high.
Regression analyses revealed that emotion regulation difficulties were related to all three men-
tal health outcomes for both study subsamples. This supports Gratz and Tull’s (2010) assertion
that disruptions in one’s ability to regulate emotional reactions may be a core process involved in
diverse clinical symptom presentations posttrauma. These results held across rather dissimilar
subsamples, indicating that it is likely a core feature related to trauma exposure that enhances
risk for posttrauma psychopathology. World assumptions were also significantly related to men-
tal health in both subsamples, with the exception of posttraumatic stress symptoms. These
results replicate previous research that has found an association between world assumptions and
depression symptoms (Lilly, Valdez, & Graham-Bermann, 2011; Harris & Valentiner, 2002).
Attachment did not show a consistent relationship with mental health outcomes. While anx-
ious attachment was related to depression symptoms for both subsamples and to posttraumatic
stress for IPV survivors, it was related to neither somatization symptoms for either group nor
posttraumatic stress symptoms for undergraduates. The differing results in regards to anxious
attachment may be because of the fact that the majority of the undergraduates were recently out
of their home of origin and away from primary attachment figures.
In sum, emotion regulation was a significant predictor of all three mental health outcomes,
followed by world assumptions, which was implicated in somatization and depression symptoms.
Anxious attachment demonstrated strong correlations with both emotion regulation and world
assumptions in both subsamples. It is possible that the effects of emotion regulation and world
assumptions on mental health outcomes trumped the effect of anxious attachment in regards
to posttraumatic stress symptoms in undergraduates, and for somatization symptoms in both
subsamples. That anxious attachment was not associated with other intrapersonal function-
ing variables (with the exception of avoidant attachment), nor with any of the mental health
outcomes, causes these authors to question whether the items on the measure really tap into
pathological internal processes, or whether the items tap into a different construct altogether
that should not be considered problematic.
Despite subsamples that were quite different in terms of interpersonal trauma exposure, age,
and ethnicity, the results revealed that areas empirically shown to be disrupted in the face of
interpersonal trauma exposure were not only significantly inter-related, but also significantly
related to a variety of mental health symptoms. Additionally, symptoms of depression, post-
traumatic stress, and somatization were also significantly correlated, raising the question of
whether there should be broader psychological constructs that are subsumed under a new cat-
egory of trauma-related disorders that capture the broad ways in which trauma affects mental
health. In fact, this has been considered for the Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition (due for publication in 2013) in which a new category entitled “Trauma
and Stressor-related Disorders” may be included. This study supports the contention that not
only are quite varied symptom pictures likely associated with trauma exposure, but that these
symptom pictures are driven by predominantly the same underlying pathogeneses, chiefly among
them, emotional dysregulation, but also negative cognitions and anxious attachment processes.
These results were largely replicated across two different interpersonal trauma exposed groups.
The present study was limited in a number of ways. To begin, all data were cross-sectional.
Therefore, it cannot be determined whether trauma exposure predated disruptions in attach-
ment, emotion regulation abilities or the presence of negative world assumptions. Further, it is
impossible to tell from the data when different psychopathological symptoms developed, and
746 Journal of Clinical Psychology, July 2013

whether particular symptoms predated other symptoms or developed concurrently. Finally, the
study intimates that psychopathology developed as a result of trauma exposure. However, it is
possible that symptoms of depression, for example, developed prior to trauma exposure and
increased risk for trauma exposure by depleting the cognitive and emotional resources of an
individual needed to identify potentially dangerous situations. Replication using research that
incorporates a longitudinal or prospective design may answer some of these difficult questions.
Another limitation includes reliance on self-report measures, which increases the possibil-
ity that some of the strong correlations observed between constructs are due to response style
bias. Additionally, use of the somatization and depression subscales of the SCL-90-R as pri-
mary measures of mental health symptomatology presents limitations in that each scale has
a limited number of items (12 for somatization and 13 for depression), but also because the
measure assesses the experience of symptoms in the past week. Given the fluctuating nature
of psychopathology, it is possible that the scores do not fully reflect the extent or severity of
psychopathology recurrently experienced by participants, or conversely, could reflect “a bad
week” for some participants that are generally quite healthy. Assessment of somatization is
particularly tricky given that a participant could be simply suffering from influenza or a cold,
which would inflate their somatization scores, but does not represent true somatization (i.e.,
experience of physical symptoms in the absence of a known medical cause). Future research that
includes multiple respondents, experimental paradigms or observational components may help
to determine whether response style bias inflated observed correlations in this study.
Despite the limitations and the need for replication, the present study offers some important
insight into psychopathology among trauma survivors that could be useful for clinicians. Clini-
cians working with trauma survivors have long known that dual diagnosis is often the rule rather
than the exception in this population, and that the current shift to manualized treatments that
focus predominantly on symptom reduction, typically of just one disorder, may be short-sighted
and overly narrow in scope. This research shows that individuals with greater symptoms of
posttraumatic stress also report greater symptomatology across depression and somatization.
Therefore, focusing on symptom reduction within one category of psychopathology will not
likely be enough to create wholesale improvement in mental health and wellbeing for a survivor
of interpersonal trauma.
That said, the present research suggests that significant improvement would likely be gained by
focusing on improvements to a survivor’s ability to tolerate, cope with, and modulate emotional
reactions, not just in regards to posttraumatic stress, but this might also improve symptoms of
depression and somatization. Similarly, a focus on world assumptions and restoration of more
positive cognitions about the world, self, and others may reduce symptoms of both depression
and somatization. So, while current treatments are often narrow in scope by focusing on individ-
ual diagnoses, the underlying pathogeneses across disorders are similar and focusing on change
within these pathogeneses could result in symptom improvement across a number of different
disorders. This is perhaps why cognitive processing therapy (CPT; Resick, & Schnicke, 1996) for
interpersonal trauma survivors has been shown to be so effective in that it incorporates both an
exposure element that focuses on emotional processing, as well as a cognitive reframing compo-
nent. Ongoing research on CPT that has shifted from trials that examine efficacy to effectiveness
will likely reveal whether the dual components of CPT are successful in reducing symptoms
across an array of psychopathology beyond just posttraumatic stress and depression.
Other treatments that have received less attention, such as STAIR (Skills Training in Affective
and Interpersonal Regulation; Cloitre, Cohen, & Koenen, 2006), were born out of the recognition
that interpersonal trauma survivors suffer from an array of clinical problem sets and diagnoses.
Incorporated into STAIR is a specific focus on interpersonal functioning, affect regulation, and
attachment processes, as well as symptom reduction, which is supported by the results of the
present study. The STAIR program has been associated with positive changes in interpersonal
functioning, affect regulation and reduction in posttraumatic stress symptoms (Cloitre, Stovall-
McClough, Nooner et al., 2010).
For now, however, it may be premature to claim any one treatment as the treatment of
choice for trauma survivors when it is clear that trauma disrupts a broad array of intrapersonal
functioning (some areas of which are never the focus of treatment), and that these pathogeneses
 Posttrauma Pathogeneses 747

are related to psychopathology across a variety of diagnostic categories. Continued research in

this area with clinical populations is needed.

References
Aldao, A., Nolen-Hoeksema, S., & Schweizer, S. (2010). Emotion-regulation strategies across psy-
chopathology: A meta-analytic review. Clinical Psychology Review, 30, 217–237. doi:10.1016/j.cpr.2009.
11.004
Bifulco, A., Moran, P. M., & Lillie, A. (2002). Adult attachment style. II: Its relationship to psychosocial
depressive-vulnerability. Social Psychiatry and Psychiatric Epidemiology, 37, 60–67. doi:10.1007/s127-
002-8216-x
Bowlby, J. (1969/1982). Attachment and loss, Vol. 1: Attachment. New York, NY: Basic Books.
Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of post-traumatic stress disorders. Clinical
Psychology Review, 23, 339–376. doi:10.1016/S0272-7358(03)00033-3
Cloitre, M., Cohen, L. R., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy
for the Interrupted Life. New York, NY: The Guilford Press
Cloitre, M., Miranda, R., Stovall-McCollough, K. C., & Han, H. (2005). Beyond PTSD: Emotion regulation
and interpersonal problems as predictors of functional impairment in survivors of childhood abuse.
Behavior Therapy, 36, 119–124. doi:10.1016/S0005-7894(05)80060-7
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., & Jackson, C. L. (2010). Treatment
for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry,
167, 915–924. doi:10.1176/appi.ajp.2010.09081247
Coyne, J. C., & Gotlib, I. H. (1983). The role of cognition in depression: A critical appraisal. Psychological
Bulletin, 94, 472–505. doi:10.1037/0033-2909.94.3.472
Derogatis, L. (1994). SCL-90-R Symptom Checklist-90-R: Administration, scoring and procedures manual
(3rd ed.). Minneapolis, MN: NCS
Ehlers, A., & Clark, D. M. (2000). A cognitive model of post-traumatic stress disorder. Behavior Research
and Therapy, 38, 319–345. doi:10.1016/S0005-7967(99)00123-0
Ellis, A. (1962). Reason and emotion in psychotherapy. Oxford, UK: Lyle Stuart.
Flanagan, A. S., & Furman, W. C. (2000). Sexual victimization and perceptions of close relationships in
adolescence. Child Maltreatment, 5, 350–359. doi:10.1177/1077559500005004006
Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information.
Psychological Bulletin, 99, 20–35. doi:10.1037//0033-2909.99.1.20
Foa, E. B. (1995). Posttraumatic Stress Diagnostic Scale – Manual. Minneapolis, MN: National Computer
Systems.
Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item-response theory analysis of self- report mea-
sures of adult attachment. Journal of Personality and Social Psycology, 78, 350–365. doi:10.1037/0022-
3514.78.2.350
Frewen, P. A., Dozois, D. J. A., Neufeld, R. W. J., & Lanius, R. A. (2008). Meta-analysis of alexithymia in
post-traumatic stress disorder. Journal of Traumatic Stress, 21, 243–246. doi:10.1002/jts.20320
Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dys-
regulation: Development, factor structure, and initial validation of the difficulties in emo-
tion regulation skills. Journal of Psychopathology and Behavioral Assessment, 26, 41–54.
doi:10.1023/B:JOBA.0000007455.08539.94
Gratz, K. L., & Tull, M. T. (2010). Emotion regulation as a mechanism of change in acceptance-and
mindfulness-based treatments. In R. A. Baer (Ed.), Assessing mindfulness and acceptance: Illuminating
the processes of change. Oakland, CA: New Harbinger Publications.
Harris, H. N., & Valentiner, D. P. (2002). World assumptions, sexual assault, depression and fearful attitudes
toward relationships. Social Cognition, 17, 286–305. doi:10.1177/0886260502017003004
Jakupcak, M., & Tull, M. T. (2005). Effects of trauma exposure on anger, aggression, and violence in a
nonclinical sample of men. Violence and Victims, 20, 589–598. doi:10.1891/vivi.2005.20.5.589
Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: Applications of the schema
construct. Social Cognition, 7, 113–136. doi:10.1521/soco.1989.7.2.113
Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York, NY:
Free Press.
748 Journal of Clinical Psychology, July 2013

Keane, T. M., Wolfe, J., & Taylor, K. I. (1987). Post-traumatic stress disorder: Evidence for diagnostic validity
and methods of psychological assessment. Journal of Clinical Psychology, 43, 32–43. doi:10.1002/1097-
4679(198701)43:1<32
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, B. B., (1995). Post-traumatic stress disorder
in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. Retrieved from
http://archpsyc.ama-assn.org
Koss, M. P., Dinero, T. E., Seibel, C. A., & Cox, S. L. (1988). Stranger and acquaintance rape. Psychology
of Women Quarterly, 12, 1–24. doi:10.1111/j.1471-6402.1988.tb00924.x
Kubany, E. S. (2004). Traumatic Life Events Questionnaire (TLEQ). Los Angeles, CA: Western Psycholog-
ical Services.
Lang, P. J. (1983). Cognition in emotion: Concept and action. In C. lzard, J. Kagan, & R. Zajonc (Eds.),
Emotion, cognition and behaviour. New York, NY: Cambridge University Press
Lilly, M. M., & Pierce, H. A. (2012). PTSD and depressive symptoms in 911 telecommunicators: The
role of peritraumatic distress and world assumptions in predicting risk. Psychological Trauma: Theory,
Research, Practice, and Policy, Jan 2012. doi:10.1037/a0026850
Lilly, M. M., Valdez, C. E., & Graham-Bermann, S. A. (2011). The mediating effect of world assumptions
on the relationship between trauma exposure and depression. Journal of Interpersonal Violence, 26,
2499–2516. doi:10.1177/0886260510383033
Massie, H., & Szajnberg, N. (2006). My life is a longing: Child abuse and its adult sequelae. The International
Journal of Psychoanalysis, 87, 471–496. doi:10.1516/2R7R-0P2T-69Q4-BX0P
McLean, L. M., & Gallop, R. (2003). Implications of childhood sexual abuse for adult borderline personality
disorder and complex post-traumatic stress disorder. American Journal of Psychiatry, 160, 369–371.
doi:10.1176/appi.ajp.160.2.369
Magwaza, A. S. (1999). Assumptive world of traumatized South African adults. Journal of Social Psychol-
ogy, 139(5), 622–630. doi:
Muller, R. T., Sicoli, L. A., & Lemieux, K. E. (2000). Relationship between attachment style and post-
traumatic stress symptomatology among adults who report the experience of childhood abuse. Journal
of Traumatic Stress, 13, 321–332. doi:10.1023/A:1007752719557
Resick, P. A., & Schnicke, M. K. (1996). Cognitive processing therapy for rape victims: A treatment manual.
Newbury Park, CA: Sage.
Rief, W., Hiller, W., & Margraf, J. (1998). Cognitive aspects of hypochondriasis and the somatization
syndrome. Journal of Abnormal Psychology, 107, 587–595. doi:10.1037/0021-843X.107.4.587
Roche, D. N., Runtz, M. G., & Hunter, M. A. (1999). Adult attachment: A mediator between child
sexual abuse and later psychological adjustment. Journal of Interpersonal Violence, 14, 184–207.
doi:10.1177/088626099014002006
Sibley, C. G., & Liu, J. H. (2004). Short-term temporal stability and factor structure of the revised experiences
in close relationships (ECR-R) measure of adult attachment. Personality and Individual Differences, 36,
969–975. doi:10.1016/S0191-8869%2803%2900165-X
Stovall-McClough, K. C., & Cloitre, M. (2006). Unresolved attachment, PTSD, and dissociation in child-
hood abuse histories. Journal of Consulting and Clinical Psychology, 74, 219–228. doi:10.1037/0022-
006X.74.2.219
Waldinger, R. J., Schulz, M. S., Barsky, A. J., & Ahern, D. K. (2006). Mapping the road from child-
hood trauma to adult somatization: The role of attachment. Psychomatic Medicine, 68, 129–135.
doi:10.1097/01.psy.0000195834.37094.a4
Waller, E., & Scheidt, C. E. (2006). Somatoform disorders as disorders of affect regulation: A development
perspective. International Review of Psychiatry, 18, 13–24. doi:10.1080/09540260500466774
Yates, T. M., Carlson, E. A., & Egeland, B. (2008). A prospective study of child maltreatment and
self-injurious behavior in a community sample. Development and Psychopathology, 20, 651–671.
doi:10.1017/S0954579408000321
Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons, Inc. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.