Intimate Partner Violence and Posttraumatic Stress Symptoms: Indirect Effects Through Negative and Positive Emotion Dysregulation

Abstract

Women who experience intimate partner violence (IPV) are at heightened risk for developing posttraumatic stress (PTS). Emotion dysregulation has been linked to both IPV and PTS, separately, however, unknown is the role of emotion dysregulation in the relation of IPV to PTS among women who experience IPV. Moreover, existing investigations in this area have been limited in their focus on negative emotion dysregulation. Extending prior research, this study investigated whether physical, sexual, and psychological IPV were indirectly associated with PTS symptom severity through negative and positive emotion dysregulation. Participants were 354 women who reported a history of IPV recruited from Amazon’s MTurk platform (M_age = 36.52, 79.9% white). Participants completed self-report measures assessing physical (Conflict Tactics Scale), sexual (Sexual Experiences Scale), and psychological (Psychological Maltreatment of Women) IPV; negative (Difficulties in Emotion Regulation Scale) and positive (Difficulties in Emotion Regulation Scale-Positive) emotion dysregulation; and PTS symptom severity (PTSD Checklist for DSM-5) via an online survey. Pearson’s correlation coefficients examined intercorrelations among the primary study variables. Indirect effect analyses were conducted to determine if negative and positive emotion dysregulation explained the relations between physical, sexual, and psychological IPV and PTS symptom severity. Physical, sexual, and psychological IPV were significantly positively associated with both negative and positive emotion dysregulation as well as PTS symptom severity, with the exception that psychological IPV was not significantly associated with positive emotion dysregulation. Moreover, negative and positive emotion dysregulation accounted for the relationships between all three IPV types and PTS symptom severity, with the exception of positive emotion dysregulation and psychological IPV. Our findings provide support for the potential underlying role of both negative and positive emotion dysregulation in the associations of IPV types to PTS symptom severity. Negative and positive emotion dysregulation may be important factors to integrate into interventions for PTS among women who experience IPV.

Keywords

emotion dysregulation positive emotions posttraumatic stress symptoms intimate partner violence physical IPV sexual IPV psychological IPV

Introduction

Intimate partner violence (IPV) is a serious public health concern (Centers for Disease Control and Prevention, 2020). IPV is highly prevalent among women in the United States, with 30.6%, 18.3%, and 36.4% of women reporting physical, sexual, and psychological violence, respectively, by an intimate partner in their lifetime (Smith et al., 2018). One in three women in the United States have experienced IPV and negative health-related outcomes resultant from IPV are common (Smith et al., 2018). Posttraumatic stress disorder (PTSD) is one health outcome that is etiologically tied to traumatic exposure (e.g., IPV; American Psychiatric Association, 2013). PTSD is a serious and debilitating mental health condition that is characterized by symptoms of intrusions, avoidance of internal and external trauma-related cues, negative alterations in cognitions and mood, and alterations in arousal and reactivity (American Psychiatric Association, 2013). PTSD frequently develops in women who experience IPV, with lifetime rates ranging from 31% to 84% (Golding, 1999), significantly higher than the lifetime prevalence rate of 9.7% for women in the general population (Mitchell et al., 2012). Indeed, the experience of IPV was associated with significantly higher risk for the development of PTSD (11.7%) compared to other trauma types, such as war-related trauma (3.5%) and non-IPV physical violence (2.8%; Kessler et al., 2017). PTSD has been associated with a range of negative outcomes in women who experience IPV, including co-occurring psychological disorders (Dichter et al., 2017; Golding, 1999; Iverson et al., 2013) and physical health conditions (Bonomi et al., 2009).

Notably, Hellmuth et al. (2014) found that women who experience IPV who do not meet full diagnostic criteria for PTSD still experience clinically significant levels of functional impairment. This finding suggests the importance of considering PTS symptoms on a spectrum, rather than focusing solely on women who meet diagnostic criteria. Furthermore, although IPV is directly related to the development of PTS symptoms in some individuals (Kessler et al., 2017), others may experience PTS symptoms that are not necessarily caused by IPV, but are negatively influenced and exacerbated by the experience of IPV (Bonomi et al., 2009; Dichter et al., 2017; Golding, 1999; Iverson et al., 2013). Given the high prevalence of PTS and its clinical relevance among women who experience IPV, further research is needed to examine specific factors that may underlie PTS symptomology to inform interventions for preventing or reducing PTS in this high-risk population.

One factor that may contribute to PTS symptom severity in women who experience IPV is emotion dysregulation. Emotion dysregulation is a transdiagnostic, multi-faceted construct characterized by maladaptive responses to emotions, including: (1) a lack of awareness, understanding, and acceptance of emotions; (2) the inability to control behaviors when experiencing emotional distress; (3) a lack of access to situationally appropriate strategies for modulating the duration and/or intensity of emotional responses in order to meet individual goals and situational demands; and (4) an unwillingness to experience emotional distress as part of pursuing meaningful activities in life (Gratz & Roemer, 2004; Gratz & Tull, 2010). Theoretical evidence implicates the importance of emotion dysregulation in the development and maintenance of PTS symptoms (Tull et al., 2020; Weiss, Forkus, et al., 2020). For example, a traumatic event may elicit intense emotional responses and arousal (Litz et al., 2000), which require high-regulation efforts and may overwhelm an individual’s capacity to regulate their emotions (Cloitre et al., 2009; Mennin, 2005). This inability to effectively modulate unwanted emotions may increase an individual’s fear and avoidance of trauma-related stimuli, thereby preventing functional exposure to trauma cues (a critical component in emotional processing) and exacerbating PTS symptoms (Brown et al., 2019; Foa & Kozak, 1986). Indeed, research consistently demonstrates that PTS symptom severity is positively associated with overall emotion dysregulation as well as each specific dimension of emotion dysregulation (Ehring & Quack, 2010; Tull et al., 2007; Weiss et al., 2012). These findings extend to women who experience IPV, regardless of the cause of PTS symptoms (specifically IPV-related or not), even after accounting for other impairments associated with the experience of interpersonal trauma, such as negative world assumptions and insecure attachment styles (Lilly & Hong Lim, 2013; Lilly et al., 2014; Weiss, Darosh, et al., 2018; Weiss, Dixon-Gordon, et al., 2018; Weiss, Nelson, et al., 2019). Furthermore, in a community sample of women experiencing IPV, Lilly et al. (2014) found that emotion dysregulation significantly accounted for the relation between childhood maltreatment and PTS symptom severity, suggesting that emotion dysregulation is an important factor underlying the link between trauma exposure, specifically childhood maltreatment, and PTS symptom severity among women experiencing IPV.

A notable limitation of existing research is that it centers primarily around difficulties regulating negative emotions, overlooking the dysregulation of positive emotions. Recent research suggests that individuals also experience difficulties regulating positive emotions (Gruber & Moskowitz, 2014; Weiss, Gratz, et al., 2015) and that these difficulties significantly influence psychopathology across a range of disorders (for reviews, see Carl et al., 2013; Dunn, 2017; Hechtman et al., 2013; Quoidbach et al., 2015). Positive emotions may induce heightened physiological arousal (Litz et al., 2000) that overlaps with PTS symptoms (Mckinnon et al., 2020; Taylor et al., 1992; Zoellner et al., 2020). This increased arousal may cause individuals with a history of trauma to interpret positive emotions as uncontrollable and distressing (Roemer et al., 2001), which may further exacerbate positive emotion dysregulation (Weiss, Gratz, et al., 2015). Initial empirical research indicates that higher levels of positive emotion dysregulation are associated with greater PTS symptom severity (Weiss, Contractor, Forkus, et al., 2020; Weiss, Contractor, Raudales, et al., 2020; Weiss, Schick, et al., 2019), including among women who experience IPV (Weiss, Darosh, et al., 2018; Weiss, Dixon-Gordon, et al., 2018; Weiss, Nelson, et al., 2019). Research is needed to further specify the role of positive emotion dysregulation in PTS symptom severity in women who experience IPV.

Although prior research has established relationships between negative and positive emotion dysregulation and both IPV and PTS symptom severity separately, no studies to our knowledge have examined the interrelations among IPV, negative and positive emotion dysregulation, and PTS symptom severity. In addition, extant literature in these areas has typically examined a single type of IPV (e.g., physical) or grouped all IPV types together as one variable. However, evidence suggests the IPV types (e.g., physical, sexual, and psychological) may have differential effects on mental health outcomes, coping strategies, and substance use (Flanagan et al., 2014; Mahoney & Iverson, 2020; Pico-Alfonso et al., 2006). Prior studies highlight a need to examine whether the IPV types are associated with PTS symptom severity via distinct mechanisms. For example, in a community sample of women experiencing IPV, Flanagan et al. (2014) found that avoidance coping accounted for the relationship between psychological and sexual, but not physical, IPV, and PTS symptom severity. Addressing these important gaps in the literature, the purpose of this study was to explore the potential underlying roles of negative and positive emotion dysregulation in the relationships between physical, sexual, and psychological IPV and PTS symptom severity. Of note, we examined PTS symptom severity among women with IPV, instead of IPV-related PTS symptom severity, to capture a wider range of traumatic experiences and symptoms among women experiencing IPV. We hypothesized that the IPV types would be indirectly associated with PTS symptom severity through both negative and positive emotion dysregulation, such that women who experience more severe physical, sexual, or psychological IPV would have greater PTS symptom severity through higher levels of both negative and positive emotion dysregulation.

Method

Participants were recruited from Amazon’s Mechanical Turk (MTurk), an internet-based crowdsourcing platform that generates reliable data (Buhrmester et al., 2011; Shapiro et al., 2013), and represents the general population in terms of demographics (Mishra & Carleton, 2017) and prevalence of mental health problems (Shapiro et al., 2013), including PTSD (van Stolk-Cooke et al., 2018). Following informed consent, participants completed a pre-screen questionnaire that determined their eligibility. Inclusion criteria were (1) aged 18 or older, (2) identifying as a woman, (3) fluent in English, and (4) a history of physical IPV (item adapted from the Conflict Tactics Scale-2 [CTS-2] [Strauss et al., 2003]; “Has a romantic partner ever done anything to physically hurt you, such as push or shove you, grab you, or punch or hit you?”). To optimize data quality, validity checks were included in the survey to assess for attentive responding and comprehension (four items; e.g., I get paid biweekly by leprechauns; Aust et al., 2013; Meade & Craig, 2012; Thomas & Clifford, 2017). We excluded participants who failed any of the four validity checks (see Exclusions and Missing Data). Eligible individuals completed the survey on Qualtrics (data collection platform) and received a monetary compensation of $2.00. All procedures were approved by the [redacted] Institutional Review Board.

Exclusions and Missing Data

A total of 1,014 participants attempted the survey. Participants were excluded for not meeting the eligibility criteria, specifically: (1) not being 18 or older (n = 5), (2) not identifying as a woman (n = 338), and (3) not experiencing lifetime physical IPV (n = 166). All participants reported being fluent in English, and thus none were excluded for this reason. Survey completers who failed at least one of the four validity checks that assessed attention and comprehension were excluded (n = 151). The final sample included 354 women who ranged in age from 19 to 75 (M = 36.52, SD = 11.78). Detailed demographics are provided in Table 1.

Table 1.

Demographic Characteristics of the Sample.

	Full Sample (N = 354) n (%)
Race White Black Asian Hispanic or Latinx American Indian/Alaska Native Not listed	283 (79.9) 44 (12.4)9 (2.5) 13 (3.7) 12 (3.4) 11 (3.1)
Ethnicity Hispanic or Latino/a Not Hispanic or Latino/a	29 (8.2) 315 (89.0)
Employment status Employed full-time Employed part-timeNot in labor force (e.g., student and homemaker)Unemployed	246 (69.5) 68 (19.2)22 (6.2) 16 (4.5)
Relationship statusNot datingCasually dating Seriously dating Married Divorced Separated Widowed	36 (10.2) 39 (11.0) 89 (25.1) 158 (44.6) 20 (5.6) 2 (0.5) 8 (2.3)

Note. All reported percentages are valid percentages to account for missing data. Respondents could endorse more than one racial category and could choose “prefer not to respond” to demographic questions.

Measures

Trauma exposure.

The life events checklist for DSM-5 (LEC-5; Weathers et al., 2013) is a 17-item self-report measure of lifetime trauma exposure. Participants indicated their exposure to each event on a 6-point scale: happened to me, witnessed it, learned about it, part of my job, not sure, and does not apply. Trauma exposure consistent with the DSM-5 Criterion A—was based on the endorsement of any of the first four response options (American Psychiatric Association, 2013). Then, participants indicate which traumatic event was the most distressing. Table 2 details the prevalence rates of traumatic events endorsed by this sample. The LEC has demonstrated strong convergent validity with measures assessing traumatic exposure and psychopathology known to relate to traumatic exposure (Gray et al., 2004).

Table 2.

Prevalence Rates of Index and Experienced Traumas from the Life Events Checklist for the DSM-5.

Traumatic Events	Index Trauma n (%)	Experienced Trauma n (%)
Sudden accidental death	13 (4.0)	165 (46.6)
Assault with a weapon (e.g., being shot, stabbed, threatened with a knife, gun, and bomb)	11 (3.4)	139 (39.3)
Transportation accident (e.g., car accident, boat accident, train wreck, and plane crash)	36 (11.2)	257 (72.6)
Life-threatening illness or injury	12 (3.7)	175 (49.4)
Physical assault (e.g., being attacked, hit, slapped, kicked, and beaten up)	68 (21.1)	291 (82.2)
Natural disaster (e.g., flood, hurricane, tornado, and earthquake)	39 (12.1)	224 (68.9)
Captivity (e.g., being kidnapped, abducted, held hostage, and prisoner of war)	1 (0.3)	72 (20.3)
Other unwanted or uncomfortable sexual experience	20 (6.2)	214 (60.5)
Serious injury, harm, or death you caused to someone else	1 (0.3)	68 (19.2)
Exposure to toxic substance (e.g., dangerous chemicals and radiation)	3 (0.7)	84 (23.7)
Serious accident at work, home, or during recreational activity	11 (3.4)	165 (46.6)
Sexual assault (e.g., rape and attempted rape)	63 (19.6)	194 (54.8)
Any other very stressful event or experience	20 (6.2)	162 (45.8)
Fire or explosion	11 (3.4)	172 (48.6)
Combat or exposure to a war-zone (i.e., in the military or as a civilian)	1 (0.3)	89 (25.1)
Severe human suffering	6 (1.9)	121 (34.2)
Sudden violent death (e.g., homicide and suicide)	9 (2.8)	155 (43.8)

Note. Valid percentages used to account for missing data.

IPV

Physical IPV was measured using the 12-item Revised CTS-2 (Strauss et al., 2003). Psychological IPV was measured using the 14-item Psychological Maltreatment of Women—Short version (PMWI-S; Tolman, 1999). Sexual IPV was measured using the 10-item Sexual Experiences Survey (SES; Koss & Oros, 1982) because this measure assesses sexual victimization more comprehensively than the CTS-2 (e.g., the CTS-2 does not measure sexual coercion using drugs or alcohol). Participants reported past 30-d physical (e.g., pushing and shoving) and sexual (e.g., fondling, kissing, or petting) IPV using a 7-point Likert-type scale ranging from 0 (never) to 6 (more than 20 times). Participants indicated past 30-day psychological IPV (e.g., yelling and restricting telephone use) using a 5-point Likert-type scale ranging from 0 (never) to 4 (very frequently). A total score was computed for each scale by summing the respective item responses, with higher scores indicating more frequent experiences of IPV. These measures have been previously used among samples of women who experienced IPV (e.g., Weiss, Dixon-Gordon, et al., 2015). Reliability for the CTS-2, PMWI-S, and SES in this study was excellent (Cronbach’s αs = .94, 96, and .95, respectively).

Negative emotion dysregulation.

The Difficulties in Emotion Regulation Scale-16 (DERS-16; Bjureberg et al., 2016) is a 16-item self-report measure of difficulties regulating negative emotions across five domains: nonacceptance of negative emotions, difficulties engaging in goal-directed behavior when distressed, difficulties controlling impulsive behaviors when distressed, limited access to effective emotion regulation strategies for negative emotions, and lack of emotional clarity. Participants rated the extent to which items apply to them using a 5-point Likert-type scale ranging from 1 (almost never) to 5 (almost always). A total score was calculated by summing all the items, with higher scores indicating greater negative emotion dysregulation. The DERS-16 has sound psychometric properties, demonstrating good test-retest reliability, convergent validity, and discriminant validity (Bjureberg et al., 2016). In this study, reliability for the DERS was excellent (Cronbach’s α = .96).

Positive emotion dysregulation.

The Difficulties in Emotion Regulation Scale-Positive (DERS-P; Weiss, Gratz, et al., 2015) is a 13-item self-report measure of difficulties regulating positive emotions across three domains: nonacceptance of positive emotions, difficulties engaging in goal-directed behaviors when experiencing positive emotions, and difficulties controlling impulsive behaviors when experiencing positive emotions. Participants rated each item using a 5-point Likert-type scale ranging from 1 (almost never) to 5 (almost always). A total score was computed by summing all items; higher scores indicate greater positive emotion dysregulation. The DERS-P demonstrates excellent psychometric properties (Weiss, Darosh, et al., 2019; Weiss, Gratz, et al., 2015), including in this study (Cronbach’s α = .97).

Posttraumatic stress symptoms.

The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013) is a 20-item self-report measure of symptoms corresponding to the DSM-5 criteria for PTSD (American Psychiatric Association, 2013). Participants completed the PCL-5 in response to the most distressing traumatic event endorsed on the LEC-5. On the PCL-5, participants indicated how often they had been bothered by each of the symptoms over the past month using a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). A total score was calculated by summing all the items; higher scores indicate greater PTS symptom severity. Probable PTSD is determined using a cut-off score of 33 on the PCL-5 (Bovin et al., 2016). The PCL-5 has excellent psychometric properties (Blevins et al., 2015; Bovin et al., 2016; Wortmann et al., 2016). The PCL-5 demonstrated excellent internal consistency in the current sample (Cronbach’s α = .97).

Data Analytic Plan

Data were first assessed for violations of assumptions of normality. Next, intercorrelations were examined among primary study variables. To address the questions of whether negative and positive emotion dysregulation, separately, explain the relations between physical, psychological, and sexual IPV and PTS symptom severity, we conducted six independent indirect effect analyses (Preacher & Hayes, 2004) with the PROCESS SPSS macro (Model 4; Hayes, 2012). The PROCESS procedures use ordinary least squares regression and bootstrapping methodology, which confers more statistical power than do standard approaches to statistical inference and does not rely on distributional assumptions. Bootstrapping was done with 5,000 random samples generated from the observed covariance matrix to estimate bias-corrected 95% confidence intervals (CIs) and significance values (MacKinnon et al., 2002; Preacher & Hayes, 2004). The effect is significant if the 95% CI does not contain zero (Preacher & Hayes, 2004). Indirect effects are reported as standardized. A Benjamini-Hochberg adjustment was utilized to minimize both Type I and Type II error (Benjamini & Hochberg, 1995). Specifically, for each model, the p values for these effects were rank ordered by size. Then, each individual p value’s Benjamini-Hochberg critical value was calculated using the formula (i/m)Q, where i = the individual p value’s rank, m = the total number of tests, and Q = the p value (.05). Original p values are then compared to respective Benjamini-Hochberg critical values. This method decreases the likelihood of an overall Type I error without increasing the risk for Type II error and unnecessarily reducing statistical power.

Results

Preliminary Analyses

Variables were within the acceptable ranges for skewness (0.28-1.46) and kurtosis (−.91-1.45). Nearly half of the sample (n = 158; 45%) were at or above the threshold for probable PTSD using a cut-off score of 33 on the PCL-5 (Bovin et al., 2016). Descriptive information and intercorrelations among study variables are presented in Table 3. Significant positive associations were identified among IPV trauma types, negative emotion dysregulation, positive emotion dysregulation, and PTS symptom severity, with the exception that psychological IPV was not significantly associated with positive emotion dysregulation.

Table 3.

Descriptive Statistics and Zero-order Correlations for Variables of Interest.

	M	SD	1	2	3	4	5	6
1. Physical IPV	12.95	13.72	__	__	__	__	__	__
2. Psychological IPV	23.66	15.04	.59^**	__	__	__	__	__
3. Sexual IPV	10.57	13.70	.59^**	.53^**	__	__	__	__
4. Negative emotion dysregulation	41.22	16.39	.20^**	.32^**	.32^**	__	__	__
5. Positive emotion dysregulation	21.62	12.24	.27^**	.10	.34^**	.45^**	__	__
6. PTS symptoms	29.67	21.87	.38^**	.46^**	.43^**	.56^**	.40^**	__

Note. Physical intimate partner violence (IPV) was measured by the Revised Conflict Tactics Scale; Psychological IPV was measured by the Psychological Maltreatment of Women—Short Version; Sexual IPV was measured by the Sexual Experiences Survey; Negative emotion dysregulation was measured by the Difficulties in Emotion Regulation Scale-16; Positive emotion dysregulation was measured by the Difficulties in Emotion Regulation Scale-Positive; Posttraumatic stress (PTS) symptoms were measured by the PTSD Checklist for DSM-5. ^**p < .001.

Primary Analyses

We examined six models explicating the roles of negative and positive emotion dysregulation, separately, in the relations between IPV type (physical, psychological, and sexual) and PTS symptom severity.

Physical IPV.

In the model examining physical IPV, the association between physical IPV and negative emotion dysregulation was found to be significant (B = .24, SE = .06, t = 3.86, p = .001). Furthermore, the association between negative emotion dysregulation and PTS symptom severity was found to be significant (B = .67, SE = .06, t = 11.72, p < .001). Additionally, there was a significant indirect effect of physical IPV on PTS symptom severity through negative emotion dysregulation (β = .10, SE = .03, 95% CI [0.05, 0.16]). Yet, the direct effect linking physical IPV and PTS symptom severity when accounting for negative emotion dysregulation remained significant (B = .43, SE = .07, t = 6.30, p < .001). Of note, this 27.45% reduction in the total effect when negative emotion dysregulation is included in the model was significant (Sobel test; t = 3.77, SE = .04, p < .001).

Next, the association between physical IPV and positive emotion dysregulation was found to be significant (B = .25, SE = .05, t = 5.23, p < .001). Also, the association between positive emotion dysregulation and PTS symptom severity was found to be significant (B = .58, SE = .09, t = 6.50, p < .001). There was a significant indirect effect of physical IPV on PTS symptom severity through positive emotion dysregulation (β = .09, SE = .02, 95% CI [0.05, 0.14]). Also, the direct effect linking physical IPV and PTS symptom severity when accounting for positive emotion dysregulation remained significant (B = .45, SE = .08, t = 5.76, p < .001). Of note, this 24.32% reduction in the total effect when positive emotion dysregulation is included in the model was significant (Sobel test; t = 3.95, SE = .04, p < .001).

Psychological IPV.

When examining psychological IPV, the association between psychological IPV and negative emotion dysregulation was found to be significant (B = .35, SE = .06, t = 6.29, p < .001). The association between negative emotion dysregulation and PTS symptom severity was also found to be significant (B = .61, SE = .06, t = 10.45, p < .001). Furthermore, there was a significant indirect effect of psychological IPV on PTS symptom severity through negative emotion dysregulation (β = .15, SE = .03, 95% CI [0.09, 0.21]). Yet, the direct effect linking psychological IPV and PTS symptom severity when accounting for negative emotion dysregulation remained significant (B = .45, SE = .06, t = 7.11, p < .001). Of note, this 32.01% reduction in the total effect when negative emotion dysregulation is included in the model was significant (Sobel test; t = 5.06, SE = .04, p < .001).

Subsequently, the association between psychological IPV and positive emotion dysregulation was found to be significant (B = .67, SE = .07, t = 9.64, p < .001). The association between positive emotion dysregulation and PTS symptom severity was found to be significant (B = .64, SE = .08, t = 8.08, p < .001). However, there was not a significant indirect effect of psychological IPV on PTS symptom severity through positive emotion dysregulation (β = .04, SE = .02, 95% CI [−0.0003, 0.08]). Also, the direct effect linking psychological IPV and PTS symptom severity when accounting for positive emotion dysregulation remained significant (B = .61, SE = .06, t = 9.57, p < .001). Of note, this 8.23% reduction in the total effect when positive emotion dysregulation is included in the model was significant (Sobel test; t = 6.14, SE = .07, p < .001).

Sexual IPV.

When examining sexual IPV, the association between sexual IPV and negative emotion dysregulation was found to be significant (B = .38, SE = .06, t = 6.20, p < .001). The association between negative emotion dysregulation and PTS symptom severity was found to be significant (B = .63, SE = .06, t = 10.66, p < .001). Moreover, there was a significant indirect effect of sexual IPV on PTS symptom severity through negative emotion dysregulation (β = 0.15, SE = 0.03, 95% CI [0.10, 0.21]). Yet, the direct effect linking sexual IPV and PTS symptom severity when accounting for negative emotion dysregulation remained significant (B = .45, SE = .07, t = 6.31, p < .001). Of note, this 34.83% reduction in the total effect when negative emotion dysregulation is included in the model was significant (Sobel test; t = 5.42, SE = .04, p < .001).

Next, the association between sexual IPV and positive emotion dysregulation symptoms was found to be significant (B = .53, SE = .09, t = 5.90, p < .001). Additionally, the association between positive emotion dysregulation and PTS symptom severity was found to be significant (B = .30, SE = .05, t = 6.68, p < .001). There was a significant indirect effect of sexual IPV on PTS symptom severity through positive emotion dysregulation (β = .10, SE = .02, 95% CI [0.06, 0.15]). Yet, the direct effect linking sexual IPV and PTS symptom severity when accounting for positive emotion dysregulation remained significant (B = .53, SE = .08, t = 6.74, p < .001). Of note, this 22.86% reduction in the total effect when positive emotion dysregulation is included in the model was significant (Sobel test; t = 4.20, SE = .04, p < .001).

Discussion

This study sought to examine the underlying effects of negative and positive emotion dysregulation on the relationships between physical, sexual, and psychological IPV and PTS symptom severity among community women who have experienced IPV. Notably, we examined women with PTS symptoms to include a broader spectrum of symptoms, rather than limiting the sample to women only with syndromal-level symptoms meeting criteria for PTSD. Consistent with existing research (Basile et al., 2004; Becker et al., 2010; Bennice et al., 2003; Coker et al., 2005; Pico-Alfonso et al., 2006), all three types of IPV were significantly positively associated with PTS symptom severity. Furthermore, negative and positive emotion dysregulation were found to explain in part the relationship between all IPV types and PTS symptom severity, with the exception that psychological IPV was not indirectly associated with PTS symptom severity through positive emotion dysregulation. Specifically, in general, higher levels of IPV were significantly associated with greater negative and positive emotion dysregulation. In turn, greater negative and positive emotion dysregulation were associated in part with more severe PTS symptoms. Our findings advance the existing literature by providing support for the roles of both negative and positive emotion dysregulation in the relationships between distinct types of IPV and PTS symptom severity. These findings have important implications for future research and practice.

Existing theoretical and empirical literature provides support for an association between negative emotion dysregulation and PTS symptom severity (Bardeen et al., 2013; Ehring & Quack, 2010; Tull et al., 2007; Weiss et al., 2012), including among women who experience IPV (Lilly & Hong Lim, 2013; Lilly et al., 2014; Weiss, Darosh, et al., 2018; Weiss, Dixon-Gordon, et al., 2018; Weiss, Nelson, et al., 2019). This study is the first to examine the role of negative emotion dysregulation in the association between IPV and PTS symptom severity. Our results provide a novel contribution to prior literature by suggesting that women who experience IPV have difficulties in regulating negative emotions that contribute in part to their PTS symptom severity, regardless of the type of IPV they experience. Given the transdiagnostic nature of negative emotion dysregulation (Gratz & Roemer, 2004; Gratz & Tull, 2010), future research should consider the underlying effect of negative emotion dysregulation in other psychological disorders occurring in women who experience IPV (e.g., anxiety, depression, and substance use; Dichter et al., 2017; Golding, 1999; Iverson et al., 2013). If negative emotion dysregulation is a common theme underlying symptom severity for multiple psychological disorders in women who experience IPV, it may be especially important to design interventions and treatments that target negative emotion dysregulation, as addressing this one key construct may help to reduce symptom severity across a wide range of disorders in this population.

Regarding the role of positive emotion dysregulation in the association between IPV and PTS symptom severity, our findings extend a fast-growing body of theoretical and empirical research emphasizing the influence of positive emotion dysregulation on PTS symptom severity (Weiss, Contractor, Forkus, et al., 2020; Weiss, Contractor, Raudales, et al., 2020; Weiss, Schick, et al., 2019), including among women who experience IPV (Weiss, Darosh, et al., 2018; Weiss, Dixon-Gordon, et al., 2018; Weiss, Nelson, et al., 2019). The experience of any type of IPV may elicit strong emotional responses (Basile et al., 2004). Intense emotions require a high level of effort to regulate and manage effectively (Cloitre et al., 2009; Mennin, 2005). If women who experience IPV are constantly experiencing stronger emotions, their capacity to regulate these emotions may become overwhelmed or diminished. Weiss, Gratz, et al. (2015) noted that difficulties regulating positive emotions parallel those of negative emotions, suggesting that the experience of strong emotions, either positive or negative, may lead to dysregulation. Positive emotion dysregulation includes the non-acceptance and avoidance of positive emotions (Weiss, Gratz, et al., 2015), which may occur in response to aversive physiological arousal (e.g., increased sympathetic activity; Roemer et al., 2001) or cognitions (e.g., “positive emotions are always short lived”; Norman et al., 2014) tied to positive emotions, such as in negative affect interference (Frewen et al., 2012) or fear of positive emotions specifically (Beblo et al., 2012). Through stimulus generalization, avoidance of positive emotions may further reinforce avoidance of other emotional stimuli including trauma-related cues (Roemer et al., 2001). Thus, women who experience IPV may have difficulties regulating strong emotions, both negative and positive, which may contribute to greater PTS symptom severity. Future research is needed to better understand how positive emotion dysregulation in women who experience IPV may lead to the development and maintenance of PTS symptoms.

Of note, the relationship between IPV type and PTS symptom severity remained significant when accounting for negative and positive emotion dysregulation. This suggests that there are other important factors that explain this association. Future research is needed to explore such constructs. For instance, other trauma exposure may be an important contributing factor, as women who experience IPV frequently report multiple forms of trauma (Coker et al., 2005; Humphreys et al., 2010). Women who experience IPV and have more trauma exposure (e.g., childhood maltreatment, revictimization by one or more intimate partners, other non-interpersonal traumatic events) may have greater PTS symptom severity from this cumulative exposure to trauma (Cloitre et al., 2009). Coping strategies may also play a key role in the relationship between IPV and PTS symptom severity. Different types of coping strategies women who experience IPV may employ to cope with the experience of IPV or other stressors may differentially influence their PTS symptom severity. Results of Weiss et al. (2017) suggested that avoidant coping was more strongly related to PTS symptoms among women who experienced IPV than social support or problem-solving coping. Similarly, a longitudinal study on women who experienced IPV found that baseline levels of avoidant coping significantly predicted PTSD symptom severity one year later (Krause et al., 2008). Research that examines these—and other—potential factors will inform more efficacious interventions for this population.

The proposed model examined here suggests that IPV influences negative and positive emotion dysregulation, which in turn influences PTS symptom severity. Although the findings of this study are consistent with existing theory (Gratz & Roemer, 2004; Gratz & Tull, 2010) and longitudinal studies (Bardeen et al., 2013; Pencea et al., 2020) that describe an association of PTS symptom severity with emotion dysregulation, the cross-sectional nature of our study design precludes determination of directionality. As such, it is important to consider the possibility of alternative models. For instance, IPV may contribute to greater PTS symptom severity, which in turn may increase negative and positive emotion dysregulation. Weiss, Dixon-Gordon, et al. (2018) proposed that elevated positive emotion dysregulation in populations characterized by PTS may stem from an aversion to the heightened physiological arousal associated with some positive emotions (Litz et al., 2000). Specifically, through stimulus generalization, distress paired with the physiological arousal elicited by PTS symptoms (Mckinnon et al., 2020; Taylor et al., 1992; Zoellner et al., 2020) may generalize to any stimuli that elicit physiological arousal. As a result, women with a history of more severe IPV who develop greater PTS symptoms, related to IPV or not, may interpret strong negative or positive emotions as more uncontrollable and distressing (Roemer et al., 2001), leading to higher negative or positive emotion dysregulation.

Alternately, PTS symptom severity or emotion dysregulation might lead to IPV. Women who have experienced IPV frequently report other forms of trauma, including childhood maltreatment (Basile et al., 2004; Coker et al., 2005; Lilly et al., 2014). Thus, it is possible that prior exposure to trauma and PTS symptoms lead to emotion dysregulation, which subsequently puts women at a higher risk of experiencing IPV. For instance, consistent with the high-risk hypothesis (Begle et al., 2011; McFarlane et al., 2009), women who struggle with emotion dysregulation may be more likely to engage in risky or reckless behaviors that lead to trauma exposure and PTS symptoms, which makes them more vulnerable to experiencing IPV. Future investigations are needed to evaluate and compare these alternative models.

As predicted, findings were generally consistent across the IPV types (physical, sexual, and psychological). All three types of IPV were positively associated with PTS symptom severity and negative and positive emotion dysregulation. This consistency of findings across the IPV types is supported by prior literature that has demonstrated significant associations between each IPV type with emotion dysregulation (Berzenski & Yates, 2010; Dugal et al., 2018; Weiss, Darosh, et al., 2018) and PTSD symptom severity (Basile et al., 2004; Becker et al., 2010; Bennice et al., 2003; Coker et al., 2005; Pico-Alfonso et al., 2006). However, while negative and positive emotion dysregulation were shown to underlie in part the relationship between physical and sexual IPV and PTS symptom severity, only the indirect effect of negative, but not positive, emotion dysregulation in the relationship between psychological IPV and PTS symptom severity was significant. A potential explanation for our findings is that the experience of psychological (compared to physical or sexual) IPV may elicit unique patterns of responding that exacerbate negative but not positive emotion dysregulation. For instance, there are key differences in the experience of psychological IPV compared to the other forms of IPV. Existing findings suggest that psychological IPV is the most frequently experienced form of IPV among women who experience IPV, and most often occurs alone (27% days) versus alongside physical IPV (6.3% days), sexual IPV (1.2% days), or both physical and sexual IPV (2.3% days; Sullivan et al., 2012). Given evidence that psychological IPV is experienced more frequently than physical or sexual IPV, it is possible that women who experience this form of IPV experience positive emotions less often. Thus, when asked to self-report difficulties regulating positive emotions, women who experience psychological IPV may not have experienced positive emotions recently or often enough to identify regulation efforts implemented. Future research using more objective measures of positive emotion dysregulation are needed to determine whether our pattern of findings is due to a lack of awareness of positive emotion dysregulation among women who experience psychological IPV. Moreover, given evidence to suggest that psychological IPV is as strong a predictor of PTS as physical and sexual IPV (Pico-Alfonso et al., 2006), further investigations are needed to explore other potential underlying factors of the psychological IPV-PTS association.

Although this study makes valuable contributions towards understanding the role of emotion dysregulation in PTS symptom severity among women who experience IPV, findings should be interpreted in the context of certain limitations. First, the cross-sectional and correlational nature of the data precludes determination of the precise nature and direction of the relations examined. Research is needed to investigate these relations through prospective, longitudinal investigations. Second, this study relied on women’s self-report of symptoms, which may have been influenced by their ability and/or willingness to report accurately. Future investigations should include additional measures of emotion dysregulation, such as behavioral (e.g., paced auditory serial addition task-computerized version; Gratz et al., 2007) or physiological (e.g., respiratory sinus arrhythmia; Vasilev et al., 2009) responses. Third, although our focus on a sample of women who have experienced IPV is arguably a strength of this study, findings may not be generalizable to other IPV populations (e.g., men and women in same sex relations) or women who have experienced other forms of victimization (e.g., non-IPV physical or sexual violence and child abuse), and thus require replication in these populations. Furthermore, we did not ask participants to specify the type of relationship (e.g., married, dating, and cohabitating) in which they experienced IPV. As different relationship types may result in different IPV patterns or outcomes (Abramsky et al., 2011; Machado et al., 2014; Sorenson & Spear, 2018), further research examining differences in negative and positive emotion dysregulation and PTS symptom severity across different types of IPV relationships is needed. Fourth, our study examined PTS symptom severity among women with IPV and did not specifically consider IPV-related PTS symptom severity, as women who experience IPV frequently report various traumas (Coker et al., 2005) that may contribute to their emotion dysregulation and subsequent PTS symptom severity. It will be important for future research to explore IPV-related PTS symptoms specifically in relation to negative and positive emotion dysregulation. Lastly, collecting data via the internet has disadvantages that may limit generalizability of results, such as sample biases and lack of control over the research environment (Kraut et al., 2004). However, the MTurk recruitment platform is a notable strength of our study, as MTurk’s subject pool is diverse compared to traditional internet-recruited samples, represents the U.S. population in several demographic characteristics, and generates reliable data (Buhrmester et al., 2011; Mishra & Carleton, 2017; Shapiro et al., 2013). Thus, while a strength, future research that integrates other data collection methods is necessary.

If replicated in longitudinal investigations, the findings of the current cross-sectional study could have relevant clinical implications. Specifically, our results provide preliminary evidence that efforts to detect and intervene with PTS symptom severity among women who have experienced IPV may benefit from consideration of both negative and positive emotion dysregulation. Empirically supported treatments with an emphasis on emotion dysregulation have shown efficacy in reducing PTS symptom severity among populations characterized by trauma. For example, Skills Training in Affective and Interpersonal Regulation (STAIR) directly targets emotion dysregulation and reduces PTS symptom severity in survivors of childhood trauma (Cloitre et al., 2002, 2010), including those who have experienced IPV as adults (Cloitre et al., 2010). Similarly, Dialectical Behavioral Therapy with Prolonged Exposure (DBT-PE)—a combination of DBT (Linehan, 1993), which has a strong focus on emotion dysregulation, and PE (Foa et al., 2007), a leading treatment for PTSD—significantly reduces PTS symptom severity among those with interpersonal trauma, including IPV (Harned et al., 2014). Notably, however, STAIR and DBT-PE only explicitly target dysregulation of negative emotions. Our findings provide initial data to suggest that PTS treatment for women who experience IPV may also benefit from addressing positive emotion dysregulation.

Despite limitations, the findings of this study contribute to our growing understanding of negative and positive emotion dysregulation and their relationships to PTS symptom severity in women who experience IPV. Specifically, negative emotion dysregulation indirectly affected in part the separate relationships between physical, sexual, and psychological IPV and PTS symptom severity. Positive emotion dysregulation indirectly affected in part the separate relations between physical and sexual, but not psychological, IPV and PTS symptom severity. These findings suggest that difficulties regulating both negative and positive emotions may be important risk factors to consider and valuable clinical targets to address in interventions aimed at reducing PTS symptom severity in women who experience IPV.

Footnotes

Declaration of Conflicting Interests

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: Work on this article by the last author (NHW) was supported by National Institutes of Health Grants K23DA039327 and P20GM125507.

ORCID iDs

Lauren E. Simpson

Miranda E. Reyes

Tami P. Sullivan

Author Biographies

Lauren E. Simpson, is an undergraduate student majoring in Psychology at Amherst College. Her research interests include the experience of interpersonal trauma and mechanisms underlying the development and maintenance of posttraumatic stress disorder (PTSD)—specifically emotion dysregulation.

Alexa M. Raudales, BA, is a Clinical Psychology doctoral student at the University of Rhode Island. Her research focuses on emotion dysregulation as a transdiagnostic factor underlying trauma-related psychopathology and self-harm behaviors. She is interested in utilizing real-time data collection methods to better understand how these processes relate temporally, with the ultimate aim of improving assessment, and intervention efforts.

Miranda E. Reyes, MA, is a Clinical Psychology doctoral student at the University of Rhode Island. Her research interests involve examining the role of contextual and cultural factors in trauma, PTSD, and co-occurring risky behaviors. She is particularly interested in the association of intimate partner violence to substance use among racially and ethnically marginalized populations.

Tami P. Sullivan, PhD, is an associate professor and the director of Family Violence Research and Programs, Division of Prevention and Community Research, at Yale University School of Medicine. Her program of research is centered on individual and system-level factors that affect the well-being of victims of intimate partner violence (IPV). At the individual level, her work aims to advance understanding of the precursors, correlates, and outcomes of IPV, with specific attention to daily processes. At the system-level, her work focuses on assessing the capacity of systems to meet the unique needs of IPV-exposed women and examining how the system’s response affects women’s well-being.

Nicole H. Weiss, PhD, is assistant professor of Psychology at the University of Rhode Island and Director of the STRESS Lab. Her research focuses on the co-occurrence of PTSD and SUD. She utilizes of ecological momentary assessment to clarify the proximal role and temporal ordering of affective processes—most notably emotion dysregulation—in PTSD symptoms and substance use over time.

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