**6. Discussion**

The first aim of this study was to explore preliminary descriptive data on the presence of significant post-traumatic symptoms in nonclinical female students attending courses at the University of Padova. Moreover, the purpose of the present study was to analyze the relationship between childhood experiences of interpersonal traumas and the presence of current posttraumatic stress disorder symptoms in an Italian sample of students. More precisely, this study tested whether romantic attachment is a significant moderator and/or mediator in the relationship between traumatic experiences and current PTSD symptoms.

#### **6.1. PTSD prevalence**

The first objective of the study was to provide preliminary descriptive data on PTSD in Italian female students. Although university students are considered high functioning samples, results highlight that around 10% of female students attending courses at the University of Padova exceed the cutoff point indicating a potential for the presence of post-traumatic symptoms. A high percentage of them, 34.9%, satisfy DSM-5 criteria for a provisional clinical diagnosis of post-traumatic stress disorder. This result supports the on-going investigations to assess long-term effects of childhood adverse experiences as well as other factors influencing post-traumatic manifestations.

#### **6.2. Moderating effect**

With regard to the study of a moderating effect played by anxiety and avoidance, the aim of the study was to observe whether the long-term effects of childhood traumatic experiences can be altered, namely increased, under two different conditions: higher levels of anxiety in close relationship and higher levels of avoidance of intimacy. Our results do not support this hypothesis.

In the hierarchical regression, no interaction between traumas and romantic attachment significantly predicted the severity of post-traumatic symptoms. As a consequence, the present study suggests that romantic attachment is not a significant moderator in the association between childhood traumatic experiences and PTSD in adulthood. This result is in line with a recent study on the moderating role of partner emotional support and negative interaction [65], in which authors found no moderation and observed that the stress buffering theory does not explain the role of social support in distress. Our results may confirm that couple attachment does not buffer the effect of childhood trauma on post-traumatic symptoms in adulthood. However, the authors [65] suggest that further investigations should run both moderation and mediation analyses in order to have different functional understanding on the role of social support variables.

A previous study [50] found a moderation of the quality of romantic relationship on the association between sexual abuse experience and depression. However, methodological limitations linked to sampling and measure may account for the absence of the same result in our study.

Direct effects show that both anxiety and avoidance represent significant predictors of PTSD. Moreover, when all conditions are controlled, students with higher levels of emotional abuse present higher PTSD symptoms, confirming the centrality of the emotion dysregulation in the expression of post-traumatic symptoms.

The physical abuse and neglect both show direct negative effects on PTSD. This result is not immediate to understand and claims for further analyses. As a consequence, functional approaches overcome the limit of descriptive interpretations of results. Finally, the variance explained by predictors and moderators suggests that other variables could be involved as independent predictors as well as significant moderators.

### **6.3. Mediating effect**

Path coefficients indicate significant direct and mediating effects. In particular, in the second model, anxiety and avoidance mediate the effect of Emotional Neglect on PTSD (β = 0.12) and avoidance shows a tending to significance mediation of Physical Abuse on PTSD (β = −0.02; *p*

For the direct effects, Emotional Abuse shows significant direct effect (β = 0.14) on PTSD; Physical Abuse shows no direct influence on PTSD, but a significant negative effect on avoidance (β = −0.15). Emotional Neglect has direct effect on PTSD as well as on avoidance and anxiety, respectively 0.16, 0.34 and 0.27. The Physical Neglect only fits negatively to PTSD

The first aim of this study was to explore preliminary descriptive data on the presence of significant post-traumatic symptoms in nonclinical female students attending courses at the University of Padova. Moreover, the purpose of the present study was to analyze the relationship between childhood experiences of interpersonal traumas and the presence of current posttraumatic stress disorder symptoms in an Italian sample of students. More precisely, this study tested whether romantic attachment is a significant moderator and/or mediator in the rela-

The first objective of the study was to provide preliminary descriptive data on PTSD in Italian female students. Although university students are considered high functioning samples, results highlight that around 10% of female students attending courses at the University of Padova exceed the cutoff point indicating a potential for the presence of post-traumatic symptoms. A high percentage of them, 34.9%, satisfy DSM-5 criteria for a provisional clinical diagnosis of post-traumatic stress disorder. This result supports the on-going investigations to assess long-term effects of childhood adverse experiences as well as other factors

With regard to the study of a moderating effect played by anxiety and avoidance, the aim of the study was to observe whether the long-term effects of childhood traumatic experiences can be altered, namely increased, under two different conditions: higher levels of anxiety in close relationship and higher levels of avoidance of intimacy. Our results do not support this

In the hierarchical regression, no interaction between traumas and romantic attachment significantly predicted the severity of post-traumatic symptoms. As a consequence, the present

Results of the mediation analyses are presented in **Figure 3**.

120 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

tionship between traumatic experiences and current PTSD symptoms.

= 0.091).

symptoms (−0.16).

**6. Discussion**

**6.1. PTSD prevalence**

**6.2. Moderating effect**

hypothesis.

influencing post-traumatic manifestations.

Results of the path analyses show that different forms of childhood traumatic experiences present different relationship with current post-traumatic symptoms: some forms of trauma show a direct influence on PTSD, while others are independent or have a combination of direct and indirect effects.

First, our results highlight that the inability to manage intimacy and closeness in romantic relationships leads to a severity of emotional neglect and ultimately, the development of posttraumatic symptoms in adulthood. Moreover, emotional abuse and emotional neglect display direct influences on PTSD.

These results allow two considerations. First, emotional components of trauma appear to have the greatest direct and mediated influences on PTSD. In particular, a possible explanation is that emotional traumas damage or compromise the development of affect regulation in infancy; such early impairment lasts into adulthood and exposes victims to a major risk of maladaptive response in stressful situations. Moreover, the emotional abuse appears to impede interpersonal affect regulation, with victims presenting higher levels of anxiety and avoidance in romantic attachment and then greater PTSD.

Emotional abuse and neglect experiences are mainly expressed in chronic familiar contexts, including ignoring the child, being constantly absent, blaming, humiliating and constantly criticizing the child. These repeated experiences produce a negative self-worth and a sense of guilt which are symptoms of complex PTSD. Moreover, emotional neglect involves showing no emotions in interactive exchanges with the child which leads to extreme difficulties in recognizing self- and other-emotions. This mechanism damages the development of reliable internal model of self and other, making victims more vulnerable to high levels of anxiety and avoidance in intimate relationship.

Second, the mediation of the relationship between emotional neglect and PTSD is provided by both anxiety and avoidance in romantic attachments. It is possible to suppose that previous levels of stress, due to traumatic repetitive experiences, like the inaccessibility of emotional support, can be reactivated by the vulnerability in the relationship, such as a perceived threat of abandonment. As a consequence, this mechanism might encourage people to read interpersonal minor stressors, quarrel and separations as trigger for high levels of stress, which, on the other hand, exposes hidden PTSD symptomatology. According to Van der Kolk [21], abused and maltreated children may show biases in the interpretation of interpersonal situations, quickly seeing the changes in voice tone and facial expression as a threat; consequently, they rapidly shift from the stimuli to a defensive reaction. In adulthood, this consolidated experience produces the internal perception of stress, even in neutral situation of fight or discussion in close relationships. The repetition of such mechanism produces dysregulation of emotion and hyper-arousal, characteristics of PTSD, as a response to non-stressing stimulus. A previous study shows that adult victims of childhood traumatic experiences are more likely to react with a deeper affective and physiological dysregulation to a harmless situation, compared to adult victims of a traumatic experience in adulthood [20].

A more controversial result is given by the negative influence of both physical abuse and neglect on post-traumatic stress disorder. Other investigations previously attested the ambiguous role of the dismissing pattern of attachment (characterized by greater avoidance) in association with PTSD. Moreover, this pattern appears to be less frequent in female samples. The two elements related to our study may affect the results. However, a possible interpretation of the results may also include that the negative emotions characterizing avoidance in romantic attachment may result in increase in emotional forms of trauma; physical abuse and neglect may have different long-terms effects, less connected with emotion regulation and PTSD. Physically abused subjects may have developed different defensive mechanisms reducing avoidance and PTSD. Further studies in this field are needed to reach a clearer interpretation.

Finally, the present study suggests that further investigations should consider the role of other independent predictors and other possible mediators, reported by literature, in the expression of post-traumatic symptoms and in the long-terms effects of physical interpersonal traumatic experiences.

#### **6.4. Limitations**

Emotional abuse and neglect experiences are mainly expressed in chronic familiar contexts, including ignoring the child, being constantly absent, blaming, humiliating and constantly criticizing the child. These repeated experiences produce a negative self-worth and a sense of guilt which are symptoms of complex PTSD. Moreover, emotional neglect involves showing no emotions in interactive exchanges with the child which leads to extreme difficulties in recognizing self- and other-emotions. This mechanism damages the development of reliable internal model of self and other, making victims more vulnerable to high levels of anxiety and

122 A Multidimensional Approach to Post-Traumatic Stress Disorder - from Theory to Practice

Second, the mediation of the relationship between emotional neglect and PTSD is provided by both anxiety and avoidance in romantic attachments. It is possible to suppose that previous levels of stress, due to traumatic repetitive experiences, like the inaccessibility of emotional support, can be reactivated by the vulnerability in the relationship, such as a perceived threat of abandonment. As a consequence, this mechanism might encourage people to read interpersonal minor stressors, quarrel and separations as trigger for high levels of stress, which, on the other hand, exposes hidden PTSD symptomatology. According to Van der Kolk [21], abused and maltreated children may show biases in the interpretation of interpersonal situations, quickly seeing the changes in voice tone and facial expression as a threat; consequently, they rapidly shift from the stimuli to a defensive reaction. In adulthood, this consolidated experience produces the internal perception of stress, even in neutral situation of fight or discussion in close relationships. The repetition of such mechanism produces dysregulation of emotion and hyper-arousal, characteristics of PTSD, as a response to non-stressing stimulus. A previous study shows that adult victims of childhood traumatic experiences are more likely to react with a deeper affective and physiological dysregulation to a harmless situation, compared to adult victims of a

A more controversial result is given by the negative influence of both physical abuse and neglect on post-traumatic stress disorder. Other investigations previously attested the ambiguous role of the dismissing pattern of attachment (characterized by greater avoidance) in association with PTSD. Moreover, this pattern appears to be less frequent in female samples. The two elements related to our study may affect the results. However, a possible interpretation of the results may also include that the negative emotions characterizing avoidance in romantic attachment may result in increase in emotional forms of trauma; physical abuse and neglect may have different long-terms effects, less connected with emotion regulation and PTSD. Physically abused subjects may have developed different defensive mechanisms reducing avoidance and PTSD. Further studies in this field are needed to reach a clearer

Finally, the present study suggests that further investigations should consider the role of other independent predictors and other possible mediators, reported by literature, in the expression of post-traumatic symptoms and in the long-terms effects of physical interpersonal traumatic

avoidance in intimate relationship.

traumatic experience in adulthood [20].

interpretation.

experiences.

The present study has some limitations. First, for a broader and more complete understanding of the variables involved in the relationship between childhood traumas and post-traumatic symptoms, the measures of childhood experiences, attachment and psychological outcomes should include interviews and different kinds of assessment. Indeed, the present results are totally produced based on self-report measures. Second, the measure of traumatic experiences is retrospective and participants are female students; further studies should be done with clinical subjects to evaluate, in clinical or high risk groups, the role of attachment on their symptomatology. Moreover, participants were all Italians; hence, the external validity is so far limited. Another limit is due to the lack of other psychopathological outcomes which might impact on the different roles played by anxiety and/or avoidance on different psychopathologies.

However, even if methodological shortcomings of the present results do not allow clear interpretations on the role that romantic attachment may play in determining adult posttraumatic symptomatology, one of the strength of the study lays in the opportunity to describe, in a functional framework, the relationship between childhood experiences and adult posttraumatic symptomatology. Indeed, the study of both moderation and mediation overcome limits linked with descriptive models.
