Pupil Response to Threat in Trauma‐Exposed Individuals With or Without PTSD

An infrequently studied and potentially promising physiological marker for posttraumatic stress disorder (PTSD) is pupil response. This study tested the hypothesis that pupil responses to threat would be significantly larger in trauma‐exposed individuals with PTSD compared to those without PTSD. Eye‐tracking technology was used to evaluate pupil response to threatening and neutral images. Recruited for participation were 40 trauma‐exposed individuals; 40.0% (n = 16) met diagnostic criteria for PTSD. Individuals with PTSD showed significantly more pupil dilation to threat‐relevant stimuli compared to the neutral elements (Cohen's d = 0.76), and to trauma‐exposed controls (Cohen's d = 0.75). Pupil dilation significantly accounted for 12% of variability in PTSD after time elapsed since most recent trauma, cumulative violence exposure, and trait anxiety were statistically adjusted. The final logistic regression model was associated with 85% of variability in PTSD status and correctly classified 93.8% of individuals with PTSD and 95.8% of those without. Pupil reactivity showed promise as a physiological marker for PTSD.     

Emotional Reactivity,Emotion Regulation Capacity,and Posttraumatic Stress Disorder in Traumatized Refugees: An Experimental Investigation

Refugees who suffer from posttraumatic stress disorder (PTSD) often react with strong emotions when confronted with trauma reminders. In this study, we aimed to investigate the associations between low emotion regulation capacity (as indexed by low heart rate variability [HRV]), probable PTSD diagnosis, and fear and anger reaction and recovery to trauma‐related stimuli. Participants were 81 trauma‐exposed refugees (probable PTSD, n = 23; trauma‐exposed controls, n = 58). The experiment comprised three 5‐min phases: a resting phase (baseline); an exposition phase, during which participants were exposed to trauma‐related images (stimulus); and another resting phase (recovery). We assessed HRV at baseline, and fear and anger were rated at the end of each phase. Linear mixed model analyses were used to investigate the associations between baseline HRV and probable DSM‐5 PTSD diagnosis in influencing anger and fear responses both immediately after viewing trauma‐related stimuli and at the end of the recovery phase. Compared to controls, participants with probable PTSD showed a greater increase in fear from baseline to stimulus presentation, d = 0.606. Compared to participants with low emotion regulation capacity, participants with high emotion regulation capacity showed a smaller reduction in anger from stimulus presentation to recovery, d = 0.548. Our findings indicated that following exposure to trauma‐related stimuli, probable PTSD diagnosis predicted increased fear reactivity, and low emotion regulation capacity predicted decreased anger recovery. Impaired anger recovery following trauma reminders in the context of low emotion regulation capacity might contribute to the increased levels of anger found in postconflict samples.     

Technology‐Enhanced Stepped Collaborative Care Targeting Posttraumatic Stress Disorder and Comorbidity After Injury: A Randomized Controlled Trial

Posttraumatic stress disorder (PTSD) and its comorbidities are endemic among injured trauma survivors. Previous collaborative care trials targeting PTSD after injury have been effective, but they have required intensive clinical resources. The present pragmatic clinical trial randomized acutely injured trauma survivors who screened positive on an automated electronic medical record PTSD assessment to collaborative care intervention (n = 60) and usual care control (n = 61) conditions. The stepped measurement‐based intervention included care management, psychopharmacology, and psychotherapy elements. Embedded within the intervention were a series of information technology (IT) components. PTSD symptoms were assessed with the PTSD Checklist at baseline prerandomization and again, 1‐, 3‐, and 6‐months postinjury. IT utilization was also assessed. The technology‐assisted intervention required a median of 2.25 hours (interquartile range = 1.57 hours) per patient. The intervention was associated with modest symptom reductions, but beyond the margin of statistical significance in the unadjusted model: F(2, 204) = 2.95, p = .055. The covariate adjusted regression was significant: F(2, 204) = 3.06, p = .049. The PTSD intervention effect was greatest at the 3‐month (Cohen's effect size d = 0.35, F(1, 204) = 4.11, p = .044) and 6‐month (d = 0.38, F(1, 204) = 4.10, p = .044) time points. IT‐enhanced collaborative care was associated with modest PTSD symptom reductions and reduced delivery times; the intervention model could potentially facilitate efficient PTSD treatment after injury.     

Effects of Threat Context,Trauma History,and Posttraumatic Stress Disorder Status on Physiological Startle Reactivity in Gulf War Veterans

In the current study, we explored exaggerated physiological startle responses in posttraumatic stress disorder (PTSD) and examined startle reactivity as a biomarker of PTSD in a large veteran sample. We assessed heart rate (HR), skin conductance (SC), and electromyographic (EMG) startle responses to acoustic stimuli under low‐, ambiguous‐, and high‐threat conditions in Gulf War veterans with current (n = 48), past (n = 42), and no history of PTSD (control group; n = 152). We evaluated PTSD status using the Clinician‐Administered PTSD Scale and trauma exposure using the Trauma History Questionnaire. Participants with current PTSD had higher HR, ds = 0.28–0.53; SC, d = 0.37; and startle responses than those with past or no history of PTSD. The HR startle response under ambiguous threat best differentiated current PTSD; however, sensitivity and specificity analyses revealed it to be an imprecise indicator of PTSD status, ROC AUC = .66. Participants with high levels of trauma exposure only showed elevated HR and SC startle reactivity if they had current PTSD. Results indicate that startle is particularly elevated in PTSD when safety signals are available but a possibility of danger remains and when trauma exposure is high. However, startle reactivity alone is unlikely to be a sufficient biomarker of PTSD.     

Structured Approach Therapy for Combat‐Related PTSD in Returning U.S. Veterans: Complementary Mediation by Changes in Emotion Functioning

To address the impact of combat‐related posttraumatic stress disorder (PTSD) on U.S. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans, the investigators developed a 12‐session manualized PTSD treatment for couples called structured approach therapy (SAT). A randomized controlled trial had shown that 29 OEF/OIF veterans with combat‐related PTSD who had participated in SAT showed significantly greater reductions in PTSD compared to 28 veterans receiving a 12‐session PTSD family education intervention (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). We conducted supplemental follow‐up and mediation analyses, which tested the hypothesis that changes in emotion functioning play a significant role in the decreases in PTSD symptoms primarily observed in veterans who had received SAT. Veterans assigned to the SAT condition showed significantly greater decreases than those assigned to PTSD family education in emotion regulation problems (p < .001, Cohen's f² = .18) and fear of intense emotions (p < .001, Cohen's f² = .152). Decreases in both emotion regulation problems (mediated effect:= .36), and fear of intense emotions (mediated effect: = .24) were found to be complementary mediators of reductions in PTSD symptoms greater with SAT. These findings suggest that SAT may aid veterans in improving their ability to regulate trauma‐related emotions.     

Impact of Self‐Blame on Cognitive Processing Therapy: A Comparison of Treatment Outcomes

Research suggests that cognitive processing therapy (CPT) may be a particularly well‐suited intervention for trauma survivors who endorse self‐blame; however, no study has examined the impact of self‐blame on response to CPT. Accordingly, the current study compared response to CPT between two groups of veterans seeking residential treatment for posttraumatic stress disorder (PTSD). In one group, participants endorsed low self‐blame at pretreatment (n = 133) and in the other group, participants endorsed high self‐blame (n = 133). Results from multilevel modeling analysis suggest that both groups experienced significant reductions in PTSD symptoms as measured by the PTSD Checklist, B = ?1.58, SE = 0.11; 95% CI [?1.78, ?1.37]; t(1654) = ?14.97, p < .001. After controlling for pretreatment symptom severity and additional covariates, there was no difference in treatment response between the low‐ and high‐self‐blame groups, Time × Self‐blame interaction: B = 0.18, SE = 0.12; 95% CI = [?0.06, 0.42]; t(1646) = 1.49, p = .138. This suggests that CPT is an effective treatment for individuals exposed to trauma, regardless of level of self‐blame.     

The Effectiveness of Eye Movement Desensitization and Reprocessing Therapy to Treat Symptoms Following Trauma in Timor Leste

The effectiveness of eye movement desensitization and reprocessing (EMDR) therapy for treating trauma symptoms was examined in a postwar/conflict, developing nation, Timor Leste. Participants were 21 Timorese adults with symptoms of posttraumatic stress disorder (PTSD), assessed as those who scored ≥2 on the Harvard Trauma Questionnaire (HTQ). Participants were treated with EMDR therapy. Depression and anxiety symptoms were assessed using the Hopkins Symptom Checklist. Symptom changes post‐EMDR treatment were compared to a stabilization control intervention period in which participants served as their own waitlist control. Sessions were 60–90 mins. The average number of sessions was 4.15 (SD = 2.06). Despite difficulties providing treatment cross‐culturally (i.e., language barriers), EMDR therapy was followed by significant and large reductions in trauma symptoms (Cohen's d = 2.48), depression (d = 2.09), and anxiety (d = 1.77). At posttreatment, 20 (95.2%) participants scored below the HTQ PTSD cutoff of 2. Reliable reductions in trauma symptoms were reported by 18 participants (85.7%) posttreatment and 16 (76.2%) at 3‐month follow‐up. Symptoms did not improve during the control period. Findings support the use of EMDR therapy for treatment of adults with PTSD in a cross‐cultural, postwar/conflict setting, and suggest that structured trauma treatments can be applied in Timor Leste.     

Positive Emotion Dysregulation Among Community Individuals: The Role of Trauma Exposure and Posttraumatic Stress Disorder

Existing literature has provided support for an association between posttraumatic stress disorder (PTSD) and emotion dysregulation. However, few studies have examined the relation between PTSD and emotion dysregulation that stems from positive emotions. Moreover, the role of trauma exposure, per se, on positive emotion dysregulation is unknown. Addressing these limitations, the current study compared levels of positive emotion dysregulation among (a) individuals without trauma exposure, (b) trauma-exposed individuals without probable PTSD, and (c) trauma-exposed individuals with probable PTSD. Participants were 400 community-dwelling individuals (M age = 43.76 years, 68.6% female; 24.2% Asian, 23.7% Black, 24.5% Hispanic, 27.6% White). Lower levels of positive emotion dysregulation were found among trauma-exposed participants without probable PTSD compared to trauma-exposed participants with probable PTSD, ds = 0.66–0.73, and unexposed participants, ds = 0.58–0.64. The present findings suggest the potential protective role of low levels of positive emotion dysregulation following trauma exposure. If replicated in longitudinal studies, these results may indicate the utility of enhancing skills for regulating positive emotions among individuals at risk for trauma exposure.     

Posttraumatic Stress Disorder and Complex Posttraumatic Stress Disorder in DSM‐5 and ICD‐11: Clinical and Behavioral Correlates

The American Psychiatric Association and the World Health Organization provide distinct trauma‐based diagnoses in the fifth edition of the Diagnostic and Statistical Manual (DSM‐5), and the forthcoming 11th version of the International Classification of Diseases (ICD‐11), respectively. The DSM‐5 conceptualizes posttraumatic stress disorder (PTSD) as a single, broad diagnosis, whereas the ICD‐11 proposes two “sibling” disorders: PTSD and complex PTSD (CPTSD). The objectives of the current study were to: (a) compare prevalence rates of PTSD/CPTSD based on each diagnostic system; (b) identify clinical and behavioral variables that distinguish ICD‐11 CPTSD and PTSD diagnoses; and (c) examine the diagnostic associations for ICD‐11 CPTSD and DSM‐5 PTSD. Participants in a predominately female clinical sample (N = 106) completed self‐report scales to measure ICD‐11 PTSD and CPTSD, DSM‐5 PTSD, and depression, anxiety, borderline personality disorder, dissociation, destructive behaviors, and suicidal ideation and self‐harm. Significantly more people were diagnosed with PTSD according to the DSM‐5 criteria (90.4%) compared to those diagnosed with PTSD and CPTSD according to the ICD‐11 guidelines (79.8%). An ICD‐11 CPTSD diagnosis was distinguished from an ICD‐11 PTSD diagnosis by higher levels of dissociation (d = 1.01), depression (d = 0.63), and borderline personality disorder (d = 0.55). Diagnostic associations with depression, anxiety, and suicidal ideation and self‐harm were higher for ICD‐11 CPTSD compared to DSM‐5 PTSD (by 10.7%, 4.0%, and 7.0%, respectively). These results have implications for differential diagnosis and for the development of targeted treatments for CPTSD.     

Couple Treatment for Alcohol Use Disorder and Posttraumatic Stress Disorder: Pilot Results From U.S. Military Veterans and Their Partners

We studied 13 U.S. male military veterans and their female partners who consented to participate in an uncontrolled trial of couple treatment for alcohol use disorder and posttraumatic stress disorder (CTAP). CTAP is a 15‐session, manualized therapy, integrating behavioral couples therapy for alcohol use disorder (AUD) with cognitive–behavioral conjoint therapy for posttraumatic stress disorder (PTSD). Due to ineligibility (n = 1) and attrition (n = 3), 9 couples completed the study, and 7 completed 12 or more sessions. There were 8 veterans who showed clinically reliable pre‐ to posttreatment reduction of PTSD outcomes. There were also significant group‐level reductions in clinician‐, veteran‐, and partner‐rated PTSD symptoms (d = 0.94 to 1.71). Most veterans showed clinically reliable reductions in percentage days of heavy drinking. Group‐level reduction in veterans’ percentage days of heavy drinking was significant (d = 1.01). There were 4 veterans and 3 partners with clinically reliable reductions in depression, and group‐level change was significant for veterans (d = 0.93) and partners (d = 1.06). On relationship satisfaction, 3 veterans and 4 partners had reliable improvements, and 2 veterans and 1 partner had reliable deterioration. Group‐level findings were nonsignificant for veteran relationship satisfaction (d = 0.26) and for partners (d = 0.52). These findings indicate that CTAP may be a promising intervention for individuals with comorbid PTSD and AUD who have relationship partners.     

Gender Differences in Neurocognitive Performance Among Children With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are frequent sequelae after motor vehicle accidents (MVAs). These two pathologies often have overlapping neurocognitive deficits across several domains, such as attention, memory, and executive functions. The present study was an effort to examine the contribution of gender to these overlapping symptoms. To this end, psychodiagnostic and neuropsychological data were collected on 61 children and adolescents 3 months following MVA. All participants were diagnosed with PTSD, and about half (n = 33) also received a diagnosis of mTBI. Analyses of variance revealed significant interactions between gender and mTBI (), such that girls with mTBIs preformed significantly worse than noninjured girls on measures of executive functions (Cohen's d = 3.88) and sustained attention (Cohen's d = 3.24). Boys, on the other hand, did not differ significantly on any of those measures, irrespective of TBI injury status. Similarly, comparisons to the normative population revealed that, whereas boys showed impaired neurocognitive performances regardless of TBI status, impaired performances in girls were limited to those cases in which the girls were comorbid for PTSD and mTBI. It appears then that whereas PTSD alone might explain boys’ reduced neurocognitive performance, among girls the comorbidity of PTSD and mTBI is required to account for performance deficits.     

Associations Among Hair Cortisol Concentrations,Posttraumatic Stress Disorder Status,and Amygdala Reactivity to Negative Affective Stimuli in Female Police Officers

Posttraumatic stress disorder (PTSD) is associated with altered hypothalamic‐pituitary‐adrenal (HPA) axis function. Measurement of hair cortisol concentrations (HCC) allows retrospective assessment of HPA axis regulation over prolonged periods of time. Currently, research investigating HCC in PTSD remains sparse. Previous cross‐sectional studies have included only civilian populations, although it is known that trauma type moderates associations between PTSD status and HPA axis function. We investigated differences in HCC between trauma‐exposed female police officers with current PTSD (n = 13) and without current and lifetime PTSD (n = 15). To investigate whether HCC was associated with neural correlates of PTSD, we additionally performed exploratory correlational analyses between HCC and amygdala reactivity to negative affective stimuli. We observed significantly lower HCC in participants with PTSD than in participants without PTSD, d = 0.89. Additionally, within participants with PTSD, we observed positive correlations between HCC and right amygdala reactivity to negative affective (vs. happy/neutral) faces, r = .806 (n = 11) and left amygdala reactivity to negative affective (vs. neutral) pictures, r = .663 (n = 10). Additionally, left amygdala reactivity to negative faces was positively correlated with HCC in trauma‐exposed controls, r = .582 (n = 13). This indicates that lower HCC is associated with diminished amygdala differentiation between negative affective and neutral stimuli. Thus, we observed lower HCC in trauma‐exposed noncivilian women with PTSD compared to those without PTSD, which likely reflects prolonged HPA axis dysregulation. Additionally, HCC was associated with hallmark neurobiological correlates of PTSD, providing additional insights into pathophysiological processes in PTSD.     

Cumulative Trauma Exposure,Emotion Regulation,and Posttraumatic Stress Disorder Among Incarcerated Women

Incarcerated women report high rates of trauma exposure and posttraumatic stress disorder (PTSD). Emotion regulation has been identified as a potential mechanism that contributes to the association between trauma exposure and PTSD severity. The present study examined associations among cumulative trauma exposure, emotion regulation difficulties, and current (30‐day) PTSD in 152 randomly selected women in prison. Utilizing structural equation modeling (SEM), results indicated cumulative trauma was significantly associated with emotion regulation difficulties, β = .31, SE = .13, p  = .005; and PTSD symptom severity, β = .41, SE = .14, p  = .005. We identified a significant indirect effect, 0.11, z = 2.37, p = .018, of emotion regulation on the association between cumulative trauma exposure and severity of current PTSD symptoms. These findings are consistent with previous longitudinal research suggesting that emotion regulation is significantly affected by trauma exposure, and they support previously identified associations between emotion regulation difficulties and severity of PTSD. Further, these findings have the potential to inform current efforts to identify and implement effective PTSD‐focused interventions with incarcerated women. In particular, it appears that emotion regulation skills may be an important component of effective PTSD focused interventions for this population.     

Dissociation and Posttraumatic Stress Disorder: A Latent Profile Analysis

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM‐5; American Psychiatric Association, 2013 ) contains a dissociative subtype for posttraumatic stress disorder (PTSD) characterized by significant depersonalization and derealization. In this study the PTSD dissociative subtype was examined using latent profile analysis in a sample of 541 trauma‐exposed college students. Items from the PTSD Checklist and Multiscale Dissociation Inventory were used as latent class indicators. Results supported a 3‐class solution including a well‐adjusted class, a PTSD class, and a PTSD/dissociative class characterized by elevated symptoms of PTSD, depersonalization, and derealization. Significant class differences were found on a number of measures of related psychopathology with Cohen's d effect size estimates ranging from 0.04 to 1.86. Diagnostic and treatment implications regarding the dissociative subtype are discussed.     

Social Anhedonia is Associated with Low Social Network Diversity in Trauma‐Exposed Adults

Social anhedonia has been proposed to contribute to social isolation in several psychiatric disorders, but it has not been examined in relation to deficits in social connection that also characterize posttraumatic stress disorder (PTSD). A growing body of evidence emphasizes the health importance of structural features of social networks, including their size and complexity. The current study examined the association between social anhedonia and social network features in a sample of trauma‐exposed participants with and without PTSD as well as in non–trauma‐exposed controls. Participants (N = 101; n = 37 healthy controls, n = 23 trauma‐exposed without PTSD; n = 41 lifetime PTSD) completed self‐report measures of social anhedonia (Revised Social Anhedonia Scale) and structural social network features, including social network size, diversity, and the number of embedded networks (Social Network Index). Relative to healthy controls, participants with PTSD reported significantly lower social network sizes and fewer embedded networks. In the combined trauma‐exposed sample, higher ratings of social anhedonia were associated with lower social network diversity, r(62) = ?.43, p < .001, an effect that remained statistically significant after controlling for PTSD and depression symptom severity. These results suggest that elevated social anhedonia in trauma‐exposed individuals may contribute to disruptions in social network structure consistent with social isolation.     

Gender Differences in Threat Biases: Trauma Type Matters in Posttraumatic Stress Disorder

Women are diagnosed with posttraumatic stress disorder (PTSD) at twice the rate of men. This gender difference may be related to differences in PTSD experiences (e.g., more hypervigilance in women) or types of trauma experienced (e.g., interpersonal trauma). We examined whether attentional threat biases were associated with gender, PTSD diagnosis, and/or trauma type. Participants were 70 civilians and veterans (38 women, 32 men; 41 with PTSD, 29 without PTSD) assessed with the Clinician Administered PTSD Scale for DSM‐IV who completed a facial dot‐probe attention bias task and self‐report measures of psychiatric symptoms and trauma history. Factorial ANOVA and regression models examined associations between gender, PTSD diagnosis, index trauma type, lifetime traumatic experiences, and attentional threat biases. Results revealed that compared to women without PTSD and men both with and without PTSD, women with PTSD demonstrated attentional biases toward threatening facial expressions, d = 1.19, particularly fearful expressions, d = 0.74. Psychiatric symptoms or early/lifetime trauma did not account for these attentional biases. Biases were related to interpersonal assault index traumas, η_p² = .13, especially sexual assault, d = 1.19. Trauma type may be an important factor in the development of attentional threat biases, which theoretically interfere with trauma recovery. Women may be more likely to demonstrate attentional threat biases due to higher likelihood of interpersonal trauma victimization rather than due to gender‐specific psychobiological pathways. Future research is necessary to clarify if sexual assault alone or in combination with gender puts individuals at higher risk of developing PTSD.     

The Neurocognitive Performance of Female Veterans With Posttraumatic Stress Disorder

Neurocognitive problems are common with posttraumatic stress disorder (PTSD) and are important to understand because of their association with the success of PTSD treatment and its potential neural correlates. To our knowledge, this is the first neurocognitive study in an all‐female U.S. veteran sample, some of whom had PTSD. We examined neurocognitive performance and assessed whether learning deficits, common in PTSD, were associated with executive functioning. Veterans with PTSD (n = 56) and without (n = 53) were evaluated for psychiatric and neurocognitive status. The PTSD group had a lower estimated IQ (d = 0.53) and performed more poorly on all neurocognitive domains (d range = 0.57–0.88), except verbal retention (d = 0.04). A subset of the 2 groups that were matched on IQ and demographics similarly demonstrated poorer performance for the PTSD group on all neurocognitive domains (d range = 0.52–0.79), except verbal retention (d = 0.15). Within the PTSD group, executive functioning accounted for significant variance in verbal learning over and above IQ and processing speed (ΔR² = .06), as well as depression (ΔR² = .07) and PTSD severity (ΔR² = .06). This study demonstrated that female veterans with PTSD performed more poorly than females without PTSD on several neurocognitive domains, including verbal learning, processing speed, and executive functioning. Replication of these results using a control group of veterans with more similar trauma exposure, history of mild traumatic brain injury, and psychiatric comorbidities would solidify these findings.     

The Ending Self‐Stigma for Posttraumatic Stress Disorder (ESS‐P) Program: Results of a Pilot Randomized Trial

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self‐stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self‐Stigma for PTSD (ESS‐P) program, a nine‐session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self‐stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS‐P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self‐stigma, self‐efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self‐stigma, d = ?0.77, and symptoms of depression, d = ?0.76, along with significant increases in general and social self‐efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS‐P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS‐P may help reduce self‐stigma and improve self‐efficacy and a sense of belonging in veterans with PTSD.     

Military and Premilitary Trauma,Attachment Orientations,and Posttraumatic Stress Disorder Severity Among Male and Female Veterans

Samples in prior studies examining attachment theory in the military have been predominantly composed of male combat veterans. Given the rates of sexual trauma among female veterans and differences in the association between attachment and posttraumatic stress disorder (PTSD) severity for sexual trauma survivors, it was necessary to consider the attachment characteristics of veterans within a mixed‐sex sample. Participants were a mixed‐sex veteran sample seeking inpatient trauma‐related treatment (N = 469). Using independent samples t tests, we examined sex differences in attachment. Consistent with our hypothesis, women reported a higher level of attachment anxiety than did men, t(351) = ?2.12, p = .034. Women also reported a higher level of attachment avoidance, t(351) = ?2.44, p = .015. Using hierarchical regression, we examined the contribution of attachment anxiety and avoidance to PTSD severity, partialing out variance accounted for by demographic variables and traumatic experiences. Consistent with our hypotheses, attachment avoidance predicted PTSD severity on the Clinician‐Administered PTSD Scale for DSM‐IV (CAPS), β = .20, p < .001, and the PTSD Checklist–Civilian Version (PCL‐C), β = .18, p < .001. Attachment anxiety did not predict CAPS severity but did predict PCL‐C severity, β = .11, p = .020. These results suggest the association between attachment avoidance and PTSD is not exclusive to combat trauma and may apply more generally to the larger veteran population. Higher levels of attachment anxiety and avoidance among female veterans potentially implicate the presence of greater attachment fearfulness among this particular subpopulation of veterans.