Trauma, Anger, and Recovery in Veterans: A Mediation Analysis of PTSD and AUD Outcomes

Background and Purpose:
Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur among military veterans, yet clinical approaches often fail to address their shared underlying mechanisms. Emotional dysregulation, particularly anger, may serve as a key link between trauma exposure and these outcomes. Grounded in the Emotion Dysregulation Model, this study examined whether anger mediates the relationship between adverse childhood experiences (ACEs), military sexual trauma (MST), and combat trauma with PTSD and AUD symptoms in a large, longitudinal sample of U.S. veterans.

Methods:
The sample consisted of veterans aged 18 - 40 (n = 1,230) recruited in February 2020 as a part of an extensive survey study of veteran attitudes and health behavior. Veterans completed follow-up assessments at 6, 9, 12, 18, and 24 months. Trauma exposures (ACEs, MST, combat) were measured at Time 1; anger at Time 4; and PTSD and AUD symptoms at Time 6. PTSD was assessed using the PCL-5, AUD using the AUDIT, and anger using the DAR-R scale. A path analysis tested whether anger mediated trauma–mental health associations, controlling for demographics, prior levels of outcomes and anger, and using full-information maximum likelihood estimation and bootstrapped confidence intervals.

Results:
Model fit was excellent (CFI = 0.97, RMSEA = 0.060, SRMR = 0.04). Anger significantly mediated the effect of ACEs on PTSD (B = 0.22, 95% CI [0.085, 0.341]) and AUD (B = 0.025, 95% CI [0.027, 0.124]), and the effect of combat trauma on PTSD (B = 0.07, 95% CI [0.001, 0.127]). The direct effect of ACEs on PTSD remained significant, indicating partial mediation, while effects from combat trauma to PTSD and ACEs to AUD were fully mediated by anger. MST was not significantly associated with PTSD or AUD through anger.

Conclusions and Implications:
Findings indicate that anger is a key pathway through which childhood and combat trauma contribute to both PTSD and AUD, aligning with emotion regulation theory by underscoring anger dysregulation as a shared mechanism in the development of trauma-related psychopathology. In contrast, the emotional pathways linking MST to these outcomes may differ. While MST has been associated with a broad range of psychological consequences, its relationship to PTSD and AUD may be more strongly mediated by other emotions (e.g., shame, guilt, depression, betrayal) or shaped by identity-based vulnerabilities, such as gender and sexual orientation—highlighting the need for more intersectional, trauma-specific approaches.

From a clinical standpoint, these findings support the relevance of interventions that target anger regulation. Evidence-based therapies that incorporate anger management modules may be especially beneficial for veterans with histories of ACEs and combat trauma. Importantly, trauma-informed treatments should continue to be adapted to reflect the unique emotional sequelae of different trauma types, especially MST.