Journal of Trauma & Dissociation

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Trauma Typology as a Risk Factor for Aggression

and Self-Harm in a Complex PTSD Population: The
Mediating Role of Alterations in Self-Perception

Kevin F. W. Dyer BSc PhD DClinPsych , Martin J. Dorahy BA MPhil PhD

DClinPsych , Maria Shannon BA & Mary Corry BA

To cite this article: Kevin F. W. Dyer BSc PhD DClinPsych , Martin J. Dorahy BA MPhil
PhD DClinPsych , Maria Shannon BA & Mary Corry BA (2013) Trauma Typology as a
Risk Factor for Aggression and Self-Harm in a Complex PTSD Population: The Mediating
Role of Alterations in Self-Perception, Journal of Trauma & Dissociation, 14:1, 56-68, DOI:
10.1080/15299732.2012.710184

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Journal of Trauma & Dissociation, 14:56–68, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 1529-9732 print/1529-9740 online
DOI: 10.1080/15299732.2012.710184

Trauma Typology as a Risk Factor

for Aggression and Self-Harm in a Complex
PTSD Population: The Mediating Role
of Alterations in Self-Perception

KEVIN F. W. DYER, BSc, PhD, DClinPsych

Trauma Resource Centre, Belfast HSC Trust, Belfast, Northern Ireland;
and School of Psychology, Queen’s University Belfast, Belfast, Northern Ireland

MARTIN J. DORAHY, BA, MPhil, PhD, DClinPsych

Department of Psychology, University of Canterbury, Christchurch, New Zealand;
and The Cannan Institute, Belmont Private Hospital, Brisbane, Australia

MARIA SHANNON, BA and MARY CORRY, BA

Trauma Resource Centre, Belfast HSC Trust, Belfast, Northern Ireland

This study examined the role of prolonged, repeated traumatic

experiences such as childhood and sectarian trauma in the devel-
opment of posttraumatic aggression and self-harm. Forty-four
adult participants attending therapy for complex trauma in
Northern Ireland were obtained via convenience sampling. When
social desirability was controlled, childhood emotional and phys-
ical neglect were significant correlates of posttraumatic hostility
and history of self-harm. These relationships were mediated by
alterations in self-perception (e.g., shame, guilt). Severity of sectari-
an-related experiences was not related to self-destructive behaviors.
Moreover, none of the trauma factors were related to overt aggres-
sive behavior. The findings have implications for understanding
risk factors for posttraumatic aggression and self-harm, as well as
their treatment.

KEYWORDS PTSD, complex, DESNOS, aggression, hostility,

self-harm, social desirability, shame

Received 20 December 2011; accepted 30 April 2012.

Address correspondence to Kevin F. W. Dyer, BSc, PhD, DClinPsych, School of
Psychology, Queen’s University Belfast, Belfast, BT9 5BP, Northern Ireland. E-mail: dyer@
qub.ac.uk

56
 Journal of Trauma & Dissociation, 14:56–68, 2013 57

Complex posttraumatic stress disorder (PTSD) or disorders of extreme

stress not otherwise specified reflects a complicated, organized set of
reactions to prolonged and repeated interpersonal victimization, often of
early onset (e.g., Courtois & Ford, 2009). Symptoms include (a) alterations
in the regulation of affect and impulses, (b) alterations in consciousness or
attention, (c) alterations in self-perception, (d) alterations in relations with
others, (e) somatization, and (f) alterations in systems of meaning (Pelcovitz
et al., 1997). A recent study of recipients of trauma treatment in Northern
Ireland reported that 75% of respondents were positive for lifetime complex
PTSD (Dorahy et al., 2009). This level of pervasiveness likely reflects the
severe sectarian violence and social deprivation experienced by sections of
the Northern Ireland populace because of the civil upheaval known as the
Troubles. The Troubles was a 30-year period of religious, social, and cultural
conflict (e.g., murder, bombings, guerrilla warfare) between Protestant
Loyalist and Catholic Republican factions in Northern Ireland. Although this
conflict ended officially with the Good Friday peace agreement in 1998,
sporadic violence and unrest still persist in select areas. Prevalence studies
report that 50% of the Northern Irish population have directly experienced
one or more Troubles-related traumata (e.g., bombings) and that more than
3,600 people have been killed in the conflict (Muldoon, Schmid, Downes,
Kremer, & Trew, 2005).
In response to such protracted, multifarious traumata, clients with com-
plex PTSD often exhibit high levels of self-destructive actions and behaviors
(i.e., anger, aggression, self-harm, suicide attempts), more so than single-
incident trauma groups and other mental health populations (Dyer et al.,
2009). However, the specific types of trauma that increase vulnerability
to self-destructive behaviors are ambiguous. No investigation has exam-
ined the role of complex adult trauma (e.g., Troubles-related trauma) in
these difficulties. Current evidence suggests that childhood rather than adult
trauma—particularly sexual abuse—is the most significant risk factor for self-
harm (Bornavalova, Tull, Gratz, Levy, & Lejuez, 2011; Fliege, Lee, Grimm, &
Klapp, 2009). Yet a meta-analysis by Klonsky and Moyer (2008) concluded
that sexual abuse was a weak predictor of self-harm, accounting for no more
than 5% of the variance in self-injurious behavior.
The inconsistent empirical picture of the role childhood trauma plays in
self-harm can be partially explained by moderating and mediating influences.
Gratz and colleagues reported that sexual abuse was a risk factor for self-
harm only in females, whereas physical abuse was the primary risk factor
in males (Gratz & Chapman, 2007; Gratz, Conrad, & Roemer, 2002). Physical
abuse may elicit cognitive-affective changes in males not shared by females,
thus leading to self-harm as a maladaptive coping strategy. This interpretation
implies a mediating relationship between childhood abuse, self-harm, and
negative posttraumatic cognitive-affective processes.
The complex PTSD symptom cluster of alterations in self-perception
may be one potential mediating factor between childhood trauma and
58 K. F. W. Dyer et al.

self-harm. Altered self-perception is a multifactor construct embodying sev-

eral posttraumatic phenomena, including shame, guilt, and a perceived loss
of moral goodness (Pelcovitz et al., 1997). Both guilt and self-perceived bad-
ness have been linked to self-harm (Klonsky, 2007). However, posttraumatic
shame is a particularly salient element of this symptom cluster, as it has
been highlighted as a significant predictor of self-destructive behaviors
over and above other aspects of alterations in self-perception (Budden,
2009). Shame represents a painful, debilitating cognitive-affective experi-
ence that comprises a perception of the self as damaged as well as a
desire to withdraw and hide from others (Tangney & Dearing, 2002).
Childhood abuse, especially sexual abuse, has been cited as a power-
ful influence in the development of trait shame (Kim, Talbot, & Cicchetti,
2009).
In Nathanson’s (1992) compass of shame model, self-harm represents
an “attack self” coping strategy whereby individuals cope with the aver-
sive feeling of shame by engaging in self-harm to punish themselves as a
result of self-loathing or as a means of directly regulating such a diffuse,
unsettling emotion (Gilbert et al., 2010). This mechanism implies that affect
and impulse dysregulation are closely associated with posttraumatic shame.
However, Dyer et al. (2009) revealed that alterations in self-perception,
including shame, predicted self-harm in a complex PTSD sample, whereas
affect and impulse dysregulation was not a significant predictor. To date,
no investigation has conducted a mediational analysis of childhood abuse,
shame, and self-harm in a trauma population.
Shame has also been cited as a mechanism in other posttraumatic self-
destructive behaviors such as aggression. Aggression represents an “attack
other” shame coping strategy in which the affective experience of shame
is externalized and directed toward another person (Nathanson, 1992).
Tangney, Wagner, Hill-Barlow, Marschall, and Gramzow (1996) asserted that
this attack other strategy can manifest in two ways: (a) as “humiliated fury”
that is expunged via direct aggression; and (b) as bitterness and hostility,
but not overt aggressive behavior, that becomes internalized, toxic, and
the subject of rumination. Both mechanisms have received support in non-
clinical populations, yet no investigation has assessed them in traumatized
populations (Tangney, Wagner, Fletcher, & Gramzow, 1992; Tangney et al.,
1996).
The current study aimed to ascertain the types of traumatic experience
presenting as risk factors for posttraumatic self-harm and aggression in a
complex trauma population. An exploratory analysis using the Baron and
Kenny (1986) model of mediation was planned to identify whether shame-
related alterations in self-perception mediated the relationships that both
childhood trauma and Troubles-related trauma have with self-destructive
behaviors. Because the measurement of such socially sensitive variables in
a trauma population has been shown to be strongly influenced by social
desirability (e.g., Dyer et al., 2009), this response bias was also to be
 Journal of Trauma & Dissociation, 14:56–68, 2013 59

controlled. It was hypothesized that childhood and Troubles-related trauma

would be significantly related to posttraumatic self-harm/aggression in a
complex trauma population. It was also predicted that the complex PTSD
symptom of alterations in self-perception would mediate the relationships
between trauma and self-harm/aggression.

METHOD
Participants
This investigation used the same sample as a previous trauma study
(i.e., Dyer et al., 2009). Participants were clients attending therapy for
chronic trauma at an urban community service in Northern Ireland. All
had experienced at least one Troubles-related traumatic event as well as
possible additional traumata. Forty-four participants (35 male, 9 female)
were obtained via convenience sampling. The mean age of participants was
43 years, ranging from 24 to 63 years.
Study inclusion criteria were (a) being 18 to 64 years old and (b) having
experienced one or more Troubles-related traumas. Potential participants
were excluded if they had (a) a learning disability or (b) a degenerative
neurological condition.

Measures
Trauma and PTSD. PTSD and complex PTSD were diagnosed with
the Posttraumatic Diagnostic Scale (Foa, 1995) and Structured Interview for
Disorders of Extreme Stress (SIDES; Pelcovitz et al., 1997), respectively.
The Childhood Trauma Questionnaire (Bernstein & Fink, 1998) was
used to assess five domains of childhood trauma (i.e., emotional abuse, emo-
tional neglect, physical abuse, physical neglect, sexual abuse), whereas the
severity of Troubles-related trauma was gauged with the Troubles-Related
Experiences Questionnaire (Dorahy, Shannon, & Maguire, 2007). This
53-item self-report questionnaire assesses the history of aversive incidents
related to the Troubles in both childhood and adulthood. Troubles-related
trauma was defined as any traumatic event that could be experienced as
a direct result of the sectarian conflict in Northern Ireland (e.g., bomb-
ings, paramilitary assaults; Dorahy et al., 2007). The internal reliability of
the scale has been reported as exemplary (i.e., .91–.93; Dorahy et al.,
2007).
The Aggression Questionnaire–short form (Buss & Warren, 2000) mea-
sured the severity of aggressive emotion (i.e., anger), cognition (i.e., hostil-
ity), and three forms of aggressive behavior (i.e., physical aggression, verbal
aggression, and indirect aggression). History of self-harm was assessed using
the self-harm subscale of the Self-Harm Behavior Questionnaire (Gutierrez,
60 K. F. W. Dyer et al.

Osman, Barrios, & Kopper, 2001). Finally, the Version C short form of the
Marlowe-Crowne Social Desirability Scale gauged levels of socially desirable
responding (Reynolds, 1982). This questionnaire was included to control
for the underreporting of socially sensitive information (e.g., aggressive
acts).

Procedure
Participants were given the following measures over three assessments: (a)
the Posttraumatic Diagnostic Scale and SIDES to ascertain trauma diagnosis;
(b) the Marlowe-Crowne Social Desirability Scale–short form, the self-harm
subscale of the Self-Harm Behavior Questionnaire, and the Aggression
Questionnaire–short form; and (c) the Childhood Trauma Questionnaire and
Troubles-Related Experiences Questionnaire.

RESULTS
Trauma History and Diagnosis
Forty-two (95%) of the 44 participants met criteria for PTSD, with 34 (77%)
also meeting criteria for lifetime complex PTSD. The two remaining partici-
pants had clinical levels of PTSD symptoms but did not satisfy the Criterion
A descriptor of experiencing fear, helplessness, or horror to meet the full
diagnosis (American Psychiatric Association, 1994). Twenty-eight participants
(64%) had experienced some form of childhood abuse or neglect in addition
to Troubles-related trauma. Rates for the specific childhood traumas were
as follows: emotional abuse, 46%; physical abuse, 41%; sexual abuse, 23%;
emotional neglect, 46%; and physical neglect, 37%.

Aggression, Trauma History, and Social Desirability

Hostility correlated significantly with emotional abuse, physical abuse,
emotional neglect, and physical neglect (see Table 1). All other aggres-
sion subscales exhibited nonsignificant correlations with childhood and
Troubles-related trauma variables. The overall trauma sample mean for
social desirability was 6.1 (SD = 2.6), which was higher than a previ-
ously cited pooled mean obtained from 11 nonclinical samples (M = 5.4,
SD = 3.3; Andrews & Meyer, 2003). Social desirability correlated negatively
with physical abuse, emotional abuse, and all of the aggression subscales.
Consequently, it can be concluded that these variables were influenced by
response bias. In subsequent analyses, social desirability was statistically con-
trolled as a covariate in order to eliminate the confounding effect of this
variable on trauma and aggression ratings.
 TABLE 1 Intercorrelations Between Social Desirability and Childhood Trauma Questionnaire Subscales

Variable 1 2 3 4 5 6 7 8 9 10 11 12

1. Social desirability — −.06 −.35∗ −.29∗ −.11 −.18 −.24 −.46∗∗ −.5∗∗ −.54∗∗ −.41∗∗ −.27∗
2. Troubles-related trauma — .18 .22 .04 .07 .33∗ .1 .15 .11 .09 .15
3. Emotional abuse — .8∗∗ .14 .78∗∗ .58∗∗ .11 .04 .12 .01 .29∗
4. Physical abuse — .16 .61∗∗ .64∗∗ .09 .07 .14 .13 .25∗
5. Sexual abuse — .13 .18 .09 .02 .05 .01 .08
6. Emotional neglect — .62∗∗ .15 .1 .02 .08 .33∗

61
7. Physical neglect — .02 .14 .06 .1 .3∗
8. Physical aggression — .48∗∗ .59∗∗ .55∗∗ .08
9. Verbal aggression — .57∗∗ .65∗∗ .19
10. Indirect aggression — .56∗∗ .21
11. Anger — .44∗∗
12. Hostility —
∗
p < .05, one-tailed.
∗∗
p < .01, one-tailed.
62 K. F. W. Dyer et al.

Mediation of Childhood Trauma and Aggression

Partial correlations between trauma and aggression subscales, controlling for
social desirability, were conducted in order to select trauma variables for
mediation analysis. Trauma variables were selected if (a) they demonstrated
a partial correlation coefficient of >.25 with an aggression subscale and
(b) the correlation was significant (i.e., p < .05). Only one partial correla-
tion between emotional neglect and hostility (rp = .29; df = 41; p = .029) met
these criteria.
Analyses were conducted to identify whether the complex trauma
symptom cluster of alterations in self-perception mediated the relation-
ship between emotional neglect and hostility when social desirability was
controlled. Successful mediation requires the following: (Criterion 1) the
independent variable is significantly related to the dependent variable;
(Criterion 2) the independent variable is significantly related to the medi-
ating variable; (Criterion 3) the mediating variable is significantly related to
the dependent variable; (Criterion 4) when the mediating variable is con-
trolled, the relationships between the independent variable and dependent
variable are appreciably reduced and nonsignificant (Baron & Kenny, 1986;
Holmbeck, 1997).
When social desirability was controlled, a significant partial correla-
tion was obtained between (Criterion 1) emotional neglect and hostility
(rp = .29; df = 41; p = .029), (Criterion 2) emotional neglect and alterations
in self-perception (rp = .40; df = 41; p = .004), and (Criterion 3) alterations in
self-perception and hostility (rp = .29; df = 41; p = .03). Finally, a hierarchical
multiple regression with hostility as the criterion variable and social desirabil-
ity, alterations in self-perception, and emotional neglect as predictor variables
was conducted in order to satisfy Criterion 4 (see Table 2). Social desirabil-
ity, alterations in self-perception, and emotional neglect were entered into
the first, second, and third blocks of the regression, respectively. This model
was significant and accounted for 28% of the variance in hostility. Alterations
in self-perception remained a significant predictor of hostility, whereas the

TABLE 2 Summary of Hierarchical Multiple Regression for the Mediation of Hostility

Block B SE B β R2 p

Block 1 .10 .037

Social desirability −0.39 0.18 −0.32 .037
Block 2 .25 .003
Social desirability −0.29 0.17 −0.23 .1
Alterations in self-perception −1.81 0.64 −0.39 .008
Block 3 .28 .004
Social desirability −0.26 0.17 −0.21 .14
Alterations in self-perception 1.58 0.66 0.34 .02
Emotional neglect 0.1 0.64 0.2 .16
 Journal of Trauma & Dissociation, 14:56–68, 2013 63

association between emotional neglect and hostility became nonsignificant

after alterations in self-perception was controlled, implying mediation.

Self-Harm, Trauma History, and Social Desirability

Twenty-nine participants (66%) reported a history of self-harm. The
presence/absence of a history of self-harm was used as a dichotomous vari-
able in point biserial correlations with social desirability and the trauma
measures. History of self-harm correlated negatively with social desirability
(r = –.34; n = 44; p = .005) and positively with both physical abuse (r = .32;
n = 44; p = .02) and physical neglect (r = .34; n = 44; p = .013).

Mediation of Childhood Trauma and Aggression

Partial point biserial correlations—controlling for social desirability—were
conducted in order to select trauma variables for mediation analysis. Only
one partial correlation between physical neglect and history of self-harm
(rp = .28; df = 41; p = .036) met the selection criteria (i.e., rp > .25; p < .05).
In terms of mediation, a significant partial correlation was obtained
between (Criterion 1) physical neglect and history of self-harm (rp = .28;
df = 41; p = .036), (Criterion 2) physical neglect and alterations in self-
perception (rp = .29; df = 41; p = .03), and (Criterion 3) alterations in
self-perception and history of self-harm (rp = .48; df = 41; p = .001). Criterion
4 was satisfied by conducting a logistic regression with social desirability,
physical neglect, and alterations in self-perception as independent variables
and history of self-harm as the dependent variable. Social desirability and
alterations in self-perception were controlled by entering the variables in
the first and second blocks, respectively. Physical neglect was entered in
the third block (see Table 3). The full model significantly predicted history
of self-harm and accounted for 46% of the variance (omnibus χ 2 = 17.53;

TABLE 3 Summary of Logistic Regression for Variables Predicting History of Self-Harm

Nagelkerke
Block Odds ratio (95% CI) χ 2 (df ) R2 p

Block 1 χ (1) = 5.42

2
.16 .02
Social desirability 0.74 (0.56 − 0.98) .032
Block 2 χ 2 (2) = 15.78 .42 <.0005
Social desirability 0.77 (0.57 − 1.05) .099
Alterations in self-perception 6.15 (1.7 − 22.5) .006
Block 3 χ 2 (3) = 17.53 .46 .001
Social desirability 0.77 (0.55 − 1.08) .13
Alterations in self-perception 4.97 (1.33 − 18.6) .017
Physical neglect 1.18 (0.9 − 1.55) .24
Notes: CI = confidence interval.
64 K. F. W. Dyer et al.

df = 3; p = .001). Physical neglect was no longer significantly related to

history of self-harm with the mediator controlled. However, alterations in
self-perception remained a significant predictor of history of self-harm, indi-
cating that physical neglect indirectly engenders a history of self-harm via
alterations in self-perception.

DISCUSSION

Childhood emotional neglect and physical neglect emerged as the specific

traumatogenic risk factors for posttraumatic hostility and self-harm. However,
these experiences of neglect had little direct influence on such constructs,
accounting for only 3%–4% of the variance. Rather, childhood trauma seems
to have an indirect role, fostering alterations in self-perception, which in
turn increases the likelihood of individuals experiencing hostile cognitions
and engaging in self-harm behaviors.
Hostility was the only aggression correlate of childhood neglect. As a
psychological construct, hostility represents the cognitive component of
aggression and comprises negative appraisals toward others (Buss & Perry,
1992). The link between emotional abuse—as opposed to physical/sexual
abuse—and hostility has received support in the literature (Allen, 2010).
The present findings suggest that childhood emotional neglect, via alter-
ations in self-perception, is instrumental in generating aggressive cognitions
rather than overt aggressive behavior. Alterations in self-perception comprise
guilt, shame, and a belief of being irreparably damaged following trauma.
As theorized by Tangney et al. (1996) and Herman (2011), it is possible that
childhood trauma, specifically emotional neglect, provokes altered, shamed
perceptions of the self that lead to externally and internally directed rumina-
tions of hostility. Such a finding does present some optimism for psycholog-
ical outcome and the treatment of individuals who have experienced child-
hood trauma, as it appears that posttraumatic aggressiveness is not directly
triggered by abuse or predetermined; rather, it operates through the shame-
related complex PTSD symptom cluster of alterations in self-perception,
which is amenable to therapeutic intervention (e.g., Gilbert, 2010).
The physical subtypes of childhood trauma, namely physical abuse
and—most prominently—physical neglect, were significant correlates of self-
harm. As with hostility, the relationship between childhood trauma and
self-harm was indirect and mediated by alterations in self-perception. This
implies that self-harm functions as an “attack self” behavioral manifestation
of internal shame, self-loathing, and self-punishment (Herman, 2011). Self-
harm is not caused by physical neglect per se. Rather, the emergence of
altered, negative perceptions of the self following such abuse experiences is
a critical factor in the development of this self-destructive behavior.
The predominant role of physical neglect as a predictor of history of
self-harm has received modest support (Gladstone et al., 2004). However,
 Journal of Trauma & Dissociation, 14:56–68, 2013 65

the present finding may also be illustrative of gender and methodological

biases in this area. The majority of studies on child maltreatment and self-
harm have been conducted on exclusively female samples (e.g., Kim et al.,
2009), whereas the present study sample was predominantly male, giving
some support to Gratz and Chapman’s (2007) proposal that different abuse
experiences are salient to different genders in terms of psychological impact.
This may also explain the surprisingly limited role of childhood sexual abuse
in predicting both self-harm and aggression in this study. Although some
studies have reported the relationship between sexual abuse and self-harm
to be overinflated (e.g., Klonsky & Moyer, 2008), the vast majority of studies
have found sexual abuse to be the most robust predictor of this behavior
(Fliege et al., 2009; Gratz, 2003). Issues concerning the measurement of sex-
ual abuse may also have played a role in the current finding, as relatively
low rates of childhood sexual abuse were reported. Although sexual abuse
was found not to be influenced by social desirability, it has been reported as
a particularly difficult subtype of abuse to assess validly (Hulme, 2004).
Troubles-related experiences also exhibited no significant relationships
with self-harm or aggression subscales, despite having previously been noted
as a substantial risk factor for the development of complex PTSD (Dorahy
et al., 2009). It may be, however, that Troubles-related experiences are salient
as a risk factor for general complex PTSD symptomatology rather than spe-
cific self-destructive behaviors. Childhood trauma can be regarded as a very
personal type of victimization often perpetrated by a loved one that leads to
shame as well as intimate cognitions and coping strategies such as hostility
and self-harm. Troubles-related experiences typically reflect general, imper-
sonal victimization perpetrated by an outgroup or members of one’s own
community and consequently may not lead to such psychological reactions.
Social desirability was a notable bias accounting for 10% and 16% of the
variance in hostility and self-harm responses, respectively. It also exhibited
correlations with the childhood trauma variables of physical abuse and emo-
tional abuse. It appears therefore that the urge for participants to “fake good”
and downplay the severity of their aggression, self-harm, and childhood
trauma history was significant. This has considerable implications for clini-
cal assessment, as the underrepresentation of severity of abuse history and
self-destructive behaviors can have long-term consequences for therapeutic
outcome (Davis, Thake, & Vilhena, 2010). The inclusion of appropriate social
desirability indices in initial assessment batteries could potentially allow this
topic to be raised sensitively and could lead to a more effective therapeutic
collaboration and prognosis.
The present investigation had a number of limitations. Retrospective
measures of trauma history were used, which, although common, have been
criticized as undermining the utility and validity of findings (Fliege et al.,
2009). The nature of the trauma sample was also limited in a number of
ways, requiring interpretations to be made with caution. The overall sample
size was relatively small, and larger scale studies are required to corroborate
66 K. F. W. Dyer et al.

the current findings. Moreover, the gender balance of the participants was
skewed toward males, which reflects the client demographic of the trauma
service but contrasts with the gender distribution for the prevalence of PTSD
in Northern Ireland (Muldoon et al., 2005). Finally, although the alterations
in self-perception scale of the SIDES is a validated generic measure and
spans several elements of the complex PTSD symptom cluster in addition to
shame, further investigations should be conducted using explicit shame mea-
sures to fully assess the mediating relationship between childhood trauma,
shame, and self-destructive behaviors. It is also still unclear how the sepa-
rate elements of alterations in self-perception (e.g., shame, guilt, loss of moral
goodness, perception of being damaged by trauma) contribute individually,
and in combination, to posttraumatic self-destructive behaviors. Future inves-
tigations may wish to measure each of these concepts and gauge their unique
contribution to self-harm and aggression.
To conclude, the present study found that emotional neglect and physi-
cal neglect do not, in isolation, appreciably increase the risk for hostility and
self-harm respectively. Instead, these traumatic experiences are only signif-
icant if mediated by alterations in self-perception. Essentially, then, discrete
life events and trauma typology may lead to alterations in the regulation
of self-perception, which influences the development of hostility and self-
harm. This interpretation highlights the importance of the development and
application of interventions focused on self-perception (e.g., shame) as well
as its potentially pivotal role in trauma populations and in dealing with self-
destructive behaviors (e.g., Gilbert, 2010; Kluft, 2007). Future research should
focus on progressing these treatment models. The development and empir-
ical evaluation of shame-focused interventions, for example, with complex
trauma populations—as well as the incorporation of elements of such inter-
ventions into traditional phase-oriented treatments for complex PTSD (e.g.,
Steele, Van der Hart, & Nijenhuis, 2004)—would be highly important avenues
of inquiry.

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