**4. Discussion**

We found that attachment orientations were associated with lifetime PTSD, particularly the insecure attachment styles. When adjusted for war exposure, this association decreased, but was still present. This means that war exposure is a confounder of the association between attachment and PTSD, or in other words, war exposure is associated with attachment and also with lifetime PTSD.

According to the attachment theory, insecure attachment is a risk factor for the development and increase in PTSD symptoms. However, Solomon et al. [21] found that PTSD symptoms predict attachment patterns better than attachment predicts PTSD symptoms. On the other hand, a longitudinal study concluded that PTSD symptoms both influenced, and were influenced by, attachment patterns, and that attachment insecurity contributes to maintaining PTSD symptoms over time [20]. Recent cross-sectional studies have found associations between attachment styles and war-related PTSD, however the design of these studies does not permit one to draw conclusions on causality e.g., [18,19]. As our study does not also allow one to make conclusions about causality, longitudinal studies should be pursued in order to clarify these relationships further.

Considering Bartholomew's [46] styles, in our study, the group of participants with the secure attachment style had a lower prevalence of lifetime PTSD than those with dismissing and fearful styles. These findings are probably related with the high association that we found between the avoidance dimension and PTSD. Clark and Owens [18] also found that the highest association with PTSD symptom severity was for avoidance attachment. As they argue, attachment avoidance may have some overlap with the avoidant and numbing PTSD symptoms, and it has been suggested that these increase across time [48]. A recent meta-analysis of the relationship between adult attachment style and post-traumatic stress symptoms found a modest overall population e ffect size for avoidant attachment [49]. In our study, all participants with the fearful style had lifetime PTSD. Other studies have found fearful style to be associated with the highest scores for PTSD symptoms (e.g., [19,49]). Studies of non-clinical and non-war-related PTSD samples also found associations between attachment and PTSD symptoms [50]—particularly associations with the dismissing and fearful styles [17,51]. Furthermore, a recent meta-analysis found that the study design (cross-sectional, longitudinal, controlled comparison, or intervention) does not moderate the relationship between insecure attachment and overall PTSD symptoms [49].

Forty years after the war ended, veterans from the study sample with lifetime PTSD demonstrate insecure attachment patterns. This finding supports the argumen<sup>t</sup> that specific psychotherapeutic interventions focusing on attachment organization [52–54] should be pursued with these patients, as attachment orientation modification was evident in one PTSD sample after exposure psychotherapy [55]. Such interventions could have consequences both in modifying PTSD symptoms, and also for the formation of a therapeutic relationship, which is also important for recovery. Furthermore, the availability of improving psychotherapeutic interventions for PTSD patients of this age group, such as prolonged exposure therapy, is required—as treatment gains do not appear to be maintained at six-months follow-up [56,57]. Independently of the possible causal relationships between attachment and PTSD, existing studies show that attachment-focused therapeutic interventions can improve PTSD symptoms [58,59]. Additionally, an attachment-directed psychotherapy model has been proposed, which is supported by the relationship between war-related TEs and "moral injury" [53]. Furthermore, one study found that attachment style can predict treatment outcome, and thus improve our knowledge with regards to which psychotherapy works best for whom, and which can be more cost-effective [60]. However, more studies are needed to help us better understand how attachment-focused interventions can be used in clinical practice with PTSD patients.

In our research, we found that total childhood adversity, and particularly, emotional abuse and physical neglect were significantly associated with lifetime PTSD development assessed 40 years after war-related TEs. The association between total childhood adversities and PTSD development was independent of total war experiences.

Another recent cross-sectional study of veterans of the Portuguese colonial wars found that those with PTSD (recruited from the Psychiatry Department of one military hospital) reported significantly higher total ACE scores, and, specifically, a greater level of childhood emotional and physical abuse than those without PTSD (recruited from a snowball sample) [61]. A study of a representative sample of veterans of the same wars found low, but significant correlations between childhood abuse and neglect and PTSD symptoms [32].

Our findings are similar to those of a longitudinal study that assessed ACE before deployment to military conflicts, which found that those who reported ACE in more than one category were at an increased risk of developing post-deployment PTSD—with the strongest association being for physical neglect [26]. Other studies found that the number of childhood traumatic experiences was significantly higher in the group of participants who developed post-deployment PTSD symptoms [62] and that this significantly predicted a high level of PTSD symptoms [23]. ACE could be linked to the increased risk of PTSD development through negative influences on attachment orientations [22], among other causes.

We found that lifetime non-war-related TEs, either before or after war, were not associated with lifetime PTSD, which is contrary to the current belief that prior traumatization [4] and additional life stress [63] are risk factors for developing PTSD. Recent studies have found that prior experience of TEs in the absence of subsequent PTSD development is not a risk factor for PTSD development [64,65]. In our study, prior PTSD was not probable, as all the veterans self-reported good mental health before going to war.

In this study, we specifically assessed TEs as defined by criterion A of the DSM-IV PTSD diagnostic criteria. This criterion enables the evaluation of only those TEs that can cause PTSD, according to DSM-IV. Other studies use a much broader concept of traumatization [66]—or they simply do not define prior TE [67]. In addition, the meta-analysis of Ozer et al. [4] found that the relationship between prior trauma and PTSD was stronger if PTSD resulted from non-combat interpersonal violence, rather than if it resulted from combat exposure.

Combat-related trauma severity is a well-known risk factor for PTSD development [29,63]. We found that all types of war-related experiences were significantly positively associated with lifetime PTSD development, except for the case of war-related experiences of injury or disease. This finding is interesting, as this experience could represent a direct threat to life, although maybe this was experienced by the majority of war veterans, as it meant the end of the war for them. Different results were reported [28], which did not find that combat exposure increases the risk of developing PTSD symptoms, however certain specific war experiences did—such as being wounded or injured and killing an enemy. Further research of this subdomain is warranted, separating injury from disease.

Several recent longitudinal studies have shown similar results to our study. Carrying out a combat role during deployment was significantly associated with probable PTSD [68]. The frequency and intensity of combat were strong predictors of new-onset probable PTSD—specifically the experience of killing [29]. Rona et al. [30] found that combat exposure was a strong and specific predictor of PTSD—especially when involving close contact with the enemy.

In our study, action against civilians was significantly associated with lifetime PTSD development, which is a combat experience that has not been independently reported recently (e.g., [29,30]). This is probably one of the war-related experiences which is most prone to cause moral injuries [31].

We found that attachment patterns did not confound or interact with the association between total war experiences and lifetime PTSD. Another study [9] did not find a moderation role for attachment in the association between intimate partner violence and PTSD, while another [11] did for the anxiety and depend dimensions, but not for the close dimension. These discrepancies could be due to the di fferent methodologies and di fferent TEs assessed. War experiences seem to be strong predictors for lifetime PTSD development in our sample, as they are neither influenced by attachment orientations, nor by childhood adversities.

The biggest strength of our study is the fact that we used a valid "gold standard" instrument to diagnose PTSD. The high cut-o ff used increases the specificity of the measure.

A longitudinal prospective study would be far more appropriate as it could investigate causality between attachment patterns and PTSD, but is not possible for the population that we studied. On the other hand, assessment more than 40 years after war could be an advantage, due to the delayed onset of PTSD. As we assessed lifetime PTSD 40 years after exposure has occurred, a long time has elapsed during which PTSD can develop, and, albeit possible, it is less probable that new cases will continue to occur. Furthermore, this population is increasing and is in greater need of care.

We did not assess participants' mental health, in our research, neither working models of attachment before war, and thus could not determine the direction of the associations between PTSD and attachment. Sample size was another limitation. Recall bias might have been a problem in our study, as the colonial wars ended 40 years ago. PTSD symptoms may cause a change in memories of exposure to war [69,70]. However, the way recall bias can influence the associations between war-related TEs and lifetime PTSD is di fficult to ascertain in a cross-sectional study, as changes in memories can reflect dissociation or repression of events that did occur, or even the addition of false memories of events that did not occur [71]. Accordingly, childhood adversity memories can also change over such a long time of assessment after their occurrence and can also be changed by war-related trauma and lifetime PTSD. However, a recent review concluded that prospective and retrospective studies of childhood maltreatment identify di fferent groups of mechanisms underlying psychopathology risk and that both have clinical value as risk indicators [72].

We did not study women, and thus the findings cannot be generalized for this population. The same applies to those with non-Caucasian ethnicity. Furthermore, these results cannot also be generalized for non-war-related PTSD.
