*Article* **Vulnerability Factors Associated with Lifetime Posttraumatic Stress Disorder among Veterans 40 Years after War**

### **Ivone Castro-Vale 1,\*, Milton Severo 2, Davide Carvalho 3 and Rui Mota-Cardoso 4**

Received: 14 August 2020; Accepted: 22 September 2020; Published: 24 September 2020

**Abstract:** Vulnerability factors for posttraumatic stress disorder (PTSD) development are still controversial. Our aim was to study the vulnerability factors for the development of war-related PTSD over a period of 40 years after exposure. A cross-sectional, observational study was carried out on 61 male traumatized war veterans, taking into consideration adverse childhood experiences (ACE), attachment orientations, number of non-war-related traumatic events, and war experiences. Lifetime PTSD was assessed by using the Clinician-Administered PTSD Scale. Insecure attachment styles were significantly associated with lifetime PTSD and even after adjustment for war exposure this was still significant. Non-war-related traumatic events were not associated with lifetime PTSD, whereas ACE were associated with lifetime PTSD. War-related experiences were also associated with lifetime PTSD, except for injury or disease. The results for our sample show that, 40 years after war, the intensity of war-related experiences and ACE were significantly and independently associated with the development of lifetime PTSD. Insecure attachment was significantly associated with lifetime PTSD, which, in turn, are both positively associated with war exposure. These findings may have implications for patient care, as they constitute a strong argument that attachment-focused therapies could well be necessary 40 years after trauma.

**Keywords:** posttraumatic stress disorder; war veterans; trauma and stressor related disorders; adverse childhood experiences; attachment