The generation that lived during/participated in the war and the generation that inherited it: association between veterans PTSD and adult offspring’s emotional regulation strategies and alexithymia levels

El Moujabber et al. BMC Psychiatry (2023) 23:599 https://doi.org/10.1186/s12888-023-05087-y BMC Psychiatry RESEARCH Open Access The generation that lived during/participated in the war and the generation that inherited it: association between veterans PTSD and adult offspring’s emotional regulation strategies and alexithymia levels Perla El Moujabber1, Vanessa Homsi2, Souheil Hallit3,4,5*† and Sahar Obeid2*† Abstract Background The long-term repercussions that war can have on both war generations and post-war generations lack in the literature. It is imperative to understand the psychological consequences of the Lebanese Civil War that took place from 1975 to 1990, on the offspring of those who took part in it. Accordingly, the objective of this study was to assess the association between paternal/veterans PTSD and adult offspring’s emotional regulation strategies and alexithymia levels, 30 years after the end of war. Method A cross-sectional study was carried out between September 2020 and September 2021 on a sample of 75 fathers of Lebanese former veterans and paramilitary veterans and their adult offspring. For the veterans and paramilitary veterans’ population, the PTSD Checklist was used to assess post-traumatic stress disorder, and the Combat Exposure Scale (CES) was used to measure the level of combat exposure. For the offspring population, the Emotional Regulation Questionnaire (ERQ) was used to assess emotional regulation strategies and the Toronto Alexithymia Scale (TAS) was used to measure the levels of alexithymia. Results Paternal PTSD (Beta = 10.19) was associated with higher levels of alexithymia in the offspring population. Regarding emotional regulation strategies, results showed that paternal PTSD (Beta = -3.24) was significantly associated with a decrease in the cognitive reappraisal score in the offspring. Also, paternal PTSD (Beta = 4.57) was significantly associated with an increase in expressive suppression score. Additionally, an older father’s age (Beta = 1.11) was significantly associated with an increased alexithymia score in the offspring. Moreover, results showed that paternal combat injuries (Beta = -4.24) were significantly associated with a decrease in the alexithymia score in the offspring population and an increase in the expressive suppression score (Beta = 3.28). † Souheil Hallit and Sahar Obeid and are last coauthors. *Correspondence: Souheil Hallit Sahar Obeid Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. El Moujabber et al. BMC Psychiatry (2023) 23:599 Page 2 of 9 Conclusion This study shows that fathers’ traumatic experience of war influences emotion regulation and alexithymia levels in their offspring. Longitudinal studies taking into account the age of the offspring at the time of onset of fathers’ symptoms may provide us with additional information to understand the influence of paternal PTSD on the emotional functioning of offspring during different phases of emotional development. Keywords Post-traumatic stress disorder, Lebanese civil war, Veterans, Offspring, Emotional regulation, Alexithymia Introduction Post-Traumatic Stress Disorder (PTSD) is a psychiatric disorder that can occur in people across all ages, cultures, or gender who have experiences or witnessed a traumatic event [1]. In a military context, trauma can occur following a threat to life through participation in armed combat or other military activities: patrols, espionage, and dangerous tasks. War-related traumatic events constitute the highest conditional risk for the development of PTSD [2]. The risk of developing PTSD in the military context depends on several factors, and largely depends on the level of stress and social support received after deployment [3]. Deployment to war primarily occurs in early adulthood, which is normally the time when combatants start their families, making the offspring population particularly vulnerable to the effects of war-related trauma. This vulnerability could be a consequence of altered combatant behavior, psychopathology regarding parenting, or secondary trauma [4]. In this line, PTSD can lead to negative alterations in an individual’s behavior, including increased anger and reactivity, as well as social withdrawal [1]. For example, the tendency to rely on strategies such as emotional numbing appears to have a ‘particularly detrimental effect on the quality of the veteran-child relationship’ [5]. Growing up in an aggressive, stressful and unpredictable family environment can have detrimental consequences on the future life of the child [6]. Characteristics of emotional numbness, such as unavailability, detachment, and disinterest as well as difficulty experiencing positive emotions, are closely linked to interpersonal impairment which consequently reduces a parent’s ability to participate and enjoy interactions with their child, thus diminishing the possibility of establishing a meaningful relationship [7]. Furthermore, withdrawal, isolation, inability to express emotions [5, 7], overprotection and excessive control of the child [8] are some of the difficulties experienced by veterans when trying to function within the family system. In such family environments, important child developmental processes are particularly disrupted, such as attachment, separation, and individualization [9]. Childhood and adolescence are particularly critical developmental stages [10], and disruptions experienced at these stages affect subsequent education, socialization and functioning in adulthood. As extensive research points out, the trauma of fighters (or parental PTSD) can impact their offspring, which can lead to later developmental, psychological, emotional, behavioral, and social difficulties [11–15]. One of these long-term impacts that need to be studied are dysfunctional emotions such as emotional identification and regulation (...truncated)