[2019] Frequent Lag Spikes - Help please

How much RAM do you have?
Can you post any of your logs? You can find them in %APPDATA%/Fatshark/Vermintide 2/console_logs
P.S. Quality settings shouldn’t really affect RAM usage much, but it should affect VRAM usage a lot

I can see, that you are running with mods.
Try removing all mods and see how it runs. I’ve seen cases before when mods caused severe issues for the game