Journal of Traumatic Stress, Vol. 23, No. 6, December 2010, pp.

767–774 (
C 2010)

Traumatic Stress, Affect Dysregulation, and

Dysfunctional Avoidance: A Structural Equation Model
John Briere
Keck School of Medicine, University of Southern California, Los Angeles

Monica Hodges
Keck School of Medicine, University of Southern California, Los Angeles and California State University,
Long Beach

Natacha Godbout
Keck School of Medicine, University of Southern California, Los Angeles

The multivariate relationship between interpersonal trauma, posttraumatic stress, affect dysregulation, and
various avoidance behaviors was examined in a sample of 418 trauma-exposed participants from the general
population. Structural equation modeling indicated that (a) suicidality, substance abuse, dissociation, and
problematic activities such as self-injury and dysfunctional sexual behaviors were all indicators of a robust latent
variable, named dysfunctional avoidance, (b) accumulated exposure to various types of interpersonal trauma was
associated with this avoidance factor, and (c) the relationship between trauma and dysfunctional avoidance was
independently mediated by both posttraumatic stress and diminished affect regulation capacity.

A substantial body of literature indicates that exposure to Stockton, Goodman, Corcoran, & Petty, 2005). Many of these
traumatic events is associated with a range of psychological out- symptoms appear to be associated with repeated and sustained
comes, including anxiety, depression, posttraumatic stress, somati- child abuse and neglect (van der Kolk et al., 1996), although later
zation, and cognitive distortions (Briere, 2004; Friedman, Keane, interpersonal traumas also may be involved (Ford, 1999).
& Resick, 2007). Studies further suggest a link between expo- As the potentially trauma-related etiology of these symptoms
sure to extended interpersonal victimization and symptoms as- and problems has become more clear, clinicians and theorists have
sociated with borderline personality traits or disorder (Sansone, sought to explain why phenomena as diverse as dissociation, sub-
Songer, & Miller, 2005), including identity disturbance, affect stance abuse, suicidal behavior, and “acting out” behaviors might
dysregulation, and problematic interpersonal relationships (Briere arise from trauma exposure. Suggested in less trauma-related con-
& Rickards, 2007; van der Kolk, Pelcovitz, Roth, Mandel, Mc- texts by Lazarus and Folkman (1984) and Hayes (e.g., Hayes,
Farlane, & Herman, 1996), as well as dissociation (Chu & Dill, Strosahl, & Wilson, 2003), a common but not fully tested view
1990), suicidality (Zlotnick, Donaldson, Spirito, & Pearlstein, is that such behaviors can represent an attempt to cope with trig-
1997), substance abuse (Ouimette & Brown, 2003), and “ten- gered or sustained posttraumatic emotional states, perhaps espe-
sion reduction” behaviors (Briere, 2002a) such as self-mutilation, cially when these states overwhelm internal affect regulation capac-
binge–purge eating, impulsivity, and excessive or dysfunctional ities and thereby motivate the need for avoidance (Briere, 2002a;
sexual activities (e.g., Briere & Rickards, 2007; Green, Krupnick, van der Kolk et al., 1996). From this perspective, certain corre-
lates of trauma exposure can be considered avoidance responses
to the extent that they alter awareness, distract, anesthetize, pro-
Monica Hodges is now at Department of Psychology, California State University, Long Beach,
CA.
duce distress-incompatible states, or temporarily forestall negative
experiences, thereby redirecting attention away from otherwise
John Briere, Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine,
University of Southern California, Los Angeles; Monica Hodges, Department of Psychiatry overwhelming emotions (Briere & Scott, 2006). For example,
and the Behavioral Sciences, Keck School of Medicine, University of Southern California, Los substance abuse, suicidality, dissociation, and tension-reduction
Angeles, and Department of Psychology, California State University, Long Beach; Natacha
behavior are often viewed as avoidance activities by clinicians and
Godbout, Department of Psychiatry and the Behavioral Sciences, Keck School of Medicine,
University of Southern California, Los Angeles. researchers (e.g., Chapman, Gratz, & Brown, 2006; Hayes et al.,
Correspondence concerning this article should be addressed to: John Briere, Psychological 2003; Khantzian, 1997; Schneidman, 1996; Spiegel, 1993). Re-
Trauma Program, 2010 Zonal Ave., 1P51, Los Angeles, CA 90033. E-mail: [email protected]. peated interpersonal trauma may especially motivate avoidance

C 2010 International Society for Traumatic Stress Studies. View this article online at because it appears to both (a) produce enduring negative emo-
wileyonlinelibrary.com DOI: 10.1002/jts.20578 tional states, and (b) disrupt (or inhibit the development of ) the

767
768 Briere, Hodges, and Godbout

biological and psychological components of emotional regulation by the Institutional Review Board of the University of Central
that otherwise serve to equilibrate or downregulate such states Florida, a random sample of registered automobile owners and/or
(Pearlman & Courtois, 2005). individuals with listed telephone numbers was collected by a na-
In support of this view, various studies report an association be- tional sampling service, stratified to match general population
tween interpersonal trauma and posttraumatic stress, affect regula- proportions on sex, age, race, and geographic location. Potential
tion difficulties, and avoidance responses, as noted above. Further, participants were mailed a questionnaire containing demographic
two studies indicate that a count of the number of different types questions and, among other measures, the three tests described
of interpersonal (but not noninterpersonal) traumas experienced above. Participants received $5.00 upon mailing back the question-
by a person is especially predictive of more complex symptoma- naire. To provide additional participants in the lower age ranges,
tology, including dysfunctional behaviors and dissociation (Briere, 70 university students were recruited from college classes and of-
Kaltman, & Green, 2008; Cloitre et al., 2009). Despite these find- fered course credit for completing the same protocol as above, but
ings, however, we know of only one published study that specifi- without financial compensation. All questionnaires were anony-
cally examined the role of trauma-related affect dysregulation and mous, although financial compensation in the general population
posttraumatic stress in the potential development of an avoidance sample was tied to names and addresses that were destroyed before
behavior. In this study (Briere, 2006), logistic regression analysis data analysis.
revealed that posttraumatic stress and affect dysregulation (but not According to the test publisher, the first 558 (10%) of 5,485
their interaction) predicted participants’ elevation on at least one potential participants to respond to an internet inquiry, along with
scale (versus no elevation on any scale) of the Multiscale Disso- the 70 university students, were included in the standardization
ciation Inventory (Briere, 2002b). Although encouraging of the sample. Demographic analysis of the student versus general pop-
avoidance hypothesis, that analysis (a) did not evaluate the full ulation subsamples indicated no differences on relevant variables
range of dissociative symptomatology (only presence or absence other than age, with the exception that women were overrepre-
of one or more scale elevations), (b) was limited to a single form sented relative to men (data on the exact gender ratio for the
of dysfunctional avoidance (e.g., dissociation, as opposed to addi- student sample is unavailable from the test publisher). As is com-
tional responses such as dysfunctional behaviors, substance abuse, mon in Web-based standardization studies, data from additional
or suicidality), and (c) did not utilize data analytic strategies that individuals in this participant pool were not collected because their
might more formally evaluate causal hypotheses. data were not required to fill relevant cells of the stratified sample
Using an existing general population dataset and structural matrix. As a result, the actual response rate is unknown, but likely
equation modeling (SEM), we sought to test two hypotheses: first, to be higher than 10% because the study was terminated before
that the construct dysfunctional avoidance is an empirically mean- all eligible participants were able to respond. Several published
ingful latent variable, as evaluated by the measurement model studies have used data from this sample (e.g., Briere, 2006; Briere,
component of SEM; and second, that the cumulative number of Scott, & Weathers, 2005).
different types of interpersonal (as opposed to noninterpersonal) Of the 628 participants, 446 (71%) reported a lifetime exposure
traumas experienced by individuals would be related to dysfunc- to one or more traumas that met Criteria A1 and A2 of the Diagnos-
tional avoidance, but that much of this relationship would (a) be tic and Statistical Manual of Mental Disorders, Fourth Edition-Text
mediated by posttraumatic stress and affect dysregulation, and (b) Revision (DSM-IV-TR; American Psychiatric Association, 2000).
moderated by the interaction between these two variables. Regard- Data missing from 28 participants on key variables resulted in their
ing the latter, we predicted that dysfunctional avoidance would exclusion from analyses, leaving a final sample of 418 participants.
especially arise when posttraumatic stress and affect dysregulation The mean age of trauma-exposed participants in this sample was
were both high, i.e., when the individual was suffering from rel- 45.0 years (SD = 16.5). One-hundred eighty (43%) participants
atively severe posttraumatic stress in the context of relatively low were female, 201 (48%) were male, and 37 (9%) did not indicate
affect regulation capacity, resulting in a need for avoidant solutions gender. Ethnicity of participants was as follows: 338 (81%) Anglo
to overwhelming negative emotions. American; 23 (5%) African American; 16 (4%) Latino Ameri-
can; 12 (3%) Asian American; 7 (2%) Native American; 6 (1%)
“Other,” and 16 (4%) who did not indicate ethnicity.
METHOD
Participants and Procedure Measures
The current study was performed on data from the Detailed Assess- The Detailed Assessment of Posttraumatic Stress was used to assess
ment of Posttraumatic Stress (Briere, 2001), Multiscale Dissocia- trauma exposure, posttraumatic stress, and two potential indica-
tion Inventory, and Inventory of Altered Self-Capacities (Briere, tors of dysfunctional avoidance (substance abuse and suicidality).
2000) standardization studies, with permission of the test pub- This measure is a 104-item standardized test of trauma and its
lisher, Psychological Assessment Resources. Subsequent to approval effects, with scales that evaluate, for example, the respondent’s

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Traumatic Stress, Affect Dysregulation, Dysfunctional Avoidance 769

lifetime number of different types of traumatic events (Relative Data Analysis

Trauma Exposure), symptoms of posttraumatic stress (Reexperi-
encing, Avoidance, Hyperarousal, and Posttraumatic Stress–Total) Hypotheses were analyzed in three phases, using Bentler’s (2005)
linked to a specific trauma and experienced over the prior month, structural equation modeling software, EQS (version 6). The first
and associated features of traumatic stress (e.g., suicidality and set of analyses examined the measurement model for the latent
substance abuse). This test has been shown to be reliable and valid dysfunctional avoidance variable, as indicated by Tension Reduc-
(Briere, 2001). tion Activity, Dissociation, Suicidality, and Substance Abuse scales.
To test hypotheses regarding the role of accumulated inter- Then the proposed mediating effects of affect dysregulation and
personal versus noninterpersonal traumas in the development of posttraumatic stress between trauma exposure and dysfunctional
dysfunctional avoidance, the Relative Trauma Exposure scale was avoidance were examined. Direct effects of cumulative noninter-
divided into two variables: the total number of different inter- personal trauma and cumulative interpersonal trauma on dysfunc-
personal traumas (e.g., sexual abuse, physical assault) experienced, tional avoidance were evaluated first, using the original and classical
and the total number of different noninterpersonal traumas (e.g., approaches described by Baron and Kenny (1986) and Holmbeck
disasters, motor vehicle accidents) experienced. Tests of hypothe- (1997) for establishing the presence of mediation. SEM models
ses regarding the role of posttraumatic stress utilized the 30-item were then constructed to test whether affect dysregulation and
Posttraumatic Stress–Total scale, which had very good internal posttraumatic stress mediated the effects of trauma on dysfunc-
consistency in the present study (α = .96). The two scales of tional avoidance.
the Detailed Assessment of Posttraumatic Stress used to index The direct effects model tested cumulative interpersonal and
dysfunctional avoidance also demonstrated acceptable reliabilities: noninterpersonal trauma as they related to dysfunctional avoid-
Suicidality (10 items, α = .90) and Substance Abuse (10 items, ance. Evaluation of this structural model, as well as associated
α = .72). Wald’s statistics, then determined whether either variable, or both,
The Multiscale Dissociation Inventory was used to assess the would be used in the next phases of analysis.
third potential indicator of dysfunctional avoidance: dissociation. In the second phase, the two measured dependent variables,
This test is a 30-item standardized and normed questionnaire affect dysregulation and posttraumatic stress, were added to the
measure of dissociative responses, consisting of six scales: Dis- direct effects model to evaluate the proposed mediating effects of
engagement, Depersonalization, Derealization, Memory Distur- affect dysregulation and posttraumatic stress in the relationship
bance, Emotional Constriction, and Identity Dissociation. It is between cumulative trauma exposure and dysfunctional avoid-
reliable and correlates as expected with victimization history, post- ance. The use of multiple mediators in structural equation mod-
traumatic stress disorder (PTSD), and other measures of dissoci- eling is increasingly common (see, e.g., MacKinnon, Lockwood,
ation (e.g., Briere, 2002b; Dietrich, 2003). In the current study, Hoffman, West, & Sheets, 2002), in part because it allows better
the total score (the sum of all items of the six scales) demonstrated representation of complex phenomena, as well as evaluation of
very good internal consistency, α = .93. the unique role of each mediator relative to the other. Given the
Two scales of the Inventory of Altered Self-Capacities were expected correlation of these variables, disturbance terms for the
used as indicators in this model: the Affect Dysregulation scale to measured mediator variables (affect dysregulation and posttrau-
assess affect dysregulation, and the Tension Reduction Activities matic stress) were covaried.
scale as the fourth potential indicator of dysfunctional avoidance. The final phase of analyses examined whether the interaction
The Inventory of Altered Self-Capacities is a 63-item standardized between affect dysregulation and posttraumatic moderated the di-
test that generates scale scores in five additional areas beyond af- rect effects of trauma exposure on the use of dysfunctional avoid-
fect dysregulation and tension reduction, including Abandonment ance. This was tested based on the mediation model described
Concerns, Identity Impairment, and Interpersonal Conflicts. A above, along with the addition of an interaction term. Moderation
factor analysis in the normative sample indicated that each of the analyses were conducted using the cross-product of affect dysreg-
scales of this instrument reflects a statistically distinct self-related ulation and posttraumatic stress variables, centered at their mean
symptom dimension (Briere, 2000), including separate factors for (Baron & Kenny, 1986).
affect dysregulation and tension reduction. Structural equation modeling estimates relationships among
The Affect Dysregulation scale demonstrated very good inter- variables, considering all relationships simultaneously and mini-
nal consistency in the present study (α = .93). Items within this mizing the effects of measurement error. Because the variables of
9-item scale tap affect instability (e.g., rapid mood changes) and interest in the current study are naturally nonnormally distributed,
affect regulation skill deficits (e.g., difficulty calming down when the robust estimation method was used. The robust method al-
upset). The 9-item Tension Reduction Activities scale had accept- lows for the calculation of the adapted Satorra–Bentler scaled chi-
able internal consistency (α = .76). Typical items of this scale refer square value, corrected fit indices, and robust standard error, all
to self-injury, food bingeing, impulsive aggression, and the use of of which address nonnormality (see Byrne, 2006). Several indices
sexual activity as a way to neutralize negative feelings. were employed to determine whether the hypothesized models fit

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
770 Briere, Hodges, and Godbout

Table 1. Frequency of Types of Traumatic Events Experi- Table 2. Participants in the present study had been exposed to
enced by Participants a mean of three different types of traumatic events in their life-
time, with an average of slightly more than one exposure type
Type n % each for noninterpersonal and interpersonal traumas. The Spear-
man correlation between accumulated types of interpersonal and
Motor vehicle accidents 237 57
noninterpersonal trauma was .11, p < .05.
Natural disaster 116 28
Work/home accident 110 26
Assault 105 25 Measurement Model
Threatened assault 132 32 Analysis of the measurement model for dysfunctional avoidance
Shooting/stabbing with injury 52 12 resulted in very good indices of fit, CFI = 1.00; χ 2 (2) < 1;
Combat 44 10 χ 2 /df = 0.23; RMSEA = .000. This variable was significantly
Robbery/mugging 48 11 represented by all of its four indicators (all at p< .01), with stan-
Sexual assault 72 17 dardized coefficients of .44 for substance abuse, .56 for suicidality,
Childhood sexual abuse 96 23 .75 for dissociation, and .80 for tension reduction activities.
Witnessed someone else getting injured 211 50
Other 107 26
Direct Effects Analyses
Structural equation modeling analysis, examining the direct effects
the observed data. A nonsignificant χ 2 indicates the absence of of both cumulative noninterpersonal trauma and cumulative in-
meaningful unexplained variance. However, because this statistic terpersonal trauma on the latent dysfunctional avoidance variable,
is sensitive to sample size, the ratio of chi-square to degrees of indicated that the structural model fit the data well, CFI = .99;
freedom (χ 2 /df ) was also considered, with values of 2.0 or less χ 2 (9) = 10.57, p = .30; χ 2 /df = 1.17; RMSEA = .02. A re-
considered satisfactory (Newcomb, 1990). The comparative fit in- view of path coefficients indicated that cumulative interpersonal
dex (CFI), which compares the hypothesized model with the null trauma significantly predicted dysfunctional avoidance (β = .43,
model, was calculated, with a value of .95 or higher indicating a p < .001), whereas cumulative noninterpersonal trauma was un-
good fit (Hu & Bentler, 1999). Finally, the root mean square error related to dysfunctional avoidance (β = .02, ns). Wald statistics
of approximation (RMSEA) considers the error of approximation for improving model fit suggested that the path from cumulative
in the population and estimates the difference between model- noninterpersonal trauma be eliminated. Removal of this variable
implied and actual variances and covariances, with values less than from the model resulted in a very good fit, CFI = 1.00; χ 2 (5) =
.06 being preferred (Hu & Bentler, 1999). 2.76, ns; χ 2 /df = 0.55; RMSEA = .00; R 2 = .19, and the path
from cumulative interpersonal trauma remained moderately strong
(β = .43, p < .001). Accordingly, cumulative noninterpersonal
RESULTS trauma was excluded from subsequent analyses.
Trauma types and frequency of each type are presented in Table 1. The direct effects of affect dysregulation and posttraumatic
Means, standard deviations, and correlations are presented in stress on dysfunctional avoidance also were tested prior to

Table 2. Means, Standard Deviations, and Correlations Among Variables Modeled in Structural Equation Modeling
M SD 1 2 3 4 5 6 7 8
1. RTE-it 1.31 1.39 1
2. RTE-nonit 1.11 0.91 .17∗∗ 1
3. PTS-T 37.90 14.74 .35∗∗ .08 1
4. AD 11.59 4.71 .35∗∗ .17∗∗ .59∗∗ 1
5. TRA 10.47 2.72 .38∗∗ .08 .58∗∗ .74∗∗ 1
6. SUB 10.73 2.00 .11∗ .01 .24∗∗ .35∗∗ .35∗∗ 1
7. SUI 10.84 2.87 .25∗∗ .03 .41∗∗ .45∗∗ .46∗∗ .23∗∗ 1
8. DIS 34.47 8.15 .30∗∗ .07 .66∗∗ .59∗∗ .60∗∗ .36∗∗ .41∗∗ 1
Note: RTE-it = Relative Trauma Exposure–interpersonal trauma; RTE-nonit = Relative Trauma Exposure–noninterpersonal trauma; PTS-T = Posttraumatic Stress–Total;
AD = affect dysregulation; TRA = tension reduction activities; SUB = substance abuse; SUI = suicidality; DIS = dissociation.
∗ p ≤ .05. ∗∗ p ≤ 01.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Traumatic Stress, Affect Dysregulation, Dysfunctional Avoidance 771

Posttraumatic
stress
.35***
.36***

Tension
.83*** reduction

.10** Dysfunctional .41***

Interpersonal Substance
avoidance
trauma .54*** abuse

Suicidality
.75***
.61***
Affect Dissociation
.35***
dysregulation

Figure 1. Results of structural equation modeling analysis of mediating effects of posttraumatic stress and affect dysregulation on
dysfunctional avoidance associated with relative exposure to interpersonal trauma.
∗∗
p < .01. ∗∗∗ p < .001.
mediation analysis and resulted in a very good fit, CFI = 1.00; dysregulation and posttraumatic stress to an equivalent degree,
χ 2 (8) = 15.57, p = .05; χ 2 /df = 1.95; RMSEA = .05, and affect dysregulation was a very strong predictor of dysfunctional
confirmed significant relationships between affect dysregulation avoidance, whereas posttraumatic stress (PTS) provided signifi-
and dysfunctional avoidance (β = .62, p < .001) as well as cant, but less, influence. As defined by MacKinnon et al. (2002),
between posttraumatic stress and dysfunctional avoidance (β = the magnitude of the mediation of the relationship between cu-
.38, p < .001). mulative interpersonal trauma and dysfunctional avoidance was
.13 for posttraumatic stress and .22 for affect dysregulation.
Mediation Analyses
A model examining the mediating effects of affect dysregulation
Moderation Analyses
and posttraumatic stress on the relationship between cumulative The final SEM analysis examined the hypothesis that the specific
interpersonal trauma and dysfunctional avoidance was tested next. combination of high posttraumatic stress and high affect dysreg-
This model provided a good fit to the data, CFI = .97; χ 2 (11) = ulation would moderate dysfunctional avoidance in individuals
19.50, p = .06; χ 2 /df = 1.77; RMSEA = .04, R 2 = .83, with no exposed to interpersonal trauma. Accordingly, an Affect Dysreg-
significant unexplained variance remaining (see Figure 1). As ex- ulation × Posttraumatic Stress interaction term was added to the
pected, exposure to accumulated interpersonal trauma was signif- mediation model. Results indicated adjustment fits similar to those
icantly associated with dysfunctional avoidance. Affect dysregula- of the mediated model, CFI = .97; χ 2 (15) = 23.13, p = .08;
tion and posttraumatic stress both strongly mediated this relation- χ 2 /df = 1.54; RMSEA = .04, but the interaction term was not
ship, as evidenced by the significant reduction of the standardized significantly related to dysfunctional avoidance (β = .14, ns).
regression coefficient in comparison to the direct effects model
(i.e., from β = .43 to .10). Affect dysregulation and posttraumatic Controlling for Posttraumatic Stress-Related Avoidance
stress significantly influenced dysfunctional avoidance, consistent
with the presence of mediation. As expected, the disturbance terms Although these results suggest that posttraumatic stress and re-
for affect dysregulation and posttraumatic stress were correlated (r duced affect regulation capacity mediate the cumulative interper-
= .54, p < .001).1 sonal trauma—dysfunctional avoidance relationship, it was possi-
These results indicate that both affect dysregulation and post- ble that the posttraumatic stress findings were confounded by the
traumatic stress independently mediate the effects of accumulated fact that posttraumatic stress (as measured by the Posttraumatic
types of interpersonal trauma on dysfunctional avoidance. How- Stress-Total scale), itself, includes avoidance symptoms. Specifi-
ever, although cumulative interpersonal trauma predicted affect cally, the diagnostic criteria for PTSD include effortful avoidance
behaviors and numbing (APA, 2000), both of which might be ex-
1 Disturbance term correlations are not included in Figure 1, in the interest of pected to correlate with other forms of avoidance, such as substance
visual clarity. abuse, suicidality, dissociation, or tension reduction behaviors. To

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
772 Briere, Hodges, and Godbout

rule out this possibility, we removed the avoidance symptoms from 2009; Follette, Polusny, Bechtle, & Naugle, 1996), the current
the PTS variable used in the prior analyses, leaving only the reliv- study employed a measure of the number of different types of
ing and hyperarousal symptoms as components of posttraumatic trauma experienced by participants, as opposed to the frequency
stress. This conservative reanalysis resulted in an equivalent robust of events within a given trauma type (e.g., the total number of
CFI, without significant modifications in the path coefficients rel- times the participant had been sexually abused), and/or the sum of
ative to the prior model, CFI = .97, χ 2 (11) = 19.02, p = .06; all trauma frequencies across different trauma types. Clearly, the
χ 2 /df = 1.73; RMSEA = .04. latter variable might especially be of interest, and should be exam-
ined in future studies. As noted by Cloitre et al. (2009), however,
the literature on interpersonal violence suggests that the frequency
DISCUSSION and duration of specific forms of victimization are surprisingly
As hypothesized, the results of this study indicate that cumula- weak predictors of subsequent symptomatology, whereas as re-
tive exposure to different types of interpersonal trauma is asso- viewed earlier, a count of types of interpersonal trauma exposures
ciated with dysfunctional avoidance, and that this relationship is appears to be a robust correlate of outcome. These findings suggest
mediated by posttraumatic stress and reduced affect regulation that there is something specifically injurious about experiencing
capacities. The relationship between posttraumatic stress and dys- multiple forms of interpersonal victimization across the life span,
functional avoidance, although important, has been demonstrated and that such cumulative experiences may motivate dysfunctional
previously (e.g., Hartl, Rosen, Drescher, Lee, & Gusman, 2005). avoidance.
The potentially superordinate role of diminished affect regulation The results of this study generally support the prediction that
capacity, however, is a newer finding, although theoreticians have phenomena such as suicidality, substance abuse, dissociation, and
suggested that affect dysregulation might underlie various “acting dysfunctional behavior may, among other things, specifically serve
out” behaviors in trauma survivors (Briere, 2002a; Pearlman & the purpose of reducing emotional distress in individuals who have
Courtois, 2005). experienced multiple forms of interpersonal trauma. They further
Although a mediational model was supported in this study, suggest that it is not the level of posttraumatic distress alone that
the hypothesized moderation was not found. Specifically, post- triggers and reinforces such behaviors, but more importantly, the
traumatic stress and affect dysregulation both independently me- effects of reduced affect regulation capacity. However, the relation-
diate the relationship between accumulated interpersonal traumas ship between affect regulation and dysfunctional avoidance might
and dysfunctional avoidance, but their interaction does not sig- partially reflect overlapping variance in the Inventory of Altered
nificantly augment or exacerbate dysfunctional avoidance. Impor- Self-Capacities scales used to measure affect dysregulation and one
tantly, this does not necessarily contradict the notion that dys- component of dysfunctional avoidance, tension-reduction behav-
functional avoidance arises from overwhelming emotional states: iors. Items of the Tension Reduction Activities scale inquire about
high levels of posttraumatic stress may exceed even intact affect the use of externalizing behaviors to reduce distress, thereby poten-
regulation capacities, and those with substantially impaired af- tially increasing the association between this scale and reports of
fect dysregulation may be overwhelmed by any significant level of inability to regulate distress. However, as noted earlier, the factor
posttraumatic stress (Briere & Scott, 2006). analysis presented in the Inventory of Altered Self-Capacities Man-
It is significant that the SEM results indicated a relationship ual (Briere, 2000) indicates that Affect Dysregulation and Tension
between dysfunctional avoidance and accumulated interpersonal Reduction Activities scales load on different factors, and thus do
traumas, but not noninterpersonal traumas. This finding is in ac- not reflect the same underlying phenomena. As well, the test of
cord with other studies on the relative impacts of interpersonal vic- the measurement model in this study indicated that dysfunctional
timization (e.g., rape) as opposed to noninterpersonal events (e.g., avoidance forms a robust, coherent factor (with perfect fit in-
disasters), wherein the former is usually more symptom-producing dices and RMSEA values of 1.0 and .00, respectively), composed
than the latter (e.g., Briere & Rickards, 2007; Green et al., 2000). of dissociation, suicidality, and substance abuse, as well as tension
Typically, human-caused traumas are viewed by victims as more in- reduction behavior. Especially relevant is the strong univariate cor-
tentional, intrusive, and malignant, and may involve perceptions of relation between affect dysregulation and dissociation (r = .59); a
betrayal, each of which are associated with more negative outcomes relationship that does not appear to reflect measurement overlap
(Briere & Scott, 2006; Freyd, Klest, & Allard, 2005). In contrast, issues.
events like disasters generally do not imply intentional maltreat- The finding that posttraumatic stress and affect regulation dif-
ment. As a result, although noninterpersonal traumas can clearly ficulties predicted unique variance in dysfunctional avoidance sug-
produce posttraumatic symptomatology in some cases, overall they gests multiple pathways to dysfunctional avoidance behaviors in
may be less likely to engender the level of distress that would mo- interpersonal trauma survivors. Some individuals may respond to
tivate dysfunctional avoidance. posttraumatic stress with dysfunctional avoidance, others may en-
It should be emphasized that, like other studies of accumulated gage in dysfunctional avoidance primarily due to insufficient affect
forms of trauma exposure (e.g., Briere et al., 2008; Cloitre et al., regulation capacity, and some may invoke dysfunctional avoidance

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
 Traumatic Stress, Affect Dysregulation, Dysfunctional Avoidance 773

in response to the additive combination of these variables. Al- some instances of dysfunctional avoidance arise from nontrauma-
though there are few studies in this area, it is possible that these related etiologies. For example, there are likely other routes to
different pathways are associated with different trauma typologies. affect dysregulation, including inherited or acquired neurobio-
For example, early trauma may predominately lead to affect dys- logical dysfunctions (Krystal & Neumeister, 2009), subtraumatic
regulation, identity, and relational issues (Pearlman & Courtois, events such as growing up in an invalidating but not grossly vio-
2005), whereas later trauma may be more associated with post- lent family environment (Linehan, 1993), and nontrauma-related
traumatic stress, depression, and anxiety (Briere, 2004). Exposure disturbance in the child’s early attachment to significant caregivers
to both early and later adverse events (i.e., complex trauma) might (Cassidy & Shaver, 2008). Because the current study demonstrated
produce a combination of high posttraumatic stress and substan- a strong pathway from affect regulation difficulties to dysfunctional
tially reduced affect regulation capacity, thereby motivating high avoidance, it is quite possible that such nontrauma etiologies will
levels of dysfunctional avoidance. result in dysfunctional behaviors and dissociation by virtue of their
The current results provide additional evidence that some phe- impacts on affect regulation capacity alone.
nomena associated with a diagnosis of borderline personality dis-
order (e.g., affect dysregulation, tension reduction behaviors, sui-
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all possible participants of this study is unknown, with a bottom American Psychological Association.
limit of 10% under the unlikely assumption that all later poten- Briere, J. (2006). Dissociative symptoms and trauma exposure: Specificity, affect
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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.