10

Emotional Dissociation in
Response to Trauma
An Information-Processing Approach

Edna B. Foa and Diana Hearst-Ikeda

Pathological reactions to trauma and extreme stress have been noted in the psycho-
logical literature for over a century. These reactions were codified in the psychiatric
literature as posttraumatic stress disorder (PTSD) (American Psychiatric Associa·
tion, 1980). The diagnosis of PTSD is made when posttrauma symptoms occur in
three domains: emotional, cognitive, and visual reexperiencing of the trauma;
avoidance of trauma-relevant stimuli; and general arousal. Since the inception of
PTSD as a diagnostic entity, experts have focused on the fear and anxiety compo-
nents of the disorder (Foa, Steketee, & Rothbaum, 1989; Keane, Zimering, &
Caddell, 1985). More recently, trauma researchers have become interested in the
phenomenon of affective and cognitive avoidance that is commonly observed
following a trauma and has been referred to as dissociation (e.g., Spiegel, Hunt, &
Dondershine, 1988), denial (Horowitz, 1986; van der Kolk, 1987), or numbing (e.g.,
Foa, Riggs, & Gershuny, 1995; Horowitz, Wilner, Kaltreider, & Alvarez, 1980; Litz,
1993; van der Kolk & Ducey, 1989). Common to these constructs is a diminished
awareness of one's emotions or thoughts, which is hypothesized to be motivated by
self-preservation.
In this chapter we will discuss the construct of emotional dissociation, de-

Edna B. Foa • Center for the Treaunent and Study of Anxiety, Medical College of Pennsylvania, Eastern
Pennsylvania Psychiatric Institute, Philadelphia, Pennsylvania 19129. Diana Hearst-Ikeda • National
Center for Posttraumatic Stress Disorder, Women's Health and Sciences Division, Boston Deparunent of
Veterans Affairs Medical Center, Boston, Massachusetts 02130.
Handbook of Dissociation: Theoretical, and Clinical Perspectives, edited by Larry K.
Michelson and William]. Ray. Plenum Press, New York, 1996. 207
208 scribe the measures that have been used to evaluate it, and review the relevant
Edna B. Foa and literature. Finally we will discuss mechanisms that are hypothesized to underlie
Diana Hearst-Ikeda dissociation and will propose that the presence of dissociation is an indicator of
incomplete emotional processing of the trauma.

DISSOCIATION, DENIAL, AVOIDANCE, AND NUMBING:

CONCEPfUAL ISSUES

The phenomenon of emotional detachment has gained considerable attention

in the late nineteenth century and was conceptualized as a defense against over-
whelming emotions (e.g., Breuer & Freud, 1985; Janet 1907, 1989). But it was Janet
(1907) who coined the term dtssociaUon to describe the lack of connection
between aspects of memory or conscious awareness observed during and after
extreme stress.
Since these early writings, many experts have noted that dissociation occurs in
nonpathological as well as in pathological states (e.g., Bliss, 1984; Braun & Sachs,
1985; Hilgard, 1977; Spiegel, 1963). Nemiah (1981) has proposed two characteristics
of pathological dissociation. The first is an alteration in one's sense of identity, as
in multiple personality disorder, and the second is a disturbance in the memory of
the specific experiences during a dissociative period (usually traumatically in-
duced). The DiagnosUc and StaUsUcal Manual of Mental Disorders, Fourth Edi-
tion (DSM-IV) has endorsed this dual view, stating "The essential feature of the
dissociative disorders is a disruption in the usually integrated functions of con-
sciousness, memory, identity, or perception of the environment" (American Psychi-
atric Association, 1994, p. 477).
A third characteristic of dissociation that has been proposed by several experts
(e.g., Coons & Milstein, 1986; Putnam, 1989; Spiegel, 1986) is its association with
traumatic experience. Accordingly, Spiegel and Cardena (1990) proposed that
"posttraumatic phenomenology frequently involves alterations in the relationship
to the self (e.g., depersonalization and multiple personality disorder), to the world
(e.g., derealization and hallucinatory phenomena), and to memory processes (e.g.,
psychogenic amnesia, fugue, and multiple personality disorder)" (p. 368). Support
for the view that dissociation is etiologically connected to traumatic experiences
also comes from clinical observations of children who have suffered repeated
exposure to extreme stress such as sexual, physical, or psychological abuse (ferr,
1991). Terr reported that children often use dissociation and numbing to escape the
trauma-related memories and the arousal they trigger.
It seems that the construct of dissociation is largely defined by a set of symp-
toms that have been observed in persons who experienced trauma. These include
amnesia, emotional detachment, feelings of depersonalization, out-of-body experi-
ences, dreamlike recall of events, feelings of estrangement, flashbacks, and abreac-
tion. In a review of psychological reactions that ensue from a traumatic experience,
Cardena and Spiegel (1993) have suggested that posttrauma dissociative symptoms
can be classified into three types of responses: (1) detachment from others and the
physical environment, (2) alterations in perceptions, and (3) impairments in
memory.
 A second construct, denial, was proposed by Horowitz (1986), who noted that 209
a common reaction to trauma is "the massive ideational denial of the event" (p. 16). Emotional
An examination of the items contained in the scale that Horowitz and his colleagues Dissociation in
developed to measure denial (i.e., the Impact of Events Scale; Horowitz, Wilner, & Response to Trauma
Alvarez, 1979) indicates that denial denotes attempts at cognitive and emotional
avoidance (e.g., "I avoid letting myself get upset when I thought about it [the
trauma] or was reminded of it," and "I tried to remove it from memory") but not
alteration in perception and memory impairment.
A third term that had been introduced into the DSM-III (American Psychiatric
Association, 1980) is "emotional numbing." This term is sometimes used inter-
changeably with denial and avoidance to describe the lack of affective expression in
trauma victims (American Psychiatric Association, 1980; Horowitz, 1986). Seven
symptoms comprise the avoidance-numbing symptom cluster ofDSM-III-R (Ameri-
can Psychiatric Association, 1987) and DSM-IV (American Psychiatric Association,
1994). These include effortful cognitive and behavioral avoidance of trauma re-
minders, memory loss, and emotional numbing (e.g., loss of interest in activities,
detachment from others, restricted affect, sense of a foreshortened future). Thus,
the effortful avoidance symptoms are grouped together with those of emotional
numbing in the diagnostic nomenclature.
The grouping of avoidance and numbing symptoms into one cluster suggests
that the DSM-IV authors had conceptualized emotional numbing and effortful
avoidance as an equivalent concept. However, a review of literature on experimen-
tal paradigms that elicit PTSD-like symptoms in animals suggests that effortful
avoidance and numbing involve separate mechanisms (Foa, Zinbarg, & Rothbaum,
1992). Foa and Riggs (1993) suggested that effortful avoidance may be regulated by
strategic psychological processes, whereas numbing may be mediated by biological
mechanisms resembling those underlying the freezing behavior in frightened ani-
mals. They further proposed that on exposure to trauma-related information, vic-
tims first mobilize effortful strategies to avoid the arousal associated with the
traumatic memories. When such strategies fails, a "shutting-down" of the affective
system occurs; this process is expressed as numbing symptoms. Consistent with
the view that effortful avoidance and numbing reflect separate phenomena are
findings from a factor analytical study of PTSD symptoms in female assault victims.
The numbing symptoms loaded on one factor that also included symptoms of
irritability and concentration problems; the effortful avoidance symptoms loaded
on a separate factor that included intrusive thoughts, emotional reactivity, hyper-
vigilance, and excessive startle (Foa et al., 1995).

MEASURES OF DISSOCIATION, DENIAL, AVOIDANCE,

AND NUMBING

As we noted earlier, many experts agree that dissociation, denial, avoidance,

and numbing are common responses to extreme stress. The first accounts of
dissociation relied on clinical observations of trauma victims. More recently, infor-
mation about this phenomenon has been based on measures that have been con-
structed to serve as operational definitions of dissociation. It is therefore important
210 to describe measures of dissociation before discussing the empirical data that have
Edna B. Foa aru1 employed these measures.
Diana Hearst-Ikeda
1. Dissociative Events Scale (DES) (Bernstein & Putnam, 1986). This is a 28-
item scale to assess the frequency and intensity of a range of experiences commonly
conceptualized as dissociation and depersonalization in a psychiatric population in
general and in traumatized individuals in particular. The DES items pertain to
disturbances of memory, attention, identity, and perception. According to Bern-
stein and Putnam, the DES is a trait measure, although this has not been empirically
validated. There are no items about numbing or cognitive avoidance in this scale.
2. Stanford Acute Stress Reaction Questionnaire (SASRQ) (Cardena, Clas-
sen, & Spiegel, 1991). The long version of this scale has 73 items that tap dissocia-
tion and anxiety experiences during and immediately after a trauma. Thirty-three
items comprise the dissociation scale that assesses five features: psychic numbing,
depersonalization, derealization, amnesia, and stupor. Forty items comprise the
anxiety scale that also assesses five features: intrusive thinking, somatic anxiety,
hyperarousal, attention disturbance, and sleep disturbance.
3. Perceptual Alterations Scale (PAS) (Sanders, 1986). This is a 25-item scale
designed to measure normal and pathological dissociation. Like the DES, it concep-
tualizes dissociation as a trait rather than a state or a pathological feature of a
disorder. The scale items were selected from the Minnesota Multiphasic Personality
Inventory. A factor analysis yielded three factors: affect and depersonalization,
depersonalization and loss of body control, and memory impairment.
4. Peritraumatic Dissodation Experiences Questionnaire (PDEQ-RV) (Mar-
mar & Weiss, 1990). This scale is available in two versions: (1) interview (nine items)
and (2) self-report (eight items). Similar to the SASRQ, it is designed to obtain
information about dissociative reactions and experiences during and immediately
after a trauma. The content of the items involve memory loss specific to the trauma,
depersonalization, and derealization.
5. Impact ofEvents Scale (IES) (Horowitz et al., 1979). This is a 15-item scale
that assesses intrusive reexperiencing and cognitive and affective avoidance. The
eight avoidance items assess effortful attempts to avoid emotional reactions to
trauma-related stimuli and thoughts about the trauma, but not depersonalization,
derealization, and emotional numbness.
6. PTSD Symptom Scale (PSS) (Foa, Riggs, Dancu, & Rothbaum, 1993b). Both
interview (PSS-1) and self-administered (PSS-SR) versions of this 17-item scale have
been validated with female victims of sexual and nonsexual assault. The items
correspond to the PTSD symptoms listed in the DSM-IY. Paralleling the DSM-IY, the
items are divided into three clusters: reexperiencing (four items), avoidance-
numbing (seven items), and arousal (six items). A factor analysis of this scale yielded
a numbing factor that combined the following symptoms: detachment from others,
irritability, sense of foreshortened future, and emotional numbness (Foa et al.,
1995).
7. The Dissodative Disorders Interview Schedule (DDIS) (Ross, Heber, Nor-
ton, Anderson, Anderson, & Barchet, 1989). The DDIS is a 131-item structured
interview developed to make diagnoses of dissociation somatization, major depres-
sion, and borderline personality disorder. Ross and colleagues (1989) recommend
the use of this scale with the DES to provide a complete picture of the range and 211
type of dissociation experiences and severity of psychopathology. Emotional
Dissociation in
Examination of the measures here described suggests that the constructs of Response to Trauma
dissociation, numbing, and avoidance primarily involve three features. The first
pertains to derealization, depersonalization, and memory loss; the second denotes
the absence of affect in emotional contexts; and the third relates to effortful
cognitive avoidance. Most measures focus on one or two of these features, with the
exception of the SASRQ, which includes all three. With these distinctions in mind,
we will now proceed to review the empirical literature on dissociation, numbing,
and avoidance.

STIJDIES OF DISSOCIATION, NUMBING, AND AVOIDANCE

Researchers have documented the presence of dissociative features following a

variety of traumatic experiences. The results of these empirical investigations are
summarized below, according to the type of trauma.

War Exposure
Using the DES with Vietnam War veterans, several studies have demonstrated
that PTSD is associated with increased use of dissociative strategies (Bernstein &
Putnam, 1986; Branscombe, 1991; Bremner et al., 1992; Coons, Bowman, Pellow &
Schneider, 1989; Huska & Weathers, 1991; Orr et al., 1990). The degree of dissocia-
tion, as measured by the DES, was higher in male veterans with PTSD than in
alcoholics, agoraphobics, and normals (Bernstein & Putnam, 1986). DES scores
were also positively related to the severity of PTSD in combat veterans (Bremner
et al., 1992; Waid & Urbanczyk, 1989). However, DES scores were also highly
correlated with depression and anxiety, suggesting that the relationship of dissocia-
tion to PTSD is not specific but rather reflects the relationship between dissociation
and psychopathology.
Several factor analytical studies of posttrauma symptoms in war veterans have
identified dissociation as a core feature of PTSD. Silver and Iacono (1984) have
conducted a factor analysis on psychiatric symptoms reported by Vietnam combat
veterans and have identified four factors: depression, grief-guilt, reexperiencing,
and detachment-anger. The latter factor was characterized by emotional detach-
ment and difficulty experiencing emotions. Since PTSD diagnosis was not deter-
mined, the relationship of these symptoms to traumatic experiences was not
determined. Davidson, Smith, and Kudler (1989) also factor analyzed the DSM-III-R
symptoms of PTSD reported by 116 veterans of World War II, Korea, and Vietnam.
Three factors were identified: reexperiencing and arousal, avoidance and detach-
ment, and constricted affect and memory impairment. In a third study, Solomon,
Mikulincer, and Benbenishty (1989) interviewed soldiers 1 year after the combat
and submitted their reported symptoms to a factor analysis. A psychic numbing
factor emerged that accounted for 20% of the variance (Solomon et al., 1989). The
symptoms that loaded on this factor were: detachment from others and from one's
surroundings, numbing of responses, mental escape, and distraction. The second
212 factor, anxiety reactions, accounted for 11% of the variance. These results point to
Edna B. Foa and the prominent position of dissociation in posttrauma sequela.
Diana Hearst-Ikeda Several studies have demonstrated that the use of dissociative strategies during
combat were associated with chronic posttrauma reactions. Using the IES, Solomon
and Mikulincer (1992) evaluated symptoms of intrusion and avoidance in two
groups of soldiers: those who suffered combat stress response (CSR), or "battle
shock," and those who did not. Soldiers with CSR reported more intrusion and
avoidance symptoms 3 years after combat than those without CSR. However, in
both groups, intrusion and avoidance symptoms decreased as a function of the time
that had elapsed since combat exposure.
In a retrospective study, Bremner et al. (1992) compared the reported dissocia-
tion at the time of specific traumatic events in Vietnam veterans with and without
ro'SD. Dissociation during combat was evaluated using a modified version of the
DES. PfSD patients reported more dissociative symptoms during combat traumas
than did those without PTSD. A similar study was conducted by Marmar and co-
workers (1992). These researchers also examined retrospectively the emotional
experiences during combat of female and male Vietnam theatre veterans using the
DES and the PDEQ-interviewer version. Consistent with the findings of Solomon
et al. (1989) and Bremner et al. (1992), dissociative experiences reported during
combat were highly associated with chronic posttrauma reactions.
Taken together, the above studies seem to indicate a common tendency to
dissociate during a combat experience, and that such dissociation results in pro-
longed pathological reactions. However, it is important to note that all three studies
used retrospective methodology, and therefore the results should be interpreted
with caution. It is possible that individuals with more severe posttrauma pathology
are more likely to report the dissociative experiences during the traumatic event
than do individuals who have successfully recovered, irrespective of the degree of
dissociation they had actually experienced during the traumatic event itself. If the
reported dissociation during trauma accurately reflects the degree of dissociation
during the trauma, then the argument can be made that although dissociation may
provide short-term relief during a stressful event, the use of this coping style
hinders recovery later on.
Several laboratory studies have explored dissociative phenomena in combat
veterans. Spiegel et al. (1988) found that combat veterans with PTSD were more
hypnotizable than their non-PTSD cohorts. Conceptualizing hypnotizability as a
measure of dissociation, they concluded that individuals with PTSD dissociate more
than those without PTSD. To study emotional numbing, veterans with and without
PTSD were given an affective recognition task. As expected, veterans with PTSD
had more difficulty evaluating and identifying emotions than those without PTSD
(Zimering, Caddell, Fairbank, & Keane, 1993). A different method to examine
numbing was employed by Orr (1991). Veterans with and without PTSD were asked
to imagine a pleasant scene. No differences emerged between the PTSD and non-
PTSD subjects on psychophysiology, self-report of emotional reactions, and facial
expression of emotions. Influenced by results from animal experiments demon-
strating opiate-mediated analgesia following uncontrollable electrical shocks, Pit-
man, van der Kolk, Orr, and Greenberg (1990) hypothesized that numbing symp-
toms in PTSD sufferers is mediated by endogenous opiates. To test this hypothesis,
veterans with and without PTSD were exposed to combat movies. Pain tolerance 213
was used as a measure of numbing. Veterans with PTSD showed decreased pain Emotional
sensitivity in response to an ice-cold water test after watching the movies. No such Dissoclatlon in
decrease occurred when naloxone, an opiate antagonist, was administered, sug- Response to Trauma
gesting an opiate-mediated stress-induced analgesia in PTSD. The non-PTSD vet-
erans showed no decrease in pain following the movies.

Abuse in Childhood
Several studies have investigated the relationship between dissociation and
PTSD in individuals who were sexually abused in childhood. Using the DES, Coons
et al. (1989) evaluated dissociation in psychiatric patients with a variety of diag-
noses, including PTSD. A significantly higher incidence of childhood abuse was
found among female patients who were referred to a counseling center than among
female bulimics attending an eating disorders clinic. Further, the incidence of
dissociation and PTSD was significantly higher in the former group.
Using the DES, Sanders and Giolas (1991) examined dissociation and childhood
abuse in a group of emotionally disturbed adolescents. Modest correlations be-
tween history of childhood abuse and DES score were obtained in this sample,
replicating the findings that have been obtained in college students (Sanders,
McRoberts, & Tollefson, 1989). Chu and Dill (1990) also found that female psychi-
atric inpatients with childhood physical or sexual abuse scored significantly higher
on the DES than did women without such a history. However, unlike the results of
Coons et al. (1989), the severity of the DES scores was not related to diagnoses of
PTSD or to dissociative disorders.
Several authors have postulated a relationship between symptoms of bor-
derline personality and childhood abuse (Gelinas, 1983; Herman, Perry, & van der
K.olk, 1989). In a retrospective study, Herman et al. (1989) examined the relation-
ship between childhood trauma histories of patients with borderline personality
disorder, PTSD symptoms (measured by lES), and the DES. They found a significant
relationship between severity of trauma history, severity of PTSD symptoms, and
the presence of borderline personality disorder. Also, patients with this disorder
generally reported higher DES scores than those without this diagnosis, suggesting
a link between sexual abuse, borderline personality, dissociation, and PTSD.
Similar results were reported in a study evaluating the sexual and physical
abuse experiences in female and male adults diagnosed with borderline personality
disorder using the Diagnostic Interview for Borderline Patients (Dill) (Gunderson,
Kolb, & Austin, 1982). Although the Dill is not specifically designed to evaluate a
wide range of dissociative experiences, a few items about derealization and deper-
sonalization are included. The results of the study confirmed the hypothesized
relationship among childhood sexual abuse, borderline personality, and dissociative
symptoms (Ogata, Silk, Goodrich, Lohr, Westen, & Hill, 1990). Finally, Boon and
Draijer (1991) reported a high prevalence of child abuse among patients who met
criteria for dissociative and personality disorders using the Structured Clinical
Interview for DSM-ill-R Dissociative Disorders (SCID-D).
The studies described above converge to suggest a relationship among child-
hood abuse, psychopathology (including PTSD, dissociative disorders, and person-
214 ality disorders), and tendency to employ dissociative strategies. However, this
Edna B. Foa and tendency is associated with general psychopathology and is not specific to PTSD.
Diana Hearst-Ikeda
Adult Victims of Assault
Symptoms of anxiety and dissociation have also been observed in adult victims
of assault (Burgess & Holmstrom, 1976). Moderate dissociation (measured by the
DES) in female victims of sexual and nonsexual assault was observed immediately
after the assault, which declined over time, reaching a normal range 3 months later
(Dancu, Riggs, Hearst-Ikeda, Shoyer, & Foa, in press). As with victims of childhood
abuse, dissociation was related to posttrauma psychopathology (e.g., RIES, Beck
Depression Inventory, State Trait Anxiety Inventory) in both rape and nonsexual
assault victims. Dissociation was also related to PTSD diagnosis in nonsexual victims
but not in rape victims. Thus, these results support the view that dissociation is
related to general psychopathology rather than PTSD. Riggs, Dancu, Gershuny,
Greenberg, and Foa (1992) also found that victims with a history of childhood
sexual abuse reported more dissociation than victims without such a history. These
findings are consistent with those of Chu and Dill (1990), and together they suggest
that trauma in childhood may predispose victims to dissociate after a subsequent
trauma in adulthood.
In the factor analytical study mentioned earlier that used the DSM-111-R symp-
toms of PTSD in recent female assault victims, Foa et al. (1993a) identified three
factors: arousal-avoidance, numbing, and intrusion. The items that loaded on the
numbing factor were: numbing of feelings, detachment from others, loss of interest,
and a sense of foreshortened future. The numbing symptoms best distinguished
assault victims with PTSD from those without PTSD 3 months after the assault.
These findings concur with those of Solomon and colleagues using the DES with
Israeli war veterans (Solomon eta!., 1989; Solomon & Mikulincer, 1992). Although
the symptoms that comprised the numbing factor differ from those of the DES, both
studies reveal association between dissociation and the experience of trauma.

Abduction and Incarceration

In two studies, Kinzie and colleagues (Kinzie, Sack, Angell, Manson, & Rath,
1986; Kinzie, Sack, Angell, Clarke, & Rath, 1989) evaluated the posttrauma reactions
of Cambodian adolescents 4 years after being incarcerated in the Pol Pot concentra-
tion camps. The victims reported a variety of traumas including separation from
family members, starvation, being beaten, and witnessing the deaths of their com-
panions. Four years after incarceration, half of these youths met DSM-111-R criteria
for PTSD, 58% avoided memories of the camp, and 43% avoided discussing their
traumas. Seven years after incarceration, 48% of the participants had PTSD and 41%
exhibited moderate to severe depression. Thus, avoidance of trauma reminders was
most common in victims of incarceration years after their traumatic experiences.
While no other dissociation symptoms were reported in this study, the high preva-
lence of PTSD suggests that many victims experienced numbing symptoms. More
direct evidence for the presence of dissociative symptoms following incarceration
comes from a review of anecdotal accounts of prisoners of war about their emo-
tional experiences during the trauma (Siegel, 1984). Twenty-six percent of the
prisoners evidenced emotional numbing and depersonalization, and 13% experi- 215
enced out of body experiences. Emotional
Dissociat:lon in
Response to Trauma
Accidents
Two studies by Noyes and colleagues examined dissociation in survivors of life-
threatening situations (e.g., an automobile accident, a drowning, a fall, a serious
illness). The first study consisted of interviewing accident survivors and administer-
ing a questionnaire inquiring about dissociative experiences during the trauma. The
questionnaire revealed a wide range of dissociative symptoms including detach-
ment, depersonalization, absence of affect, perceptual distortions, and feelings of
unreality (Noyes & Kletti, 1977). In the second study, the dissociative symptoms of
hospitalized automobile accident survivors and psychiatric patients were examined
(Noyes, Hoenk, Kuperman, & Slymen, 1977). Accident victims were asked about
their dissociative experiences during the trauma, and psychiatric patients were
asked about dissociative experiences during the most recent episode of their
illness. A 56-item questionnaire administered in this study was submitted to factor
analysis. Three factors emerged for both populations: detachment, mental cloud-
ing, and alertness. Both victims and psychiatric patients reported experiences of
depersonalization and dissociation; "mental clouding" was prevalent in psychiatric
patients, whereas perceptual and time distortions were the predominant symptoms
in accident victims. High prevalence of avoidance and numbing symptoms (about
25 to 40%) was also found among adult survivors of severe flame, chemical,
electrical, or scald bums (Roca, Spence, & Munster, 1992) and among survivors of
the Hyatt Regency Hotel skywalk collapse (Wilkinson, 1983) 4 to 5 months after the
trauma.

Natural Disasters
Dissociation and avoidance symptoms have also been reported in victims of
natural disasters and appear to be associated with persistent posttrauma psycho-
pathology. Using an expanded version of the Hopkins Symptom Checklist to in-
clude PTSD items, Madakasira and O'Brien (1987) evaluated the posttrauma reac-
tions of disaster victims after a tornado in North Carolina. Five months after the
trauma, 82% of the victims were bothered by intrusive thoughts, 61% suffered
memory loss of the trauma, 57% experienced feelings of estrangement, and 31%
avoided trauma reminders.
Two studies used the SASRQ to examine dissociation after a natural disaster. In
the first study, two groups of earthquake survivors were compared. One group was
evaluated 1 week after the earthquake and the other 4 months later. As expected,
more symptoms of dissociation and anxiety were reported by the former than the
latter group (Cardena & Spiegel, 1993). In the second study, firestorm survivors
were evaluated on two occasions: within the first month after the fire and 7 to 9
months later. Dissociation and anxiety were highly correlated within the first
month posttrauma and both symptom clusters followed similar recovery courses.
Interestingly, dissociative symptoms were stronger predictors of chronic post-
trauma reactions than symptoms of anxiety (Koopman, Cardefia, Classen, &
Spiegel, Ch. 17, this volume). Similarly, McFarlane (1986) reported that DSM-Ill-R
216 symptoms of avoidance predicted persistent PTSD in survivors of the Ash Wednes-
Edna B. Foa and day brush fires. These findings, like those ofFoa et al. (1995a), point to the cardinal
Diana Hearst-Ikeda role of dissociation in PTSD.

Witnessing Trauma
Using a short version of the SASRQ, Freinkel, Koopman, and Spiegel (1994)
studied anxiety and dissociation symptoms of journalists during and immediately
after witnessing· an execution. Symptoms of emotional numbing, cognitive avoid-
ance, and derealization were more prevalent than anxiety symptoms. The fre-
quency of the dissociation symptoms reported by this sample was as high as that of
survivors of natural disasters (Koopman, Classen, & Spiegel, 1994) but did not
persist as long.
In summary, the studies reviewed above indicate that dissociative experiences
during and immediately after a trauma are frequent and are strongly associated with
persistent posttrauma reactions. Moreover, dissociative symptoms during or shortly
after a trauma may be a stronger predictor of PTSD than anxiety symptoms. It is
unclear, however, whether the tendency to dissociate has a causal relationship to
the development of chronic PTSD. It is possible that both the tendency to dissociate
and the vulnerability to develop chronic PTSD are mediated by other factors such as
childhood experiences. The strong relationship between childhood abuse and
dissociation strongly supports this proposition. Most studies also indicate that
dissociative symptoms are not unique to trauma victims; rather, they seem to reflect
general psychopathology. How can we explain the relationship between traumatic
experiences, dissociation, and psychopathology?

INFORMATION-PROCESSING PERSPECfiVE OF EMOTIONAL

DISSOCIATION IN RESPONSE TO TRAUMA

Many authors have noted that emotional experiences are often relived long
after the original emotional events have occurred (e.g., Freud, 1920; Lindemann,
1944; Rachman, 1980; Foa & Kozak, 1991). As is apparent from the studies reviewed
above, this phenomenon is clearly exemplified in individuals who have experi-
enced traumatic events. Usually, the frequency and intensity of this emotional re-
experiencing of the trauma gradually diminishes over time. Thus, shortly after the
attack, a rape victim may experience intense fear when reminded of the assault, and
with time this fear lessens, although perhaps it never completely disappears.
Rachman (1980) discussed the significance of the processes that underlie the
decline of emotional reexperiencing and suggested that when these processes are
impaired, psychopathology surfaces. He further proposed that the persistence of
neurotic symptoms such as intrusive thoughts, nightmares, excessive feats, and
sleep disturbances are signs of unsatisfactory "absorption" of the emotional experi-
ence. The overlap between these signs and the symptom criteria for PTSD is
striking, and it has lead Foa (1993) to propose that the presence of PTSD reflects
impairment in emotional processing of a traumatic experience. If this is true, Foa
(1993) suggested, the identification of factors that differentiate trauma victims with
chronic PTSD from victims without PTSD would shed light on the mechanisms that 217
facilitate or hinder emotional processing. Moreover, successful treatment of PTSD Emotional
can be viewed as assisting in emotional processing, and thus, factors that distin- Dissociation In
guish individuals who improved with treatment from those who failed to show Response to Trauma
improvement may further our knowledge of the pathology underlying PTSD.
To explain the mechanism by which cognitive-behavioral therapy reduced
pathological anxiety (i.e., signs of impaired processing), Foa and Kozak (1986)
extended Lang's (1977, 1979) bioinformation model of pathological fear. Using this
framework, we will provide an information-processing analysis of how dissociation
impairs the normal processing of a traumatic event, thereby contributing to the
development and maintenance of chronic PTSD. We will also provide an explana-
tion of how exposure treatment prevents or negates the deleterious effects of
dissociation.

The Cognitive Structure of Fear

Lang (1977, 1979) proposed that fear is represented in memory as a structure
that comprises information about: (1) feared stimuli, (2) physiological and motor
responses, and (3) interpretive information about their meaning. Lang further
suggested that a fear structure constitutes a "program" for escape from threat. 1f a
fear structure is a program for escaping danger, then it must involve information
that trauma-related stimuli and/or responses are dangerous. And it is this meaning
information, Foa and Kozak (1986) contended, that distinguishes a fear structure
from other cognitive structures.
Most people experience fear in some circumstances, which implies the "run-
ning" of a fear program. "Normal" fear occurs when an individual perceives actual
threat, and it subsides when the danger is removed. When does a fear become
pathological? Foa and Kozak (1986) noted that several characteristics distinguish
pathological fear. First, fear becomes pathological when it is extremely intense and
when it persists, despite information that it is unrealistic. In other words, a patho-
logical fear structure involves excessive response elements, such as representations
of avoidance and physiological activity, that are resistant to modification. Second, a
pathological fear structure includes unrealistic elements. This implies that stim-
ulus-stimulus associations do not accurately represent the world. For example, for
the rape victim who was raped at gunpoint by a tall, bearded man, the elements
"tall, bearded man" may become erroneously associated with the stimulus "gun."
Third, mistaken associations between nondangerous stimuli and escape or avoid-
ance responses are also characteristic of a pathological fear structure. Indeed,
running away from a "tall, bearded man" is not likely to enhance the safety of the
victim.
In addition to erroneous association among elements, victims with patholog-
ical fear make several evaluative mistakes. First, they commonly believe that anxi-
ety, once experienced, will persist unless they escape the feared situation. Second,
they overestimate the probability that the feared stimuli or responses will cause
physical or psychological harm. And third, their feared consequences have an
extremely high negative valence.
According to Foa and Kozak (1986), different anxiety disorders represent
218 different pathological fear structures. For example, there is evidence to suggest that
Edna B. Foa and erroneous interpretations of fear responses distinguish the structure of agora-
Diana Hearst-Ikeda phobia from that of simple phobia. Agoraphobics commonly interpret anxiety
responses, themselves, as threatening, since they expect these responses to result
in physical or psychological harm. For an agoraphobic, stimulus elements such as
"tunnels" are not perceived as inherently dangerous; rather, the danger is perceived
to exist in the anxiety that these elements engender. In contrast, for simple phobics,
the danger lies in the stimulus situation itself, such as "snakes," "airplanes;• or
"insects:•
Foa (1993) suggested that PTSD, like the other anxiety disorders, can be
construed as reflecting a pathological fear structure that contains faulty associations
and erroneous evaluations. She further proposed that a trauma memory can be
viewed as a fear structure. It includes information about stimuli and responses
related to the trauma, as well as information about their meaning. The trauma
structure of a woman who was raped at gunpoint at her home in the suburbs will
include the stimulus elements of "gun;• "man," his physical characteristics such as
"tall," and "beard," and environmental stimuli such as "home" and suburbs." The
response elements will include physiological responses such as "tachycardia" and
behavioral responses such as "struggling" and "screaming."
In a trauma memory of a non-PTSD victim, "rape" and "pointed gun" are
associated with a "danger" meaning but neutral stimuli such as "man," "home," and
"suburbs" are not. In a pathological trauma structure that underlies PTSD, stimuli
that are inherently neutral such as "tall, bearded man;• "home," and "suburbs" are
associated with the meaning "danger." Because many stimuli become associated
with danger meaning, the world as a whole is perceived as threatening by the victim
with PTSD. Foa and Riggs (1993) have suggested that a pathological trauma struc-
ture includes not only erroneous interpretations of stimulus elements but also
mistaken interpretations of response elements. In particular, they proposed that
responses during the trauma such as "struggling" and "screaming" become associ-
ated with the meaning "self-incompetence." A pathological trauma structure also
includes particularly intense response elements that are reflected in PTSD symp-
toms such as excessive avoidance and arousal. In summary, a pathological trauma
structure is distinguished by excessive response elements, as well as erroneous
interpretations of intrinsically neutral stimuli as dangerous and normal responses
to trauma as reflecting self-incompetence.

Modification of the Trauma Structure

Studies have revealed that 95% of female rape victims and 75% of female
nonsexual assault victims met symptom criteria for PTSD within the first 2 weeks
after the trauma (Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992). It follows that,
for most people, immediately after a traumatic experience the trauma memory
includes pathological elements such as excessive responses and faulty interpreta-
tions. Rothbaum et al. (1992) further noted that over time, only 50% of rape victims
and 25% of nonsexual assault victims met criteria for the disorder. This finding
suggests that, in the course of time, the trauma structure of many victims undergoes
modification.
 Foa and Kozak (1986) have suggested that the modification of a pathological 219
fear structure is the essence of emotional processing, and that successful therapy Emotional
promotes emotional processing. How does emotional processing occur in the Dissociation in
natural progression of recovery from a trauma? We argue that the understanding of Response to Trauma
how cognitive behavioral therapy reduces pathological fear will help us concep-
tualize natural recovery from a trauma.
Foa and Kozak (1986) proposed that two conditions are necessary for emo-
tional processing to occur. First, therapists must activate the fear structure by
providing information that matches the information represented in the structure.
For if the fear structure remains unaccused, it will not be available for correction.
Second, information provided during therapy must also be incompatible with the
pathological elements in the structure. Extending this model, we propose that in
order to acquire a spontaneous decline of posttrauma emotional disturbances, the
trauma memory, including its emotional elements, must be repeatedly activated by
contact with trauma-related stimuli. Further, this contact should include corrective
information about the world (e.g., "not all tall, bearded men carry guns and rape")
and about oneself (e.g., "screaming during the rape does not mean that I am
incompetent").

Dissociation Impedes Emotional Processing

The view that repeated engagement with the trauma memory is important for
a successful resolution of the traumatic experience has been shared by many
theorists (e.g., Freud, 1920; Horowitz, 1986). In fact, Horowitz (1986) invented the
term completion principle to denote the natural tendency to process new informa-
tion until it is "brought up to date" with inner schemas of the self and of the world.
A stressful life event, he suggested, includes by definition information that is
incompatible with a person's inner cognitive models, and thus requires more
processing activity than nonstressful experiences. But the completion principle
conflicts with the tendency to avoid trauma reminders in order to protect oneself
from emotional pain, the pain that is associated with the trauma. Dissociation or
numbing, like avoidance, is a strategy to avert trauma-related distressing emotions
(Davidson & Foa, 1991; Spiegel eta!., 1988). If recovery (i.e., emotional processing)
requires repeated engagement with the trauma memory, then dissociation is ex-
pected to impede this process.
Indirect evidence supporting the hypothesis that dissociation impairs emo-
tional processing and hence impedes recovery comes from the repeated finding
that dissociation during or immediately after the traumatic experience is associated
with later psychopathology. More direct evidence comes from a study examining
the facial fear expression of assault victims during therapy that involved reliving of
the trauma (Foa, Riggs, Massie, & Yarczower, in press). Assault victims who dis-
played more intense facial fear expressions and reported greater subjective distress
during the first reliving session benefited more from treatment than those who
displayed less intense fear. These findings converge with those of other studies that
measured fear activation via increase in heart rate. With simple phobics, Lang,
Melamed, and Hart (1970) found that clients who evidenced higher heart rate
response during the first imaginal exposure to feared stimuli manifested greater
220 improvement in their phobias. Similar results were reported with obsessive-
Edna B. Foa aod compulsives: a strong positive correlation was found between heart rate increase
Diana Hearst-Ikeda during the first in vivo exposure to the patients' most feared situations and change
in measures of obsessional fear (Kozak, Foa, Steketee, & Grayson, 1988). In all of
these studies, emotional engagement with the feared memory enhanced emotional
processing. Conversely, emotional disengagement (i.e., dissociation) hampered
emotional processing. Interestingly, in the Foa and co-workers' (in press) study
described above, victims who reported more anger prior to treatment displayed
less fear during reliving of the trauma and benefited less from treatment. These
results correspond with the finding that intense anger shortly after an assault
predicts PTSD severity 1 month later in female victims (Riggs et al., 1992). If, as we
suggested, PTSD reflects a failure to emotionally process the traumatic event, then
anger appears to impede the mechanisms underlying both the "natural" emotional
processing and emotional processing during treatment. The negative association
between anger and facial fear expression implies that anger impedes processing of
the trauma by inhibiting the activation of fear. It is possible that anger, like effortful
avoidance and dissociation, is a means by which victims with PTSD regulate their
arousal and emotional distress.

FURTHER CONSIDERATIONS

In this chapter we have adopted the view that dissociation or numbing may
represent a strategy for reducing or avoiding trauma-related emotional distress. We
have proposed that excessive use of dissociation prevents the activation of the
traumatic memory, and that repeated activation is a necessary condition for emo-
tional processing to occur. It follows that dissociation is one factor underlying the
persistence of posttrauma disturbances, and thus, it is implicated in the develop-
ment of chronic PTSD and related psychopathology.
The conceptualization of dissociation that we have offered here carries impli-
cations for the treatment of trauma-related psychopathology. If recovery from a
trauma requires emotional engagement with the traumatic memory, then treatment
of chronic PTSD should involve the promotion of such engagement. Indeed, suc-
cessful treatments for PTSD consist of the reliving of the trauma in imagination
(Boudewyns & Wilson, 1972; Boudewyns, 1975; Foa, Rothbaum, Riggs, & Murdock,
1991; Keane, Fairbank, Caddell, & Zimering, 1989; Keane & Kaloupek, 1985).
The use of exposure therapy to promote emotional processing assumes that
the tendency to dissociate will be conquered by therapeutic instructions to engage
in the emotional reliving of the trauma. The results of treatment studies that
employed exposure support this presumption.
For the most part, successful reduction of trauma-related distress via treatment
should eliminate the function of dissociation, and thus reduce dissociative re-
sponses. However, clinical observations reveal that some traumatized individuals
continue to dissociate during the reliving of the trauma, rendering exposure ther-
apy ineffective. For such individuals, therapeutic techniques directly aimed at
reducing dissociation must be implemented. Such interventions are reported in the
literature (for a summary of treatment for multiple personality disorder, see Put- 221
nam, 1989), but studies of their efficacy are awaiting controlled investigation. Emotional
Dissociation in
AcKNOWLEDGMENTS. This research was supported by NIMH grant #MH42178-07 to Response to Trauma
the first author.

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