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This review examines empirical reports of treatment for Dissociative Disorders (DD), including 16 DD treatment outcome studies and 4 case studies that used standardized measures. Collectively, these reports suggest that treatment for DD is associated with decreased symptoms of dissociation, depression, posttraumatic stress disorder, distress, and suicidality. Effect sizes, based on pre/post measures, are in the medium to large range across studies. Patients with dissociative disorder who integrated their dissociated self states were found to have reduced symptomatology compared with those who did not integrate. The magnitude of pre/post effect sizes for these DD studies are comparable to pre/post effect sizes in treatment studies of complex PTSD. There are significant methodological limitations in the current DD treatment outcome literature that reduce internal and external validity including regression towards the mean, limited sample sizes, and nonrandomized research designs. Implications for future research and treatment planning for patients suffering from DD are discussed. [ABSTRACT FROM AUTHOR]

With a reliable retrospective link to early-life traumatic stress, dissociation has been formulated as a pathology of abnormal socioemotional development. Dissociation hence should be identifiable and diagnosable in childhood. This study aimed to address the extent to which current formulation and diagnostic criteria of adult dissociation is applicable to children. This case study documented and analyzed the potentially dissociative experiences and behaviors in a 11-year-old boy from a residential facility accommodating children from high-risk families. The first-person account from the child client about his potentially dissociative experiences and the observations of the clinician witnessing the targeted behaviors were documented, revealing a symptom profile similar to adult dissociation. Dissociation disrupted multiple domains of typically integrated mental functioning including memory, consciousness, and the sense of self. The child client presented unusual forgetfulness that was observed by others, while the child himself was able to describe experiences involving gaps in consciousness and a fragmented and disconnected sense of self. This case study renders support for the current formulation of dissociative pathology and its applicability to high-risk cases in early developmental stages. This finding also indicates the importance of trauma-informed care in child residential settings. With gentle guiding prompts, children are able to recognize and articulate unusual experiences, facilitating the early identification of dissociation.

Objective: Dissociation is thought to be traumagenic, though this conceptualization is not without misunderstanding and stigma. There is little research regarding people's conceptualizations of their dissociative experiences and client-clinician discrepancies in understanding dissociation., Method: An online survey assessed 208 self-reported dissociative participants' understandings of their dissociation and their beliefs about their clinicians' understanding of dissociation via two open-ended questions. Template analysis, a codebook thematic analysis approach, was employed to explore and compare the ways people understand their dissociation and their perceptions of their clinicians' conceptualizations., Results: Four themes were developed to capture participants' perspectives: (1) Dissociation as Stigmatized and Underexplored ( n = 83; 39.90%); (2) Dissociation as Individualized and Normalized Lived Experience ( n = 173; 83.17%); (3) Dissociation as Clinical and/or Pathological ( n = 112; 53.85%); and (4) Dissociation Through Etiological Frameworks ( n = 67; 32.21%). Overall, 73.48% of participants indicated discrepancies between their understandings of their dissociation and those of their clinicians. Participants understood their dissociation through a lens of individualized and normalized lived experiences (100.00%) more often than their clinicians (23.12%). They believed their clinicians held more clinical understandings of dissociation (81.25%) than themselves (69.64%)., Conclusions: Given the perceived discrepancies between clients' and clinicians' understandings of dissociation, clinicians should engage in discussions with their clients about their dissociation-related lived experiences with awareness that they may have been misunderstood by previous providers. Client-clinician discrepancies should be addressed, as failure to do so could lead to misunderstandings and ruptures in the therapeutic relationship. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Individuals with histories of complex psychological trauma, such as those with dissociative disorders, are often high utilizers of inpatient services and thus warrant further research attention. The present study sought to examine whether treatment on a specialized inpatient trauma unit was associated with improvements in adaptive functioning, emotion regulation, and dissociation among patients experiencing complex posttraumatic and dissociative symptoms., Method: This study used archival data collected as part of treatment provided to inpatients ( N = 54), the majority of whom had a dissociative disorder, at a specialized trauma disorders unit to analyze differences in scores between intake and discharge on measures of adaptive functioning, emotion regulation, and dissociation., Results: Adaptive functioning and emotion regulation were significantly improved at discharge compared to intake, t (299) = -11.28, p < .001; t (305) = 8.54, p < .001, respectively, with very large effect sizes ( d = 1.60; d = 1.20), and there was a significant decrease, t (311) = 2.15, p = .032, d = .30, in dissociative absorption., Conclusions: Our findings suggest that inpatient treatment modeled after expert consensus treatment guidelines is associated with significant improvements in adaptive functioning and emotion regulation and reduced dissociative absorption in individuals experiencing severe and acute complex posttraumatic and dissociative symptoms. Appropriate screening and symptom-specific treatment of complex posttraumatic and dissociative symptoms are recommended to improve outcomes for this population during inpatient hospital admission. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Past research found that undergraduate psychopathology textbooks present child maltreatment (CM) and its consequences inadequately or inaccurately. Given the prevalence and psychological impact of CM, it is essential that mental health professionals receive adequate training in CM, including trauma-related dissociation. Updated research is needed to determine whether current psychopathology textbooks adequately present information about CM and its consequences., Method: Ten undergraduate psychopathology textbooks were analyzed for the number of times CM was mentioned, number of Diagnostic and Statistical Manual of Mental Disorders (5th ed., Text Revision; DSM-5-TR) diagnostic categories CM was associated with, number of citations used to support claims about CM and related psychopathology, and coverage of trauma-related dissociation., Results: Textbooks varied in their coverage of CM and dissociation. The average number of times CM-related keywords mentioned per book was 259.00 ( SD = 110.42; range: 113-508). Childhood sexual abuse and sex trafficking received the most attention, followed by general references of child abuse or childhood trauma. The average number of citations provided with mentions of CM or related psychopathology for each textbook was 123.2 ( SD = 77.44; range: 44-316). CM was stated to be associated with many DSM-5 -TR diagnostic categories, including but not limited to trauma, dissociative, anxiety, mood, somatic, and personality disorders. The textbooks' coverage of dissociation was found to be largely inadequate, with most textbooks emphasizing popular media, the fantasy model of dissociation, and myths about dissociation., Conclusions: Undergraduate psychopathology textbooks need to improve their scholarly coverage of CM and its mental health consequences. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Purpose: Complex dissociative disorders (CDDs) are prevalent among psychotherapy clients, and research suggests carefully paced treatment for CDDs is helpful. The purpose of the present study is to qualitatively explore helpful and meaningful aspects of the TOP DD Network programme, a web-based adjunctive psychoeducational programme for the psychotherapeutic treatment of clients with CDDs. Methods: TOP DD Network programme participants (88 clients and 113 therapists) identified helpful and meaningful aspects of their participation in response to two open textbox questions. Framework analysis was used to qualitatively analyze client and therapist responses. Findings: Participants found the TOP DD Network programme helpful and meaningful in nuanced ways. Three themes were created: (1) Components of the Programme (subthemes: content , structure ), (2) Change-Facilitating Processes (subthemes: heightened human connection, receiving external empathy and compassion, contributing to something bigger, improved therapeutic work and relationship ), and (3) Outcomes (subthemes: insight, increased hope, self-compassion, increased safety and functioning ). The most emphasized theme was components of the programme, which captured its content and structure. Conclusion: Clients and therapists in the TOP DD Network programme described the programme's components and processes as helpfully facilitating positive outcomes in the treatment of CDDs. Therapists may consider integrating the components and processes in the programme into their practice with clients with CDDs.

Objective: This study sought to determine the utility of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in accurately distinguishing genuine dissociative identity disorder (DID) patients from coached and uncoached DID simulators., Method: DID patients ( n = 34) who were diagnosed using the Structured Clinical Interview for DSM-IV -Dissociative Disorders were recruited from inpatient and outpatient settings. Coached ( n = 25) and uncoached ( n = 64) simulator groups were recruited from a Mid-Atlantic university. All participants completed the MMPI-2., Results: MMPI-2 validity scales reliably distinguished simulators from DID patients with high sensitivity (0.95) and specificity (0.97). The scales showing greatest promise making the distinction were F minus K index, back infrequency scale, and superlative self-presentation. Simulators and genuine DID patients also differed in their pattern of symptoms. All results were calculated with White female DID patients and simulators only., Conclusions: Genuine DID patients can be differentiated from simulators. Simulators appear to overweight symptoms of paranoia and alienation relative to mood and somatic symptoms. Further research is needed to generalize these findings to male and non-White populations. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Background: Individuals with dissociative identity disorder (DID) experience severe and broad-ranging symptoms which can be associated with elevations on measures designed to detect feigning and/or malingering. Research is needed to determine how to distinguish genuine DID from simulated DID on assessment measures and validity scales., Objective: This study examined whether the Miller Forensic Assessment of Symptoms Test (M-FAST), a screening measure of malingering, could differentiate between individuals with DID and DID simulators., Method: Thirty-five individuals with clinical, validated DID were compared to 88 individuals attempting to simulate DID on the M-FAST. A MANCOVA compared the two groups on total M-FAST score and subscales. Univariate ANCOVA's examined differences between the groups. A series of logistic regressions were conducted to determine whether group status predicted the classification of malingering. Utility statistics evaluated how well the M-FAST discerned clinical and simulated DID., Results: The M-FAST correctly classified 82.9% of individuals with DID as not malingering when using the suggested cut-off score of six. However, utilizing a cut-off score of seven correctly classified 93.6% of all participants and maintained adequate sensitivity (.96) but demonstrated increased specificity (.89)., Conclusions: The M-FAST shows promise in distinguishing genuine DID when the cut-off score is increased to seven. This study adds to the growing body of literature identifying tests that can adequately distinguish clinical from simulated DID. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Upto 86% of dissociative individuals engage in non-suicidal self-injury (NSSI). Research suggests that people who dissociate utilize NSSI to regulate posttraumatic and dissociative experiences, as well asrelated emotions. Despite high rates of NSSI, no quantitative study has examined the characteristics, methods, and functions of NSSIwithin a dissociative population. The present study examined thesedimensions of NSSI among dissociative individuals, as well aspotential predictors of intrapersonal functions of NSSI. The sample included 295 participants who indicated experiencing one or more dissociative symptoms and/or having been diagnosed with a trauma- or dissociation-related disorder. Participants were recruited through online trauma- and dissociation- related forums. Approximately 92% of participants endorsed a history of NSSI. The most common methods of NSSI were interfering with wound healing (67%), hitting oneself (66%), and cutting (63%). After controlling for age and gender, dissociation was uniquely associated with cutting, burning, carving, interfering with wound healing, rubbing skin against rough surfaces, swallowing dangerous substances, and other forms of NSSI. Dissociation was correlated with affect regulation, self-punishment,anti-dissociation, anti-suicide, and self-care functions of NSSI;however, after controlling for age, gender, depressive symptoms, emotion dysregulation, and PTSD symptoms, dissociation was no longer associated with any function of NSSI. Instead, only emotion dysregulation was associated with the self-punishment function ofNSSI and only PTSD symptoms were associated with the anti-dissociation function of NSSI. Understanding the unique properties of NSSI among dissociative individuals may improve the treatment of people who dissociate and engage in NSSI.

Objective: Academic training programs for mental health professionals rarely include comprehensive instruction on trauma, consequently leaving clinicians inadequately prepared to provide trauma treatment. The present study sought to: (a) ascertain what percentage of participants had received training in complex trauma and dissociation; (b) examine pre- and posttraining differences in knowledge related to complex trauma populations; and (c) investigate changes in participants' competence and empathy in working with survivors., Method: We examined self-reported changes in knowledge, competence, and empathy regarding individuals with complex trauma among mental health professionals who attended a complex trauma training workshop. Participants provided feedback about previous trauma training experience and areas of additional trauma training that they perceived would be beneficial., Results: Prior to completing the program, 68% of participants reported feeling inadequately trained to assess trauma and 75% felt inadequately trained to treat trauma. Ten percent had not received training in complex trauma and 30% had not received training in treating patients with dissociative symptoms. Participants showed significant increases in knowledge and self-reported competence following the training. They suggested that learning about dissociation and dissociative disorders was the most helpful information gained and that learning more techniques and skills for complex trauma populations would improve their ability to treat this group., Conclusions: The majority of participants felt inadequately trained to treat clients who have experienced complex trauma and experienced dissociation. They reported the trauma training as beneficial in that it increased their sense of knowledge and competence about treating trauma-exposed individuals. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The 4-dimensional (4-D) model of trauma-related dissociation differentiates between dissociative experiences involving trauma-related altered states of consciousness and symptoms of distress that do not appear to involve alterations in normal waking consciousness across four phenomenological dimensions (i.e., our experience of time, thought, body, and emotions). The current study evaluated hypotheses associated with the 4-D model using analyses of variance and correlation analyses in individuals with a primary diagnosis of a trauma-related dissociative disorder who were participating in the TOP DD internet study involving a combination of in-person psychotherapy and an online psychoeducational program ( n = 111). Intrusive memories of traumatic events were more frequently endorsed than flashbacks, but emotional numbing was more frequently endorsed than other forms of affect dysregulation. Negative thoughts and emotion dysregulation were more strongly intercorrelated than were voice hearing and emotional numbing. Distress symptoms were more strongly associated with PTSD symptoms and difficulties in emotion regulation, whereas experiences of depersonalization were more strongly associated with dissociative self-states. Greater reduction in distress symptoms was also seen in comparison with trauma-related altered states of consciousness over the course of the combined psychotherapy and internet-based psychoeducational intervention. Overall, results continue to suggest that measures of distress and dissociative experiences can be distinguished by measures of symptom frequency, co-occurrence, and convergence with other measures of distress vs. dissociation albeit that results varied across the four phenomenological dimensions that were surveyed.

Background: Dissociative disorders (DDs) are characterized by interruptions of identity, thought, memory, emotion, perception, and consciousness. Patients with DDs are at high risk for engaging in dangerous behaviours, such as self-harm and suicidal acts; yet, only between 28% and 48% of individuals with DDs receive mental health treatment. Patients that do pursue treatment are often misdiagnosed, repeatedly hospitalized, and experience disbelief from providers about their trauma history and dissociative symptoms. Lack of dissociation-specific treatment can result in poor quality of life, severe symptoms requiring utilization of hospitalization and intensive outpatient treatment, and high rates of disability., Objective: Given the extensive and debilitating symptoms experienced by individuals with DDs and the infrequent utilization of treatment, the current study explored barriers to accessing and continuing mental health treatment for individuals with dissociative symptoms and DDs., Method: A total of 276 participants with self-reported dissociative symptoms were recruited via online social media platforms. Participants completed a survey which featured 35 possible barriers to accessing treatment and 45 possible reasons for discontinuing treatment, along with open text boxes for adding barriers/reasons that were not listed., Results: Results showed 97% of participants experienced one or more barriers to accessing treatment ( M = 9 barriers) and 92% stopped treatment with a provider due to at least one of the reasons captured in the survey (e.g. limited insurance coverage, poor therapeutic alliance, disbelief from providers, etc.; M = 7 barriers)., Conclusions: The most frequently endorsed barriers were structural barriers, such as those related to finances, insurance, and lack of provider availability. It is imperative more service providers are trained to treat dissociation and that insurers and health care systems recognize the need for specialized, dissociation-focused treatment., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Dissociative disorder (DD) patients report high rates of self-injury. Previous studies have found dissociation and self-injury to be related to emotional distress. To the best of our knowledge, however, the link between emotion dysregulation and self-injury has not yet been examined within a DD population., Objective: The present study investigated relations between emotion dysregulation, dissociation, and self-injury in DD patients, and explored patterns of emotion dysregulation difficulties among DD patients with and without recent histories of self-injury., Method: We utilized linear and logistic regressions and t -test statistical methods to examine data from 235 patient-clinician dyads enrolled in the TOP DD Network Study., Results: Analyses revealed emotion dysregulation was associated with heightened dissociative symptoms and greater endorsement of self-injury in the past six months. Further, patients with a history of self-injury in the past six months reported more severe emotion dysregulation and dissociation than those without recent self-injury. As a group, DD patients reported the greatest difficulty engaging in goal-directed activities when distressed, followed by lack of emotional awareness and nonacceptance of emotional experiences. DD patients demonstrated similar patterns of emotion dysregulation difficulties irrespective of recent self-injury status., Conclusions: Results support recommendations to strengthen emotion regulation skills as a means to decrease symptoms of dissociation and self-injury in DD patients., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Most individuals with dissociative disorders (DDs) report engaging in self-injury., Objective: The present study aimed to understand the reasons for self-injury among a clinical sample of 156 DD patients enrolled in the TOP DD Network study., Method: Participants answered questions about self-injury, including a prompt asking how often they are aware of the reasons they have urges to self-injure, as well as a prompt asking them to list three reasons they self-injure., Results: Six themes of reasons for self-injury, each with subthemes, were identified in the qualitative data: (1) Trauma-related Cues, (2) Emotion Dysregulation, (3) Stressors, (4) Psychiatric and Physical Health Symptoms, (5) Dissociative Experiences, and (6) Ineffective Coping Attempts. Participants reported that they were able to identify their reasons for self-injuring sometimes (60.26%) or almost always (28.85%), with only 3.20% unable to identify any reasons for their self-injury., Conclusion: Results suggest that the vast majority of DD patients (92.31%) reported being at least partially unaware of what leads them to have self-injury urges, and many individuals with DDs experience some reasons for self-injury that are different from those with other disorders. The treatment implications of these findings are discussed., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Individuals with dissociative identity disorder (DID) have complex symptoms consistent with severe traumatic reactions. Clinicians and forensic assessors are challenged by distinguishing symptom exaggeration and feigning from genuine symptoms among these individuals. This task may be aided by administering validity measures., Objective: This study aimed to document how individuals with DID score on the Structured Inventory of Malingered Symptomatology (SIMS). The second objective was to compare coached DID simulators and healthy controls to DID patients on the SIMS's total score and subscales. The third objective was to examine the utility rates of the SIMS in distinguishing simulated DID from clinically diagnosed DID., Method: We compared SIMS data gathered from participants from two Dutch sites, one Swiss site and one U.S. site. Sixty-three DID patients were compared to 77 coached DID simulators and 64 healthy controls on the SIMS. A multivariate analysis compared the groups on the SIMS total scores and subscales, and post-hoc Games Howell tests and univariate ANOVAs examined differences between the groups. Utility statistics assessed the accuracy of the SIMS in distinguishing clinical from simulated DID., Results: DID simulators scored significantly higher than DID individuals and healthy controls on every SIMS subscale as well as the total score. The majority (85.7%) of the individuals with DID scored above the cut-off, which is typically interpreted as indicative of possible symptom exaggeration. DID individuals scored higher than the healthy controls on every subscale except Low Intelligence, even after controlling for dissociation. The subscales and items most frequently endorsed by the DID group are consistent with symptoms associated with complex trauma exposure and dissociative reactions. The SIMS total score had a sensitivity of 96% but an unacceptably low specificity of 14%., Conclusions: The findings indicate that the instrument is not accurate in assessing potential symptom exaggeration or feigning in DID., Competing Interests: The authors have no conflicts of interest., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

The Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition (DSM-5) revised the diagnostic criteria for dissociative identity disorder (DID) to more accurately reflect the symptom profile of DID patients. No study has examined how this change affects clinical diagnosis of DID. The present study examined clinician reports of patient symptoms in relation to DSM-IV-TR and DSM-5 DID diagnostic criteria. Data were analyzed from 169 clinicians who participated in the Treatment of Patients with Dissociative Disorders Network Study with a patient they assigned a DID diagnosis. Clinicians evaluated their patients with respect to DSM-IV-TR and DSM-5 DID diagnostic criteria. Researchers determined a clinician-assigned DID diagnosis as "accurate" when the patient's reported dissociative symptoms matched DSM-IV-TR and/or DSM-5 criteria for DID. Most of the clinicians (95.27%) accurately diagnosed DID. Of those accurately diagnosed, 83.85% of patients met DSM-IV-TR and DSM-5 DID criteria, 9.94% only met DSM-IV-TR DID criteria, and 6.21% only met DSM-5 DID criteria. Further examination of responses suggested that possible idiomatic responses to the negative wording of the DSM-5 exclusionary criteria might have accounted for the DSM-IV-TR appearing to fit for a greater number of cases in this study. Changes in the DSM criteria for DID did not substantially change the frequency or accuracy of assigned DID diagnoses, but the removal of the requirement in DSM-5 that self-states regularly take control of an individual's behavior slightly increased the number of individuals meeting criteria for DID.

Childhood trauma is common among survivors and perpetrators of intimate partner violence (IPV). Although symptoms of posttraumatic stress disorder (PTSD) and dissociative disorders (DDs) are predictors of IPV victimization and perpetration, few studies explore IPV among those with DDs. The present study examined IPV and symptoms as predictors among participants in the Treatment of Patients With Dissociative Disorders (TOP DD) Network study, an educational intervention for individuals with DDs and their clinicians. Both clinicians and patients reported on patients' history of physical, emotional, and sexual IPV as both victims and perpetrators. Patients self-reported dissociative, posttraumatic (PTSD), and emotion dysregulation symptoms, as well as IPV-specific dissociative symptoms. According to patients and clinicians, patients were frequently victims of IPV, most commonly emotional IPV. Dissociative symptoms predicted IPV exposure, whereas dissociative and emotion dysregulation symptoms predicted IPV-specific dissociative symptoms.

Inaccurate diagnosis of dissociative disorders (DDs) remains a frequent problem. Misdiagnoses may lead to delayed or ineffective treatment, and subsequently poorer quality of life for those struggling with DDs, who frequently utilize mental health treatment and evidence high rates of self-harm and suicidality. This study's objective was to examine the magnitude of the effects with which the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) and revised version (SCID-D-R) - henceforth referred to as the "SCID-D interviews" - provide diagnoses of DDs and differentiate them from nondissociative disorders as well as factitious and simulated dissociative presentations. For inclusion, studies had to be empirical investigations comparing SCID-D data of DD populations with other populations. Using combined methods of searching for "SCID-D" in electronic indexing databases, seeking recommendations from experts, and reviewing reference sections of identified studies, 15 studies were identified and subjected to meta-analytic review. Analyses showed that the overall SCID-D interview score (effect size 3.12) as well as each of the five subscales - particularly amnesia and identity alteration (effect sizes 2.16 and 2.87, respectively) - significantly differentiated DD from non-DD. Findings suggest that the SCID-D interviews show good validity identifying and differentiating those with DDs as compared to those without DDs. The SCID-D interviews are valid instruments for diagnosing and differentiating DD from other psychiatric disorders and feigned presentations of DD. Clinicians, researchers, and forensic experts can use the SCID-D interviews with confidence to make differential diagnoses of DDs. Future research using the SCID-D interviews is discussed.

Objective: Dissociative disorders (DDs) are associated with intensive, long-term treatment, suicidality, recurrent hospitalizations, and high rates of disability. However, little is known about the specifics of the economic burden associated with DDs. This worldwide, systematic review examines the results of studies in adults on direct and indirect costs associated with DDs., Method: We searched 6 databases and the reference lists of articles. We also approached researchers to identify unpublished studies. No language restrictions were imposed., Results: A total of 1,002 records met the search criteria, of which 29 papers were selected for full-text inspection. Ultimately, of these, we reviewed four empirical studies. We provide a narrative discussion of study findings. Our findings suggest that DDs are costly to society, and that there is a reduction in service utilization and associated costs over time with diagnosing of and specialized treatment for DDs. However, the overall quality of the economic evaluations was low; several types of DDs, comorbid conditions, and costs were not included; and men were underrepresented. Due to the heterogeneity among studies, we could not perform a meta-analysis., Conclusions: Due to the heterogeneity and low quality of the identified economic evaluations, no firm conclusions about the economic burden of DDs alone can be drawn. Higher quality research, including a detailed description of the study design, population, and primary outcome measures used, utilizing appropriate clinical alternatives and including major comorbidities, is urgently needed to more rigorously assess the economic impact of DDs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective: Undergraduate psychology textbooks often present trauma, particularly child maltreatment (CM) and its consequences, inadequately or inaccurately. Adequate education about CM and adult trauma (AT) is crucial because they are prevalent and their health impacts are widespread and enduring. Furthermore, mental health professionals are called upon to treat disorders and problematic behaviors associated with trauma yet have often not received adequate knowledge and training about trauma and its treatment. This is the first study to investigate the adequacy and accuracy of the coverage of CM and AT in graduate psychology psychopathology textbooks., Method: To address this gap, we reviewed and scored 10 graduate psychology psychopathology textbooks to determine the adequacy, completeness, and balance in their coverage of CM and AT., Results: There was a surprisingly wide range of scores, with some textbooks presenting little research on trauma or unbalanced coverage of trauma-related debates. Even the texts that earned the highest scores could more fully address trauma and/or provide more balanced discussion of debates., Conclusions: Graduate textbooks would benefit from increased attention to, and more balanced coverage of, CM and AT. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The inclusion of the dissociative subtype of post-traumatic stress disorder (PTSD-DS) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the importance of assessing PTSD-DS. We developed the Dissociative Subtype of PTSD Interview (DSP-I). This clinician-administered instrument assesses the presence and severity of PTSD-DS (i.e., symptoms of depersonalization or derealization) and contains a supplementary checklist that enables assessment and differentiation of other trauma-related dissociative symptoms (i.e., blanking out, emotional numbing, alterations in sensory perception, amnesia, and identity confusion). The psychometric properties were tested in 131 treatment-seeking individuals with PTSD and histories of multiple trauma, 17.6 % of whom met criteria for PTSD-DS in accordance with the DSP-I. The checklist was tested in 275 treatment-seeking individuals. Results showed the DSP-I to have high internal consistency, good convergent validity with PTSD-DS items of the CAPS-5, and good divergent validity with scales of somatization, anxiety and depression. The depersonalization and derealization scales were highly associated. Moreover, the DSP-I accounted for an additional variance in PTSD severity scores of 8% over and above the CAPS-5 and number of traumatic experiences. The dissociative experiences of the checklist were more strongly associated with scales of overall distress, somatization, depression, and anxiety than scales of depersonalization and derealization. In conclusion, the DSP-I appears to be a clinically relevant and psychometrically sound instrument that is valuable for use in clinical and research settings.

There is a shortage of clinicians who have been trained in treating traumatized clients, despite the high prevalence of trauma exposure and its frequent link with psychopathology. To address this need, professional guidelines and resources have been developed, including a core set of trauma competencies that professionals must develop to provide trauma-informed services to clients and several treatment guidelines. We discuss The New Haven Competencies for Trauma Training and Practice, then review recently developed clinical and professional practice guidelines, with an emphasis on the American Psychological Association (APA)'s Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD; "APA PTSD Guideline"). The APA PTSD Guideline was developed to guide clinicians in treatment planning for traumatized clients. However, numerous concerns about the Guideline and its limitations have been raised, and we present those that are relevant to training students and professionals about treating traumatized clients. We consider whether the APA Guideline is consistent with current trauma training needs, models, initiatives, and resources. We conclude that students and professionals who apply the treatments identified by the APA PTSD Guideline as "strongly supported" by empirical evidence may inadvertently overwhelm some clients with complex trauma presentations, which could result in poor outcomes or even harm. Furthermore, the Guideline does not adequately address aspects of treatment that are crucial to training about trauma, such as considering the client's cultural and individual needs and clinician self-care. We suggest training methods that take into consideration the limitations of the APA PTSD Guideline. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: Few studies have assessed malingering in individuals with complex trauma and dissociation. This is concerning because these individuals' severe and ranging symptoms are associated with elevations on some, but not all, validity scales that detect symptom exaggeration. Dissociative individuals may experience dissociative amnesia, yet no study to date has examined how to distinguish clinical from malingered amnesia with dissociative samples. The current study examined whether the Test of Memory Malingering (TOMM) can accurately distinguish patients with clinically diagnosed dissociative identity disorder (DID) and simulators coached to imitate DID., Method: Utility statistics classify individuals' TOMM scores as suggestive of clinical or simulated DID. TOMM scores from 31 patients diagnosed with DID via structured interviews were compared to those of 74 coached DID simulators., Results: Discriminant analyses found scores from TOMM Trials 1 and 2 and total TOMM scores accurately classified clinical or simulated DID group status. In addition, TOMM Trial 1 demonstrated high specificity (87%) and positive predictive power (94%), as well as moderate sensitivity (78%), negative predictive power (63%), and overall diagnostic power (81%). Despite exposure to DID-specific information, simulators were not able to accurately feign the DID group's TOMM scores, which is inconsistent with the iatrogenic/sociocultural model of DID., Conclusion: The TOMM shows promise as useful in clinical and forensic contexts to detect memory malingering among DID simulators without sacrificing specificity. Accurate distinction between genuine and feigned complex trauma-related symptoms, including dissociative memory, is integral to the accurate diagnosis of traumatized populations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: The first objective was to understand how individuals with complex dissociative disorders (CDD) score on the Trauma Symptom Inventory-2 (TSI-2). These individuals have high elevations on many psychological measures' validity and clinical scales because of the severe traumatic reactions they experience; thus, creating a challenge for clinicians who seek to determine whether these individuals are exaggerating reported symptoms. The second objective was to compare coached CDD simulators to CDD profiles on the TSI-2s clinical and validity scales. The third objective was to examine the utility rates of the TSI-2s Atypical Response Scale (ATR) in distinguishing feigned CDD from clinical CDD., Method: This study compared 39 CDD inpatients to 51 coached CDD simulators on the TSI-2. A profile analysis compared the CDD group and coached simulators on the TSI-2 scales, and post hoc 1-way analysis of covariances (ANCOVAS) examined significant differences between the groups., Results: The CDD patients elevated on most of the TSI-2 clinical scales and factors. There were significant differences between CDD patients' and CDD simulators' TSI-2 profiles, with simulators failing to endorse some of the co-occurring symptoms common in CDD. The ATR correctly classified only 60-73% of participants and its specificity scores were low., Conclusions: It is important to understand how CDD individuals score on the TSI-2 so that their results can be recognized and meaningfully interpreted. The TSI-2 may not be a useful measure for distinguishing feigned CDD from CDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individuals with dissociative disorders (DDs) are underrecognized, underserved, and often severely psychiatrically ill, characterized by marked dissociative and posttraumatic stress disorder (PTSD) symptoms with significant disability. Patients with DD have high rates of nonsuicidal self-injury (NSSI) and suicide attempts. Despite this, there is a dearth of training about DDs. We report the outcome of a web-based psychoeducational intervention for an international sample of 111 patients diagnosed with dissociative identity disorder (DID) or other complex DDs. The Treatment of Patients with Dissociative Disorders Network (TOP DD Network) program was designed to investigate whether, over the course of a web-based psychoeducational program, DD patients would exhibit improved functioning and decreased symptoms, including among patients typically excluded from treatment studies for safety reasons. Using video, written, and behavioral practice exercises, the TOP DD Network program provided therapists and patients with education about DDs as well as skills for improving emotion regulation, managing safety issues, and decreasing symptoms. Participation was associated with reductions in dissociation and PTSD symptoms, improved emotion regulation, and higher adaptive capacities, with overall sample |d|s = 0.44-0.90, as well as reduced NSSI. The improvements in NSSI among the most self-injurious patients were particularly striking. Although all patient groups showed significant improvements, individuals with higher levels of dissociation demonstrated greater and faster improvement compared to those lower in dissociation |d|s = 0.54-1.04 vs. |d|s  = 0.24-0.75, respectively. These findings support dissemination of DD treatment training and initiation of treatment studies with randomized controlled designs., (© 2019 The Authors. International Society for Traumatic Stress Studies published by Wiley Periodicals, Inc. on behalf of Society for International Society for Traumatic Stress Studies.)

Background: Interpersonal trauma and trauma-related disorders cost society billions of dollars each year. Because of chronic and severe trauma histories, dissociative disorder (DD) patients spend many years in the mental health system, yet there is limited knowledge about the economic burden associated with DDs. Objective: The current study sought to determine how receiving specialized treatment would relate to estimated costs of inpatient and outpatient mental health services. Method: Patients' and individual therapists' reports of inpatient hospitalization days and outpatient treatment sessions were converted into US dollars. DD patients and their clinicians reported on use of inpatient and outpatient services four times over 30 months as part of a larger, naturalistic, international DD treatment study. The baseline sample included 292 clinicians and 280 patients; at the 30-month follow-up, 135 clinicians and 111 patients. Missing data were replaced in analyses to maintain adequate statistical power. The substantial attrition rate (>50%) should be considered in interpreting findings. Results: Longitudinal and cross-sectional analyses of cost estimates based on patient reported inpatient hospitalization significantly decreased over time. Longitudinal cost estimates based on clinician-reported outpatient services also significantly decreased over time. Cross-sectional cost estimates based on patient and clinician reported inpatient hospitalization were significantly lower for patients in later stages of treatment compared to those struggling with safety and stabilization. Cross-sectional cost estimates based on clinician-reported outpatient services were significantly lower for patients in later stages of treatment compared to those in early stages. Conclusions: This pattern of longitudinal and cross-sectional reductions in inpatient and outpatient costs, as reported by both patients and therapists, suggests that DD treatment may be associated with reduced inpatient and outpatient costs over time. Although these preliminary results show decreased mental health care utilization and associated estimated costs, it is not clear whether it was treatment that caused these important changes.

Objective : Literature on the treatment of dissociative disorders (DDs) suggests that these individuals require long-term and specialized treatment to achieve stabilization and functionality. There is considerable empirical support for specialized phasic, dissociation-focused treatment in reducing a myriad of psychological symptoms and self-harm in this population. However, until recently, there has been a paucity of longitudinal treatment research on DD patients. Method : In the present six-year follow-up study, 61 therapists who participated in the initial phase of the Treatment of Patients with Dissociative Disorders (TOP DD) study answered questionnaires about their study patient's stressors, quality of life, global functioning, victimization, and safety. These results provided a view of patients' progress six years since the beginning of the TOP DD study. Results : Longitudinal analyses demonstrated patients had significantly fewer stressors ( Χ 2 (6) = 18.76, p  < .01, canonical r  = .48, N  = 76), instances of sexual revictimization ( X 2 (1) = 107.05, p  < .001) and psychiatric hospitalizations ( t (54) = 2.57, p  < .05, Cohen's d  = .43), as well as higher global functioning ( Χ 2 (2) = 59.27, p  < .001, canonical r  = .65, N  = 111). Conclusions : These findings continue to support the initial results of the TOP DD study that, despite marked initial difficulties and functional impairment, DD patients benefit from specialized treatment.

Controversy exists regarding the merits of exposure-based treatments for posttraumatic stress disorder (PTSD) versus a phased approach when prominent dissociative symptoms are present. The first aim of this study was to examine the degree to which diagnosing dissociation in two traumatized patients' vignettes influenced clinicians' preference for phase-oriented treatment and whether clinicians' treatment experience contributed to their treatment preference. The second aim was to assess the extent to which participants had observed traumatized patients worsen when treated with exposure therapy or phase-oriented therapy and whether the theoretical orientation and treatment experience of the clinician were related to the observed deterioration. In the tradition of expert and practitioner surveys, 263 clinicians completed a survey of their diagnoses and treatment preferences for two vignettes and their treatment experience, theoretical orientation, and observations of patients' deterioration. When a marked degree of dissociation was noted in the PTSD vignette, respondents favored phased approaches regardless of the diagnosis given. Reports of having observed patient deterioration during both exposure and phased therapy were predicted by years of experience. Psychodynamic therapists reported more observations of worsening during exposure therapy than cognitive behavior therapy therapists. Clinical experience treating PTSD may heighten awareness of negative therapeutic effects, potentially because experienced clinicians have a lower threshold for detecting such effects and because they are referred more challenging cases.

Background: The role of mental illness in violent crime is elusive, and there are harmful stereotypes that mentally ill people are frequently violent criminals. Studies find greater psychopathology among violent offenders, especially convicted homicide offenders, and higher rates of violence perpetration and victimization among those with mental illness. Emotion dysregulation may be one way in which mental illness contributes to violent and/or criminal behavior. Although there are many stereotyped portrayals of individuals with dissociative disorders (DDs) being violent, the link between DDs and crime is rarely researched., Methods: We reviewed the extant literature on DDs and violence and found it is limited to case study reviews. The present study addresses this gap through assessing 6-month criminal justice involvement among 173 individuals with DDs currently in treatment. We investigated whether their criminal behavior is predicted by patient self-reported dissociative, posttraumatic stress disorder and emotion dysregulation symptoms, as well as clinician-reprted depressive disorders and substance use disorder., Results: Past 6 month criminal justice involvement was notably low: 13% of the patients reported general police contact and 5% reported involvement in a court case, although either of these could have involved the DD individual as a witness, victim or criminal. Only 3.6% were recent criminal witnesses, 3% reported having been charged with an offense, 1.8% were fined, and 0.6% were incarcerated in the past 6 months. No convictions or probations in the prior 6 months were reported. None of the symptoms reliably predicted recent criminal behavior., Conclusions: In a representative sample of individuals with DDs, recent criminal justice involvement was low, and symptomatology did not predict criminality. We discuss the implications of these findings and future directions for research.

Few assessors receive training in assessing dissociation and complex dissociative disorders (DDs). Potential differential diagnoses include anxiety, mood, psychotic, substance use, and personality disorders, as well as exaggeration and malingering. Individuals with DDs typically elevate on many clinical and validity scales on psychological tests, yet research indicates that they can be distinguished from DD simulators. Becoming informed about the testing profiles of DD individuals and DD simulators can improve the accuracy of differential diagnoses in forensic settings. In this paper, we first review the testing profiles of individuals with complex DDs and contrast them with DD simulators on assessment measures used in forensic contexts, including the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Personality Assessment Inventory (PAI), and the Structured Inventory of Reported Symptoms (SIRS), as well as dissociation-specific measures such as the Dissociative Experiences Scale (DES) and Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). We then provide recommendations for assessing complex trauma and dissociation through the aforementioned assessments., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The Trauma Model of dissociative identity disorder (DID) posits that DID is etiologically related to chronic neglect and physical and/or sexual abuse in childhood. In contrast, the Fantasy Model posits that DID can be simulated and is mediated by high suggestibility, fantasy proneness, and sociocultural influences. To date, these two models have not been jointly tested in individuals with DID in an empirical manner., Method: This study included matched groups [patients (n = 33) and controls (n = 32)] that were compared on psychological Trauma and Fantasy measures: diagnosed genuine DID (DID-G, n = 17), DID-simulating healthy controls (DID-S, n = 16), individuals with post-traumatic stress disorder (PTSD, n = 16), and healthy controls (HC, n = 16). Additionally, personality-state-dependent measures were obtained for DID-G and DID-S; both neutral personality states (NPS) and trauma-related personality states (TPS) were tested., Conclusion: For Trauma measures, the DID-G group had the highest scores, with TPS higher than NPS, followed by the PTSD, DID-S, and HC groups. The DID-G group was not more fantasy-prone or suggestible and did not generate more false memories. Malingering measures were inconclusive. Evidence consistently supported the Trauma Model of DID and challenges the core hypothesis of the Fantasy Model., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Dissociative identity disorder (DID) is a complex, posttraumatic, developmental disorder for which we now, after four decades of research, have an authoritative research base, but a number of misconceptualizations and myths about the disorder remain, compromising both patient care and research. This article examines the empirical literature pertaining to recurrently expressed beliefs regarding DID: (1) belief that DID is a fad, (2) belief that DID is primarily diagnosed in North America by DID experts who overdiagnose the disorder, (3) belief that DID is rare, (4) belief that DID is an iatrogenic, rather than trauma-based, disorder, (5) belief that DID is the same entity as borderline personality disorder, and (6) belief that DID treatment is harmful to patients. The absence of research to substantiate these beliefs, as well as the existence of a body of research that refutes them, confirms their mythical status. Clinicians who accept these myths as facts are unlikely to carefully assess for dissociation. Accurate diagnoses are critical for appropriate treatment planning. If DID is not targeted in treatment, it does not appear to resolve. The myths we have highlighted may also impede research about DID. The cost of ignorance about DID is high not only for individual patients but for the whole support system in which they reside. Empirically derived knowledge about DID has replaced outdated myths. Vigorous dissemination of the knowledge base about this complex disorder is warranted.

Abnormal psychology courses introduce undergraduate students to the range, causes, and treatments of psychological disorders. These courses present important opportunities to instruct students about disorders and treatments associated with childhood maltreatment (CM) as well as its prevalence. Little research has examined the adequacy with which abnormal psychology textbooks present information about CM. The present study reviewed the CM content of 10 abnormal psychology textbooks. The content was assessed in terms of the number of times CM was mentioned, the number of psychological disorders linked to CM, and the number of CM-related research citations. In addition, the authors conducted a content analysis to examine the significance, depth of detail, and organizational structure of the information provided within the sections of text addressing CM. There were significant differences in scores and the accuracy of coverage of CM across textbooks. Most of the textbooks lack key information on CM. The information presented in many textbooks is not consistent with current research and is overly focused on controversies. These findings are concerning because research has linked many psychological disorders and problematic outcomes to CM, but this information is not adequately conveyed to students via abnormal psychology textbooks. The authors make recommendations for improving the coverage of CM in abnormal psychology textbooks., ((c) 2016 APA, all rights reserved).)

Elevated scores on some MMPI-2 (Minnesota Multiphasic Inventory-2) validity scales are common among patients with dissociative identity disorder (DID), which raises questions about the validity of their responses. Such patients show elevated scores on atypical answers (F), F-psychopathology (Fp), atypical answers in the second half of the test (FB), schizophrenia (Sc), and depression (D) scales, with Fp showing the greatest utility in distinguishing them from coached and uncoached DID simulators. In the current study, we investigated the items on the MMPI-2 F, Fp, FB, Sc, and D scales that were most and least commonly endorsed by participants with DID in our 2014 study and compared these responses with those of coached and uncoached DID simulators. The comparisons revealed that patients with DID most frequently endorsed items related to dissociation, trauma, depression, fearfulness, conflict within family, and self-destructiveness. The coached group more successfully imitated item endorsements of the DID group than did the uncoached group. However, both simulating groups, especially the uncoached group, frequently endorsed items that were uncommonly endorsed by the DID group. The uncoached group endorsed items consistent with popular media portrayals of people with DID being violent, delusional, and unlawful. These results suggest that item endorsement patterns can provide useful information to clinicians making determinations about whether an individual is presenting with DID or feigning., (© 2016 American Academy of Psychiatry and the Law.)

The present study investigates whether symptom severity can distinguish patients diagnosed with dissociative identity disorder and dissociative disorder not otherwise specified with a recent history of nonsuicidal self-injury (NSSI) and suicide attempts from those patients without recent self-harm. A total of 241 clinicians reported on recent history of patient NSSI and suicide attempts. Of these clinicians' patients, 221 completed dissociative, depressive, and posttraumatic stress disorder symptomatology measures. Baseline cross-sectional data from a naturalistic and prospective study of dissociative disorder patients receiving community treatment were utilized. Analyses evaluated dissociative, depressive, and posttraumatic stress disorder symptom severity as methods of classifying patients into NSSI and suicide attempt groupings. Results indicated that dissociation severity accurately classified patients into NSSI and suicidality groups, whereas depression severity accurately classified patients into NSSI groups. These findings point to dissociation and depression severity as important correlates of NSSI and suicidality in patients with dissociative disorders and have implications for self-harm prevention and treatment.

Due to high elevations on validity and clinical scales on personality and forensic measures, it is challenging to determine if individuals presenting with symptoms of dissociative identity disorder (DID) are genuine or not. Little research has focused on malingering DID, or on the broader issue of the profiles these patients obtain on the Minnesota Multiphasic Personality Inventory (MMPI-2), despite increasing awareness of dissociation. This study sought to characterize the MMPI-2 profiles of DID patients and to determine the utility of the MMPI-2 in distinguishing DID patients from uncoached and coached DID simulators. The analyses revealed that Infrequency, Back Infrequency, and Infrequency-Psychopathology (Fp) distinguished simulators from genuine DID patients. Fp was best able to discriminate simulated DID. Utility statistics and classification functions are provided for classifying individual profiles as indicative of genuine or simulated DID. Despite exposure to information about DID, the simulators were not able to accurately feign DID, which is inconsistent with the iatrogenic/sociocultural model of DID. Given that dissociation was strongly associated with elevations in validity, as well as clinical scales, including Scale 8 (i.e., Schizophrenia), considerable caution should be used in interpreting validity scales as indicative of feigning, and Scale 8 as indicative of schizophrenia, among highly dissociative individuals., ((c) 2015 APA, all rights reserved).)

There is a paucity of empirical data to assist clinicians in choosing interventions to use with patients with complex dissociative disorder (DD; i.e., dissociative identity disorder and dissociative disorder not otherwise specified) at different stages in treatment. This study compared interventions used by a sample of international outpatient therapists treating DD clients in the 1st 2 stages of treatment with those recommended by expert DD therapists. There were many similarities between therapists' and experts' interventions, including the use of several emotion regulation and dissociation-focused interventions. However, community therapists reported significantly less focus on relationally oriented interventions, teaching and using grounding and containment skills, and stabilizing patients after revictimization by alleged perpetrators. This study has important implications for the development and implementation of training opportunities for DD therapists.

Emotion dysregulation is a core feature of chronic complex dissociative disorders (DD), as it is for borderline personality disorder (BPD). Chronic complex DD include dissociative identity disorder (DID) and the most common form of dissociative disorder not otherwise specified (DDNOS, type 1), now known as Other Specified Dissociative Disorders (OSDD, type 1). BPD is a common comorbid disorder with DD, although preliminary research indicates the disorders have some distinguishing features as well as considerable overlap. This article focuses on the epidemiology, clinical presentation, psychological profile, treatment, and neurobiology of chronic complex DD with emphasis placed on the role of emotion dysregulation in each of these areas. Trauma experts conceptualize borderline symptoms as often being trauma based, as are chronic complex DD. We review the preliminary research that compares DD to BPD in the hopes that this will stimulate additional comparative research.

Background: Childhood maltreatment (CM) is a risk factor for subsequent intimate partner violence (IPV) in adulthood, with high rates of retrospectively reported CM among IPV victims and perpetrators. A theorized mechanism of the link between CM and IPV is dissociation. Dissociation may allow perpetrators of violence to remain emotionally distant from their behavior and minimize empathy toward those they victimize, enabling them to commit acts of violence similar to their own experiences. Indeed, elevated rates of dissociation and dissociative disorders (DD) have been found among IPV survivors and perpetrators. In addition, in pilot studies, DD clinicians have reported high levels of violent behavior among DD patients., Objective: The present study investigates IPV among DD patients with Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified, a group with CM rates of 80-95% and severe dissociative symptoms., Methods: DD clinicians reported on rates of CM and IPV among 275 DD patients in outpatient treatment. DD patients also completed a self-report measure of dissociation. Analyses assessed the associations between CM typologies and IPV, as well as trait dissociation and IPV., Results: Physical and emotional child abuse were associated with physical IPV, and childhood witnessing of domestic violence (DV) and childhood neglect were associated with emotional IPV., Conclusions: The present study is the first to provide empirical support for a possible CM to adult IPV developmental trajectory among DD patients. Future research is needed to better understand the link between CM and IPV among those with trauma and DD.

Objective: Some claim that treatment for dissociative identity disorder (DID) is harmful. Others maintain that the available data support the view that psychotherapy is helpful., Method: We review the empirical support for both arguments., Results: Current evidence supports the conclusion that phasic treatment consistent with expert consensus guidelines is associated with improvements in a wide range of DID patients' symptoms and functioning, decreased rates of hospitalization, and reduced costs of treatment. Research indicates that poor outcome is associated with treatment that does not specifically involve direct engagement with DID self-states to repair identity fragmentation and to decrease dissociative amnesia., Conclusions: The evidence demonstrates that carefully staged trauma-focused psychotherapy for DID results in improvement, whereas dissociative symptoms persist when not specifically targeted in treatment. The claims that DID treatment is harmful are based on anecdotal cases, opinion pieces, reports of damage that are not substantiated in the scientific literature, misrepresentations of the data, and misunderstandings about DID treatment and the phenomenology of DID. Given the severe symptomatology and disability associated with DID, iatrogenic harm is far more likely to come from depriving DID patients of treatment that is consistent with expert consensus, treatment guidelines, and current research.

We respond to Lynn et al.'s (2014) comments on our review (Dalenberg et al., 2012) demonstrating the superiority of the trauma model (TM) over the fantasy model (FM) in explaining the trauma-dissociation relationship. Lynn et al. conceded that our meta-analytic results support the TM hypothesis that trauma exposure is a causal risk factor for the development of dissociation. Although Lynn et al. suggested that our meta-analyses were selective, we respond that each omitted study failed to meet inclusion criteria; our meta-analyses thus reflect a balanced view of the predominant trauma-dissociation findings. In contrast, Lynn et al. were hypercritical of studies that supported the TM while ignoring methodological problems in studies presented as supportive of the FM. We clarify Lynn et al.'s misunderstandings of the TM and demonstrate consistent superiority in prediction of time course of dissociative symptoms, response to psychotherapy of dissociative patients, and pattern of relationships of trauma to dissociation. We defend our decision not to include studies using the Dissociative Experiences Scale-Comparison, a rarely used revision of the Dissociative Experiences Scale that shares less than 10% of the variance with the original scale. We highlight several areas of agreement: (a) Trauma plays a complex role in dissociation, involving indirect and direct paths; (b) dissociation-suggestibility relationships are small; and (c) controls and measurement issues should be addressed in future suggestibility and dissociation research. Considering the lack of evidence that dissociative individuals simply fantasize trauma, future researchers should examine more complex models of trauma and valid measures of dissociation.

Objective: Despite its long and auspicious place in the history of psychiatry, dissociative identity disorder (DID) has been associated with controversy. This paper aims to examine the empirical data related to DID and outline the contextual challenges to its scientific investigation., Methods: The overview is limited to DID-specific research in which one or more of the following conditions are met: (i) a sample of participants with DID was systematically investigated, (ii) psychometrically-sound measures were utilised, (iii) comparisons were made with other samples, (iv) DID was differentiated from other disorders, including other dissociative disorders, (v) extraneous variables were controlled or (vi) DID diagnosis was confirmed. Following an examination of challenges to research, data are organised around the validity and phenomenology of DID, its aetiology and epidemiology, the neurobiological and cognitive correlates of the disorder, and finally its treatment., Results: DID was found to be a complex yet valid disorder across a range of markers. It can be accurately discriminated from other disorders, especially when structured diagnostic interviews assess identity alterations and amnesia. DID is aetiologically associated with a complex combination of developmental and cultural factors, including severe childhood relational trauma. The prevalence of DID appears highest in emergency psychiatric settings and affects approximately 1% of the general population. Psychobiological studies are beginning to identify clear correlates of DID associated with diverse brain areas and cognitive functions. They are also providing an understanding of the potential metacognitive origins of amnesia. Phase-oriented empirically-guided treatments are emerging for DID., Conclusions: The empirical literature on DID is accumulating, although some areas remain under-investigated. Existing data show DID as a complex, valid and not uncommon disorder, associated with developmental and cultural variables, that is amenable to psychotherapeutic intervention.

Background: Research has shown that the therapeutic alliance plays an important role in enhancing treatment outcome among individuals with a variety of disorders, including posttraumatic stress disorder (PTSD). However, the therapeutic alliance and treatment outcome has not yet been studied in dissociative disorders (DD)., Objectives: The current study sought to investigate the impact of alliance on treatment outcome for DD patients., Methods: Data from a naturalistic, longitudinal international treatment study of DD patients and their therapists were analyzed to determine if the alliance, as reported by patients and therapists, was associated with treatment outcome., Results: Patients with higher self-rated alliance had fewer symptoms of dissociation, PTSD, and general distress, as well as higher levels of therapist-rated adaptive functioning. Over time, self-rated alliance scores predicted better outcomes, after controlling for patient adaptive capacities including symptom management at the time when the alliance ratings were made. Patient-rated alliance was more strongly associated with outcome than therapist-rated alliance., Conclusion: Therapists who work with DD patients should understand the importance of the alliance on treatment outcome. These findings are consistent with previous literature demonstrating the importance of developing and maintaining a strong therapeutic alliance, although the effect sizes of individuals with DD were stronger than what has been found in many other patient groups. A greater understanding of the impact of the alliance in traumatized individuals may contribute to better outcomes for these individuals.

Individuals with dissociative disorders (DDs) suffer from high levels of dissociation as well as posttraumatic stress disorder (PTSD) and general distress. No research has investigated how changes in dissociation relate to changes in other symptoms over the course of treatment in patients with DD. Using a prospective, naturalistic design, we collected reports of symptoms from a sample of therapists and their patients diagnosed with dissociative identity disorder or dissociative disorder not otherwise specified who participated in the Treatment Outcome of Patients with Dissociative Disorders study. The patients completed surveys at intake (Time 1) into the study and at 30-month follow-up (Time 4). We found that dissociative symptoms, including amnesia, depersonalization/derealization, and absorption, at the initial assessment of the study ("initial") were related to initial levels of PTSD and general distress and that changes in dissociative symptoms were related to changes in PTSD and general distress. Initial dissociation was a significant predictor of change in dissociation at 30 months when we controlled for length of time for follow-up, length of time practicing therapy, and length of time treating dissociative patients. Our results suggest that a reduction in dissociative symptoms in DD patients is associated with reductions in the overall severity of dissociative, posttraumatic stress, and distress symptoms.

Revictimization and life stressors are common among dissociative disorder (DD) patients, yet no studies have examined the prevalence rates for these experiences or their relationships with treatment outcome. This study aimed to examine the rates of revictimization and victimization of others using therapist-DD patient pairs from the naturalistic Treatment of Patients with Dissociative Disorders (TOP DD) study while also considering the role of revictimization and life stressors among 49 patients who greatly improved or worsened during 30 months of treatment. Therapists reported that sexual and physical revictimization in the previous 6 months was high among the patients (3.5%-7.0% and 4.1%-7.1% in the overall TOP DD sample, respectively), and emotional revictimization was quite high (29%-36%). Revictimization showed a decreasing trend over the 30 months of the study. Therapists reported that more than a quarter of the patients who were revictimized were also occasionally emotionally or physically abusive to others. More patients showed sudden improvement versus sudden worsening in patient-reported symptoms at 1 or more time point(s). Patients who improved had significantly fewer revictimizations and stressors overall than patients who worsened, suggesting that revictimization and/or stressors may contribute to worsening in treatment. Further research is needed to learn more about the roles of revictimization, victimization of others, and stressors in DD treatment. [Supplementary material is available for this article. Go to the publisher's online edition of Journal of Trauma & Dissociation for the following supplemental resource: Baseline Demographic Information of TOP DD Improving and Worsening Subgroups].