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Dissociative Experiences Scale (DES)
Introduction -
The Dissociative Experiences Scale (DES) was developed by Eve Bernstein Carlson, Ph.D.
and Frank W. Putnam, M.D. The overall DES score is obtained by adding up the 28 item
scores and dividing by 28: this yields an overall score ranging from 0 to 100.
Copies of the DES can be obtained through the Sidran Institute.

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Diagnosing Trauma Related Disorders
Introduction -
Like all psychiatric disorders, the gold standard for diagnosing trauma-related
disorders is the clinical interview. Throughout psychiatry, standarized methods
of history taking are also employed for systematic clinical assessment and research -
these are called structured interviews. In the trauma field there are several
structured interviews in use, including the Dissociative Disorders Interview Schedule
(DDIS), developed by Dr. Ross. Data from the DDIS appear in many of the scientific
papers listed under Publications on this web site.

The full text and scoring rules of the DDIS appear below. Clinical diagnoses should
not be made using the DDIS alone. The DDIS should not be used for making clinical
or research diagnoses by persons who are not mental health professionals or who
are not acting under the supervision or in consultation with qualified mental
health professionals. The DDIS has been placed on this web site as an educational
service only.

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Guidelines for Treating Dissociative Identity Disorder
(Multiple Personality Disorder) in Adults (1997)
Members of the committee were Peter Barach, PhD (chair), Elizabeth Bowman, MD,
Catherine Fine, PhD, George Ganaway, MD, Jean Goodwin, MD, Sally Hill, PhD,
Richard Kluft, MD, Richard Loewenstein, MD, Rosalinda ONeill, MA,
Jean Olson, MSN, Joanne Parks, MD, Gary Peterson, MD, and Moshe Torem, MD.
Introduction -
The guidelines attempt to summarize the numerous publications on
the dissociative disorders, including case reports, open clinical trials,
and investigations utilizing standardized tools. The guidelines reflect
current scientific knowledge and clinical experience specific to diagnosing
and treating dissociative identity disorder (DID), supplementing generally
accepted principles of psychotherapy and psychopharmacology.

Given the fact that ongoing research on the diagnosis and treatment
of dissociative disorders will undoubtedly lead to further developments
in the field, therapists are advised to consult relevant published literature
subsequent to the publication of these guidelines. It should be noted
that the guidelines are not intended to dictate the treatment of specific
patients, as treatment should always be individualized. Therapists should
always conform to the local mental health code and related laws,
as well as to ethical principles of their professional disciplines.

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Guidelines for the Evaluation and Treatment of Dissociative Symptoms
in Children and Adolescents
ISSD Task Force on Children and Adolescents, February, 2003
Introduction -
The ISSD Task Force on Children and Adolescents is pleased to present the Guidelines for the
Assessment and Treatment of Dissociative Symptoms in Children and Adolescents. In utilizing these
Guidelines, you might keep the following principle in mind. According to the Criteria for Evaluating
Treatment Guidelines of the American Psychological Association (2000), Guidelines should avoid
encouraging an overly mechanistic approach that could undermine the treatment relationship.
We hope these Guidelines prove to be useful rather than prescriptive, and improve the care
of children and adolescents with dissociative symptoms and disorders.

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The Treatment of Traumatic Memories: Synthesis, Realization, and Integration
Onno van der Hart, Ph.D., Kathy Steele, R.N., M.N., C.S.
Suzette Boon, Ph.D. and Paul Brown, M.D.

Introduction -
This paper is based on Pierre Janet's dissociation theory and his concept of the
non-realization of a traumatic event. A model of treatment that integrates Janet's
dissociation-integration theory with contemporary trauma-based models of therapy is
delineated. The nature of traumatic memories is described, and a stage-oriented model
for their treatment in patients with multiple personality disorder (MPD) is presented.
Ideally a discrete phase in the overall treatment of MPD, this phase can itself be
subdivided into the following stages: (1) preparation; (2) synthesis; and
(3) realization/integration. Although a number of treatment recommendations are offered,
the emphasis here is more on clarifying concepts than on the description of techniques.

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Multiple Personalities: Some Psychoanalytic Listening Perspectives
Lawrence E. Hedges
Abstract
The history of multiple personality is reviewed. Major research findings are presented
and discussed along with the most important treatment recommendations that have been made
by leading experts in the field. A radically different approach to understanding and working
with multiples is presented, one derived from contemporary psychoanalysis, object relations,
and self psychology. The Listening Perspective approach is introduced and the four major
watersheds of psychotherapeutic listening discussed and applied to the problem of multiples.
The central thesis is that "multiple personalities" express the emergence and creative
elaboration in the psychotherapy setting of the earliest affect-ego states, and that
they may be considered unintegrated "ego nuclei".

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A Reader's Guide To Pierre Janet: A Neglected Intellectual Heritage
Onno Van der Hart, Ph.D. & Barbara Friedman, M.A., M.F.C.C.
Abstract
A century ago there occurred a peak of interest in dissociation and the
dissociative disorders, then labeled hysteria. The most important scientific
and clinical investigator of this subject was Pierre Janet (1859-1947),
whose early body of work is reviewed here. The evolution of his dissociation
theory and its major principles are traced throughout his writings.
Janet's introduction of the term "subconscious" and his concept of the
existence of consciousness outside of personal awareness are explained.
The viability and relevance of dissociation as the underlying phenomenon
in a wide range of disorders is presented. It is proposed that Janet's
theory and methodology of psychological analysis and dynamic psychotherapy
are cogent and relevant for today's students and practitioners.

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Two-Year Follow-Up of Inpatients With Dissociative Identity Disorder
Joan W. Ellason, M.A., L.P.C., and Colin A. Ross, M.D.
Abstract
Objective: A patient group of 135 inpatients with dissociative identity disorder
was followed for two years to monitor treatment outcome. Method: Fifty four
of these patients were located and re-assessed after a two year period,
by using the same self-report measures and structured clinical interviews that
had been initially administered. Results: The patients showed marked improvement
on Schneiderian first rank symptoms, mood and anxiety disorders, dissociative symptoms,
and somatization, with a significant decrease in the number of psychiatric
medications prescribed. Patients who were treated to integration, were significantly
more improved than those who had not yet reached integration. Conclusion:
Our findings, though preliminary, provide empirical validation of previous clinical
impressions that patients with dissociative identity disorder may respond well to treatment.
(American Journal of Psychiatry 1997; 154:832-839)

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Trauma and Dissociation in Delinquent Adolescents.(Statistical Data Included)
Victor G. Carrion, Hans Steiner
Abstract
To assess history of trauma and dissociation in a group of juvenile delinquents and to
assess how adolescents would respond to a structured interview for dissociative symptoms.
Method: Sixty-four adolescents in juvenile probation hall participated in 2 investigational
sessions in 1996-1997. For session 1 they answered the Childhood Trauma Questionnaire (CTQ),
the Response Evaluation Measure for Youth-71 (REMY-71), and the Weinberger Adjustment
Inventory. For session 2 they were given the Childhood Trauma Interview (CTI) and the
Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Results: In this
sample 28.3% met criteria for a dissociative disorder and 96.8% endorsed a history of traumatic
events. There were significant positive correlations between CTI and CTQ trauma scores and
SCID-D and REMY-71 dissociative symptoms. All dissociative symptoms were endorsed, but
depersonalization was the most common experience. There was a lack of congruence between
the different methods of assessing dissociation. Conclusions: This study provides support
for an early link between history of trauma and dissociation. Adolescents were able to answer
questions from a structured interview assessing dissociation.
March, 2000

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Dissociative psychopathology, non-epileptic seizures, and neurology
RICHARD J. BROWN, MICHAEL R. TRIMBLE
Abstract
The latest edition of the International Classification of Diseases (ICD-10)1 defines
dissociation as " . . . a partial or complete loss of the normal integration between memories
of the past, awareness of identity and immediate sensations, and control of body movements"
(p 151). Thus defined, the concept of dissociation captures a heterogeneous group of psychiatric
conditions previously subsumed within the broader construct of hysteria. The dissociative
(conversion) disorders category in ICD-10 comprises subcategories of dissociative amnesia,
dissociative fugue, trance and possession disorders, dissociative anaesthesia and sensory loss,
dissociative motor disorders and dissociative convulsions, and waste basket categories included
to capture uncommon, impure, or less severe instances of dissociation. Other symptoms previously
viewed as hysterical are placed within the somatoform disorders category of ICD-10, on the
grounds that their primary characteristic is an apparent disturbance of bodily rather than
cerebral function. By contrast, DSM-IV2 classifies convulsions, motor dysfunction, and sensory
loss as somatoform disorders, despite adopting an otherwise similar definition of dissociation
and categorisation of dissociative complaints. In the context of this editorial we embrace the
more inclusive scheme offered by ICD-10.

The basis for their inclusion within current psychiatric nosology is the assumption that
dissociative disorders are primarily psychological in nature.1 Nevertheless, the concept
of dissociation has important implications for practice and research within the neurological
sphere also. Dissociative psychopathology was witnessed almost exclusively within the
neurological setting until the late 19th and early 20th centuries, and many such patients present
to neurologists even now. What is striking about dissociative symptoms is their apparent
similarity to those found in many common neurological conditions, and it is often extremely
difficult to distinguish between the two; the case of dissociative convulsions provides an
instructive example.
J Neurol Neurosurg Psychiatry 2000;69:285-289 (September)

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Memories of Childhood Abuse: Dissociation, Amnesia, and Corroboration
James A. Chu, M.D., Lisa M. Frey, Psy.D., Barbara L. Ganzel, Ed.M., M.A., and Julia
A. Matthews, Ph.D., M.D.
Abstract
OBJECTIVE: This study investigated the relationship between self-reported childhood
abuse and dissociative symptoms and amnesia. The presence or absence of corroboration
of recovered memories of childhood abuse was also studied. METHOD: Participants were 90
female patients admitted to a unit specializing in the treatment of trauma-related disorders.
Participants completed instruments that measured dissociative symptoms and elicited details
concerning childhood physical abuse, sexual abuse, and witnessing abuse. Participants also
underwent a structured interview that asked about amnesia for traumatic experiences, the
circumstances of recovered memory, the role of suggestion in recovered memories, and
independent corroboration of the memories. RESULTS: Participants reporting any type of
childhood abuse demonstrated elevated levels of dissociative symptoms that were significantly
higher than those in subjects not reporting abuse. Higher dissociative symptoms were correlated
with early age at onset of physical and sexual abuse and more frequent sexual abuse.
A substantial proportion of participants with all types of abuse reported partial or complete
amnesia for abuse memories. For physical and sexual abuse, early age at onset was correlated
with greater levels of amnesia. Participants who reported recovering memories of abuse generally
recalled these experiences while at home, alone, or with family or friends. Although some
participants were in treatment at the time, very few were in therapy sessions during their
first memory recovery. Suggestion was generally denied as a factor in memory recovery.
A majority of participants were able to find strong corroboration of their recovered memories.
CONCLUSIONS: Childhood abuse, particularly chronic abuse beginning at early ages, is related
to the development of high levels of dissociative symptoms including amnesia for abuse memories.
This study strongly suggests that psychotherapy usually is not associated with memory recovery
and that independent corroboration of recovered memories of abuse is often present.

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Abreaction Re-evaluated
Onno van der Hart, Ph.D. and Paul Brown, M.D
Abstract
Contemporary clinicians working in the field of multiple personality disorder (MPD)
generally agree that pathogenic traumatic memories are at the root of this dissociative
disorder. Examination of contemporary studies, however, shows that diagnostic and therapeutic
conceptualization remains muddled and frequently contradictory. This confusion stems back
to Breuer and Freud's "Studies of Hysteria," in which they used two contradictory models
concerning the nature and treatment of traumatic memories. The first model was in terms of
dissociation and integration, processes which already had a French pedigree (particularly
with Pierre Janet), and the second was their own model which they developed in terms of
the principle of psychological constancy and abreaction. In the literature on trauma since
Breuer and Freud, e.g., studies on post-traumatic stress during and after World Wars I
and II and the Vietnam war, different authors have emphasized either one or both models.
The present authors critically re-evaluate abreaction and advocate the dissociation-integration
model as the basis for further conceptualization, discussing the role of emotional expression
within it.

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Persecutory Alters and Ego States: Protectors, Friends, and Allies
Lisa Goodman & Jay Peters
Abstract
Persecutor alters in Dissociative Identity Disorder are uniformly described
in behavioral terms as belligerent, abusive, and violent. While most authors
agree that persecutors begin as helpers there is no consensus about their later
development or function within the system. This paper presents a theoretical
model of the etiology and development of persecutor alters. It elucidates
the underlying and continuously protective nature of the alter which becomes
masked by the apparently "persecutory" behavior.

Using clinical examples which build on their appreciation of the positive
function of persecutor alters the authors present their treatment techniques,
which include: engagement, building rapport with the underlying protective function,
psychoeducation of the alter, and finally, family therapy style negotiations of roles,
expectations, and boundaries.

The paper concludes with an examination of the countertransference issues which
commonly arise in working with persecutor alters and their impact on the clinician
and the therapeutic task.

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Multiple Personality and Moral Responsibility
Stephen E. Braude
Abstract
The philosophical literature on multiple personality has focused primarily on problems
about personal identity and psychological explanation. But multiple personality and
other dissociative phenomena raise equally important and even more urgent questions about
moral responsibility, in particular: In what respect(s) and to what extent should a multiple
be held responsible for the actions of his/her alternate personalities? Cases of dreaming
help illustrate why attributions of responsibility in cases of dissociation do not turn on
putative changes in identity, as some have supposed. Instead, it is argued that traditional
criteria of rationality and behavioral control apply also to cases of dissociation. It is noted,
however, that one can distinguish different kinds of responsibility in cases of dissociation,
and that one is responsible for one's dreams in a different sense from that in which one is
responsible for actions one can control and evaluate. It is also argued that in cases of
multiple personality it is important to distinguish control over switching of personalities
from an alter's control over its own behavior. Moreover, the author considers reasons for
thinking that amnesia is less relevant to attributions of responsibility than many have supposed.

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Time Distortions in Dissociative Identity Disorder: Janetian Concepts and Treatment
Onno van der Hart, Ph.D. & Kathy Steele,R.N.,M.N.,C.S.
Abstract
This paper addresses the time disturbances DID patients may frequently and intensely experience.
Time sense is described as a subset of reality perception. In his pioneering work, Pierre
Janet analyzed these time disturbances in terms of degrees of perceived reality.
His normative hierarchy of time and related experiences (such as fantasies, ideas, and thoughts)
is presented. Janet distinguished two basic ways in which patients manifest their disturbance
of reality and time sense: placing accounts of episodes too high in the hierarchy, and placing
accounts too low. This distinction is utilized in discussing some ways in which DID patients
may suffer time disturbances. Special attention is paid to the ways in which reactivated traumatic
memories interfere with the experience of a normal sense of reality and time. Therapeutic change
is, in essence, the reorganization of the experience of reality and time. In this paper, therapeutic
approaches that address this reorganization are presented within the context of a phase-oriented
treatment.

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A Review of Visual/Kinesthetic Disassociation in the Treatment
of Posttraumatic Disorders: Theory, Efficacy and Practice Recommendations
Anne M. Dietrich, M.A.
Abstract
In this article, the literature on the Neurolinguistic Programming (NLP) technique of
Visual/Kinesthetic Disassociation (V/KD) is reviewed in relation to the treatment of
Posttraumatic sequelae. An overview of the V/KD technique is provided, along with postulated
mechanisms of change, based on current theory and research in the field of PTSD. Three
published reports -- two case studies and one, uncontrolled, small-n study -- are reviewed
in terms of treatment effectiveness for Posttraumatic sequelae. Currently, the V/KD technique
is rated as an experimental approach, according to the American Psychological Association's
Division 12 Task Force (1995) report and recommendations on empirically validated psychological
treatments. Recommendations for use of exposure-based treatments with traumatized populations are
provided.

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Dissociation and the Fragmentary Nature of Traumatic memories:
Overview and Exploratory Study
Bessel A. van der Kolk & & Rita Fisler
Abstract
Since trauma is an inescapably stressful event that overwhelms people's coping mechanisms
it is uncertain to what degree the results of laboratory studies of ordinary events have
relevance to the understanding of traumatic memories. This paper first reviews the literature
on the differences between recollections of stressful and of traumatic events. It then reviews
the evidence implicating dissociative processes as the central pathogenic mechanisms that give
rise to PTSD. We present the results of a systematic exploratory study of 46 subjects with PTSD
which indicates that traumatic memories are retrieved, at least initially, in the form of
dissociated mental imprints of sensory and affective elements of the traumatic experience:
as visual, olfactory, affective, auditory and kinesthetic experiences. Over time, subjects
reported the gradual emergence of a personal narrative that can be properly referred to as
"explicit memory". The implications of these findings for understanding the nature of traumatic
memories is discussed.

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The Psychoanalysis Of Dissociative States, The Sense Of Safety And
Self Blame In Victims Of Childhood Sexual Abuse
Daniel Paul, Ph.D.
Abstract
The integration of dissociated states, the lack of a sense of safety and the tendency
of the victim to blame herself are three issues frequently met with in the analysis of people
suffering from childhood sexual abuse. I use her throughout this paper only because many of
the victims are women. The paper addresses these three fundamental issues.

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Understanding Integration As A Natural Part Of Trauma Recovery
Rachel Downing, L.C.S.W.-C.
Introduction -
The purpose of writing this article is to provide survivors with DID and therapists who treat
DID with a greater understanding of integration and life after integration. One of the least
understood aspects of the treatment of Dissociative Identity Disorder (DID) is the concept of
integration. Information on this topic for professionals or individuals with DID is limited.
Therapists may have difficulty explaining what integration means and how it will benefit their
clients. Individuals with DID often express fear of integration. Sometimes survivors feel
that the integration of personalities is disrespectful of the important role they have played
in their survival.

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Multiplicity and Victimization: What part of 'No!' don't you understand?
Vs. What part of you doesn't understand 'No!'?"
Patricia D. McClendon, MSSW, CSW
Abstract
Although ego-state therapy (Watkins & Watkins, 1988 and Watkins, 1993) is essential in the
treatment of dissociative disorders and multiple personality disorder, it is seldom used with
the general client population. Since all people have multiplicity (Beahrs, 1982), I believe
that ego-state therapy is underutilized; it can be used to address people's multiplicity or
different levels of consciousness. Ego-state therapy is equivalent to doing family/group
therapy within the individual. State-dependent learning and memory are involved who we are
in a given context; we are a microcosm of our environment (Rivera, 1989). In cases of
victimization, dissociative disorders and multiple personality disorder are overlooked in
the rush to punish the victimizer and empower the victim. Drug and/or alcohol abuse is
frequently involved in cases of victimization. Many victims and victimizers are chemically
dependent and are medicating the pain of their own victimization that they experienced as
children. Drugs and alcohol need to be recognized as chemical dissociators (Beahrs, 1982;
Braun, 1986; and Ross, 1989). The cycle of victimization cannot be broken unless the
victimizer's and the victim's multiplicity are therapeutically acknowledged and confronted.
Ross' (1989) general trauma model is the beginning of a paradigm shift away from viewing
psychiatric symptoms as psychopathological and biomedical: to, viewing them as natural
outcomes of trauma.

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Parents As Partners in the Treatment of Dissociative Children
Frances S. Waters, M.S.W.
Abstract
Effective treatment of the traumatized dissociative child includes engaging the child's family
to facilitate the child's ongoing recovery from trauma. As demonstrated repeatedly
(Dell & Eisenhower, 1990; Fagan & McMahon, 1984; Silberg & Waters, Chapter 6, this volume),
dissociative children who make the most gains from appropriate therapy are the ones in a safe
and nurturing environment with consistent parents. Consistent parenting promotes healthy
attachment, provides affect modulation and containment, and helps to counteract the pessimism
and demoralization learned from the child's abusive experiences. Providing the ideal environment
for dissociative children is a challenge, as their behavior may be provocative, rejecting,
and out of control. Many parents report that these children may seem uncaring or unattached,
and parents are embarrassed by their child or adolescent's unpredictable behavior.
Families are hungry for any clues that might help them understand, manage, and normalize
their child's behavior.

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Recommendations for Home of the Innocents (HOTI) Regarding Therapeutic Intervention
Patricia D. McClendon, MSSW candidate
Abstract
Since many children at HOTI (Home of the Innocents) have histories of physical, sexual,
emotional abuse, as well as, neglect and abandonment issues - careful psychiatric evaluations
are imperative. All child victims of abuse or significant trauma should be evaluated for
dissociative disorders, as well as, other psychiatric disorders. In light of the recent
increase and/or increase in reporting of child abuse, the importance of prudent evaluation
is essential. Diagnoses given to the victims undoubtedly influence how others (family,
friends, communities, and professionals) view them and treat them. An erroneous diagnosis
can doom these child victims to a lifetime of inappropriate psychiatric treatment,
as well as, stigmas of being beyond help for the rest of their lives. A diagnosis now
can certainly influence further evaluations from being objective. Early intervention and
treatment of children who are dissociative can turn the tide in reducing child abuse in future
generations.

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