1 Instructions for Coming of Age in Mississippi

1
Instructions for Coming of
Age in Mississippi
Due Sunday, April 25th, 2021
Late papers will be penalized. Failure to turn in this
assignment will result in
the automatic failure of the class.
Anne Moody’s Coming of Age in Mississippi is an
autobiographical presentation of
her life and experiences in the segregationist South during the
middle third of the
20th Century. Although Moody was intensively involved in the
civil rights
movement of the 1950’s and 1960’s, the real value of her
autobiography is that she
describes what it was like to grow up in Mississippi long before
she became a civil
rights activist.

Your book essay for Coming of Age in Mississippi should
explore and discuss the
following topics and questions:
1. Begin with a brief overview of the book: in general, what is
it about, who wrote
it, etc.
2. Moody’s decision to become engaged in the political activism
central to the
Civil Rights Movement was a result of her experiences at both
work and play
growing up in Mississippi. What kinds of incidents from her
life led Moody to
become politically active in the movement? For example, what
does she notice
about how she is treated as a black person in Southern white
society?
3. Women played an important role in Moody’s life. Using
examples from her
autobiography, discuss what Moody learned about race, class
and sexual

orientation from the women around her. Who were the most
important women in
her life? Discuss each and explain why that person was so
important.
4. Moody was a participant and observer of some of the most
important historical
events of the 1950’s and 1960’s. How did she view and describe
these events – for
example, the murder of Emmitt Till, the sit-in protests, the
voter registration drive
in Mississippi, Ku Klux Klan activities and the assassination of
Medgar Evars and
2
others? In general, what do her descriptions tell you about the
struggle for civil
rights?
5. What did you think of this book? Did you like it/ not like it?
Explain why.
Writing Instructions:

1. Use the above questions/topics as your paper outline and
answer them in the
order they are presented.
2. Use some common sense in how much you write on each
topic. The general
overview of the book, for example, can be covered in one
relatively brief
paragraph. Other topics may require more extensive coverage.
The main body of
your paper should focus on topics 2-4. You should explore
those thoroughly and
back up any general comments with specific details that
illustrate and support
them. Topics 1 and 5 should be about a paragraph in length.
3. Although I don’t grade in terms of the length of the paper,
under most
circumstances I would expect a paper somewhere within the
range of 4-5 pages.
As a general rule, it’s better to write more than less.
4. The paper must be typed using a standard word processing
program, double-

spaced using normal- sized fonts (11 or 12) and margins.
5. The best grades will go to papers that have discussed each
topic/question
completely, are well-organized and well-written and follow
directions. Points will
be deducted for excessive grammatical and/or typographical
errors so be sure
that you proofread before turning it in.
6. Be careful about plagiarism. If you quote anything from this
book, use
quotation marks and cite the page number. If you use other
sources, identify
those sources and use quotation marks and page numbers as
appropriate.
Failure to do this could result in a grade of 0 for the assignment
or, in serious
cases, failure of the course.
7. Make and keep a copy of your paper.
3

8. You don’t need a separate title page, but on the first page of
this paper you
should put your name and the author and title of the book.
9. All Papers must include citations and a Works Cited page.
Please use this
format when citing: (Bell, p.27). Every citation must be placed
either at the
end of the sentence cited or at the end of the paragraph
containing the
citation. I require that you have a minimum of five (5) citations
within your
paper but keep in mind that more would be better. A Works
Cited page must
be included on a separate sheet at the end of your paper. Please
use the Out
of this Furnace book as your only reference material! This
means that you
will have only one reference work cited in the Works Cited
page! The Works
Cited page should contain the name of the book cited as well as
the author(s)
name, publication date, number of pages, etc., and that is all!

10. Papers are due on Sunday, April 25th, 2021. Failure to turn
in this paper
will result in failure of the course.
If you need help with any aspect of this assignment, don’t
hesitate to contact me.
I’ll be happy to clarify the topics and show you how to find the
required
information. I’m also willing to look at early drafts of your
paper provided you get
them to me at least five days for the due date.
ARTICLE
Comorbid personality disorders and their impact on severe
dissociative
experiences in Mexican patients with borderline personality
disorder
Andr�es Rodr�ıguez-Delgadoa, Ana Fres�anb, Edgar
Mirandaa, Eduardo Garza-Villarrealb,c, Ruth Alcal�a-Lozanob,
X�ochitl Duque-Alarc�ond, Thania Balduccie and Iv�an
Arango de Montisa

aCl�ınica de Trastorno L�ımite de la Personalidad, Instituto
Nacional de Psiquiatr�ıa Ram�on de la Fuente Mu~n�ız,
Mexico City, Mexico;
bSubdirecci�on de Investigaciones Cl�ınicas, Instituto
Nacional de Psiquiatr�ıa Ram�on de la Fuente Mu~n�ız,
Mexico City, Mexico; cCenter of
Functionally Integrative Neuroscience, University of Aarhus,
Aarhus, Denmark; dCl�ınica de Especialidades en
Neuropsiquiatr�ıa, Instituto de
Seguridad y Servicios Sociales de Los Trabajadores Del Estado
(ISSSTE), Mexico City, Mexico; eFacultad de Medicina,
Universidad Nacional
Aut�onoma de M�exico, Mexico City, Mexico
ABSTRACT
Objective: To identify personality disorders comorbid with
borderline personality disorder (BPD) that
may confer greater risk for the presence of severe dissociative
experiences.
Method: Three hundred and one outpatients with a primary
diagnosis of BPD were evaluated using
the Structured Clinical Interview for DSM-IV Axis II
personality disorders, the Borderline Evaluation of
Severity Over Time (BEST) and the Dissociative Experiences
Scale (DES).
Results: The most frequent personality disorders comorbid to
BPD were paranoid (83.2%, n ¼ 263)
and depressive (81.3%, n ¼ 257). The mean BEST and DES
total score were 43.3 (SD ¼ 11.4, range
15–69) and 28.6 (SD ¼ 19.8, range 0–98), respectively. We
categorized the sample into patients with
and without severe dissociative experiences (41% were
positive). A logistic regression model revealed
that Schizotypal, Obsessive-compulsive and Antisocial
personality disorders conferred greater risk for
the presence of severe dissociative experiences.

Discussion: Our results suggest that a large proportion of
patients with BPD present a high rate of
severe dissociative experiences and that some clinical factors
such as personality comorbidity confer
greater risk for severe dissociation, which is related to greater
dysfunction and suffering, as well as a
worse progression of the BPD.
ARTICLE HISTORY
Received 19 March 2019
Revised 12 August 2019
Accepted 17 August 2019
KEYWORDS
Comorbid personality
disorders; dissociation;
borderline personality
disorder; personality
disorders; dissociative
experiences
1. Introduction
Borderline personality disorder (BPD) is a psychiatric condition
characterized by affective instability, impulsivity, chaotic inter -
personal relationships, and identity disturbances which cause
alterations in multiple functioning areas [1]. BPD is considered
a common disorder that affects from 0.5% to 5.9% of the gen-
eral population [2], and is more commonly present in women;
however, this evidence has not been consistent [3]. In clinical
populations, BPD is the most common personality disorder
(PD), with a prevalence of 10% in psychiatric outpatie nts and
from 15% to 25% in inpatients [4,5]. About 80% of patients
with BPD have a co-occurring PD [6]. The most frequent PDs
reported in patients with BPD are as follows: (1) from cluster
A,

paranoid PD has been reported in 30–38%; (2) from cluster B,
histrionic and antisocial PD have been reported in 15–25% and
in 13–19%, respectively; and (3) from cluster C, dependent and
avoidant PD in 30–50% and in 20–40%, respectively [2,7,8].
About two thirds of BPD patients report dissociative expe-
riences such as unbidden intrusions into awareness and
behavior with accompanying losses of continuity in
subjective experience (e.g. absorption, identity confusion,
depersonalization and derealization), and/or an inability to
access information or to control mental functions that nor-
mally are controlled (e.g. amnesia) [1,9–11]. The level of dis-
sociation is significantly higher in BPD patients than in
healthy controls, general psychiatric patients and patients
with another PD. In fact, only patients with dissociative disor-
ders (DD) present higher rates of dissociative symptoms than
BPD patients [12,13]. It has been suggested that the phe-
nomenon of dissociation within BPD seems to constitute a
continuum of severity [11]. Using the Dissociative
Experiences Scale (DES), Zanarini et al. [12,14] described BPD
inpatients with low, moderate and severe dissociation. The
presence of severe dissociation in BPD patients has been cor -
related with more self-reported traumatic experiences, post-
traumatic symptoms, behavioral disturbances, and self-
injurious behavior, as well as lower adaptive functioning,
including higher frequency and duration of inpatient treat-
ments, as well as lower age of inpatient admission [10,15].
PD and comorbid dissociative experiences may worsen
the emotional and behavioral manifestation during the
CONTACT Iv�an Arango de Montis [email protected] Cl�ınica
de Trastorno L�ımite de la Personalidad, Instituto Nacional de
Psiquiatr�ıa Ram�on de la
Fuente Mu~n�ız, Mexico City 14370, Mexico

This article has been republished with minor changes. These
changes do not impact the academic content of the article.
� 2019 The Nordic Psychiatric Association
NORDIC JOURNAL OF PSYCHIATRY
2019, VOL. 73, NO. 8, 509–514
https://doi.org/10.1080/08039488.2019.1658127
http://crossmark.crossref.org/dialog/?doi=10.1080/08039488.20
19.1658127&domain=pdf&date_stamp=2019-09-25
https://doi.org/10.1080/08039488.2019.1658127
http://www.tandfonline.com
course of BPD, thus hindering treatments and functional
reintegration of these patients to daily life. It is therefore,
necessary to increase our knowledge about how PD comor-
bidity may affect the overt manifestation of severe dissocia-
tive experience (SDE) in this population. The aim of the
present study was to identify the most important comorbid
PDs and to determine if these are predictors of SDE in
patients with BPD.
2. Material and methods
2.1. Participants
This was a retrospective design with the use of the institu-
tional clinical databases. We included the demographic and
clinical data from all male and female patients between 18
and 65 years of age who entered the BPD Clinic at the
Instituto Nacional de Psiquiatr�ıa Ram�on de la Fuente
Mu~n�ız
(INPRF), located in Mexico City, between October 2015 and
February 2018, and who had the confirmed diagnosis of BPD
according to the Diagnostic and Statistical Manual of Mental

Disorders IV-TR (DSM-IV-TR) [16]. Patients with diagnoses of
psychotic disorders, bipolar disorder, active eating disorder
or substance dependence (except nicotine dependence)
were excluded. This study was conducted according to the
Declaration of Helsinki and was approved by ethics and
research committee of the INPRF (INPDSCEC-02-20.1). All
patients gave their oral and written consent for the use of
their data for research purposes.
2.2. Measurement instruments and procedure
Patients who met the criteria for admission to the BPD Clinic
were evaluated according to the Clinic’s protocol, which
includes obtaining general demographic data and a clinical
evaluation through an interview conducted by a psychiatrist
at the Clinic. This evaluation was complemented with the
administration of several scales and questionnaires. We used
the Clinical Interview for DSM-IV Axis II Personality Disorders
self-report screening questionnaire (SCID-II-PQ) to explore all
PDs. The SCID-II-PQ has 119 items with affirmative or nega-
tive answers for determination of whether a feature of any
PD is present. Different cutoff points have been suggested to
determine the diagnosis of a PD [17]. The overall PD diagno-
sis agreement reported with the use of the SCID-II-PQ vs. the
SCID II interview is adequate, with overall K of agreement of
0.75 [18]. For BPD diagnosis, we used both the SCID-II-PQ
and the SCID II interview, while only the SCID-II-PQ was used
for the remaining PDs, and were considered as present
according to the cutoff scores proposed [17]. The overall
severity of BPD symptoms in the 30 days prior to the inter-
view was evaluated with the Borderline Evaluation of
Severity Over Time (BEST) scale, a self-report instrument of
15 items rated on a 5-point Likert scale [19]. The score of
item 5, ‘Feeling paranoid or like you are losing touch with real -
ity’, which is a dissociation symptom included in the scale,
was removed from statistical analysis to avoid criterion con-

tamination. The DES, which consists of 28 self-report items
evaluated on a visual analog scale from 0 to 100, was used
to assess the presence and severity of dissociative experien-
ces [20]. We used a score of 30 or more as an indicator of
SDE, following Zanarini et al. [12,14]. This score was used to
divide the sample between those with and without SDE.
2.3. Statistical analysis
Demographic and clinical characteristics were described with
frequencies and percentages for categorical variables, and
means and standard deviations (SD) for continuous variables.
The comparisons between patients with and without SDE
were done using chi-square tests (x2) for categorical variables
and with independent sample t-tests for continu-
ous variables.
Variables where significant differences arose in the com-
parative analyses were included in a logistic regression ana-
lysis to determine the risk conferred by demographic
variables and the presence of comorbid PD in the presenta-
tion of SDE. The Aikake Information Criterion (AIC) was deter -
mined to identify which of the models best approximated
the data of the present sample. The level of statistical signifi -
cance was set at p � 0.05.
3. Results
A total of 316 patients with BPD were included in the study,
of which 85.8% (n ¼ 271) were female with an average age
of 29.7 years (SD ¼ 10.5, range 17–62). A large percentage of
patients had completed their high-school studies (48.4%,
n ¼ 153), followed by those with a bachelor’s degree (32.6%,
n ¼ 103). Twelve patients did not complete the BEST scale;
therefore, we reported the data obtained from 304 patients,

whose average score was 43.3 points (SD ¼ 11.4, range
15–69) indicative of moderate symptom severity. Likewise, 14
patients did not complete the DES scale; thus, the average
severity score of the dissociative experiences of the remain-
ing 301 patients in the sample was of 28.6 points (SD ¼ 19.8,
range 0–98). Using the cutoff point of 30, 41.9% (n ¼ 126) of
the patients were classified with SDE.
The most frequent comorbid PDs were paranoid PD
(83.2%, n ¼ 263) and depressive (81.3%, n ¼ 257), while those
with the lowest presentation were schizotypal (25.6%, n ¼ 81)
and antisocial (37.0%, n ¼ 117). The comparisons of demo-
graphic characteristics and comorbidity with PDs among
patients with and without SDE are displayed in Table 1. Both
groups were similar in terms of sex, age and level of educa-
tion. BPD patients with schizoid, schizotypal, antisocial,
obsessive-compulsive, and passive-aggressive comorbidities
presented SDE more often. In addition, patients with SDE
reported greater severity of BPD symptoms.
Five comorbid PDs and the total score of the BEST scale
were included in an initial logistic regression model. After
adjustments, the final logistic regression equation correctly
classified 67.0% of the cases and was significant for the pre -
sent sample according to the Hosmer and Lemeshow statis-
tical value (p ¼ 0.84). As shown in Table 2, the main
predictors of SDE were schizotypal PD, obsessive-compulsive
510 A. RODR�IGUEZ-DELGADO ET AL.
PD, antisocial PD and more severe BPD symptomatology.
This model was adequate according to the reduction
observed in the AIC values.

4. Discussion
We observed a high rate of PD comorbidity, confirming that
BPD as a unique personality diagnosis is infrequent. In this
study, we found paranoid, depressive and passive-aggressive
PDs were the most common comorbidities in patients with
main diagnosis of BPD, and antisocial and schizotypal PD
were the least common ones. This finding contrasts with
other studies where schizotypal, narcissistic and dependent
were the most frequent PDs comorbid with BPD [21]. We
found rates of PD comorbidity higher than others reported
in the literature, which could be explained by the fact that
we used a self-report questionnaire to establish comorbidity.
Methodological factors such as the kind of instrument used
for assessment may inflate diagnosis estimates, and self-
report questionnaires are more prone to this bias [22]. In this
respect, the SCID-II-PQ presents an overrating of 19%, and
therefore, our results should be interpreted with caution [18].
We observed antisocial PD comorbidity as one of the less
common PD comorbidities, which could be the result of a
selection bias. Perhaps some patients with BPD and intense
antisocial symptoms are not sent to the clinic because they
are diagnosed with an antisocial PD as main diagnosis.
However, antisocial PD was present in 37% of the sample,
which represents a higher rate compared to other investiga-
tions that report ranges between 13% and 19% [2,7]. As
stated before, this could be a result of the use of a self-
report measure, but it also suggests the possibility that we
were dealing with a group of patients with severe
psychopathology.
The mean DES total score in our study (28.6) is higher
than means reported in other studies where BPD patients
presented a mean DES score from 17.8 to 27.4 [23] but lower
than other studies (44.4 total score) where 64% of the BPD

sample met criteria for an additional diagnosis of DD [24].
More than 40% of our patients presented SDE, which repre-
sents a higher percentage than the ones reported in other
studies. For example, Zanarini et al. [12,14] found that 26%
of a sample of inpatients with diagnosis of BPD presented
SDE. This is interesting since our sample were outpatients
and SDE has been correlated with higher stress and poorer
functioning, features associated with the clinical presentation
of inpatients [9]. One possible explanation could be that
Zanarini et al. [12,14] used an instrument based on DSM-III-R,
a diagnostic system that did not include item 9 about transi -
ent, stress-related dissociative symptoms, which was added to
the diagnostic criteria for BPD in the DSM-IV. Perhaps a sig-
nificant proportion of our sample could present a DD comor -
bid with BPD and not only intense dissociative experiences
[16,25]. However, BPD criterion 9 in the DSM-IV and DSM-5
mentions that dissociative symptoms are generally of insuffi -
cient severity or duration to warrant an additional diagnosis.
For some authors, this is an unspecific rule for deciding
when dissociative symptoms represent a separate DD diag-
nosis or can be considered as a BPD criterion [1,11,16].
Table 1. Demographic and clinical characteristics between
patients with and without severe dissociative experiences
(SDE).
Totala Without SDE n ¼ 175 With SDE n ¼ 126 Statistics
Demographic n %
Sex - Women 257 85.4 148 84.6 109 86.5 Fisher ¼ 0.74
Education - High-school 145 48.2 84 48.0 61 48.4 Fisher ¼ 1.00
Personality disorder n %
Avoidant 229 76.1 129 73.7 100 79.4 Fisher ¼ 0.27
Dependent 124 41.2 65 37.1 59 46.8 Fisher ¼ 0.09
Obsessive-compulsive 236 78.4 125 71.4 111 88.1 Fisher ¼

0.001
Passive-aggressive 241 80.1 129 73.7 112 88.9 Fisher ¼ 0.001
Depressive 249 82.7 139 79.4 110 87.3 Fisher ¼ 0.08
Paranoid 250 83.1 139 79.4 111 88.1 Fisher ¼ 0.06
Schizotypal 79 26.2 27 15.4 52 41.3 Fisher < 0.001
Schizoid 189 62.8 99 56.6 90 71.4 Fisher ¼ 0.01
Histrionic 144 47.8 80 45.7 64 50.8 Fisher ¼ 0.41
Narcissistic 205 68.1 112 64.0 93 73.8 Fisher ¼ 0.08
Antisocial 113 37.5 51 29.1 62 49.2 Fisher < 0.001
Mean SD
Age 29.7 10.5 30.4 10.6 28.2 9.7 t ¼ 1.7, p ¼ .07
BEST scaleb 41.7 11.1 40.0 10.8 44.0 11.1 t ¼ –3.1, p ¼ .002
an ¼ 301 patients completed the DES.
bTotal score without item 5 ‘Feeling paranoid or like you are
losing touch with reality’.
Table 2. Logistic regression models for the prediction of severe
dissociative
experience (SDE) in BPD patients.
b OR 95% C.I. p
Initial model: AIC value 357.33
Higher BEST scoring 0.01 1.01 0.99–1.04 0.11
Schizoid PD 0.41 1.51 0.88–2.62 0.13
Passive-Aggressive PD 0.47 1.60 0.77–3.29 0.20
Antisocial PD 0.60 1.83 1.08–3.10 0.02
Obsessive-compulsive PD 0.79 2.22 1.12–4.39 0.02
Schizotypal PD 1.20 3.32 1.85–5.96 <0.001
Final model: AIC value 302.96
Higher BEST scoring 0.02 1.02 1.01–1.04 0.04
Antisocial PD 0.64 1.91 1.13–3.20 0.01
Obsessive-compulsive PD 0.92 2.52 1.29–4.91 0.007
Schizotypal PD 1.24 3.48 1.96–6.18 <0.001

NORDIC JOURNAL OF PSYCHIATRY 511
We found that higher severity of borderline personality
symptoms increases the risk for SDE (OR ¼ 1.02). This is con-
sistent with D’Ambrosio and Vacca [26], who reported that
the presence of BPD, regardless of trauma antecedent or per -
sonality comorbidity, increases the risk for dissociative symp-
tom 4.41 times, which suggests that BPD syndrome itself
represents a risk factor for the occurrence of dissociative
phenomena [12,14]. Contrary to D’Ambrosio and Vacca [26],
we found that PD comorbidity is an important predictor of
SDE. Antisocial (OR ¼ 1.91), obsessive-compulsive (OR ¼
2.52)
and schizotypal (OR ¼ 3.48) PDs were the most important
predictors of SDE in patients with main diagnosis of BPD.
Consistent with others’ reports, we found that one PD of
each cluster predicts SDE. For example, it has been reported
that any type of PD confers a higher risk for dissociation;
cluster B PDs had the highest risk (OR ¼ 7.23), followed by
cluster A PDs (OR ¼ 4.39) and finally, cluster C PDs
(OR ¼ 3.47) [27]. Specifically, Semiz et al. [28] investigated
the
association between antisocial PD and dissociative symptoms
in a sample of Turkish recruits, observing a mean of 32.6
(SD ± 22) in the DES, which represents a similar score to
those observed in individuals with a BPD diagnosis. Also,
there is evidence that the level of dissociation that occurs in
individuals with schizotypal PD is similar to that observed in
those with a BPD diagnosis [29]. In fact, some investigations
have shown an association between schizotypal personality
traits and dissociative symptoms, suggesting that both con-
structs could be a manifestation of a superordinate trait,
openness to experience [11,30]; however, other studies have

shown that this personality factor is not related to the level
of dissociation [31]. Interestingly, we found that obsessive-
compulsive PD predicts SDE, a finding not observed in other
studies [26]. Nevertheless, it is important to keep in mind
that information about dissociation and PDs other than BPD
is scarce, and most studies of dissociation and BPD do not
explore the effect of the PD comorbidities or use different
instruments to assess dissociative experience, and therefore,
our results are difficult to extrapolate.
The Five-Factor Model (FFM) is a dimensional model for the
assessment of the general structure of personality [32]. This
model divides personality into five domains or factors: neuroti -
cism, extraversion, openness to experience, agreeableness and
conscientiousness. All of them include various facets related to
specific traits. There is evidence that all DSM-5 PDs can be
understood as maladaptive variants of the general personality
structure described through the FFM [33]. Studies conducted
to assess the relationship between the FFM and dissoci ation
have shown that neuroticism, highly associated with border-
line and schizotypal PDs, predicts dissociation [31,34,35]. This
could explain why we observed that high severity of border -
line symptoms and schizotypal PD comorbidity predicted SDE
in our study. The dimension of extraversion, related to anti -
social PD, and conscientiousness, a characteristic factor
observed in obsessive-compulsive PD, have been shown to be
negatively correlated with dissociative symptoms in several
studies [31,35]. However, we observed that both PDs’ comor-
bidities predict SDE. These findings could suggest that traits of
extraversion and conscientiousness predict dissociation when
they occur in patients who also present traits of neuroticism or
that neuroticism has a stronger relationship with the presence
of dissociation than other FFM domains. Other PDs such as
narcissistic and histrionic have also been found to be related
to extraversion, and one might expect that comorbidity with

these PDs would also predict SDEs, as is the case of patients
with antisocial PD comorbidity; however, this was not the case.
Similarly, the avoidant and dependent PDs have been related
to high levels of neuroticism, as well as schizotypal PD, and
they also did not predict SDE. Future studies in BPD patients,
taking into account comorbidity and the FFM model, including
the specific facets of each domain, could offer more specific
information about why PDs related to the same FFM domain
present a different risk for dissociation.
4.1. Limitations
Some study limitations should be noted. One of the main limi -
tations in this study is the use of a self-report instrument to
establish the presence of PDs other than BPD, which possibly
caused an overrating. Other investigations could be conducted
using more reliable diagnostic methods. The DES scale is an
adequate self-report questionnaire to assess severity of dis-
sociation; however, it explores only the psychological compo-
nent of the phenomenon [36]. A complete exploration of
dissociation could include a somatoform dimension and, in
this sense, our approach towards the dissociative phenom-
enon could be partial. We did not explore some Axis I disor -
ders with potential impact on the results. Patients with DD
and posttraumatic stress disorder presents high levels of dis-
sociation, and both disorders present high comorbidity with
BPD. Therefore, exploring these comorbidities would have
been important for results interpretation. Similarly, previous
research has found dissociative experiences in BPD patients to
be positively correlated with higher co-occurrence of alcohol
abuse and traumatic events during childhood; that connection
was also not explored in the present study. Despite these limi -
tations, our study provides further evidence regarding the
complexity and heterogeneity of the dissociative phenomenon
presented in BPD, increasing knowledge about the clinical fac-
tors, such as PD comorbidity, that confer greater risk for

dissociation.
4.2. Conclusions
SDE are associated with severe dysfunctio n and suffering, as
well as a worse clinical course and prognosis in patients with
BPD. Comorbidity with other PDs may represent additional
prognostic factors for BPD patients that is necessary to identify
during daily clinical consultation. Future research should
include the evaluation of BPD from a broader perspective. In
addition to the assessment of BPD symptoms and functional
impairment, the impact of comorbidity with other disorders,
including PDs, should be closely monitored. The above should
not only increase our knowledge about BPD but also may
increase the possibility of carrying out early interventions and
make more specific treatment decisions for these patients
based on research results, improving their prognosis in terms
of symptom severity, global functioning, quality of life and
well-being.
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Andr�es Rodriguez Delgado: Child and adolescent psychiatrist
of the
Borderline Personality Disorder Clinic at the National Institute
of
Psychiatry Ram�on de la Fuente Mu~niz in Mexico City.

Ana Fres�an: PhD in Psychology and health from the Faculty of
Psychology of the National Autonomous University (UNAM).
Currently
head of the Laboratory of Clinical Epidemiology at the National
Institute
of Psychiatry Ram�on de la Fuente Mu~niz. Member of the
National
Research System (SNI) level III of CONACYT. Her research
focuses on
stigma, psychopathology assessment and violence.
Edgar Miranda: Clinical psychologist with a Master in
Cognitive
Behavioral Therapy (CBT). Researcher in Dialectical
Behavioral Therapy
(DBT) in Borderline Personality Disorder (BPD) and Post
Traumatic Stress
Disorder (PTSD). Clinical Psychotherapist at the National
Institute of
Psychiatry Ram�on de la Fuente Mu~niz in Mexico City.
Eduardo Garza-Villarreal: PhD in Medicine (Neuroscience)
from the
Center of Functionally Integrative Neuroscience of the
University of
Aarhus, Denmark. Assistant Professor at the National
Laboratory of
Magnetic Resonance Imaging (LANIREM), Institute of
neurobiology,
National Autonomous University of Mexico(UNAM),
Quer�etaro,M�exico.
Member of the National Research System (SNI) level I of
CONACYT. His
work focuses on the study of neuropsychiatric disorders in
humans and

animal models using neuroimaging.
Ruth Alcal�a-Lozano: Psychiatrist with a Master degree in
Medical
Sciences from the Faculty of Medicine of the National
Autonomous
University (UNAM) and current PhD student at UNAM. Clinical
researcher
in the Laboratory of Clinical Epidemiology at the National
Institute of
Psychiatry Ram�on de la Fuent Mu~niz.
X�ochitl Duque-Alarc�on: Clincial psychiatrist and PhD in
Medical Sciences
from the Faculty of Medicine of the National Autonomous
University in
M�exico (UNAM). Researcher at the Neuropsychiatry Specialty
Clinic at
the Instituto de Seguridad y Servicio Sociales de los
Trabajadores del
Estado (ISSSTE) in M�exico City.
Thania Balducci: Psychiatrist with a Master degree in Medical
Sciences
from the Faculty of Medicine of the National Autonomous
University of
Mexico (UNAM). Current PhD student at UNAM, attending a
research
residency at the Research Institute for Neurosciences and
healthy
Ageing at the University of Groningen, Netherlands.
Iv�an Arango de Montis: Clinical Psychiatrist. Master in
Medial Science by
the National Autonomous University of M�exico (UNAM).
Coordinator of

the Borderline Personality Disorder Clinic at the National
Institute
of Psychiatry Ram�on de la Fuente Mu~niz, M�exico City
(INPRF). Member
of the National Research System (SNI) level I of CONACYT.
His work
focuses on the study of development, parenting and
psychopathology
factors associated with personality disorders.
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AbstractIntroductionMaterial and
methodsParticipantsMeasurement instruments and
procedureStatistical
analysisResultsDiscussionLimitationsConclusionsDisclosure
statementNotes on contributorsReferences
Journal of Traumatic Stress
February 2019, 32, 156–166
An Online Educational Program for Individuals With
Dissociative
Disorders and Their Clinicians: 1-Year and 2-Year Follow-Up
Bethany L. Brand,1 Hugo J. Schielke,2 Karen T. Putnam,3
Frank W. Putnam,3 Richard J. Loewenstein,4
Amie Myrick,5 Ellen K. K. Jepsen,6 Willemien Langeland,7
Kathy Steele,8 Catherine C. Classen,9
and Ruth A. Lanius10
1Department of Psychology, Towson University, Towson,
Maryland, USA
2California Department of State Hospitals, Napa, California,
USA
3The Department of Psychiatry, University of North Carolina

School of Medicine at Chapel Hill, Chapel Hill, North Carolina,
USA
4Sheppard Pratt Health System and University of Maryland
School of Medicine, Baltimore, Maryland, USA
5Family and Children’s Services, Bel Air, Maryland
6Modum Bad Psychiatric Center, Vikersund, Norway
7Bascous, France
8Atlanta, Georgia
9University of California San Francisco and Zuckerberg San
Francisco General Hospital, San Francisco, California, USA
10Western University, London, Ontario, Canada
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.
Dissociative disorders (DDs) have a reported lifetime preva -
lence of 9–18% in international general population studies,
Some data from this paper were presented at an invited Master
Clinician
presentation at the 33rd Annual Meeting of the International
Society for the
Study of Traumatic Stress in Chicago, Illinois, November 8,
2017.
Correspondence concerning this article should be addressed to
Dr. Bethany
Brand, Towson University, Psychology Department, Towson,
Maryland,

21252. E-mail: [email protected]
C© 2019 The Authors. International Society for Traumatic
Stress Studies pub-
lished by Wiley Periodicals, Inc. on behalf of Society for
International Society
for Traumatic Stress Studies. View this article online at
wileyonlinelibrary.com
DOI: 10.1002/jts.22370
This is an open access article under the terms of the Creative
Commons At-
tribution-NonCommercial License, which permits use,
distribution and repro-
duction in any medium, provided the original work is properly
cited and is not
used for commercial purposes.
with the most severe DD, dissociative identity disorder (DID),
present in approximately 1–1.5% of the general population
(Şar, 2011). Dissociative disorders are common in inpatient,
day treatment, outpatient, emergency department, and sub-
stance abuse treatment populations (Loewenstein, Frewen, &
Lewis-Fernández, 2017; Şar, 2011). Nonetheless, DDs remain
underdiagnosed and undertreated. For example, in a sample of
patients from an urban clinic in the United States, only 16.7%
of patients who were found to meet criteria for a DD carried
a DD diagnosis (Foote, Smolin, Kaplan, Legatt, & Lipschitz,
2006). As a result of this underdiagnosis, DID patients spend
an average of 5–12.4 years receiving mental health treatment
before they are diagnosed with DID (Spiegel et al., 2011).
Typically, DID in particular is characterized by a complex
symptom picture and high degree of functional impairment; it
156

http://creativecommons.org/licenses/by-nc/4.0/
http://creativecommons.org/licenses/by-nc/4.0/
Online Intervention for Dissociative Disorders 157
is also associated with higher rates of childhood trauma than
any other diagnostic group (Spiegel et al., 2011). Patients with
DD have high rates of comorbid posttraumatic stress disorder
(PTSD), major depressive disorder, somatic symptom disorder,
and substance use disorders as well as high rates of nonsuicidal
self-injury (NSSI) and suicide attempts (Foote, Smolin, Neft,
& Lipschitz, 2008; Webermann, Myrick, Taylor, Chasson,
& Brand, 2015). Patients with DD also have higher rates of
suicide attempts than individuals with borderline personality
disorder, PTSD, or substance abuse disorders but do not have
a comorbid DD (Foote et al., 2008). Dissociative disorders are
also associated with a high level of impairment. For example,
in a representative sample of New York citizens, DD patients’
average impairment scores were 50% higher than those of
patients with other psychiatric disorders, with DID individuals
demonstrating the highest level of impairment (Johnson,
Cohen, Kasena, & Brook, 2006). The severity and chronicity of
DD patients’ symptoms usually necessitate frequent treatment
at more restrictive levels of care (Mueller-Pfeiffer et al., 2012),
which is associated with significant health care costs.
However, effective treatment for DDs has been shown to
reduce patient suffering and health care costs (Brand et al.,
2013; Lloyd, 2016; Myrick, Webermann, Langeland, Putnam,
& Brand, 2017). Meta-analyses of eight open trials of DD treat-
ment yielded an average effect size of d = 0.71 for decreased
dissociation, anxiety, depression, somatoform symptoms, sub-
stance use, and general distress (Brand, Classen, McNary, &
Zaveri, 2009). A study of DD patients found cross-sectional and
longitudinal reductions in inpatient and outpatient costs, as re-

ported by patients and therapists, which suggests that DD treat-
ment may be associated with reduced costs over time (Myrick
et al., 2017).
A prospective, longitudinal study of 280 DD patients and
292 clinicians from six continents found that, over the course
of 30 months of individual treatment, patients showed signifi -
cant decreases in depression, PTSD, distress, dissociation, sui-
cide attempts, NSSI, hospitalizations, drug use, physical pain,
and treatment costs (Brand, Classen, Lanius et al., 2009; Brand
et al., 2013; Myrick et al., 2017). A Norwegian inpatient study
(Jepsen, Langeland, Sexton & Heir, 2014) discovered that for
DD patients, a generic trauma-focused treatment without at-
tention to dissociation failed to reduce amnesia or dissociative
identity alteration although depression and general psychiatric
symptoms improved. Jepsen and colleagues (2014) concluded
that unless a dissociation-specific treatment is provided, disso-
ciative symptoms associated with DDs are unlikely to improve.
Studies of individuals with PTSD, both with and without bor-
derline personality disorder, have found that higher dissociation
levels predict poor response to standard treatments, such as
eye movement desensitization and reprocessing (EMDR) and
dialectical behavior therapy (DBT; Bae, Kim, & Park, 2016;
Kleindienst et al., 2011). Despite these data, most psychiatric
and psychology textbooks fail to present empirical research
about DDs, or they provide inaccurate or sensationalized in-
formation about diagnosis and treatment of DDs (Loewenstein
et al., 2017; Wilgus, Packer, Lile-King, Miller-Perrin, & Brand,
2016).
Expert consensus treatment guidelines are available for DID
in children and adults (International Society for the Study of
Trauma and Dissociation [ISSTD], 2004, 2011). These guide-
lines recommend a phasic treatment model that, consistent with
a survey of international DD experts (Brand et al., 2012), em-

phasizes patient safety and stabilization. Due to the severity and
complexity of DD symptoms and impairment, the first stage ex-
plicitly focuses on safety and stabilization; DD patients often
decompensate if there is a premature attempt to process trau-
matic memories before behavioral stabilization and acquisition
of emotion and symptom management skills (ISSTD et al.,
2011). The symptoms of these chronic complex DDs have been
conceptualized as reflective of emotional dysregulati on related
to trauma (Brand & Lanius, 2014), and emotional dysregulation
and posttraumatic stress have been found to predict increased
dissociation and tension reduction actions (Briere, Hodges, &
Godbout, 2010). Conceptualizing NSSI and suicidal behav-
iors as attempts at self-regulation, Stage 1 treatment is recom-
mended to utilize a multimodal, present-centered approach that
emphasizes psychoeducation and cognitive-behavioral inter-
ventions while conceptualizing relationship dynamics through
psychodynamic and attachment theories (Brand, 2001). Patients
are taught healthy coping skills to manage dysregulation, in-
cluding grounding to reduce dissociation; emotion regulation
skills to replace reliance on unhealthy behaviors (e.g., NSSI,
substance abuse) to reduce overwhelming emotions; contain-
ment of intrusive PTSD symptoms; and methods for managing
unsafe behaviors. When patients demonstrate improved aware-
ness and tolerance of emotions, decreased dissociation, mastery
of basic symptom management skills, and improved safety,
they may (optionally) progress to Stage 2, which adds carefully
paced processing of trauma memories. A survey of 36 interna-
tional experts (Brand et al., 2012) indicated that experts remain
attentive to safety and stability until the third phase of
treatment.
In Stage 3, patients are able to devote more energy to increas -
ing social and occupational activities and may completely or
partially integrate self-states (Loewenstein et al., 2017).
Despite these guidelines, accessing specialized trauma
treatment can be difficult or impossible for many pa-

tients with DDs, partially due to the fact that few clini -
cians report having any training in the diagnosis and treat-
ment of dissociation and DDs (Brand et al., 2014, 2016).
Internet-based interventions, by contrast, are easy to access
(Bolton & Dorstyn, 2015; Litz, Engel, Bryant, & Papa, 2007),
and Internet-based interventions aimed at treating symptoms
of depression, anxiety, and PTSD have been associated with
medium-to-large effect sizes (Bolton & Dorstyn, 2015). Unfor-
tunately, DD patients are typically excluded from most Internet-
and non-Internet-based PTSD treatment studies due to typical
exclusion criteria, including high dissociation scores, active
substance abuse, NSSI, suicidality, psychosis, lack of social
support, and/or high levels of stressors, among others (Bolton
& Dorstyn, 2015; Klein et al., 2010; Knaevelsrud & Maercker,
Journal of Traumatic Stress DOI 10.1002/jts. Published on
behalf of the International Society for Traumatic Stress Studies.
158 Brand et al.
2007; Litz et al., 2007). Internet-based DD-focused interven-
tions have not yet been investigated; however, in a study of
Internet-based cognitive behavior therapy (CBT) interventions
for PTSD that excluded highly dissociative individuals, the au-
thors did find that dissociation scores significantly decreased
during the intervention (Klein et al., 2010).
For the present study, we designed an Internet-based program
for early-stage DD patients and their therapists that focused
on stabilization, safety, and management of DD and PTSD
symptoms in an effort to determine whether psychoeducation
consistent with ISSTD treatment guidelines and expert recom-
mendations would be associated with decreased symptoms and
improved functioning. The TOP DD Network program’s psy-

choeducational intervention is an online, password-protected
program consisting of 45 short (i.e., 5–15-min) educational
videos, 40 of which are paired with structured writing and be-
havioral practice exercises that assist patients in cognitively
and behaviorally applying the video’s educational content. In
this report, we present 2-year outcomes, including changes in
adaptive capacities, emotion regulation, PTSD and dissociative
symptoms, NSSI, suicide attempts, and hospitalizations.
Method
Participants
Patient-therapist dyads were recruited through announce-
ments on mental health professional listservs and by contacting
therapists who had participated in the naturalistic TOP DD
study. Interested therapists were instructed to invite one patient
who had been diagnosed with DID, DD not otherwise specified
(DDNOS), or other specified DD (OSDD) to participate in the
study. The DDNOS diagnosis is specific to the fourth edition
(text revision) of the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-IV-TR; American Psychiatric Association
[APA], 2000), and the OSDD is specific to the fifth edition of
the DSM (DSM-5; APA, 2013). At the time of the study, clini-
cians were still shifting from DSM-IV-TR to DSM-5; thus,
either
clinical diagnosis was permitted. Patient exclusion criteria were
as follows: being younger than 18 years of age, unable to read
English, and/or not having access to the Internet. Therapist ex-
clusion criteria were: not having an interested/eligible patient,
not being able to read English, and/or not having Internet
access.
We did not exclude patients with comorbid disorders, current
suicidality, NSSI, substance abuse, psychosocial stressors, in-
stability, or isolation. Participants were not compensated. As
this study is still in progress, dyads included in the presented

analyses (N = 111) are a subset of those who will be ultimately
enrolled. Participants were included in these analyses if they
completed a baseline survey and a progress survey at either the
12-month or 24-month time points. We compared baseline data
of individuals who were not included in the presented analyses
with those included and found no differences in demographics
or measures at entry into the program. Participants in this in-
ternational sample were mostly female (88.3%) and Caucasian
(86.5%); see Table 1 and Supplementary Table S1 for additional
patient demographic information.
Therapists and patients accessed password-protected web-
sites to complete informed consents and surveys and access ed-
ucational videos, journaling, and behavioral practice exercises.
Surveys were identified by code numbers. The study received
Institutional Review Board approval from Towson University
(Towson, MD). The consent materials explained that partici-
pant pairs could discontinue at any time, but if the therapist
discontinued, the patient would be unenrolled to ensure suffi -
cient patient support during the intervention.
Procedure
Therapists and patients completed a screening survey; if both
members met inclusion criteria, they were emailed a URL to
an initial survey (baseline), followed by an e-mail that pro-
vided access to the psychoeducational program and links to
surveys every 6 months for 2 years. The educational materials
were developed based on the research team’s decades of ex-
perience working with DD patients in inpatient and outpatient
settings, drawing on the results of a survey of experts (Brand
et al., 2012), the ISSTD treatment guidelines, and findings that
DD therapists and their patients could benefit from increased
emphasis on trauma symptom management techniques (e.g.,
Myrick, Chasson, Lanius, Leventhal, & Brand, 2015). See the

online Supplementary Materials for additional information re-
garding the theoretical and empirical foundations of the pro-
gram’s content.
A team of three authors (Brand, Schielke, & Lanius) wrote
the video transcripts and outlined the journaling and behavioral
exercises. These were then reviewed by members of the TOP
DD team and DD patient and consumer advocates involved in
public educational efforts. None of the patient or consumer re-
viewers were in treatment with research team members. The
45 final 5–15-min videos were filmed with the first author as
spokesperson. Participants could watch the videos, read the
video transcripts, and access the exercises as often as they
found useful. To allow patients time to make meaningful use
of the journaling and behavioral exercises, access to the next
set of materials was delayed 1 week from the time of access-
ing the previous week’s materials. Although patients and their
therapists were required to participate together in the TOP DD
program, we suggested that participants watch the videos and
complete assignments outside of therapy to protect session time
for individualized work.
The psychoeducational materials addressed the impact of
trauma, including symptoms of PTSD, complex trauma re-
actions, and DDs; symptom and emotion management tech-
niques; and the nature and functions of NSSI, suicidal, and
risky
behaviors (henceforth referred to collectively as “unsafe” or
“unhealthy” behaviors) among traumatized people. We empha-
sized that although unsafe behaviors frequently represent at-
tempts to self-regulate painful affects and intrusive memories,
they fail to resolve the underlying emotional and trauma-based

Table 1
Patient Demographics and Characteristics at Intake
Variable High DES Group Low DES Group
M SD M SD ta df
Age at intake (years) 43.1 9.73 41.98 11.23 0.55 108
% n % n χ2a df
Gender
Female 89.0 63 87.5 35 0.73 2
Male 9.9 7 12.0 5
Transgender 1.4 1 0.0 0
Race/ethnicity
Caucasian 83.1 59 92.5 37 0.23 4
Latino or Hispanic 5.6 4 0.0 0
Asian 2.8 2 0.0 0
Black 1.4 1 2.5 1
Other 7.0 5 5.0 2
Treatment stage
Stabilization and safety 39.4 28 32.5 13 5.70 4
Between safety and processing 47.9 34 50.0 20
Processing trauma 12.7 9 10.0 4
Between processing trauma and reconnection 0.0 0 5.0 2
Reconnection and integration 0.0 0 2.5 1
DD diagnosisb
DID (DSM-IV-TR, DSM-5) 76.5 52 53.9 21 6.23 3

DDNOS (DSM-IV-TR) 20.6 14 41.0 16
OSDD (DSM-5) 2.9 2 5.0 2
Note. DES = Dissociative Experiences Scale; DID =
dissociative identity disorder; DDNOS = dissociative disorder
not otherwise specified; OSDD = other specified
dissociative disorder; DSM-IV-TR = Diagnostic and Statistical
Manual of Mental Disorders (4th ed., text rev.); DSM-5 =
Diagnostic and Statistical Manual of Mental
Disorders (5th ed.).
at or chi-square tests used to examine differences between
groups. bDiagnosis data missing for four participants (high DES
group, n = 3; low DES group, n = 1).
symptoms that perpetuate their distress. Throughout the pro-
gram, self-compassion and acceptance of emotions were em-
phasized, and, for DID patients, healthy collaboration among
self-states (note that the DSM-5 uses the term “personality
states.” We prefer the term “self-states” as more conceptually
and clinically accurate in terms of DID phenomenology and
subjective experience). The content of the program is elabo-
rated in the Supplementary Materials.
Measures
Dissociative experiences. The Dissociative Experiences
Scale II (DES; Carlson & Putnam, 1993) is a 28-item self-
report measure of dissociative experiences. Each item presents
11 Likert scale response options ranging from 0% (never) to
100% (always). Higher average scores indicate a higher level
of dissociation, with a possible score of 0 to 100. The DES
cut point of 30 or above is based on a receiver operating
characteristic (ROC) curve of 1,051 subjects in nine psychi -
atric disorder categories from seven centers (Carlson et al.,
1993). Discriminant analysis has indicated that using a cutoff

score of 30 screens for DID with 76% sensitivity and speci -
ficity, and 85% specificity in a more representative subsample
(Carlson et al., 1993). The DES has demonstrated good internal
consistency (mean Cronbach’s α across 16 studies = .93) and
convergent validity (r = .67 overall; see paper for methodology
comparing rs with 8 different measures across 26 studies), and
test–retest reliability ranging from .78 to .93 over 4–8 weeks
(6 studies; van IJzendoorn & Schuengel, 1996). In this study,
Cronbach’s alpha was .96 at each time point.
Emotion regulation. The Difficulties in Emotion Regula-
tion Scale (DERS; Gratz & Roemer, 2004) is a 36-item self-
report measure of nonacceptance of emotional responses, dif-
ficulties engaging in goal-directed behavior, impulse control
difficulties, lack of emotional awareness, limited access to emo-
tion regulation strategies, and lack of emotional clarity. Items
are rated on a 5-point Likert scale of 1 (almost never, 0–10%) to
5 (almost always, 91–100%); scores can range from 36 to 180,
with higher scores indicating greater dysregulation. The DERS
has demonstrated good internal consistency (Cronbach’s α =
.93) and test–retest reliability (ρI = .88, p < .01) and adequate
160 Brand et al.
subscale test–retest reliability and well as construct and predic-
tive validity (Gratz & Roemer, 2004). Cronbach’s alpha values
ranged from .94 to .96 in the current sample.
Posttraumatic stress symptoms. The Posttraumatic
Stress Checklist—Civilian Form (PCL-C; Weathers, Litz,
Huska, & Keane, 1994) is a 17-item self-report measure of

DSM-IV-TR PTSD symptoms in the past month. Items are rated
on a 5-point Likert scale that ranges from 1 (not at all) to 5 (ex-
tremely). Scores can range from 17 to 85; higher scores indicate
a higher level of distress (Weathers & Ford, 1996). The PCL-
C has demonstrated high overall diagnostic efficiency (90%;
Blanchard, Jones-Alexander, Buckley, & Forneris, 1996) and
strong test–retest reliability (.96 in a 2–3 day interval; Weathers
et al., 1994). Cronbach’s alpha values ranged from .88 to .92 in
the current sample.
Treatment progress. The Progress in Treatment Ques-
tionnaire, patient version (PITQ-p; Schielke, Brand, & Marsic,
2017) is a self-report measure that assesses ability to manage
emotions, symptoms, relationships, safety, and well-being over
the prior 7 days. The PITQ-p consists of 32 expert-identified
items, 6 of which (items 27–32) are only completed by
patients who report experiencing dissociative self-states
(DSS). Responses are rated on an 11-point Likert scale with
options ranging from 0% (never true) to 100% (always true).
Responses are added and then averaged (using either 26 or 32
items, depending on whether the patient has DSS). Possible
scores range from 0 to 100; higher scores indicate better
adaptive functioning. The PITQ-p has demonstrated evidence
of good internal consistency (Cronbach’s α = .92) and
adequate convergent validity with measures of emotion-related
functioning (DERS; r = −.67), PTSD (PCL-C; r = −.47),
and dissociation (DES; r = −.42), as well as correlations in
expected directions with NSSI (r = −.34) and psychological
(r = .64) and social (r = .28) quality of life (Schielke et al.,
2017). In the current sample, Cronbach’s alpha values ranged
from .92 to .96 for patients with DSS and from .91 to .96 for
patients without DSS.
The Progress in Treatment Questionnaire, therapist version
(PITQ-t; Schielke et al., 2017) is a therapist-completed measure
of dissociative patients’ ability to manage emotions, symptoms,

relationships, safety, and well-being over the prior 6 months.
The 29-item instrument assesses the percentage of time pa-
tients have demonstrated expert-identified adaptive behaviors
and includes 6 items (items 24–29) that the therapist completes
only for their patients with DSS. Responses are rated on an
11-point Likert scale with options ranging from 0% (never)
to 100% (always), with higher average scores indicative of
better adaptive functioning; possible scores range from 0 to
100. The PITQ-t has demonstrated good internal consistency
(Cronbach’s α = .91) and adequate convergent validity with
measures of emotion-related functioning (DERS; r = −.35),
PTSD (PCL-C; r = −.41), and dissociation (DES; r = −.29),
as well as correlations in expected directions with NSSI
(r = −.37) and psychological (r = .45) and social (r = .22)
quality of life (Schielke et al., 2017). In the current sample,
Cronbach’s alpha values ranged from .92 to .95 for patients
with DSS and from .89 to .94 for patients without DSS.
Clinical data. Therapists reported on patients’ demograph-
ics, DD diagnosis, and stage of treatment. They also indicated
the level of NSSI, suicide attempts, and hospitalizations over
the prior 6 months.
Data Analysis
Based on prior research that has indicated differences in
therapeutic response related to severity of dissociation (e.g.,
Bae et al., 2016), we divided the sample into low dissocia-
tion (DES scores less than 30; n = 40) and high dissociation
(DES scores of 30 or more; n = 71) groups using the ROC-
derived cut point of 30 (Carlson et al., 1993). We calculated
distributions and descriptive statistics; when normality was vi-
olated, dependent variables were analyzed with nonparametric
methods.

The data were analyzed in two tiers. First, Cohen’s d effect
sizes were calculated using paired data to examine change in the
observed variables post- and midintervention. Confidence in-
tervals accounting for correlated paired data were constructed,
and Cohen’s (1988) traditional cut points were used to inter -
pret the effect sizes as small (0.20), medium (0.50), or large
(0.80).
We then ran a series of mixed models using SAS
(Version 9.3). First, we examined whether time involved in the
study was a significant predictor of change in the observed vari -
ables. Next, a series of 2 × 3 repeated measures models exam-
ined the linear within-subject effects over time and the between-
subject effects of the high and low DES groups. Smaller Akaike
information criterion (AIC) and -2 log-likelihood values in-
dicated that an unstructured covariance matrix demonstrated
the best model fit. Clinically relevant covariates (includi ng fe-
male/male gender, age, native English-speaking country, how
long the subject had been diagnosed with a DD, and treatment
stage) were then included to evaluate how much variance they
accounted for in the dependent variable, and significant covari -
ates were included in the final models (countries in the native
English-speaking category included the United States, Canada,
United Kingdom, Australia and New Zealand. Non-English
native language countries included Belgium, Israel, Norway,
Spain, Sweden, and India). It should be noted that the SAS
MIXED procedure accommodates missing data. Mixed models
apply an iterative estimation of the restricted or residual max-
imum likelihood (REML) method instead of the basic least-
squares method of general linear models. The REML method
utilizes all available data and estimates the parameter for each
subject. Bonferroni post hoc comparisons were constructed for
significant interactions and main effects. Additional informa-
tion on the overall sample, effect sizes, and model analyses can
be found in the online Supplementary Materials.

Table 2
Means and Standard Deviations for Continuous Outcome
Measures: High and Low Dissociation (DES) Groups
High Dissociation Low Dissociation
Baseline Year 1 Year 2 Baseline Year 1 Year 2
(n = 71) (n = 50) (n = 51) (n = 40) (n = 26) (n = 27)
Reporter and Scale M SD M SD M SD M SD M SD M SD
Patient
PITQ-p 41.54 14.56 49.15 15.69 58.57 19.53 51.24 11.43 55.28
17.43 62.40 13.40
DERS 125.66 21.69 113.16 23.86 100.04 26.34 107.35 16.11
104.46 20.65 91.15 19.29
PCL-C 65.42 8.97 59.46 10.55 54.14 13.37 52.60 9.56 50.12
13.67 47.15 12.14
DES 50.89 14.31 44.50 18.64 37.82 18.36 18.21 7.57 18.34
13.42 15.67 7.32
Therapist
PITQ-t 48.39 12.49 53.53 13.48 54.77 14.07 53.64 12.48 57.37
14.62 59.15 17.29
Note. DES = Dissociative Experiences Scale; PCL-C =
Posttraumatic Stress Checklist–Civilian; DERS = Difficulties in
Emotion Regulation Scale; PITQ-p = Progress
in Treatment Questionnaire–patient; PITQ-t = Progress in

Treatment Questionnaire–therapist.
Results
Patient demographics and characteristics at intake are
presented in Table 1. Table 2 provides the means and standard
deviations for the low and high dissociation groups at baseline,
Year 1, and Year 2. Table 3 reports the postintervention (Year
2)
and midintervention (Year 1) effect sizes for the overall sample
and both DES groups and demonstrates postintervention
improvements in each group on each measure. Supplementary
Table S4 contains the parsimonious model summaries for
significant main effects, covariates, and Time × DES group
interactions.
Changes in Adaptive Capacities, Emotion Regulation,
and Symptoms
At study completion, overall sample effect sizes indicated
large improvements in adaptive capacities (as indicated by
PITQ-p scores; |d| = 0.86), and emotion regulation (as indi-
cated by DERS scores; d = 0.90); medium improvements in
PTSD symptoms (as indicated by PCL-C scores; d = 0.65);
and slightly smaller improvements in dissociation (as indi -
cated by DES scores; d = 0.48). The high dissociation group
demonstrated the greatest improvements, with large improve-
ments in adaptive capacities (|d| = 0.94), emotion regulation
(d = 1.04), PTSD symptoms (d = 0.93), and dissociation (d =
0.81). The low DES group demonstrated medium-approaching-
strong improvements in postintervention adaptive capacities
(|d| = 0.75) and emotion regulation (d = .74), and small im-
provements in PTSD symptoms (d = 0.32) and dissociation
(d = 0.24).
At the study’s halfway mark, overall sample effect sizes

indicated small improvements in adaptive capacities (|d| =
0.47), emotion regulation (d = 0.36), PTSD symptoms (d =
0.41), and dissociation (d = 0.22). The high dissociation group
again demonstrated the greatest improvements, with medium
improvements in adaptive capacities (|d| = 0.53), emotion reg-
ulation (d = 0.54), and PTSD symptoms (d = 0.61), and the
strongest improvements in dissociation of the three groups at
this time point (d = 0.45). The low DES group demonstrated
small improvements in midintervention adaptive capacities
(|d| = 0.39), emotion regulation (d = 0.26), and PTSD symp-
toms, (d = 0.20). Dissociation was unchanged for the low DES
group midintervention (d = 0.08).
Therapist-Reported Adaptive Capacities
Therapist-reported adaptive capacities (as measured using
the PITQ-t) increased in the overall sample and both groups at
Year 2 compared to baseline, with a medium effect size for the
high DES group (|d| = 0.54) and small effect sizes for the over -
all and low DES groups (|d|s = 0.44 and 0.30, respectively).
There were no DES group main effects, only time effects,
F(2, 102) = 10.56, p < .001. Bonferroni post hoc comparisons
showed improvements for the overall group from baseline to
Year 1, p = .003, and Year 2, p < .001. Finally, therapist ratings
of patients’ adaptive capacities covaried with treatment stage,
F(1, 102) = 5.66, p = .019.
Interactions, Covariates, and Post Hoc Comparisons
for Patient Ratings
We identified interactions between DES group and time in
relation to the DERS, F(2, 107) = 3.95, p = .022, and PCL-C,
F(2, 104) = 4.10, p = .019. The high DES group demonstrated
higher DERS and PCL-C scores at baseline and steeper reduc-
tion slopes compared to the low DES group.

Years diagnosed with a DD was weakly associated with PCL-
C reductions, F(1, 104) = 3.98, p = .049, with lower scores
found among those who had been diagnosed longer. Scores on
the DERS covaried with gender, F(1, 107) = 5.86, p = .017,
as did PITQ-p scores, F(1, 105) = 4.71, p = .032: Female
162 Brand et al.
Table 3
Effect Size Comparisons and Patient Measures for the Overall
Sample and High and Low Dissociation (DES) Groups
Postintervention Midintervention
(Year 2) (Year 1)
d 95% CI d 95% CI
PITQ-pa
Overall sample −0.86 [−1.10, −0.60] −0.47 [−0.67, −0.27]
High DES group −0.94 [−1.25, −0.62] −0.53 [−0.77, −0.29]
Low DES group −0.75 [−1.19, −0.31] −0.39 [−0.77, 0.00]
DERS
Overall sample 0.90 [0.65, 1.14] 0.36 [0.21, 0.62]
High DES group 1.04 [0.72, 1.36] 0.54 [0.23, 0.77]
Low DES group 0.74 [0.29, 1.18] 0.26 [−0.05, 0.56]
PCL-C
Overall sample 0.65 [0.44, 0.86] 0.41 [0.21, 0.60]

High DES group 0.93 [0.62, 1.23] 0.61 [0.33, 0.89]
Low DES group 0.32 [0.02, 0.61] 0.20 [−0.16, 0.56]
DES
Overall sample 0.48 [0.31, 0.65] 0.22 [0.07, 0.37]
High DES group 0.81 [0.53, 1.09] 0.45 [0.19, 0.70]
Low DES group 0.24 [−0.06, 0.53] −0.08 [−0.46, 0.29]
PITQ-ta
Overall sample −0.44 [−0.77, −0.09] −0.31 [−0.50, 0.−13]
High DES group −0.54 [−0.80, −0.27] −0.38 [−0.65, −0.10]
Low DES group −0.30 [−0.72, 0.13] −0.25 [−0.50, 0.01]
Notes. PITQ-p = Progress in Treatment Questionnaire–patient;
DERS = Difficulties in Emotion Regulation Scale; PCL-C =
Posttraumatic Stress Checklist–Civilian;
DES = Dissociative Experiences Scale; PITQ-t = Progress in
Treatment Questionnaire–therapist.
aHigher scores are better for the PITQ-t and PITQ-p; for these
measures, a negative effect size reflects improvement.
participants demonstrated higher DERS scores (M = 121.20
for female vs. M = 105.09 for male participants) and lower
PITQ-p scores (M = 43.82 for female vs. M = 53.69 for male
patients) at baseline.
Main effect post hoc comparisons indicated differences be-
tween the high and low DES groups at all three time points;
Bonferroni post hoc comparisons showed higher PCL-C scores
for the high DES compared to the low DES group at baseline,
p < .001; Year 1, p < .001; and Year 2, p = .026. The high DES
group demonstrated significant improvement at post-2-year in-
tervention, p < .001, and at the mid-1-year intervention, p <
.001. Post hoc PITQ-p comparisons indicated that the low DES
group had higher average scores (M = 56.49) than the high

DES group (M = 49.63), p = .016. Patient-reported PITQ-p
scores correlated with therapist-reported PITQ-t scores, r = .49,
p < .001.
Changes in Safety and Hospitalization
In our sample, NSSI events were not normally distributed
(M = 20.61; SD = 37.08; Mdn = 6; range: 0–150). Thera-
pist reports of patients’ NSSI events in the past 6 months had
maximum values of 150 events at baseline, decreasing to max-
imum counts of 10 at Years 1 and 2. For the 67 subjects with
reported NSSI events, therapists reported patients engaged in
NSSI an average of 13.75 times in the 6 months prior to intake;
this rate dropped to 1.96 times and 1.74 times by Years 1 and
2, respectively. More than half of the patients who engaged in
NSSI (68.60%, n = 46) decreased NSSI events over 2 years;
25.40% (n = 17) reported an increase in NSSI from baseline.
The remaining 6% (n = 4) had no change in NSSI (n = 2),
increased then decreased (n = 1), or decreased then increased
(n = 1) over the three time intervals. Wilcoxon signed rank
tests examined the hypothesis that median differences between
baseline to Year 1, Year 1 to Year 2, and baseline to Year 2
were equal for the high and low DES groups. The high DES
group had a median count of two NSSI events at baseline and
decreased at Year 1, z = 2.65, p = .008, and Year 2, z = 4.00,
p < .001. The median number of NSSI events for the low DES
group was 1. This decreased significantly by Year 1, z = 2.35,
p = .018. Year 2 reductions (z = 1.69, p = .086) did not meet
the p < .05 significance criteria. There were no differences in
the high and low DES groups’ NSSI between Years 1 and 2.
At study completion, patients’ average number of suicide
attempts in the prior 6 months was lower than at intake (intake
M = 0.39, SD = 1.54 vs. M = 0.17; SD = 0.80 at year 2).
Patients required an average of 22.27 days of hospitalization

in the 6 months prior to engaging in the study and 11.50 days
of hospitalization 2 years later. Although the change in suicide
attempts and days hospitalized were in the direction suggesting
that the intervention was beneficial, they were not statistically
significant.
Discussion
This study examined the effectiveness of a web-based
psychoeducation program designed to assist therapists of
and patients with complex DDs, an underserved and severely
symptomatic population. Participation in the TOP DD Network
program was associated with reductions in dissociation and
PTSD symptoms, improved emotion regulation, and higher
adaptive capacities (i.e., PITQ scores). As indicated by effect
size, the overall sample demonstrated large improvements in
emotion regulation and patient-reported adaptive capacities,
medium-sized improvements in PTSD symptoms, and small
improvements in dissociation. Notably, however, patients with
higher initial DES scores demonstrated the strongest and most
consistent improvements. By Year 2, patients who entered the
study with high dissociation demonstrated large improvements
in emotion regulation, PTSD symptoms, dissociation, and
patient-reported adaptive capacities. Patients with lower initial
levels of dissociation also benefited at Year 2 relative to intake
and demonstrated medium changes in emotion regulation and
patient-reported adaptive capacities as well as small reductions
in PTSD and dissociation symptoms. In addition, despite the

chronicity and severity of NSSI in our sample, there were sig-
nificant overall reductions in therapist-reported patient NSSI.
Therapists’ (PITQ-t) and patients’ (PITQ-p) reports of im-
provements in adaptive capacities were directionally consistent,
but differed in effect size. As is the case in therapeutic alliance
(including among DD individuals; Cronin, Brand, & Mattanah,
2014), patients’ reports of their adaptive capacities demon-
strated stronger associations with other outcomes than did those
of their therapists. Differences in reports of adaptive capacities
may be because therapists’ and patients’ measures referred to
different time frames (i.e., 6 months vs. 1 week) and/or
patients’
greater awareness of their daily experience and capacities. Ther -
apists’ ratings of their patients’ adaptive capacities were found
to covary with their assessment of patient’s treatment stage,
which suggests that higher PITQ-t scores are associated with
later stages of treatment. Female patients demonstrated higher
levels of emotional dysregulation and lower adaptive capacities
at baseline. Results did not covary with age or native language
of the participant’s country, which suggests that the psychoedu-
cation program had a similar impact regardless of age or native
language.
This program was designed to facilitate symptom manage-
ment and patient stabilization, targeting unsafe behaviors as
well as the symptoms and emotions that contribute to them. We
were generally successful in recruiting patients who were in
the early stabilization stages of treatment; 85% of the partici -
pants were judged by their therapists to be working on symptom
management and stabilization at intake. We received feedback
from patients and therapists that the educational materials were
relevant, clear, and useful for patients struggling with safety
and symptom stabilization (see the Supplementary Materials
for examples of specific feedback; analysis of qualitative and
quantitative patient feedback is forthcoming).

Improving DD patients’ capacity for emotion regulation is
foundational for their recovery (Brand et al., 2012; ISSTD et
al.,
2011), as increased capacity for emotion regulation enables DD
patients to tolerate painful emotions, thereby reducing their re-
liance on NSSI, other unsafe behaviors, and dissociation to
manage overwhelming emotions related to traumatic intrusions
and compartmentalized self-states. Consistent with this view,
we found that significant improvements in emotion regulation
were accompanied by improvements in PTSD symptoms, dis-
sociation, and NSSI.
As expected for DD patients in early treatment, our sample
had high levels of NSSI that would have resulted in most of
these
patients being excluded from typical treatment studies. Even
the most chronically self-injuring patients appeared to benefit.
For example, the therapists of the three patients who had the
highest reported NSSI at intake (self-injuring approximately
100, 125, and 150 times in the last 6 months) reported their
patients’ NSSI had decreased considerably by the end of the
program (self-injuring 0, 10, and 10 times, respectively, in the
last 6 months). This is a crucial finding, as highly self-injurious
patients are largely excluded from treatment studies yet are
often the most challenging to treat (Brand, 2001).
At the beginning of the study, therapists reported that their
patients averaged .39 suicide attempts in the prior 6 months (SD
= 1.54) and required an average of 22.27 days of hospitalization
compared to a mean of 0.17 attempts and 11.50 days of hos-
pitalization 2 years later. The reduction in suicide attempts is
important given the high suicidality among DD patients, which
often necessitates intensive intervention and is likely associ-
ated with impairment (Brand et al., 2013, Foote et al., 2008).
It is possible that these changes in patients’ safety may reflect

underlying improvements in emotion regulation, which was a
target of this program. These are promising findings for im-
proved management of safety in this severely and chronically
self-injuring group of patients.
Despite improvements, most patients continued to report
levels of symptoms that implied need for further treatment.
This is consistent with treatment outcome data for evidence-
based PTSD treatments: A review of randomized controlled
trials (RCTs) for military PTSD found that two-thirds of
the patients who received treatment still met criteria for
PTSD after treatment, despite those studies’ exclusion of
patients with the severe symptoms and comorbidities common
in the current sample (Steenkamp, Litz, Hoge, & Marmar,
2015). This highlights the significance of the current study’s
findings: Participation in the TOP DD Network program was
associated with significant benefits among highly self-injuring,
164 Brand et al.
chronically ill, severely symptomatic DD patients, a popul ation
rarely targeted or included in treatment studies.
Compared to participants with lower levels of dissocia-
tion, the most highly dissociative among our DD patients
demonstrated the greatest improvements. The high dissocia-
tion group began with higher levels of symptoms, more dif-
ficulties with emotion regulation, and lower levels of adap-
tive capacities, yet they demonstrated faster and greater
improvement than the low dissociation group. These data show
that treatment that includes emphasis on providing psychoedu-

cation and stabilization-focused adaptive self-regulation skills
can result in meaningful improvements in quality of life for
even the most symptomatic and self-injurious DD patients. Al-
though it is possible that regression to the mean contributed to
these changes, these data also suggest that, although the pro-
gram was associated with benefits for all DD patients, it may be
especially beneficial to those with high levels of dissociation.
The strengths of the study included a large international sam-
ple, inclusion of all DD patients regardless of symptom
severity,
use of therapist and patient reports, and a standardized inter -
vention using a prospective, longitudinal design. The TOP DD
Network program was developed with input and feedback from
DD patients and expert DD clinicians in collaboration with
researchers (see the Supplementary Materials for additional in-
formation about the program’s content).
Several design issues constrain our interpretations. Thera-
pists may have shown a selection bias and invited patients who
were especially motivated for treatment, and the sample pop-
ulation consisted predominantly of female Caucasian patients.
Thus, these results may not generalize to all outpatients with
complex DDs. The patients received clinical diagnoses of DD
by their therapists rather than by using validated diagnostic
instruments such as the Structured Clinical Interview for Disso-
ciative Disorders–Revised (Steinberg, 1994). It is possible that
use of these measures would have led us to exclude some partic-
ipants. For example, given the relatively low DES scores in the
low DES group, some of these individuals may have other dis-
orders, such as the dissociative subtype of PTSD or borderline
personality disorder with relatively high levels of dissociation,
rather than a DD. Our study design did not permit assessment
of regression to the mean, expectancy bias, changes due to
individual therapy or medications, or other possible causes
for observed changes. We cannot definitively make causal

inferences without a comparison group. However, the strength
and breadth of the outcome data are consistent with benefit
of the program itself, particularly for commonly refractory
symptoms such as NSSI. Finally, other than what the program
itself provided, we did not control for therapists’ training. De-
spite the likely heterogeneity of therapists’ training, we found
a wide range of improvements, suggesting that the program
may be beneficial to DD patients regardless of their therapists’
training.
Future work should examine whether there are symptom re-
ductions and/or cost savings for patients who participate in this
program beyond those that have been found for individual DD
therapy alone. Future work could also investigate whether pa-
tients’ and therapists’ knowledge about managing safety and
symptoms increased over time, whether patients’ use of symp-
tom management skills increased over time, whether there is
a dose-effect relationship between patients’ involvement with
program materials and outcomes, and whether or how prein-
tervention therapist training contributes to patient participants’
progress. Patient and therapist feedback is informing the next
iteration of the TOP DD Network program, which will be stud-
ied as part of a randomized controlled trial.
Future studies should strive to increase representation of
groups underrepresented in the current study. In addition, some
study participants indicated they had already stabilized safety
and thus found the focus on safety unhelpful and dropped out
of the study. Future stabilization programs should screen for
early stage patients.
In view of the high costs associated with DD treatment, both
in terms of burden of disease and costs to the healthcare system,
it is exciting that this relatively inexpensive online program was
shown to be associated with significant improvements for the

most symptomatic DD patients. It is particularly encouraging
that these improvements were found in a sample that included
patients irrespective of safety issues, comorbid conditions, and
symptom severity, suggesting a broad applicability of this in-
tervention. Finally, the prospective, longitudinal data presented
here further underscore that DD patients can be meaningfully
helped when treated with the phasic trauma treatment model
exemplified by the ISSTD Treatment Guidelines and expert
consensus.
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