See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/316022423

Traumatic Dissociation: Theory, Research, and Treatment

Article in Clinical Psychology Science and Practice · April 2017

DOI: 10.1111/cpsp.12195

CITATIONS READS
39 6,364

2 authors:

Tyson Bailey Bethany L Brand

Spectrum Psychological Associates Towson University
7 PUBLICATIONS 73 CITATIONS 134 PUBLICATIONS 4,867 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Brand, B.L., Schielke, H.J., Schiavone, F., & Lanius, R.A. (2022). Finding Solid Ground: Overcoming Obstacles in Trauma Treatment. Oxford University Press. View project

Encyclopedia of Personality and Individual Differences View project

All content following this page was uploaded by Bethany L Brand on 10 October 2017.

The user has requested enhancement of the downloaded file.

 You have received this document via Cook Library’s
interlibrary loan service.

Please report any problems to our ILL office at:

ill@towson.edu or 410-704-3292

NOTICE: THIS MATERIAL MAY BE

PROTECTED BY COPYRIGHT LAW
(TITLE 17, U.S. CODE)

Any further reproduction or distribution of

this material may be prohibited by law.

This document will be available through ILLiad for 30 days.

Thank you for using interlibrary loan.

Traumatic Dissociation: Theory, Research, and Treatment
Tyson D. Bailey, Private Practice
Bethany L. Brand, Towson University
Adverse and traumatic experiences in childhood have
been linked to a number of symptoms, including disso-
ciation. We provide an overview of the theoretical and
scientific literature on the relationship between antece-
dent trauma and dissociation. Further, we discuss the
effects of disrupted attachment and dissociation on
emotional, cognitive, and neurobiological development.
Within treatment and research settings, high dissocia-
tion and its comorbid conditions can impact retention
and alter treatment outcomes, making it crucial that
clinicians and researchers understand methods
assessing, treating, and studying dissociation.
review the assessment and treatment of dissociative
conditions, including the dissociative subtype of post-
traumatic stress disorder and the dissociative disorders.
Finally, we highlight areas for future research.
Key words: child abuse, dissociation, dissociative
disorders, DPTSD, trauma, treatment. [Clin Psychol Sci
Prac 24: 170–185, 2017]
Traumatic events can have a profound impact on an
individual’s ability to function, particularly when they
occur during childhood. Exposure to trauma during
early development can negatively impact mood, behav-
ior, cognitive abilities, health, and overall functioning
(Felitti et al., 1998). There is a clear link between
experiencing traumatic events during childhood and
developing a complex, chronic symptom profile into
Address correspondence to Tyson D. Bailey, Spectrum
Psychological Associates, 19221 36th Ave. W, Suite 208,
Lywnnod, WA 98036. E-mail: tyson@spectrumpsychwa.com.
doi:10.1111/cpsp.12195
© 2017 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
170
adulthood (see other articles in this special issue),
including dissociation (Briere, Kaltman, & Greene,
2008; Cloitre et al., 2009; Hodges et al., 2013). The
more types of trauma experienced, the greater the
symptom complexity, including higher risk of complex
dissociative experiences (Briere, Dietrich, & Semple,
2016). Dissociation is “a disruption and/or disconti-
nuity in the normal integration of consciousness,
memory, identity, emotion, perception, body represen-
tation, motor control, and behavior” (American Psychi-
atric Association [APA], 2013, p. 291), which can
of accompany other posttraumatic symptoms. High levels
We of chronic dissociation may interfere with treatment
engagement and retention, as well as individuals’ daily
functioning and quality of life (Lanius, Brand, Vermet-
ten, Frewen, & Spiegel, 2012). Therefore, it is crucial
that clinicians and researchers are trained in assessing,
treating, and studying dissociation. This article reviews
theories about traumatic dissociation, assessment meth-
ods and measures, treatment of dissociative reactions,
and implications for future research.
DEVELOPMENTAL MODELS OF DISSOCIATION
Infants are biologically wired to maintain proximity to
adults as a method of ensuring safety. However, if a
caregiver is unable to remain connected and attuned
within the relationship, the fear system becomes chron-
ically activated (Schore, 2001, 2003, 2009). When chil-
dren experience persistent terror with no way to
escape, as is common in neglect, attachment disrup-
tions, or trauma, dissociation provides protection
against emotional distress (Kluft, 1985; Liotti, 1992;
Nijenhuis, Vanderlinden, & Spinhoven, 1998; Spiegel,
1984). Research has linked a number of factors to the
development of dissociation, including attachment style
All rights reserved. For permissions, please email: permissions@wiley.com.
(primarily insecure and disorganized types; Liotti, 1992,
1999; Lyons-Ruth, 2008; Schore, 2009), neurobiologi-
cal and cognitive functioning, and cultural variables
(Draijer & Langeland, 1999; Lanius, Frewen, Vermet-
ten, & Yehuda, 2010; Liotti, 1992; Reinders, Willem-
sen, Vos, den Boer, & Nijenhuis, 2012). Almost all
theories about dissociation conceptualize antecedent
trauma and attachment difficulties as causal factors. We
next review the theories that hold trauma and attach-
ment difficulties as a fundamental cause for dissociation.
This is followed by a review of the fantasy/sociocul-
tural model of dissociation, which holds that sug-
gestibility, fantasy proneness, and cultural influences
create dissociation and dissociative disorders (DDs) in
psychologically and cognitively vulnerable individuals.
TRAUMA AND ATTACHMENT MODELS OF DISSOCIATION
Childhood maltreatment and adverse childhood experi-
ences can be broadly conceptualized to include prob-
lematic caregiver behaviors, such as frightening the
infant or being frightened by the infant’s distress, that
cause attachment disruptions (Main & Hesse, 1990),
particularly disorganized attachment (Cyr, Euser, Bak-
ermans-Kranenburg, & Van Ijzendoorn, 2010). Disor-
ganized attachment is characterized by seemingly
contradictory behavior, where the child appears to
both seek connection, yet also simultaneously shows a
fear-based avoidance of the caregiver (Main & Hesse,
1990). An example of this contradictory behavior
would be a toddler both reaching for his mother with
his arms while his feet take a step away from her so
that he is out of reach.
Early disorganized attachment is associated with later
difficulties with dissociation, social relationships, and
academic as well as cognitive sequelae. Children with
disorganized attachment begin to display controlling/
punitive behavior (e.g., rejection, being commanding)
and role reversals by age six, which generally replaces
the fear-based behaviors seen in infants and toddlers
(Lyons-Ruth & Dozier, 2016). Longitudinal research
has found ambivalent or disorganized children had
lower IQ and grades in middle childhood, which was
primarily mediated by their ability to cooperate with
school rules and the extent to which their mothers
encouraged the academic process (West, Mathews, &
Kerns, 2013). There is preliminary evidence that
TRAUMATIC DISSOCIATION  BAILEY & BRAND
disorganized attachment negatively affects how adults
interpret and respond to social interactions, including
in a therapeutic setting (Beeney et al., in press; Prunetti
et al., 2008).
Research indicates that early trauma and attachment
disruptions can cause subsequent dissociation. Schore
(2009) argues that children who develop disorganized
attachment are faced with the impossible task of
inhibiting behavior designed to increase and deepen
relationships, which leads to the use of primitive disso-
ciative defenses on a prolonged basis. Prospective stud-
ies have found that objective, verified childhood
trauma and highly disrupted communication between
the caregiver and child (e.g., mother acting intensely
angry toward infant) are related to dissociation in adult-
hood (Byun, Brumariu, & Lyons-Ruth, 2016; Diseth,
2006; Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006;
Ogawa, Sroufe, Weinfeld, Carslson, & Egeland, 1997;
Trickett, Noll, & Putnam, 2011). A longitudinal study
showed increased dissociation at a 10-year follow-up in
those who had experienced daily painful medical pro-
cedures (i.e., anal dilation to treat anal birth defects)
that were performed by their parents (Diseth, 2006).
Diseth (2006) indicated that even though the parents
were not malevolent in their actions, the traumatic nat-
ure of the procedure interfered with the development
of an organized attachment relationship, increasing the
likelihood of dissociative symptoms over time. Due to
the level of distress the children and parents endured
during this treatment, parents in Norway are no longer
required to provide this treatment to children with this
condition. A mixed methods study followed 50 infants
for 18 years and assessed an additional 62 matched
young adults at one time period to determine whether
attachment disorganization mediated the relationship
between childhood abuse and dissociation (Byun et al.,
2016). The severity of abuse was related to dissociation
in adulthood as well as “unresolved attachment” status
(the adult equivalent of infant disorganized attachment,
as assessed by the Adult Attachment Interview [AAI]).
Young adults who experienced more severe childhood
abuse interacted more punitively or showed more dis-
orientation toward their mothers, even after controlling
for demographic variables. Surprisingly, unresolved
attachment was not related to dissociation in adult-
hood. However, Byun et al. (2016) suggest that the
171
AAI may not be sufficiently sensitive with high-risk
populations because individuals have to be able and
willing to disclose their trauma and loss history to be
classified as having unresolved attachment. Highly dis-
sociative individuals, with their contradictory states of
mind, may not be aware of, and report, such experi-
ences. Instead, behavioral manifestations of unresolved
attachment were related to dissociation: hostility and
helplessness during AAI discussions, as well as disori-
ented interactions during discussions of conflict and
caregiving/role confusion when interacting with moth-
ers. Byun and colleagues’ (2016) mediation analyses
suggest there may be two pathways to dissociation: a
child abuse path as well as a nonabuse path that is par-
tially mediated by the quality of current young adult–
parent interactions.
Exposure to antecedent trauma has been shown to
be the most consistent and robust among the causal
factors for dissociation in a wide range of samples using
diverse methodologies, including longitudinal, con-
trolled studies as well as meta-analyses (Dalenberg
et al., 2012, 2014). The ability to dissociate during
chronic childhood maltreatment allows for an atypical
developmental pathway in which powerful, contradict-
ing feelings and attachment patterns with traumatizing
caregivers can coexist. Armstrong (1994) suggested this
atypical developmental pathway may enable the disso-
ciative child to preserve the ability to experience a
range of emotions, including terror and betrayal, as
well as hope and joy. Dissociation allows the child to
maintain the capacity for attachment, despite chronic
trauma or neglect by caregivers. While separating our
consciousness from the present moment is a remarkable
strategy that youth and adults can temporarily utilize in
times of overwhelming distress, it can cause disruptions
in functioning when it becomes a dominant strategy or
one that persists when danger ceases (Kluft, 1991,
2009; Nijenhuis et al., 1998).
Just as disorganized attachment is associated with a
range of subsequent social and cognitive difficulties, so
is dissociation. For example, in a recent review,
McKinnon et al. (2016) found dissociation was related
to deficits in a number of neuropsychological domains,
including executive functioning (e.g., response inhibi-
tion, divided attention), social cognition, and numerous
aspects of memory (e.g., working, autobiographical).
172 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
Disorganized attachment and trauma are thought to be
a contributing factor to the development of contradic-
tory, dissociative states that may endure and become
more structuralized in individuals with severe dissocia-
tive disorders (Blizard, 2003; Liotti, 1992, 1999). We
will further delineate the difficulties associated with dis-
sociation below.
Theorists have emphasized different aspects of the
link between antecedent trauma and dissociation. Put-
nam’s (1997) discrete behavioral state model posits that
behavioral states develop as part of normal maturation.
When children experience attuned parenting, they
learn to integrate behavioral states. However, when
exposed to abuse or other adverse experiences, integra-
tion may be hampered, possibly resulting in emotion
regulation deficits and an inability to access previously
known information, particularly when abuse has been
severe, chronic, and perpetrated by caregivers. Factors
that interfere with the integration of these states, such
as disrupted attachment between mother and child,
were found to be correlated with adolescent dissocia-
tion in an 18-year longitudinal study of 168 children
who were considered at high risk of developmental dif-
ficulties, primarily based on the mother’s socioeco-
nomic status (Ogawa et al., 1997). Other longitudinal
studies have also found attachment-related problems to
be significantly associated with the later development
of dissociative symptoms (Diseth, 2006; Lyons-Ruth
et al., 2006).
Betrayal trauma theory (Freyd, 1996) also acknowl-
edges the primary role of abuse by caregivers with an
emphasis on the necessity of the traumatized child
maintaining attachment to abusive caregivers, despite
the betrayal, terror, shame, and physical pain the care-
givers intermittently create. Betrayal trauma theory sug-
gests dissociation is a process of forgetting details that
would interfere with the desire to remain in close
proximity to a dangerous attachment figure, thus serv-
ing as a protective mechanism when it is not possible
to physically escape (Freyd, 1996; Goldsmith, Barlow,
& Freyd, 2004). Chu and DePrince (2006) found that
a history of betrayal trauma was associated with disso-
ciative symptoms in mothers and children.
Frewen and Lanius (2015) have suggested dissocia-
tion arises from trauma-related altered states of con-
sciousness (TRASC) associated with one’s
 V24 N2, JUNE 2017
phenomenological experience of the “4 Ds,” that is,
the dimensions of time, emotion, sense of embodi-
ment, and cognition. This model primarily focuses on
one’s ability to alter aspects of consciousness to manage
overwhelming emotions related to traumatic experi-
ences during childhood. A study of 2,478 community
adults found that those who demonstrated TRASC
were more likely to have experienced adverse events
during childhood, specifically physical abuse/neglect
and sexual abuse (Frewen, Brown, & Lanius, 2016).
The structural theory of dissociation (Nijenhuis &
van der Hart, 2011) posits that identity becomes frag-
mented into two or more parts during exposure to
prolonged, severe threat. The “apparently normal”
parts (ANP) of the person develop to maintain distance
from traumatic memories and related emotions, while
the “emotional” parts (EP) maintain access. Switching
between the parts is mediated by action systems pri-
marily organized around defenses designed to keep the
individual safe from threat. Below we discuss a series of
neurobiological studies that support the structural the-
ory of dissociation.
Neurobiological research illustrates the impact of
trauma, including the complex influence of dissocia-
tion, and provides support for the trauma model of dis-
sociation. A full review is beyond the scope of this
article but is available (Frewen & Lanius, 2015). Disso-
ciative states generally arise when escape from a feared
stimulus is impossible, resulting in a “freeze” or “flag”
response in some animals and humans (Nijenhuis et al.,
1998; Schauer & Elbert, 2010). Endogenous opioids
may be involved, as they regulate affect (Bodnar, 2016;
Simeon & Knutelska, 2005). Traumatized individuals
fluctuate between being in dissociative, hypo-aroused
states and being in hyperaroused, emotionally flooded
states (Frewen & Lanius, 2006a, 2006b; Lanius,
Frewen, et al., 2010; Schore, 2009). Studies using a
variety of traumatized populations demonstrate that
trauma-based dissociation is associated with a state of
hypo-arousal during which some regions of the brain
(e.g., the prefrontal cortex) overregulate regions associ-
ated with awareness and intensity of emotions and sen-
sations (Lanius, Vermetten, et al., 2010). Consistent
with these patterns, Reinders et al. (2003, 2006, 2014)
have found differences in cortical blood flow and car-
diovascular response when trauma scripts are read to
TRAUMATIC DISSOCIATION  BAILEY & BRAND
individuals with dissociative identity disorder (DID)
while in emotionally neutral (i.e., ANP) versus trauma-
tized (i.e., EP) states, suggesting emotional under- and
over-arousal, respectively. Professional actors attempt-
ing to simulate DID could not replicate the patterns of
brain activation or heart rate variability (HRV) found
in DID (Reinders et al., 2006, 2012, 2014). HRV has
also been shown to be significantly different for those
with a DD (93% of whom were classified as unre-
solved/disorganized by the AAI) compared with
matched controls. Specifically, individuals with DDs
showed an increase in a ratio thought to represent
sympathetic and parasympathetic response after recall-
ing attachment-related memories, which seems to
reflect emotional dysregulation and/or switching
between dissociative states (Farina, Speranza, Impera-
tori, Quintiliani, & Marca, 2015). This research pro-
vides support for the discrete behavioral state theory
suggested by Putnam and the structural theory of disso-
ciation (Nijenhuis & van der Hart, 2011), as well as
empirical validation for DDs.
Trauma and stress are associated with structural dif-
ferences in the brain as well. For example, Lyons-
Ruth, Pechtel, Yoon, Anderson, and Teicher (2016)
found attachment disorganization was related to
increased amygdala volume in a longitudinal study of
18 adults when assessed at 29 years old. Further, a
study of 15 adults diagnosed with DDNOS who had
disrupted paternal attachment relationships and matched
healthy controls found decreased white matter in the
corpus callosum and decreased connection between the
limbic system and frontal lobes in the DDNOS group
(Basmaci Kandemir et al., 2016). In summary, neurobi-
ological research provides support for the trauma model
of dissociation (Dalenberg et al., 2012), including DID
and other DDs.
THE TRAUMA VERSUS FANTASY/SOCIOCULTURAL MODEL OF
DISSOCIATION
Some authors doubt the causal role between antecedent
trauma and dissociation. Proponents of the fantasy
model (FM) of dissociation, sometimes called the
sociocognitive or iatrogenic model, argue that highly
dissociative individuals, particularly those with DID,
are fantasy prone and suggestible, so that they are sus-
ceptible to fantasizing trauma that did not occur (false
173
memories; Giesbrecht, Lynn, Lilienfeld, & Merckel-
bach, 2008; Lynn et al., 2014). Dalenberg et al. (2012,
2014) reviewed almost 1,500 studies to determine
whether the “trauma model” (TM) versus the FM had
the most empirical support. The results were consistent
with TM assertions, including several longitudinal stud-
ies that relied on corroboration of trauma(s). Dalenberg
and colleagues’ meta-analysis found the trauma–dissoci-
ation relationship was moderate for childhood sexual
abuse (CSA; r = 0.31) and physical abuse (r = 0.27).
The effect size was stronger among individuals with
DD (i.e., 0.54 for CSA and 0.52 for physical abuse). In
contrast to the FM’s prediction that dissociation should
be strongly related to suggestibility, dissociation pre-
dicted only 1–3% of the variance in suggestibility,
directly challenging the FM hypothesis that dissociative
individuals are highly suggestible. Subsequent studies
have also found that individuals with DID are no more
suggestible or prone to creating false memories than are
individuals with posttraumatic stress disorder (PTSD),
actors simulating DID, or healthy controls (Vissia et al.,
2016). Despite the lack of support for this theory, it
continues to be presented in many psychology text-
books as if it is a scientifically based explanation for dis-
sociation (Wilgus, Packer, Lile-King, Miller-Perrin, &
Brand, 2015). This misinformation has contributed to
skepticism among many people about the validity of
dissociation and the DDs, despite the substantial
research showing both are common, neurologically
linked psychological problems caused by trauma and
disruptions in attachment.
DISSOCIATIVE DISORDERS
There are five DDs in the DSM-5 (APA, 2013): DID,
dissociative amnesia, depersonalization/derealization
disorder, other specified DD, and unspecified DD (for-
merly DD not otherwise specified). Depersonalization/
derealization disorder involves persistently experiencing
unreality and/or detachment from aspects of self or the
environment. Dissociative amnesia includes autobio-
graphical memory loss that can range from a single
moment to a lifetime of experiences, and is not better
accounted for by normative forgetting. DID is charac-
terized by at least two identity states coupled with
recurrent amnestic experiences. Other specified DDs
include dissociative symptoms such as a mixed
174 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
dissociative symptoms presentation similar to DID that
fails to meet full criteria; identity disturbance symptoms
due to intense, coercive persuasion such as brainwash-
ing; dissociative trance; and acute dissociative symp-
toms due to stress that has lasted less than one month.
Unspecified DD is diagnosed when dissociation is pre-
sent, but the etiology or symptom profile does not
meet criteria for one of the other established DDs.
Population estimates of the lifetime prevalence of
any DD range from approximately 9% to 18%, with
DID occurring in approximately 1% (Johnson, Cohen,
Kasen, & Brook, 2006; Ross, 1991; Sßar, Aky€ uz, &
Dogan, 2007); these rates are generally consistent
between Europe and North America (Friedl, Draijer,
& de Jonge, 2000). Most cases of DD are associated
with a variety of types of childhood trauma, although
depersonalization/derealization is linked only with
emotional abuse (Simeon & Loewenstein, 2009). Clini-
cians often expect obvious, dramatic switching of per-
sonality states in DID, despite such presentations
occurring in only 5% of cases (Kluft, 2009). In contrast,
DID patients typically present with a complex and sev-
ere range of dissociative symptoms, depression, chronic
self-harm and suicidality, eating disorders, substance
abuse, and somatoform symptoms (e.g., Brand et al.,
2013; Dell, 2002; Putnam, Guroff, Silberman, Barban,
& Post, 1986).
DPTSD
DPTSD has been found in between 6% and 30% of
individuals with PTSD (Armour, Elklit, Lauterbach, &
Elhai, 2014; Blevins, Weathers, & Witte, 2014;
Steuwe, Lanius, & Frewen, 2012; Wolf, Lunney, et al.,
2012; Wolf, Miller, et al., 2012). In a World Health
Organization study of 16 countries, DPTSD was found
in 14.4% of those with PTSD (Stein et al., 2013) and
was associated with exposure to childhood trauma and
adversities, onset of PTSD in childhood, male gender,
and history of separation anxiety disorder and phobias,
as well as high role impairment and suicidality.
Although many initial studies relied on two or three
questions from the CAPS to distinguish DPTSD and
PTSD, a variety of validated measures of dissociation
have been used in recent studies, some of which have
also found neurobiological differences between DPTSD
and PTSD. Using the Multiscale Dissociation
 V24 N2, JUNE 2017
Inventory (MDI; Briere, 2002) to measure depersonal-
ization and derealization symptoms, studies found
increased connectivity between the amygdala and pre-
frontal cortex (Nicholson et al., 2015) and insula and
amygdala (Nicholson et al., 2016) between those with
DPTSD when compared with participants with PTSD
and matched controls.
COMORBIDITY AND UNDER-RECOGNITION OF DISSOCIATION
Highly dissociative adults are likely to suffer from a vari-
ety of psychological disorders and psychiatric difficulties,
including PTSD, DPTSD, borderline personality disor-
der (BPD), suicidal ideation and attempts, depression,
substance abuse, somatization disorder, and DD (Anda
et al., 2006; Briere et al., 2016; Sßar et al., 2003; Weber-
mann, Myrick, Taylor, Chasson, & Brand, 2016). Disso-
ciation was a more powerful moderator of self-directed
violence than both posttraumatic and depressive symp-
toms in a small, community-based sample (Briere &
Eadie, 2016). Individuals with high dissociation some-
times have difficulty engaging in treatment, resulting in
being at risk of dropping out, increased likelihood of
relapse, and less durability of treatment gains (Kleindi-
enst et al., 2011, 2016; Rufer et al., 2006).
Individuals high in dissociation typically present
with a varied symptom profile, particularly when a
DD is present, and may require individualized treat-
ment planning with particular attention to engaging
them in treatment and relapse prevention (Briere
et al., 2016). Unfortunately, this complex symptom
profile often leads clinicians to diagnose and treat the
comorbid conditions while overlooking, and therefore
not treating, dissociation (Armstrong et al., 2015;
Brand, Armstrong, & Loewenstein, 2006). For exam-
ple, a study of youth found that those with DD had
the highest impairment of any of the disorders studied
yet the lowest level (2.3%) of referral for psychiatric
treatment (Ferdinand, van der Reijden, Verhulst,
Nienhuis, & Giel, 1995). A nationally representative
sample of German adolescents and young adults with
DD were also found to be quite impaired, yet only
16% had ever received mental health care (Lieb, Pfis-
ter, Mastaler, & Wittchen, 2000).
These studies and others indicate that individuals
with DDs are under-recognized and rarely receive
treatment targeting dissociation. They are also often
TRAUMATIC DISSOCIATION  BAILEY & BRAND
highly impaired by their symptoms. For example,
adults with DDs showed significantly more impairment
than those who did not have a dissociative presenta-
tion, as measured by the Global Assessment of
Functioning scale, even after controlling for age,
comorbidity, and gender (Johnson et al., 2006). In a
study of over 53,000 admissions for U.S. soldiers, the
number of days patients were hospitalized for a DD
within the last 12 months was associated with extre-
mely high risk of suicide in the following year (odds
ratio = 5.6; Kessler et al., 2015). Chronic dissociation
can impair functioning across a number of domains
(i.e., work, family, interpersonal relationships, sense of
self) and may impact the course and outcome of treat-
ment, particularly if clinicians are unaware of, or do
not address, chronic, severe dissociation (Jepsen, Lange-
land, Sexton, & Heir, 2014). Therefore, it is critical
that clinicians routinely assess dissociative symptomatol-
ogy, especially if clients have a history of repeated vic-
timization, attachment disruptions, or other forms of
interpersonal betrayal (Draijer & Langeland, 1999;
Freyd, 1994; Kluft, 1985; Liotti, 1992; Putnam, 1985;
Schore, 2009).
USE OF ASSESSMENT MEASURES IN PREPARATION FOR
TREATMENT
Trauma experts recommend assessing for dissociation
during the initial phase of treatment (Armstrong et al.,
2015). Using validated trauma and dissociation assess-
ment measures can be helpful in better understanding a
client’s experiences and in planning treatment. They
can also be used repeatedly throughout therapy to
assess the client’s progress.
GLOBAL TRAUMA MEASURES
Measures that assess a range of trauma-related symptoms
in adults that contain a dissociation scale include the
Trauma Symptom Inventory-2 (TSI-2; Briere, 2011)
and Detailed Assessment of Posttraumatic States (DAPS;
Briere, 2001). The advantage of these scales is that they
assess a range of posttraumatic symptoms. However,
they do not provide specific information about the sub-
types of dissociation (e.g., depersonalization, identity
fragmentation), nor do they assess for DID. Thus, if the
dissociation subscales are elevated on these measures,
clinicians should follow up with more careful
175
assessment, preferably using a dissociation-specific mea-
sure, to determine the nature and severity of possible
dissociative experiences.
DISSOCIATION-SPECIFIC MEASURES
The Dissociative Experiences Scale (DES; Bernstein &
Putnam, 1986) is the most commonly utilized self-report
measure of dissociation. Other measures provide addi-
tional information about specific types of dissociation,
including the Multidimensional Inventory of Dissocia-
tion 6.0 (MID; Dell, 2006), the MDI (Briere, 2002), the
Cambridge Depersonalization Scale (CDS; Sierra &
Berrios, 2000), the Somatoform Dissociation Question-
naire (SDQ-20; Nijenhuis, Spinhoven, van Dyck, van
der Hart, & Van der Linden, 1996), and, most recently,
the Dissociative Symptom Scale (DSS; Carlson et al.,
2016). The MDI provides data about specific aspects of
dissociation and can provide a standardized score. Only
the MID and TSI-2 have validity scales. These measures
are psychometrically sound and can assist in diagnostic
formulation, treatment planning, and research.
Although these measures can be helpful in gaining a
better understanding of clinical problems, it is critical
to differentiate between screening and diagnostic
instruments. Screening measures are designed to deter-
mine whether or not a particular symptom should be
further assessed; they do not provide the rich level of
detail that diagnostic measures do, nor can they lead to
diagnoses. For instance, elevated DES scores may signal
the presence of a dissociative process; however, diag-
nostic evaluation by a clinician is required due to the
possibility that an individual may not understand the
items or may be over- or underreporting symptoms.
TREATMENT OF DISSOCIATIVE REACTIONS
Treatment for clients who present with the range of
difficulties associated with complex trauma and attach-
ment disruptions must target a wider range of symp-
toms and developmental deficits, rather than targeting
only the classic symptoms of PTSD (Courtois & Ford,
2009; Herman, 1992). As emotion regulation, relation-
ship, and safety problems are so pervasive and disrup-
tive for those who have experienced adverse events
during childhood, these are specifically targeted, along
with addressing dissociation and PTSD symptoms. The
expert consensus model for the treatment of
176 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
dissociative reactions, particularly those that arise from
repeated, early trauma, relies on a carefully paced,
three-stage treatment (Courtois & Ford, 2009; Her-
man, 1992; International Society for the Study of Dis-
sociation et al., 2011). The first stage focuses on
building a therapeutic relationship and helping the cli-
ent increase safety and stability, which involves skill
building to assist in regulating emotions and managing
dissociation. Once the client can maintain present
moment awareness and safety, processing traumatic
memories usually becomes the focus of treatment. The
third stage emphasizes building an integrated sense of
self, as well as further developing relationships and a
life that the individual perceives as meaningful. Treat-
ment often does not follow a linear path and frequently
involves revisiting previous stages.
TREATING DISSOCIATIVE DISORDERS
Despite the prevalence of DD and the rapidly growing
literature on dissociation, there are only a few random-
ized controlled DD treatment studies involving
psychotropic medication or biofeedback for depersonal-
ization/derealization disorder (Somer, Amos-Williams,
& Stein, 2013), none of which show consistent evi-
dence of being efficacious. There are relatively few
treatment studies for the more chronic, complex DDs
due to the methodological and funding challenges of
studying patients with comorbid conditions and high
suicidality who require long-term treatment (Brand,
2012).
In a meta-analysis of DD treatment studies, Brand
and colleagues found that treatment was associated with
decreases in symptoms across eight studies (Brand,
Classen, McNary, & Zaveri, 2009). With the exception
of substance abuse, which showed a moderate effect,
treatment had large effect sizes with decreased mood
disturbances (i.e., anxiety and depression), dissociation,
borderline features, somatic complaints, posttraumatic
symptoms, and generalized distress. While none of
these studies used a control group, it appears likely that
treatment is beneficial for DD clients, although we
cannot make conclusive statements about treatment
causing these improvements.
Jepsen and colleagues (Jepsen, Langeland, & Heir,
2013, 2014) found severe dissociative symptoms
and interpersonal difficulties were associated with
 V24 N2, JUNE 2017
poorer outcomes and higher overall symptoms after a
three-month inpatient program for women sexually
abused in childhood. Additional analyses indicated that
despite improvement after trauma treatment that did not
specifically address dissociation, those with DD showed
clinically significant distress (Jepsen, et al., 2014). The
patients continued to receive outpatient treatment after
discharge from the hospital. The authors noted the effect
sizes among the DD group improved on some measures
at follow-up compared with those with low dissociation,
who had stable scores, which may indicate DD clients
require additional time to consolidate gains.
The Treatment of Patients with Dissociative Disor-
ders (TOP DD) study is the largest, most geographi-
cally diverse study on the treatment of DD to date
(Brand, Classen, Lanius, et al., 2009; Brand et al.,
2013). This naturalistic, longitudinal study followed an
international sample of community therapist (n = 292)
and client (n = 280) pairs over 30 months. Treatment
was associated with a reduction in dissociation, suicide
attempts, nonsuicidal self-injury, risky behaviors, and
substance use. There was an increase in adaptive func-
tioning, including socializing, attending college, and
utilizing effective coping strategies. The results of the
TOP DD study support the phasic treatment model
and indicate that safety and the therapeutic relationship
continue to be an important focus throughout treat-
ment (Brand et al., 2013). The therapeutic alliance
accounted for more of the variance in treatment out-
come for individuals in the TOP DD study than those
found in many other diagnoses, highlighting the cen-
trality of the alliance among highly dissociative individ-
uals (Cronin, Brand, & Mattanah, 2014).
Some authors suggest treatment of dissociation will
increase or create, rather than alleviate, dissociative
states in clients with severe DD (Lilienfeld, 2007;
Lynn, Lilienfeld, Merckelbach, Giesbrecht, & van der
Kloet, 2012). There is no empirical support for this
assertion if treatment is consistent with expert consen-
sus guidelines (International Society for the Study of
Dissociation, 2011). To the contrary, treatment
research has found a reduction in dissociative symptoms
in DD individuals (Brand & Loewenstein, 2014; Brand,
Loewenstein, & Speigel, 2014), as well as increased
social and occupational functioning (Brand et al.,
2013).
TRAUMATIC DISSOCIATION  BAILEY & BRAND
TREATING DISSOCIATION IN THE CONTEXT OF DISORDERS
OTHER THAN DDS
Dissociation can occur in a variety of clinical syn-
dromes, yet not reach the severity or frequency
required to merit diagnosis with a DD, including BPD
and DPTSD (Frewen, Kleindienst, Lanius, & Schmahl,
2014), depression (Friedman et al., 2009), obsessive-
compulsive disorder (Rufer et al., 2006), psychosis (Sßar
et al., 2010), and complex PTSD (Courtois & Ford,
2009). High dissociation is often associated with higher
levels of dropout or worse outcome (Friedman et al.,
2009; Kleindienst et al., 2011, 2016; Rufer et al.,
2006). Although dissociation can be comorbid with the
above disorders, the treatment literature has primarily
focused on PTSD.
Dissociation can interfere with a client’s ability to
fully engage in treatment, particularly when intense
emotions are involved (Lanius, Frewen, et al., 2010;
Lanius, Vermetten, et al., 2010). As the fundamental
requirement in exposure therapy is habituating to
intense trauma-related fear while maintaining a con-
nection with the present moment, it is critical that
researchers study the effects of different levels of sever-
ity and types of dissociation on treatment, as well as
the timing of when dissociation occurs (e.g., at entry
into treatment versus during an exposure session). Most
studies do not specifically assess or target dissociation
during treatment sessions, yet this is a critical issue that
appears to impact outcome (Kleindienst et al., 2016;
Price, Kearns, Houry, & Rothbaum, 2014; Rufer
et al., 2006).
Several studies have suggested dissociation is related
to nonresponsiveness and/or worse outcomes in treat-
ment and follow-up. Bae, Kim, and Park (2016) found
a relationship between dissociative symptoms and
comorbidity and treatment nonresponsiveness in eye
movement desensitization and reprocessing therapy.
Price et al. found dissociation at the start of treatment
predicted poor overall response; unfortunately, dissocia-
tion was not assessed at follow-up (Price et al., 2014).
Kleindienst et al. (2011) found dissociation interfered
with treatment gains in females diagnosed with BPD
who were involved in dialectical behavior therapy
(DBT). Further, individuals who dissociated during
trauma-focused DBT (DBT-PTSD) sessions showed
less improvement after 24 weeks of treatment
177
(Kleindienst et al., 2016). More concerning is a natu-
ralistic study by D’Andrea and Pole (2012), which
found no improvement in dissociation with psychody-
namic therapy, and worsening of symptoms in the pro-
longed exposure (PE) condition.
Some authors have asserted that dissociation does
not have a significant impact on outcome. Hagenaars,
van Minnen, and Hoogduin (2010) found that
although PTSD symptom severity remained higher for
those who experienced dissociative symptoms, both
high and low dissociators changed at the same rate.
Thus, dissociation did not moderate the effectiveness of
PE, although at a six-month follow-up, the rates of
PTSD were seven times higher in those with high dis-
sociation. This suggests that those with high dissocia-
tion would have likely required longer treatment to
achieve similar PTSD remission rates. Similarly, Hal-
vorsen, Stenmark, Neuner, and Nordahl (2014) com-
pleted a secondary analysis of data comparing narrative
exposure therapy to treatment as usual for a trauma-
tized refugee population. Dissociation did not signifi-
cantly moderate treatment outcomes; however, the
PTSD scores for the highly dissociative group were still
in the severe PTSD range at follow-up.
Alternatively, Cloitre, Petkova, Wang, and Lu
(2012) found that among women with PTSD, skill
building preceding modified exposure provided greater
benefits in PTSD reduction as compared to no skills
building; this effect was more pronounced as severity
of baseline dissociation increased. Another study indi-
cated women who endorsed higher levels of dissocia-
tion responded better to standard cognitive processing
therapy rather than a modified version of cognitive
therapy with no written trauma narratives (Resick,
Suvak, Johnides, Mitchell, & Iverson, 2012). Overall,
complex trauma experts and much of the research sup-
port the phasic model described above and the idea
that treatment may need to be adapted when working
with highly dissociative individuals, particularly if they
dissociate during treatment sessions and/or have very
high levels of dissociation (Brand et al., 2013).
Future studies about the treatment of trauma-based
dissociation should address the timing of dissociation.
Lanius et al. (2012) hypothesized that dissociation dur-
ing treatment sessions prevents the extinction of
learned fear and shame responses in exposure therapy;
178 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
as noted above, there is some research that supports
this hypothesis. Similarly, dissociation at the onset of
treatment was the only variable that predicted treat-
ment outcome in persons seeking services at an emer-
gency department following trauma; it accounted for
substantial variance in PTSD (i.e., 51%; Price et al.,
2014). More knowledge is needed about how the tim-
ing (i.e., dissociation at enrollment in a study versus
during treatment sessions), chronicity, severity, and
type of dissociation experienced (e.g., depersonalization
versus amnesia) relate to treatment outcome.
SUMMARY AND IMPLICATIONS FOR FUTURE RESEARCH
Exposure to adverse events during the formative
years can have a variety of impacts on mood, behav-
ior, cognitive abilities, health, and overall functioning
(Felitti et al., 1998). Trauma exposure is known to
have a cumulative effect, with comorbidity and sev-
ere symptoms increasing in conjunction with the
number of traumas, particularly when attachment fig-
ures are involved (Briere et al., 2008, 2016; Cloitre
et al., 2009). While dissociation does not always fol-
low traumatic events, antecedent trauma has been
shown to be one of its most robust predictors
(Dalenberg et al., 2012, 2014). Therefore, it is criti-
cal that clinicians and researchers understand how to
define, assess, and treat the spectrum of dissociative
experiences and disorders.
Dissociative reactions may require longer treatment
than typical for PTSD (Brand et al., 2013; Frewen &
Lanius, 2014; Lanius, Bluhm, & Frewen, 2011).
Although there are mixed opinions about whether dis-
sociation impacts treatment (i.e., Hagenaars et al.,
2010; Halvorsen et al., 2014), individuals high in disso-
ciation often continue to have worse symptoms at ter-
mination and follow-up than do those with low
dissociation. Furthermore, the timing of dissociation is
not typically addressed in treatment studies but appears
to be of critical importance (Kleindienst et al., 2016;
Price et al., 2014). While there has been an increase in
research on dissociation, there remains a paucity of
controlled treatment studies among individuals high in
dissociation, particularly those with DD. However,
most studies to date, including naturalistic and uncon-
trolled DD treatment studies, indicate that treatment is
associated with reduced symptoms and increased
 V24 N2, JUNE 2017
functioning (Brand, Classen, Lanius, et al., 2009;
Brand, Classen, McNary, et al., 2009; Brand et al.,
2013).
Dissociation research has made significant gains over
the past several decades, yet many questions need to be
answered. Controlled studies of dissociation are critical
to evaluating the effectiveness of various treatments and
to verify the link between treatment and symptom
reduction (Brand, 2012). Neurobiological research (i.e.,
Bremner, 2009; Frewen & Lanius, 2006a, 2014; Lanius,
Frewen, et al., 2010; Reinders et al., 2014) is revealing
promising directions for clarifying the mechanisms
underlying dissociative reactions; however, application
of this knowledge to treatment is in its infancy. Given
the high prevalence and significant comorbidity and dis-
ability associated with dissociation, additional research
and training about dissociation are urgently needed.
REFERENCES
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington,
DC: Author.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D.,
Whitfield, C., Perry, B. D., . . . Giles, W. H. (2006). The
enduring effects of abuse and related adverse experiences
in childhood: A convergence of evidence from
neurobiology and epidemiology. European Archives of
Psychiatry and Clinical Neuroscience, 256, 174–186. doi:10
.1007/s00406-005-0624-4
Armour, C., Elklit, A., Lauterbach, D., & Elhai, J. D. (2014).
The DSM-5 dissociative-PTSD subtype: Can levels of
depression, anxiety, hostility, and sleeping difficulties
differentiate between dissociative-PTSD and PTSD in rape
and sexual assault victims? Journal of Anxiety Disorders, 28,
418–426. doi:10.1016/j.janxdis.2013.12.008
Armstrong, J. G. (1994). Reflections on multiple personality
disorder as a developmentally complex adaptation.
Psychoanalytic Study of the Child, 49, 349–364.
Armstrong, J. G., Brand, B., Briere, J., Carlson, E., Courtois,
C., Dalenberg, C., . . . Winters, N. (2015). Division 56
guidelines for psychologists regarding the assessment of trauma in
adults. Manuscript submitted for publication.
Bae, H., Kim, D., & Park, Y. C. (2016). Dissociation
predicts treatment response in eye-movement
desensitization and reprocessing for posttraumatic stress
disorder. Journal of Trauma and Dissociation, 9732, 1–19.
doi:10.1080/15299732.2015.1037039
TRAUMATIC DISSOCIATION  BAILEY & BRAND
Basmaci Kandemir, S., Bayazit, H., Selek, S., Kilicaslan, N.,
Kandemir, H., Karababa, I. F., . . . Cece, H. (2016).
Tracking down the footprints of bad paternal relationships
in dissociative disorders: A diffusion tensor imaging study.
Journal of Trauma & Dissociation, 17, 371–381. doi:10
.1080/15299732.2015.1111282
Beeney, J. E., Wright, A. G., Stepp, S. D., Hallquist, M. N.,
Lazarus, S. A., Beeney, J. R., . . . Pilkonis, P. A. (in press).
Disorganized attachment and personality functioning in
adults: A latent class analysis. Personality Disorders, Advance
online publication. doi:10.1037/per0000184
Bernstein, E. M., & Putnam, F. W. (1986). Development,
reliability, and validity of a dissociation scale. Journal of
Nervous and Mental Disease, 174, 727–735.
Blevins, C. A., Weathers, F. W., & Witte, T. K. (2014).
Dissociation and posttraumatic stress disorder: A latent
profile analysis. Journal of Traumatic Stress, 27, 388–396.
Blizard, R. A. (2003). Disorganized attachment, development
of dissociated self states, and a relational approach to
treatment. Journal of Trauma & Dissociation, 4, 27–50.
doi:10.1300/J229v04n03_03
Bodnar, R. J. (2016). Endogenous opiates and behavior:
2014. Peptides, 75, 18–70. doi:10.1016/j.peptides.2015.10
.009
Brand, B. L. (2012). What we know and what we need to
learn about the treatment of dissociative disorders. Journal
of Trauma & Dissociation, 13, 387–396.
Brand, B. L., Armstrong, J. G., & Loewenstein, R. J. (2006).
Psychological assessment of patients with dissociative
identity disorder. Psychiatric Clinics of North America, 29,
145–168.
Brand, B. L., Classen, C., Lanius, R., Loewenstein, R.,
McNary, S., Pain, C., & Putnam, F. (2009). A naturalistic
study of dissociative identity disorder and dissociative
disorder not otherwise specified patients treated by
community clinicians. Psychological Trauma: Theory,
Research, Practice, and Policy, 1, 153–171.
Brand, B. L., Classen, C. C., McNary, S. W., & Zaveri, P.
(2009). A review of dissociative disorders treatment
studies. Journal of Nervous and Mental Disease, 197, 646–
654. doi:10.1097/NMD.0b013e3181b3afaa
Brand, B. L., & Loewenstein, R. J. (2014). Does phasic
trauma treatment make patients with dissociative identity
disorder treatment more dissociative? Journal of Trauma &
Dissociation, 15, 52–65.
Brand, B. L., Loewenstein, R. J., & Speigel, D. (2014).
Dispelling myths about dissociative identity disorder
treatment: An empirically based approach. Psychiatry, 77,
169–189.
179
Brand, B. L., McNary, S. W., Myrick, A. C., Classen, C. C.,
Lanius, R., Loewenstein, R. J., . . . Putnam, F. W.
(2013). A longitudinal naturalistic study of patients with
dissociative disorders treated by community clinicians.
Psychological Trauma: Theory, Research, Practice, and Policy,
5, 301–308. doi:10.1037/a0027654
Bremner, J. D. (2009). Neurobiology of dissociation: A view
from the trauma field. In P. F. Dell & J. A. O’Neil (Eds.),
Dissociation and the dissociative disorders: DSM-V and beyond
(pp. 329–336). New York, NY: Routledge.
Briere, J. (2001). Detailed Assessment of Posttraumatic Stress
(DAPS). Odessa, FL: Psychological Assessment Resources.
Briere, J. (2002). The Multiscale Dissociation Inventory:
Professional manual. Lutz, FL: Psychological Assessment
Resources.
Briere, J. (2011). Trauma Symptom Inventory-2 (TSI-2):
Professional manual. Lutz, FL: Psychological Assessment
Resources.
Briere, J., Dietrich, A., & Semple, R. J. (2016). Dissociative
complexity: Antecedents and clinical correlates of a new
construct. Psychological Trauma, 8, 577–584. doi:10.1037/
tra0000126
Briere, J., & Eadie, E. M. (2016). Compensatory self-injury:
Posttraumatic stress, depression, and the role of
dissociation. Psychological Trauma, 8, 618–625. doi:10
.1037/tra0000139
Briere, J., Kaltman, S., & Greene, R. (2008). Accumulated
childhood trauma and symptom complexity. Journal of
Traumatic Stress, 21, 223–226. doi:10.1002/jts
Byun, S., Brumariu, L. E., & Lyons-Ruth, K. (2016).
Disorganized attachment in young adulthood as a partial
mediator of relations between severity of childhood abuse
and dissociation. Journal of Trauma & Dissociation, 17, 460–
479. doi:10.1080/15299732.2016.1141149
Carlson, E. B., Waelde, L. C., Palmieri, P. A., Macia, K. S.,
Smith, S. R., & McDade-Montez, E. (2016).
Development and validation of the Dissociative Symptoms
Scale. Assessment. Advance online publication. doi:10
.1177/1073191116645904
Chu, A., & DePrince, A. P. (2006). Development of
dissociation: Examining the relationship between
parenting, maternal trauma and child dissociation. Journal
of Trauma & Dissociation, 7, 75–89. doi:10.1300/
J229v07n04_05
Cloitre, M., Petkova, E., Wang, J., & Lu, F. (2012). An
examination of the influence of a sequential treatment on
the course and impact of dissociation among women with
PTSD related to childhood abuse. Depression and Anxiety,
29, 709–717. doi:10.1002/da.21920
180 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
Cloitre, M., Stolbach, B. C., Herman, J. L., van der Kolk,
B., Pynoos, R., Wang, J., & Petkova, E. (2009). A
developmental approach to complex PTSD: Childhood
and adult cumulative trauma as predictors of symptom
complexity. Journal of Traumatic Stress, 22, 399–408.
doi:10.1002/jts.20444
Courtois, C. A., & Ford, J. D. (2009). Treating complex
traumatic stress disorders: An evidence-based guide. New York,
NY: Guilford Press.
Cronin, E., Brand, B. L., & Mattanah, J. F. (2014). The
impact of the therapeutic alliance on treatment outcome
in patients with dissociative disorders. European Journal of
Psychotraumatology, 5. doi:10.3402/ejpt.v5.22676
Cyr, C., Euser, E. M., Bakermans-Kranenburg, M. J., & Van
Ijzendoorn, M. H. (2010). Attachment security
and disorganization in maltreating and high-risk families:
A series of meta-analyses. Development and Psychopathology,
22, 87–108. doi:10.1017/S0954579409990289
Dalenberg, C. J., Brand, B. L., Gleaves, D. H., Dorahy, M.
J., Loewenstein, R. J., Cardena, E., . . . Spiegel, D.
(2012). Evaluation of the evidence for the trauma and
fantasy models of dissociation. Psychological Bulletin, 138,
550–588. doi:10.1037/a0027447
Dalenberg, C. J., Brand, B. L., Loewenstein, R. J., Gleaves,
D. H., Dorahy, M. J., Carde~ na, E., . . . Spiegel, D.
(2014). Reality versus fantasy: Reply to Lynn et al.
(2014). Psychological Bulletin, 140, 911–920. doi:10
.1037/a0036685
D’Andrea, W., & Pole, N. (2012). A naturalistic study of the
relation of psychotherapy process to changes in symptoms,
information processing, and physiological activity in
complex trauma. Psychological Trauma: Theory, Research,
Practice, and Policy, 4, 438–446. doi:10.1037/a0025067
Dell, P. F. (2002). Dissociative phenomenology of dissociative
identity disorder. Journal of Nervous and Mental Disease, 190,
10–15. doi:10.1097/00005053-200201000-00003
Dell, P. F. (2006). The Multidimensional Inventory of
Dissociation (MID): A comprehensive measure of
pathological dissociation. Journal of Trauma & Dissociation,
7, 77–106. doi:10.1300/J229v07n02_06
Diseth, T. H. (2006). Dissociation following traumatic
medical treatment procedures in childhood: A longitudinal
follow-up. Development and Psychopathology, 18, 233–251.
doi:10.1017/S0954579406060135
Draijer, N., & Langeland, W. (1999). Childhood trauma and
perceived parental dysfunction in the etiology of
dissociative symptoms in psychiatric inpatients. American
Journal of Psychiatry, 156, 379–385. doi:10.1176/ajp.156
.3.379
 V24 N2, JUNE 2017
Farina, B., Speranza, A. M., Imperatori, C., Quintiliani, M.
I., & Marca, G. D. (2015). Change in heart rate
variability after the Adult Attachment Interview in
dissociative patients. Journal of Trauma & Dissociation, 16,
170–180. doi:10.1080/15299732.2014.975309
Felitti, V. J., Nordenburg, D., Williamson, D. F., Spitz, A.
M., Edwards, V., Koss, M. P., & Marks, J. S. (1998).
Relationship of childhood abuse and household
dysfunction to many of the leading causes of death in
adults: The Adverse Childhood Experiences (ACE) study.
American Journal of Preventative Medicine, 14, 245–258.
doi:10.1016/S0749-3797(98)00017-8
Ferdinand, R. F., van der Reijden, M., Verhulst, F. C., Nienhuis,
F. J., & Giel, R. (1995). Assessment of the prevalence of
psychiatric disorder in young adults. British Journal of Psychiatry,
166, 480–488. doi:10.1192/bjp.166.4.480
Frewen, P. A., Brown, M. F. D., & Lanius, R. A. (2016).
Trauma-related altered states of consciousness (TRASC)
in an online community sample: Further support for the
4-D model of trauma-related dissociation. Psychology of
Consciousness: Theory, Research, and Practice, Advance
online publication. doi:10.1037/cns0000091
Frewen, P. A., Kleindienst, N., Lanius, R., & Schmahl, C.
(2014). Trauma-related altered states of consciousness in
women with BPD with or without co-occurring PTSD.
European Journal of Psychotraumatology, 5, 1–10. doi:10
.3402/ejpt.v5.24863
Frewen, P. A., & Lanius, R. A. (2006a). Neurobiology of
dissociation: Unity and disunity in mind-body-brain.
Psychiatric Clinics of North America, 29, 113–128. doi:10
.1016/j.psc.2005.10.016
Frewen, P. A., & Lanius, R. A. (2006b). Toward a
psychobiology of posttraumatic self-dysregulation:
Reexperiencing, hyperarousal, dissociation, and emotional
numbing. Annals of the New York Academy of Sciences,
1071, 110–124. doi:10.1196/annals.1364.010
Frewen, P. A., & Lanius, R. A. (2014). Trauma-related
altered states of consciousness: Exploring the 4-D model.
Journal of Trauma & Dissociation, 15, 436–456. doi:10
.1080/15299732.2013.873377
Frewen, P. A., & Lanius, R. (2015). Healing the traumatized
self: Consciousness, neuroscience, treatment. New York, NY:
W. W. Norton.
Freyd, J. J. (1994). Betrayal trauma: Traumatic amnesia as an
adaptive response to childhood abuse. Ethics and Behavior,
4, 307–329. doi:10.1207/s15327019eb0404_1
Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting
childhood abuse. Cambridge, MA: Harvard University Press.
TRAUMATIC DISSOCIATION  BAILEY & BRAND
Friedl, M. C., Draijer, N., & de Jonge, P. (2000). Prevalence
of dissociative disorders in psychiatric in-patients: The
impact of study characteristics. Acta Psychiatrica
Scandinavica, 102, 423–428. doi:10.1034/j.1600-0447
.2000.102006423.x
Friedman, E. S., Wisniewski, S. R., Gilmer, W., Nierenberg,
A. A., Rush, A. J., Fava, M., . . . Trivedi, M. H. (2009).
Sociodemographic, clinical, and treatment characteristics
associated with worsened depression during treatment
with citalopram: Results of the NIMH STARD trial.
Depression and Anxiety, 26, 612–621. doi:10.1002/da
.20568
Giesbrecht, T., Lynn, S. J., Lilienfeld, S. O., & Merckelbach,
H. (2008). Cognitive processes in dissociation: An analysis
of core theoretical assumptions. Psychological Bulletin, 124,
617–647. doi:10.1037/0033-2909.134.5.617
Goldsmith, R. E., Barlow, M. R., & Freyd, J. J. (2004).
Knowing and not knowing about trauma: Implications for
therapy. Psychotherapy: Theory, Research, Practice, Training,
41, 448–463. doi:10.1037/0033-3204.41.4.448
Hagenaars, M. A., van Minnen, A., & Hoogduin, K. A. L.
(2010). The impact of dissociation and depression on the
efficacy of prolonged exposure treatment for PTSD.
Behaviour Research and Therapy, 48, 19–27. doi:10.1016/
j.brat.2009.09.001
Halvorsen, J. Ø., Stenmark, H. K., Neuner, F., & Nordahl,
H. M. (2014). Does dissociation moderate treatment
outcomes of narrative exposure therapy for PTSD? A
secondary analysis from a randomized controlled clinical
trial. Behaviour Research and Therapy, 57, 21–28. doi:10
.1016/j.brat.2014.03.010
Herman, J. L. (1992). Trauma and recovery. New York, NY:
Basic Books.
Hodges, M., Godbout, N., Briere, J., Lanktree, C., Gilbert,
A., & Kletzka, N. T. (2013). Cumulative trauma and
symptom complexity in children: A path analysis. Child
Abuse and Neglect, 37, 891–898. doi:10.1016/j.chiabu
.2013.04.001
International Society for the Study of Dissociation (Chu, J.
A., Dell, P. F., Somer, E., Van der Hart, O., Carde~ na, E.,
. . . Twombly, J. (2011). Guidelines for treating
dissociative identity disorder in adults, third revision.
Journal of Trauma & Dissociation, 12, 115–187. doi:10
.1080/15299732.2011.537247
Jepsen, E. K. K., Langeland, W., & Heir, T. (2013). Impact
of dissociation and interpersonal functioning on inpatient
treatment for early sexually abused adults. European Journal
of Psychotraumatology, 4. doi:10.3402/ejpt.v4i0.22825
181
Jepsen, E. K. K., Langeland, W., & Heir, T. (2014). Early
traumatized inpatients high in psychoform and
somatoform dissociation: Characteristics and treatment
response. Journal of Trauma & Dissociation, 15, 572–587.
doi:10.1080/15299732.2014.924461
Jepsen, E. K. K., Langeland, W., Sexton, H., & Heir, T.
(2014). Inpatient treatment for early sexually abused
adults: A naturalistic 12-month follow-up study.
Psychological Trauma, 6, 142–151. doi:10.1037/a0031646
Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2006).
Dissociative disorders among adults in the community,
impaired functioning, and Axis I and II comorbidity.
Journal of Psychiatric Research, 40, 131–140. doi:10.1016
/j.jpsychires.2005.03.003
Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V.,
Rose, S., Bromet, E. J., . . . Ursano, R. J. (2015). Predicting
suicides after psychiatric hospitalization in US Army
soldiers: The Army Study to Assess Risk and Resilience in
Service members (Army STARRS). JAMA Psychiatry, 72,
49–57. doi:10.1001/jamapsychiatry.2014.1754
Kleindienst, N., Limberger, M. F., Ebner-Priemer, U. W.,
Keibel-Mauchnik, J., Dyer, A., Berger, M., . . . Bohus,
M. (2011). Dissociation predicts poor response to
dialectical behavioral therapy in female patients with
borderline personality disorder. Journal of Personality
Disorders, 25, 432–447. doi:10.1521/pedi.2011.25.4.432
Kleindienst, N., Priebe, K., G€ org, N., Dyer, A., Steil, R.,
Lyssenko, L., . . . Bohus, M. (2016). State dissociation
moderates response to dialectical behavior therapy for
posttraumatic stress disorder in women with and without
borderline personality disorder. European Journal of
Psychotraumatology, 7. doi:10.3402/ejpt.v7.30375
Kluft, R. P. (1985). Childhood multiple personality disorder:
Predictors, clinical findings, and treatment results. In R.
P. Kluft (Ed.), Childhood antecedents of multiple personality
(pp. 167–196). Washington DC: American Psychiatric
Press.
Kluft, R. P. (1991). Clinical presentations of multiple
personality disorder. Psychiatric Clinics of North America, 14,
605–629.
Kluft, R. P. (2009). A clinician’s understanding of
dissociation: Fragments of an acquaintance. In P. F. Dell
& J. A. O’Neil (Eds.), Dissociation and the dissociative
disorders: DSM-V and beyond (pp. 599–623). New York,
NY: Routledge/Taylor & Francis Group.
Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How
understanding the neurobiology of complex post-traumatic
stress disorder can inform clinical practice: A social
cognitive and affective neuroscience approach. Acta
182 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
Psychiatrica Scandinavica, 124, 331–348. doi:10.1111/
j.1600-0447.2011.01755.x
Lanius, R. A., Brand, B., Vermetten, E., Frewen, P. A., &
Spiegel, D. (2012). The dissociative subtype of
posttraumatic stress disorder: Rationale, clinical and
neurobiological evidence, and implications. Depression and
Anxiety, 29, 701–708. doi:10.1002/da.21889
Lanius, R. A., Frewen, P. A., Vermetten, E., & Yehuda, R.
(2010). Fear conditioning and early life vulnerabilities:
Two distinct pathways of emotional dysregulation and
brain dysfunction in PTSD. European Journal of
Psychotraumatology, 1, 5467. doi:10.3402/ejpt.v1i0.5467
Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B.
L., Schmahl, C., Bremner, J. D., & Spiegel, D. (2010).
Emotional modulation in PTSD: Clinical and
neurobiological evidence for a dissociative subtype.
American Journal of Psychiatry, 167, 640–647. doi:10.1176/
appi.ajp.2009.09081168
Lieb, R., Pfister, H., Mastaler, M., & Wittchen, H.-U.
(2000). Somatoform syndromes and disorders in a
representative population sample of adolescents and young
adults: Prevalence, comorbidity and impairments. Acta
Psychiatrica Scandinavica, 101, 194–208. doi:10.1046/
j.0902-4441.2000.ap90071.x
Lilienfeld, S. O. (2007). Psychological treatments that cause
harm. Perspectives on Psychological Science, 2(1), 53–70.
doi:10.1111/j.1745-6916.2007.00029.x
Liotti, G. (1992). Disorganized/disoriented attachment in the
etiology of the dissociative disorders. Dissociation: Progress in the
Dissociative Disorders, 5, 196–204. doi:1994-05679-001
Liotti, G. (1999). Disorganization of attachment as a model
for understanding dissociative psychopathology. In
J. Solomon & C. George (Eds.), Attachment disorganization
(pp. 291–317). New York, NY: Guilford Press.
Lynn, S. J., Lilienfeld, S. O., Merckelbach, H., Giesbrecht,
T., McNally, R. J., Loftus, E. F., . . . Malaktaris, A.
(2014). The trauma model of dissociation: Inconvenient
truths and stubborn fictions. Comment on Dalenberg
et al. (2012). Psychological Bulletin, 140, 896–910. doi:10
.1037/a0035570
Lynn, S. J., Lilienfeld, S. O., Merckelbach, H., Giesbrecht,
T., & van der Kloet, D. (2012). Dissociation and
dissociative disorders: Challenging conventional wisdom.
Current Directions in Psychological Science, 21, 48–53. doi:10
.1177/0963721411429457
Lyons-Ruth, K. (2008). Contributions of the mother-infant
relationship to dissociative, borderline, and conduct
symptoms in young adulthood. Infant Mental Health
Journal, 29, 203–218. doi:10.1002/imhj.20173
 V24 N2, JUNE 2017
Lyons-Ruth, K., & Dozier, M. (2016). Attachment
disorganization from infancy to adulthood:
Neurobiological correlates, parenting contexts, and
pathways to disorder. In J. Cassidy & P. R. Shaver (Eds.),
Handbook of attachment: Theory, research, and clinical
applications (3rd ed.). New York, NY: Guilford Press.
Lyons-Ruth, K., Dutra, L., Schuder, M. R., & Bianchi, I.
(2006). From infant attachment disorganization to adult
dissociation: Relational adaptations or traumatic
experiences? Psychiatric Clinics of North America, 29, 63–86.
doi:10.1016/j.psc.2005.10.011
Lyons-Ruth, K., Pechtel, P., Yoon, S. A., Anderson, C. M.,
& Teicher, M. H. (2016). Disorganized attachment in
infancy predicts greater amygdala volume in adulthood.
Behavioural Brain Research, 308, 83–93. doi:10.1016/j.bbr
.2016.03.050
Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic
experiences are related to infant disorganized attachment
status: Is frightened and/or frightening parental behavior
the linking mechanism? In M. T. Greenberg, D.
Cicchetti, & E. M. Cummings (Eds.), Attachment in the
preschool years: Theory, research, and intervention (pp. 161–
182). Chicago, IL: University of Chicago Press.
McKinnon, M. C., Boyd, J. E., Frewen, P. A., Lanius, U.
F., Jetly, R., Richardson, J. D., & Lanius, R. A. (2016).
A review of the relation between dissociation, memory,
executive functioning and social cognition in military
members and civilians with neuropsychiatric conditions.
Neuropsychologia, 90, 210–234. doi:10.1016/j.neuropsychologia
.2016.07.017
Nicholson, A. A., Densmore, M., Frewen, P. A., Theberge,
J., Neufeld, R. W., McKinnon, M. C., & Lanius, R. A.
(2015). The dissociative subtype of posttraumatic stress
disorder: Unique resting-state functional connectivity of
basolateral and centromedial amygdala complexes.
Neuropsychopharmacology, 40, 2317–2326. doi:10.1038/npp
.2015.79
Nicholson, A. A., Sapru, I., Densmore, M., Frewen, P. A.,
Neufeld, R. W., Theberge, J., . . . Lanius, R. A. (2016).
Unique insula subregion resting-state functional
connectivity with amygdala complexes in posttraumatic
stress disorder and its dissociative subtype. Psychiatry
Research, 250, 61–72. doi:10.1016/j.pscychresns.2016.02
.002
Nijenhuis, E. R. S., Spinhoven, P., van Dyck, R., van der
Hart, O., & Van der Linden, J. (1996). The development
and psychometric characteristics of the Somatoform
Dissociation Questionnaire (SDQ-20). Journal of Nervous
TRAUMATIC DISSOCIATION  BAILEY & BRAND
and Mental Disease, 184, 688–694. doi:10.1097/00005053-
199611000-00006
Nijenhuis, E. R. S., & van der Hart, O. (2011). Dissociation
in trauma: A new definition and comparison with
previous formulations. Journal of Trauma & Dissociation, 12,
416–445. doi:10.1080/15299732.2011.570592
Nijenhuis, E. R. S., Vanderlinden, J., & Spinhoven, P.
(1998). Animal defensive reactions as a model for trauma-
induced dissociative reactions. Journal of Traumatic Stress,
11, 243–260. doi:10.1023/A:1024447003022
Ogawa, J. R., Sroufe, L. A., Weinfeld, N. S., Carslson, E. A.,
& Egeland, B. (1997). Development and the fragmented
self: Longitudinal study of dissociative symptomatology in a
nonclinical sample. Development and Psychopathology, 9, 855–
879. doi:10.1017/S0954579497001478
Price, M., Kearns, M., Houry, D., & Rothbaum, B. O.
(2014). Emergency department predictors of posttraumatic
stress reduction for trauma-exposed individuals with and
without early intervention. Journal of Consulting and
Clinical Psychology, 82, 336–341. doi:10.1037/a0035537
Prunetti, E., Framba, R., Barone, L., Fiore, D., Sera, F., &
Liotti, G. (2008). Attachment disorganization and
borderline patients’ metacognitive responses to therapists’
expressed understanding of their states of mind: A pilot
study. Psychotherapy Research, 18, 28–36. doi:10.1080/
10503300701320645
Putnam, F. W. (1985). Dissociation as a response to extreme
trauma. In R. P. Kluft (Ed.), Childhood antecedents of
multiple personality (pp. 65–97). Washington, DC:
American Psychiatric Press.
Putnam, F. W. (1997). Dissociation in children and adolescents:
A developmental perspective. New York, NY: Guilford Press.
Putnam, F. W., Guroff, J. J., Silberman, E. K., Barban, L., &
Post, R. M. (1986). The clinical phenomenology of
multiple personality disorder: Review of 100 recent cases.
Journal of Clinical Psychiatry, 47, 285–293.
Reinders, A. A., Nijenhuis, E. R. S., Paans, A. M. J., Korf,
J., Willemsen, A. T. M., & den Boer, J. A. (2003). One
brain, two selves. NeuroImage, 20, 2119–2125. doi:10
.1016/j.neuroimage.2003.08.021
Reinders, A. A., Nijenhuis, E. R. S., Quak, J., Korf, J.,
Haaksma, J., Paans, A. M. J., . . . den Boer, J. A. (2006).
Psychobiological characteristics of dissociative identity
disorder: A symptom provocation study. Biological Psychiatry,
60, 730–740. doi:10.1016/j.biopsych.2005.12.019
Reinders, A. A., Willemsen, A. T. M., den Boer, J. A., Vos,
H. P. J., Veltman, D. J., & Loewenstein, R. J. (2014).
Opposite brain emotion-regulation patterns in identity
183
 states of dissociative identity disorder: A PET study and
neurobiological model. Psychiatry Research: Neuroimaging,
223, 236–243. doi:10.1016/j.pscychresns.2014.05.005
Reinders, A. A., Willemsen, A. T., Vos, H. P., den Boer, J.
A., & Nijenhuis, E. R. S. (2012). Fact or factitious? A
psychobiological study of authentic and simulated
dissociative identity states. PLoS ONE, 7, e39279. doi:10
.1371/journal.pone.0039279
Resick, P. A., Suvak, M. K., Johnides, B. D., Mitchell, K. S.,
& Iverson, K. M. (2012). The impact of dissociation on
PTSD treatment with cognitive processing therapy.
Depression and Anxiety, 29, 718–730. doi:10.1002/da.21938
Ross, C. A. (1991). Epidemiology of multiple personality
disorder and dissociation. Psychiatric Clinics of North
America, 14, 503–517.
Rufer, M., Held, D., Cremer, J., Fricke, S., Moritz, S.,
Peter, H., & Hand, I. (2006). Dissociation as a predictor
of cognitive behavior therapy outcome in patients with
obsessive-compulsive disorder. Psychotherapy and
Psychosomatics, 75, 40–46. doi:10.1159/000089225
Sßar, V., Aky€ uz, G., & Dogan, O. (2007). Prevalence of
dissociative disorders among women in the general
population. Psychiatry Research, 149, 169–176. doi:10
.1016/j.psychres.2006.01.005
Sßar, V., Kundakci, T., Kiziltan, E., Yargic, I. L., Tutkun, H.,
€
Bakim, B., . . . Ozdemir, € (2003). The Axis-I
O.
dissociative disorder comorbidity of borderline personality
disorder among psychiatric outpatients. Journal of Trauma
& Dissociation, 4, 119–136. doi:10.1300/J229v04n01_08
Sßar, V., Taycan, O., Bolat, N., Ozmen, € M., Duran, A.,
€ urk, E., & Ertem-Vehid, H. (2010). Childhood
Ozt€
trauma and dissociation in schizophrenia. Psychopathology,
43, 33–40. doi:10.1159/000255961
Schauer, M., & Elbert, T. (2010). Dissociation following
traumatic stress: Etiology and treatment. Zeitschrift f€ur
Psychologie/Journal of Psychology, 218, 109–127. doi:10
.1027/0044-3409/a000018
Schore, A. (2001). The effects of early relational trauma on
right brain development, affect regulation, and infant
mental health. Infant Mental Health Journal, 22, 201–269.
doi:10.1002/1097-0355(200101/04)22:1 < 201:AID-
IMHJ8 > 3.0.CO;2-9
Schore, A. (2003). Affect regulation and the repair of the self.
New York, NY: Norton Professional Books.
Schore, A. (2009). Attachment trauma and the developing
right brain: Origins of pathological dissociation. In P. F.
Dell & J. A. O’Neil (Eds.), Dissociation and the dissociative
disorders: DSM-V and beyond (pp. 107–141). New York,
NY: Routledge/Taylor & Francis Group.
184 CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE
Sierra, M., & Berrios, G. E. (2000). The Cambridge
Depersonalization Scale: A new instrument for the
measurement of depersonalization. Psychiatric Research, 93,
153–164. doi:10.1016/S0165-1781(00)00100-1
Simeon, D., & Knutelska, M. (2005). An open trial of
naltrexone in the treatment of depersonalization disorder.
Journal of Clinical Psychopharmacology, 25, 267–270.
Simeon, D., & Loewenstein, R. J. (2009). Dissociative
disorders. In B. J. Sadock, V. A. Sadock, & P. Ruiz
(Eds.), Comprehensive textbook of psychiatry (9th ed., Vol. 1,
pp. 1965–2026). Philadelphia, PA: Wolters Kluwer/
Lippinoctt Williams & Wilkens.
Somer, E., Amos-Williams, T., & Stein, D. J. (2013).
Evidence-based treatment for depersonalisation-
derealisation disorder (DPRD). BMC Psychology, 1, 20.
doi:10.1186/2050-7283-1-20
Spiegel, D. (1984). Multiple personality as a post-traumatic
stress disorder. Psychiatric Clinics of North America, 7, 101–
110.
Stein, D. J., Koenen, K. C., Friedman, M. J., Hill, E. M.,
McLaughlin, K. A., Petukhova, M., . . . Kessler, R. C.
(2013). Dissociation in posttraumatic stress disorder:
Evidence from the World Mental Health Surveys. Biological
Psychiatry, 73, 302–312. doi:10.1016/j.biopsych.2012.08
.022
Steuwe, C., Lanius, R. A., & Frewen, P. A. (2012).
Evidence for a dissociative subtype of PTSD by latent
profile and confirmatory factor analyses in a civilian
sample. Depression and Anxiety, 29, 689–700. doi:10.1002/
da.21944
Trickett, P. K., Noll, J. G., & Putnam, F. W. (2011). The
impact of sexual abuse on female development: Lessons
from a multigenerational, longitudinal research study.
Development and Psychopathology, 23, 453–476. doi:10
.1017/s0954579411000174
Vissia, E. M., Giesen, M. E., Chalavi, S., Nijenhuis, E. R.
S., Draijer, N., Brand, B. L., & Reinders, A. A. (2016). Is
it trauma- or fantasy-based? Comparing dissociative
identity disorder, post-traumatic stress disorder, simulators,
and controls. Acta Psychiatrica Scandinavica, 134, 111–128.
doi:10.1111/acps.12590
Webermann, A. R., Myrick, A. C., Taylor, C. L., Chasson,
G. S., & Brand, B. L. (2016). Dissociative, depressive, and
PTSD symptom severity as correlates of nonsuicidal self-
injury and suicidality in dissociative disorder patients.
Journal of Trauma & Dissociation, 17, 67–80. doi:10
.1080/15299732.2015.1067941
West, K. K., Mathews, B. L., & Kerns, K. A. (2013).
Mother–child attachment and cognitive performance in
 V24 N2, JUNE 2017
 middle childhood: An examination of mediating
mechanisms. Early Childhood Research Quarterly, 28, 259–
270. doi:10.1016/j.ecresq.2012.07.005
Wilgus, S. J., Packer, M. M., Lile-King, R., Miller-Perrin,
C. L., & Brand, B. L. (2015). Coverage of child
maltreatment in abnormal psychology textbooks:
Reviewing the adequacy of the content. Psychological
Trauma: Theory, Research, Practice, and Policy, 8, 188–197.
doi:10.1037/tra0000049
Wolf, E. J., Lunney, C. A., Miller, M. W., Resick, P. A.,
Friedman, M. J., & Schnurr, P. P. (2012). The
dissociative subtype of PTSD: A replication and
TRAUMATIC DISSOCIATION  BAILEY & BRAND
View publication stats
extension. Depression and Anxiety, 29, 679–688. doi:10
.1002/da.21946
Wolf, E. J., Miller, M., Reardon, A. F., Ryabchenko, K. A.,
Castillo, D., & Freund, R. (2012). A latent class analysis
of dissociation and posttraumatic stress disorder: Evidence
for a dissociative subtype. Archives of General Psychiatry, 69,
698–705. doi:10.1001/archgenpsychiatry.2011.1574
Received March 24, 2016; revised September 18, 2016;
accepted September 20, 2016.
185