Val i da tion of the He brew Version of the Dissociative Experiences Scale (H-DES) in Israel

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1 Val i da tion of the He brew Version of the Dissociative Experiences Scale (H-DES) in Israel Eli Somer, PhD Mi chael Dolgin, PhD Meir Saadon, PhD ABSTRACT. Objectives : The pur pose of this re search was to ex plore the va lid ity of the con cept of dis so ci a tion as mea sured by a He brew ver - sion of the Dissociative Ex pe ri ences Scale (H-DES) in Is rael. De sign: The first study ex am ined the re li abil ity and va lid ity of the H-DES by as sess ing 340 con sec u tive ad mis sions to an Is raeli out pa tient clinic, and 290 non-clin i cal sub jects. The sec ond study ex plored the con - struct va lid ity of the con cept of dis so ci a tion by study ing re la tion ships be tween re ported past traumatization and cur rent lev els of dis so ci a tion among a dif fer ent co hort of 70 women Is raeli out pa tients. Re sults: The H-DES has good test-re test and split-half re li abil ity in clin i cal and non-clin i cal sub jects, and is in ter nally con sis tent. Its con ver - gent va lid ity with the MMPI 2 Philips Dis so ci a tion Scale is good, and it has good cri te rion-re lated va lid ity with DSM-IV dissociative disorder diagnoses. The concept of dissociation as measured in Israel by the H-DES has high re li abil ity and va lid ity. Conclusions: The re li able iden ti fi ca tion of dis sociative ex pe ri ences in Is rael as well as in sev eral cul tures out side North Amer ica sup ports dis so - ci a tion as a valid psy cho log i cal con struct with wide spread cross- cul tural ap pli ca bil ity. This study con tra dicts claims that dis so ci a tion is merely a pass ing North Amer i can pro fes sional fash ion. [Ar ti cle cop ies avail able for a fee from The Haworth Doc u ment De liv ery Ser vice: ad - dress: <getinfo@haworthpressinc.com> Website: < com> 2001 by The Haworth Press, Inc. All rights re served.] Eli Somer, Mi chael Dolgin, and Meir Saadon are af fil i ated with the Maytal Israel In sti tute for Treat ment and Study of Stress. Mi chael Dolgin is also af fil i ated with the Fac ulty of So cial Wel fare and Health Studies, Uni ver sity of Haifa, Mt. Car mel, Haifa 31905, Is rael. Ad dress cor re spon dence to: Eli Somer, PhD, School of So cial Work, Uni ver sity of Haifa, Mt. Car mel, Haifa 31905, Is rael ( somer@re search.haifa.ac.il). Jour nal of Trauma & Dissociation, Vol. 2(2) by The Haworth Press, Inc. All rights re served. 53

2 54 JOURNAL OF TRAUMA & DISSOCIATION KEYWORDS. Dis so ci a tion, Dissociative Ex pe ri ences Scale (DES), Israel, val i da tion The es sen tial fea ture of dissociative dis or ders (DDs) is dis tur bance or al ter ation in the nor mally in te grated func tions of iden tity, mem ory or con scious ness (American Psy chi at ric As so ci a tion, 1994). DDs have been re ported by cli ni cians to have a posttraumatic eti ol ogy (e.g., Kluft, 1991, Spiegel and Cardeña, 1991). Nev er the less, the con cept has gen er - ated con sid er able con tro versy cen tered on whether DDs, and par tic u - larly Dissociative Iden tity Dis or der (DID) are valid clin i cal di ag no ses (Mersky, 1992; Spanos, 1994) and on the mean ing of the in creased num ber of di ag nosed cases (Horevitz, 1995). Some men tal health au thors have claimed that cli ni cians in ad ver tently elicit these clin i cal phe nom - ena dur ing ther apy be cause of their fas ci na tion with the dis so ci a tion model (Bowers, 1991; Frankel, 1990). Oth er au thors have sug gested that the no ta ble in crease in the di ag no sis of DID re flects a North Amer i - can pop u lar/pro fes sional trend that has de vel oped into a form of so cial hys te ria (Aldridge-Mor ris, 1989; Radwin, 1991). To de ter mine whether DDs are a cul ture-spe cific phe nom e non, sys tem atic in ter na tional largescale stud ies of the prev a lence of DDs need to be con ducted. Such en - deavors had been vir tu ally im pos si ble in Israel, be cause a re li able screen ing in stru ment was lack ing. The only self-re port in stru ment used to sys tem at i cally study the prev a lence of dissociative ex pe ri ences in the gen eral pop u la tion has been the Dissociative Ex pe ri ences Scale (DES). This in stru ment has been de vel oped in the United States (Bernstein & Putnam, 1986; Carlson & Putnam, 1993) and was used to mea sure the fre quency of 28 dissociative ex pe ri ences that are as pects of the dis so ci - a tion con struct (Putnam, 1991). The in stru ment was shown to be a valid and re li able screen ing in stru ment (Frischholtz et al., 1990; Waller, 1995) that in con junc tion with clin i cal di ag no sis has en abled the ac cu - mu la tion of data sup port ing the re li abil ity and va lid ity of the di ag no sis of DID and other DDs. The DES, which was ini tially de vel oped in Eng - lish in 1986, is now avail able in at least 18 lan guages, in di cat ing the ex - tent of the in ter na tional in ter est in this clin i cal phe nom e non (Bow man, 1996). The va lid ity of the trans lated in stru ment has been in ves ti gated in the Neth er lands (Ensink & Van Otterloo, 1989), Tur key (Yargic, Tutkun & Sar, 1993) Ja pan (Umesue, Matsuo, Iwata & Tashiro, 1996), Ger many (Spitzer et al., 1998) and in France (Darves-Bornoz, Degiovanni, & Gal li ard, 1999).

3 Somer, Dolgin, and Saadon 55 In Is rael, sev eral clin i cal and the o ret i cal pa pers on dis so ci a tion have been pre sented in pro fes sional con fer ences and pub lished in lo cal sci - en tific jour nals (e.g., Margalit & Wiztum, 1997a, 1997b; Somer, 1987, 1989, 1993, 1994, 1995; Somer & Somer, 1997). How ever, no em pir i - cal stud ies have been con ducted in the Mid dle East to as cer tain the rel e - vance of the DES to the lo cal pop u la tion. The pur pose of the pres ent re search was to test the va lid ity and re li - abil ity of the DES in Is rael. Two stud ies were con ducted. In study 1 we assessed the ap pli ca bil ity of a trans lated ver sion of the DES to Is raeli sub jects by ex am in ing the re li abil ity and va lid ity of the scale. There is a growing body of re search in di cat ing a causal con nec tion be tween a his - tory of trauma in child hood and dissociative ex pe ri ences and symp toms (e.g., Fine, 1990; Hornstein & Tyson, 1991; Kirby, Chu, & Dill, 1993; Spiegel, 1991). There fore, con struct va lid ity for dis so ci a tion scales has also been as sessed by com par ing them to trauma in di ces (e.g., Putnam, Helmers & Trickett, 1993). In study 2 we ex plored the con struct va lid - ity of the scale by study ing re la tion ships be tween past traumatization and cur rent lev els of dis so ci a tion among Is raeli sub jects. Methods Subjects STUDY 1: THE PSYCHOMETRICS OF THE H-DES Six hun dred thirty sub jects par tic i pated in this study. Our re search sam ple con sisted of two main groups: (1) A clin i cal group of 340 con - sec u tive pa tients ad mit ted for out pa tient psy cho ther apy at Maytal Is - rael In sti tute for Treat ment and Study of Stress, and (2) A com par i son group con sist ing of 290 non-clin i cal sub jects sam pled from uni ver sity stu dents and faculty. The clin i cal group in cluded 89 pa tients with ad - justment dis or ders and DSM-IV V-codes, 87 pa tients with anx i ety dis - or ders (other than Posttraumatic Stress Dis or der or Acute Stress Dis or der (PTSD/ASD)), 36 pa tients with dissociative dis or ders, 32 with per son - al ity dis or ders, 21 with schizo phre nia, 17 with af fec tive dis or ders, and 15 with PTSD or ASD. Forty-three pa tients re ceived no di ag no sis. The mean ± SD age of the clin i cal and non-clin i cal groups were 31.9 ± 10.8 (range = 15-70) and 23.4 ± 7.9 (range = 16-52), re spec tively. Of the 340 pa tients, 207 were women (61%) and 133 were men (39%). Of

4 56 JOURNAL OF TRAUMA & DISSOCIATION the 290 com par i sons, 202 were women (70%) and 80 were men (30%). Thus, our non-clin i cal group was younger and com prised of more women than the clin i cal group. Past re search has shown sig nif i cant age ef fects on DES scores for youn ger peo ple (e.g., Bernstein & Putnam, 1986; Ross et al., 1989) and for women (e.g., Putnam et al., 1996). Psychopathological ef fects on the DES would be more dif fi cult to dem - on strate in this study and would in crease the power of sta tis ti cally sig - nif i cant dif fer ences. Measures 1. The DES II (Carlson & Putnam, 1993), a 28-item ques tion naire, scored on a 10-point Likert scale, was trans lated into He brew by the first au thor (a native He brew speaker) and later was backtrans lated into Eng lish by a na tive Eng lish speaker who was blind to the original Eng lish ver sion. The back-trans la tion was com - pared to the orig i nal ver sion and dif fer ences were rec on ciled. 2. The clin i cal group was eval u ated with the Struc tured Clin i cal In - ter view for DSM-III-R (SCID), a guided semi-struc tured di ag nos - tic in ter view (Spitzer & Wil liams, 1986) and with the Struc tured Clin i cal In ter view for DSM-IV Dissociative Dis or ders (SCID-D) (Steinberg, 1993). 3. As part of their in take as sess ment pro ce dure, the pa tients were also asked to com plete the He brew ver sions of the MMPI-2. Con - ver gent va lid ity in this study was cal cu lated by com par ing scores of the H-DES with scores of the Phil lips Dissociation Scale (PDS), a 20-item in stru ment de rived from the MMPI-2 (Phil lips, 1994). Pro ce dure The clin i cal sam ple was eval u ated dur ing their in take pro ce dure and in cluded all con sec u tive He brew speak ing pa tients. All el i gi ble sub jects gave their con sent to par tic i pate in the study. The non-clin i cal sub jects were re cruited in fac ulty meet ings and lec ture halls. Sub jects were in - formed that the pur pose of the study was to in ves ti gate the fre quency of the ex pe ri ences de scribed in the ques tion naire. Sev enty-six per cent of the non-clin i cal sub jects we ap proached gave con sent for par tic i pa tion. One hun dred forty-one com par i son sub jects were ap proached again one month fol low ing their first com ple tion of the H-DES and asked to com -

5 plete the ques tion naire again. These 141 sub jects rep re sented an 89% response rate. Data Anal y sis Ini tial re view of our data re vealed that the dis tri bu tion of the H-DES scores within the in ves ti gated sam ple was skewed. There fore, in data anal y sis we ap plied non-para met ric sta tis ti cal meth ods when ever pos si - ble. Results Re li abil ity Mea sures Stu dents in one of the large in tro duc tory uni ver sity classes that had orig i nally com pleted the H-DES were ap proached again after one month and were asked to re peat the task. The H-DES to tal score test-re - test re li abil ity co ef fi cient was.87 (p < , N = 141). The in ter nal con sis tency was ex am ined at sev eral lev els: split-half re li abil ity co ef fi - cient, Cronbach s al pha co ef fi cient, and cor rected item-to tal cor re la - tions. Split-half re li abil ity coefficient (cal cu lated us ing the Spearman Brown for mula) was.86 both for the en tire sam ple (p < , N = 584), and for our nor mal com par i sons (p < , N = 290). For the clinical sub-groups the Split-half reliability coefficient scores ranged between.75 (for pa tients with Ad just ment Dis or ders and V-Codes) to.93 (for pa tients with Schizo phre nia and for those suf fer ing from Af fec - tive Dis or ders). The Split-half re li abil ity for the 36 pa tients pre sent ing with Dissociative Dis or ders co ef fi cient was.84. All re li abil ity co ef fi - cients for the clin i cal sub-groups were sig nif i cant at a p < level. Cronbach s al pha co ef fi cient for the H-DES scores was 0.91 for both the non-clin i cal group (N = 290) and the clin i cal group (N = 293). Re li - abil ity co ef fi cients of the cor rected item-to tal ranged from 0.26 to 0.73, with a me dian of 0.59 score for the non-clin i cal group and 0.34 to 0.66, with a me dian of 0.55 score for the clin i cal group. All of these val ues are sig nif i cant at p < Va lid ity Mea sures Somer, Dolgin, and Saadon 57 Con ver gent validity was cal cu lated by comparing scores of the H-DES with scores of the Phil lips Dis so ci a tion Scale (PDS), a 20-item in stru ment de rived from the MMPI-2. There is no item over lap be tween

6 58 JOURNAL OF TRAUMA & DISSOCIATION the H-DES and the PDS. Tau tol ogy was, there fore, ruled out. Testing of the PDS scale by the de vel oper with a dissociative group and a gen eral psy chi a try group showed the PDS to be in ter nally re li able and to dif fer - en tially di ag nose dissociative dis or ders (Phil lips, 1994). A Spearman Cor re la tion be tween the H-DES and the PDS scores for 284 patients was cal cu lated and yielded r = 0.59 (p < ). Di ver gent va lid ity was cal cu lated by com par ing the scores of the H-DES and the Male/Fe male scale of the MMPI-2 and yielded r = 2.03 (p < 0.28). H-DES scores did not dif fer by sex in the non-clin i cal group [t (280) = 21.51, NS] or in the clin i cal group [t (291) = 21.18, NS], but scores were sig nif i cantly neg a - tively cor re lated with age in both the non-clin i cal group (r = 20.31, p < ) and the clin i cal group (r = 20.19, p < 0.001). Cri te rion-ref er enced va lid ity was cal cu lated when we com pared H-DES scores across the dif fer ent di ag nos tic groups. The mean H-DES score for the non-clin i cal group was The mean H-DES scores for the var i ous clin i cal groups were as fol low ing: Anx i ety Dis or ders: 9.62; Ad - justment Dis or ders and V Codes: 9.82; Per son al ity Dis or ders: 11.25; Af fec tive Dis or ders: 13.07; Schizo phre nia: 16.22; Posttraumatic Stress Disorder and Acute Stress Dis or der: 20.36; and Dissociative Dis or ders: A Kruksal-Wallis test dem on strated that H-DES scores dif fered sig nif i cantly be tween the groups (chi-square = 62.19, N = 290, df = 7, p < ). Pairwise com par i sons of each group s mean score by Scheffe s test re vealed that all but one clin i cal group yielded sig nif i cant dif fer - ences. H-DES mean score dif fer en ti ated the DD group from other di ag - nos tic groups and from the non-pa tient pop u la tion. Methods Subjects STUDY 2: CONSTRUCT VALIDITY OF THE H-DES The sec ond re search sam ple con sisted of a new cohort of seventy con sec u tive women ad mit ted for out pa tient psy cho ther apy at Maytal Is rael In sti tute for Treat ment and Study of Stress. Their mean age ± SD was 33.5 ± 12.2 (range: 16-55). Thirty-five suf fered from Anx i ety Dis - or ders, 19 were given ei ther a V-code or an Ad just ment Dis or der di ag - no sis, 10 had an Af fec tive Dis or der and 6 were as sessed as hav ing a Per son al ity Dis or der. No DDs were in cluded in this sam ple.

7 Pro ce dures and Mea sures Somer, Dolgin, and Saadon 59 The intake pro ce dure em ployed at Maytal includes a struc tured trauma his tory in ter view based on the Trau matic Ex pe ri ences Ques tion - naire (TEQ), an in stru ment de vel oped by Nijenhuis, Van der Hart and Vanderlinden and later slightly mod i fied and relabeled Trau matic Ex - pe ri ences Check list (Nijenhuis, Van der Hart, & Vanderlinden, 1999). The TEQ is a self-re port ques tion naire in quir ing about 25 types of in ter - personal and non-in ter per sonal life events that could be po ten tially trau matic. When in ter per sonal violence was explored, sub jects were asked to in di cate if im me di ate fam ily mem bers, rel a tives or, oth ers had hurt them. TEQ items in quire if re spon dents had suf fered from the fol - lowing stress ors: parentification (a child needing to act in a pa ren tal role) (P), ma jor loss, such as a death of a loved one (L), in ter per sonal life-threats (e.g., having been assaulted with a weapon) (TH), other trau matic life events (e.g., fires, nat u ral di sas ters, road ac ci dents) (LE), emo tional ne glect (EN), emo tional abuse (EA), phys i cal abuse (PA), sex ual ha rass ment (SH) or, sex ual abuse (SA). The TEQ spe cif i cally ad dresses the sub jec tive im pact of the event (i.e., how trau matic was it for the re spon dent), and also re quests in for ma tion about the num ber of perpetrators of emo tional, phys i cal, and sex ual abuse. The ques tions con tain short de scrip tions that de fine the events of con cern. All items are pre ceded by the phrase: Did this hap pen to you? An ex am ple of sex ual ha rass ment within the fam ily is: Sex ual ha rass ment (acts of a sex ual na ture that DO NOT in volve phys i cal con tact) by your par ents, broth ers, or sis ters. A sex ual abuse by ex tended fam ily item is: Sex ual abuse (un wanted sex ual acts in volv ing phys i cal con tact) by other rel a - tives. Mod er ate to strong as so ci a tions of the TEQ to tal score and com pos - ite scores, in par tic u lar phys i cal and sex ual abuse, with cur rent psy cho - log i cal and somatoform dis so ci a tion, sup port the con struct va lid ity of the TEQ. These as so ci a tions were found when study ing psy chi at ric out - pa tients with dissociative dis or ders and other men tal dis or ders (Nijenhuis et al., 1998), gy ne col ogy pa tients with chronic pel vic pain (Nijenhuis et al., 1999), and women who re ported child hood sex ual abuse (Nijenhuis, 1999). Re cent re search with this in stru ment in di cated that the re li abil ity of the TEQ was sup ported by sat is fac tory in di ces of in ter nal con sis - tency. Cronbach s al pha for the first ad min is tra tion of the TEQ was.86, and was.90 for the retest. The test-re test re li abil ity of the TEQ to tal score was r =.91, p < The cor re la tion be tween the TEQ and the Stressful Life Events Screening Ques tion naire (SLESQ; Goodman,

8 60 JOURNAL OF TRAUMA & DISSOCIATION Corconan, Turner, Yuan, & Green, 1998) to tal scores is strong, r =.77, p <.0001, sug gest ing that both in stru ments as sess a highly sim i lar con - struct. The com pos ite trauma score of the TEQ and the SLESQ that as - sess physical abuse and de lib er ate threat to life from a per son, and sexual trauma were also cor re lated, i.e., re spec tively, rho =.56, p <.0001 and rho =.78, p <.0001 (Nijenhuis, Van der Hart, & Kruger, sub - mit ted). Among the key fac tors that de ter mine what makes an event trau matic are the per cep tion of the event as hav ing highly neg a tive va lence (e.g., Carlson, 1997), mul ti ple per pe tra tors (e.g., Pe ters, 1988), du ra tion and fre quency of the abuse (e.g., Elliott & Briere, 1992), and abuse at an ear lier age (e.g., Zivney, Nash, & Hulsey, 1988). The TEQ com pos ite trauma score re flects these rel e vant traumatogenic fac tors. Each ex pe ri - ence iden ti fied as a trauma item was given one point. Sub jects could score 0-3 trauma points, depending on the num ber of per pe trat ing sources. Ad di tional points were given to each trauma event en dorsed if the trauma oc curred when the sub ject was youn ger than age 10, if the trauma lasted more than one year, and if the im pact of the trau matic event was rated as 4 or 5 on a 5-point sub jec tive se ver ity scale. Scores for spe cific trauma events in each of the nine cat e go ries range from 0-7. Com pos ite trauma scores range from Sub jects were also given the H-DES. Results Emo tional Ne glect was the TEQ trauma cat e gory with the high est mean score (M = 1.22; SD = 1.47; N = 39) in our sam ple. This score re - flects the num ber of dif fer ent per pe tra tors or, if not abuse-re lated, dis - crete trau matic events, early age on set, du ra tion of ex po sure and sub jec tive ef fect. Sex ual Abuse re ceived the low est mean trauma score (M = 0.27; SD = 0.50; N = 19), re flect ing a rel a tively low rep re sen ta tion of this variable in the trauma his tory of our sam ple. A Spearman cor re la tion between the mean composite TEQ trauma score (M = 14.14; SD = 16.35; N = 70) and the mean com pos ite H-DES score (M = 12.02; SD = 11.56; N = 70) was r = 0.62 (p < ; N = 70). The H-DES was also significantly cor re lated with the num ber of trauma sources in all the trauma sub cat e go ries ex cept Sex ual Abuse (see Ta ble 1). Ta ble 1 re - veals that the num ber of dif fer ent per sons who had sex u ally abused the re spon dent (trauma sources) was not a sig nif i cant sta tis ti cal pre dic tor of dis so ci a tion. We also com puted cor re la tions be tween the means of the other com po nents of the non-sex ual trauma scores and the H-DES.

9 Somer, Dolgin, and Saadon 61 TABLE 1. Significant Correlations of He brew-des with Num ber of Trauma Sources by Cat e gory Trauma cat e gory N sub jects r Parentification ** Loss * Life threats ** Threat en ing life events ** Emo tional ne glect *** Emo tional abuse *** Phys i cal abuse * Sex ual ha rass ment *** Sex ual abuse (NS) * p < 0.05 ** p < 0.01 *** p < NS not sig nif i cant Early age dur ing the trauma, length of vic tim iza tion, and per ceived se - ver ity of the ex pe ri ence were not sig nif i cant pre dic tors of the mean H-DES score for all the trauma cat e go ries but Sex ual abuse. Spearman cor re la tions between the mean H-DES score and the other sex ual trauma com po nents were as fol low ing: Early age of on set: r = 0.59 (p < 0.05; N = 17); Lengthy du ra tion: r = 0.61 (p < 0.01; N = 17); Per ceived severity: (r = 0.47; p < 0.05; N = 19). DISCUSSION Our re sults demonstrate the re li abil ity and va lid ity of the He brew ver sion of the DES. The H-DES has good test-re test and split-half re li - abil ity and is in ter nally con sis tent. Ev i dence for good cri te rion-re lated validity was provided by show ing ev i dence that the H-DES scores agree with cri te ria of DSM-IV and SCID-D dissociative dis or der di ag - no ses and dif fer en ti ate be tween different di ag nos tic groups. H-DES scores also agree with PDS, an MMPI-2 dis so ci a tion scale with no over - lap ping items with the H-DES. If the H-DES mea sures dis so ci a tion, it should be as so ci ated with the sequelae of trau matic ex pe ri ences. Con - struct va lid ity of the H-DES was pro vided by an as so ci a tion be tween

10 62 JOURNAL OF TRAUMA & DISSOCIATION H-DES scores (dissociative ex pe ri ences) and a re ported trauma his tory. These find ings are in agree ment with 26 stud ies re port ing an as so ci a - tion be tween the DES and phys i cal or sex ual abuse ex pe ri ences (N = 2,108) (Van Ijzendoorn & Schuengel, 1996). Our find ings also dem on - strate that ag gra vat ing vari ables of sex ual trauma such as in tense se ver - ity, pro longed du ra tion, and young age during abuse were uniquely re lated to dissociative ex pe ri ences. These lat ter find ings are in line with stud ies in which the au thors have been able to ob tain doc u men ta tion for chil dren and adolescents with dissociative disorders (Hornstein and Putnam, 1992; Coons, 1994) and with stud ies that showed re la tion ships between in di ces of trauma se ver ity and dis so ci a tion (e.g., Chu and Dill, 1990; An der son et al. 1993). The cur rent find ings from a Jew ish pop u la tion in the Mid dle East rep li cate the high de gree of re li abil ity and va lid ity of DES that has been dem on strated by pre vi ous stud ies con ducted in North Amer ica (Bern- stein & Putnam, 1986; Ross et al., 1989; Frischoltz et al., 1990; Sand - berg & Lynn, 1992; Dobester & Braun, 1995), the Neth er lands (Ensink & Van Otterloo, 1989), Tur key (Yargic, Tutkun, & Sar, 1995), Ja pan (Umesue et al., 1996), Ger many (Spitzer et al., 1998) and France (Darves-Bornoz, Gegiovanni, & Gaillard, 1999) as well as in a meta-an - a lytic study (van Ijzendoorn & Schuengel, 1996). The ac cu mu lated data suggest that dissociative experiences are not North Amer i can cul - ture-bound phe nom ena and that the con cept, orig i nally named in France at the end of the 19th cen tury (Janet, 1905; Van der Hart & Horst, 1989) re mains a valid psy cho log i cal con struct with cross-cul tural ap pli ca bil - ity. REFERENCES Aldridge-Mor ris, R. (1989). Mul ti ple Per son al ity: An Ex er cise in De cep tion. Hillsdale, NJ: Law rence Erlbaum. Amer i can Psy chi at ric As so ci a tion (1994). Di ag nos tic and Sta tis ti cal Man ual of Men - tal Dis or ders (fourth edi tion), Wash ing ton, DC: Au thor. An der son, G. L., Yasenik, L., & Ross, C. A. (1993). Dissociative ex pe ri ences and dis - or ders among women who iden tify them selves as sex ual abuse sur vi vors. Child Abuse and Ne glect 17(5), Bernstein, E. M., & Putnam, F. W. (1986). De vel op ment, re li abil ity, and va lid ity of a dis so ci a tion scale. Jour nal of Ner vous and Men tal Dis ease, 174, Bowers, K. (1991). Dis so ci a tion in hyp no sis and mul ti ple per son al ity dis or der. In ter - na tional Jour nal of Clin i cal and Ex per i men tal Hyp no sis, 39 (3),

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