Combination Treatment With Individually Deep Brain Reorienting (DBR) Processing and Group Intervention for People With Complex Dissociative Disorder

Integrating Individual Deep Brain Reorienting with a Supportive Group Intervention for Complex Dissociative Disorders:

A 16-Week Feasibility and Pilot Study

1. Background and current state of knowledge Complex dissociative disorders (CDD), including dissociative identity disorder (DID) and other specified dissociative disorders (OSDD), are severe conditions that often develop as a consequence of early, repeated, and overwhelming traumatic events. Patients frequently present with extensive dissociative symptoms such as amnesia and identity confusion, emotional dysregulation, relational difficulties, and marked functional impairment. Despite high levels of burden for both patients and health services, there is very limited research-based knowledge about effective treatment for this group.

For PTSD in general, trauma-focused exposure treatment is recommended as first choise (NICE guidelines). There is increasing evidence that such approaches may also be useful in more complex traumatization (Oprel et al., 2021; Raabe et al., 2022; Sele et al., 2023; van Vliet et al., 2021), while some studies suggest that patients with particularly high levels of dysregulation often need a more phase-oriented approach (e.g., Bohus et al., 2020). For complex dissociative disorders, there are currently only two randomized controlled trials (RCTs) that specifically target this patient group. In Brand et al. (2025), a psychoeducational skills training program ("Finding Solid Ground") as the first phase of treatment showed a significant effect over and above usual individual therapy. In another RCT, where a 20-week psychoeducational group intervention was compared with standard individual therapy, both groups showed improved functioning, but there was no additional effect of the group and no clear symptom reduction (Bækkelund et al., 2022). There are no RCTs testing the effect of trauma-focused exposure treatment for individuals with CDD.

International guidelines (ISSTD, 2011; Brand et al., 2012) recommend a phase-oriented approach to treatment of CDD. In phase 1, work focuses on stabilization and skills training before progressing to more direct trauma processing. A central clinical dilemma is that these treatment courses often become very long, and many patients never reach phase 2, where the traumatic memories themselves are processed. The field lacks methods that can safely address the core of the trauma before patients have built substantial capacity through long-term stabilization work.

Deep Brain Reorienting (DBR) is a relatively new, transdiagnostic trauma treatment based on neuropsychological and neurobiological research (Corrigan et al., 2024). The method aims to access and process traumatic experiences by following the original sequence of physiological responses that occurred when the midbrain was alerted to a threat or relational injury that exceeded the person's integrative capacity. DBR focuses on processing the "shock" in subcortical, pre-verbal systems, and targets the orienting response and the subsequent fear sequence (Corrigan et al., 2024). Rather than working directly with trauma memories, DBR can address current trigger situations and process underlying shock responses without necessarily activating the most overwhelming feelings and memories.

A randomized controlled study (Kearney et al., 2023) of eight web-based DBR sessions compared with a waitlist condition found substantial reductions in PTSD symptoms immediately after treatment and at three-month follow-up. The active treatment group had nearly 50% symptom reduction, and many participants no longer met criteria for PTSD. The results suggest that DBR may be as effective as established trauma treatments, while appearing more tolerable and having a lower dropout rate. Further research, including fMRI studies conducted by the research group around Lanius and adaptations for more complex patient groups, is underway (e.g., Corrigan et al., 2024; Gerge, 2025).

The field has so far not identified methods that can safely address the traumatic events and the causes of dissociative symptoms early in treatment, before patients have built significant capacity through extended stabilization work. For some patients this can take a very long time, and some never reach genuine trauma processing. DBR appears to be a promising approach for working with the "imprint" of trauma without necessarily having to activate the trauma memories themselves, and may potentially enable earlier processing than what has been common so far. This constitutes the background for the present study. 2. Aim of the study

The aim of this study is to carry out a feasibility/pilot study of a 16-week integrated treatment program for patients with complex dissociative disorders, in which individual DBR is combined with a supportive group intervention. More specifically, we aim to: * assess the feasibility and acceptability of such a program at the Trauma Outpatient Clinic at Modum Bad (recruitment, attendance, dropout, tolerability, and treatment integrity), * explore participants' experiences of receiving DBR in combination with a supportive group, including perceived benefits, burden, and suggestions for improvement, * examine preliminary changes in symptoms, functioning, and quality of life (pre-post and 6-month follow-up), as well as evaluate the usefulness of two new DBR-specific measures.

In the longer term, the project may contribute to developing a more targeted treatment offering for a patient group that currently has a large unmet need, and provide a basis for a subsequent, larger controlled study. 3. Description of the intervention

The intervention is delivered on an outpatient basis at the Trauma Outpatient Clinic and includes: * 1-3 preparatory individual sessions to assess symptoms and treatment goals, and to introduce the method. * Two initial group sessions, where we: * provide psychoeducation about the background and rationale for the method and how it is conducted, * introduce and practice a central orienting exercise ("Where Self"), * work to establish a safe and supportive group climate. * 16 weeks of treatment, consisting of: * one weekly individual DBR session with a DBR-trained therapist at the Trauma Outpatient Clinic, * two brief digital group meetings per week: * the first to identify a suitable focus or issue for the upcoming DBR session and to practice "Where Self" to strengthen orienting capacity, * the second focusing on further adaptation of "Where Self" and deepening new perspectives and experiences arising from the DBR processing. * During the treatment period, we collect self-report data, * After 16 weeks: one individual summary session and one focus group interview * After 6 months: a new focus group interview and completion of self-report questionnaires 4. Research questions

1. Feasibility and acceptability

* To what extent is it feasible to offer a 16-week DBR program combined with a supportive group intervention to patients with CDD (recruitment rate, attendance, dropout, tolerability)? * How do participants describe their experience of taking part in such a program, and in what ways do they experience it as helpful or burdensome? 2. Preliminary clinical changes

\- What changes in symptoms, functioning, and quality of life do participants report from before to after treatment and at 6-month follow-up? 3. Evaluation of two DBR-specific process measures - To what extent are these instruments useful and meaningful for this patient group, both as research measures and as support for their own processing? 5. Rationale for choice of design, data, and methods The aim of the study is to examine (a) feasibility and acceptability of a DBR-based combined individual and group program for patients with CDD, (b) participants' experiences of taking part in the program, and (c) preliminary changes in symptoms, functioning, and quality of life.

We therefore use a mixed-methods approach: * Quantitative data (pre-post and 6-month follow-up) from self-report questionnaires make it possible to describe trends in change in symptoms and functioning, and to test two new DBR-specific measures (Where Self Awareness Scale, Shock Induced Vigilance Scale). * Qualitative data from focus group interviews provide access to participants' own descriptions of how they experienced the treatment, what they found helpful or challenging, and how the program can be improved. 6. Research participants We plan to include 10 adult participants who meet criteria for DID or OSDD (CDD) and who have already been referred for treatment at the Trauma Outpatient Clinic.

Such a sample is too small to provide sufficient statistical power to draw firm conclusions about effectiveness, but is considered sufficient to: * provide indications of possible clinical changes, * test recruitment and feasibility parameters (attendance, dropout, tolerability), * collect qualitative data about participants' experiences.

The study is thus explicitly designed as a feasibility/pilot study.

Recruitment Patients referred to the Trauma Outpatient Clinic at Modum Bad in Oslo are assessed according to the clinic's standard procedures. As part of this assessment, the most suitable treatment offering at the clinic is considered. Patients who appear to be a good fit for the DBR program are informed about the study verbally and in writing, and invited to an assessment session where the study is reviewed in more detail. 7. Analysis The qualitative data from the focus groups will be suitable for hermeneutic-phenomenological analysis, with the aim of illuminating participants' experiences of the treatment, how they understand their own change processes, and what adjustments to the program they propose.

The quantitative pre-post measures will be analysed descriptively and with simple statistical analyses to explore possible trends in change in symptoms, functioning, and quality of life, and to assess the usefulness of the DBR-specific questionnaires (Where Self Awareness Scale and Shock Induced Vigilance Scale) as outcome and process measures.

Given the small sample, the analyses will be exploratory and hypothesis-generating, not conclusive. 8. Ethical considerations - potential benefits and burdens Potential benefits

* Participants may experience it as meaningful and validating to contribute to research in an area where their patient group has traditionally been underrepresented, and where their experiences can influence the future development of trauma treatment. * They may gain access to a structured treatment program (combined DBR and group) that could contribute to symptom reduction, improved functioning, and a greater sense of coherence, although this cannot be guaranteed. * At a broader level, the project may contribute to the development of better treatment offerings in specialist mental health services for people with CDD, a group for whom there is currently little research.

Possible disadvantages/burdens * Participants may find it burdensome to take part in focus group interviews and to complete self-report questionnaires. * Some will have prior experience with assessment in psychiatric services, whereas others may be asked to report on trauma experiences and symptoms for the first time; this may lead to emotional reactions and new insight into their own difficulties. * Patients who want the treatment but do not wish to take part in the study may experience a certain indirect pressure related to the wish for timely access to treatment. This is addressed through clear information and the availability of alternative treatment options.

Measures to reduce risk and burden * Participants receive both oral and written information about the purpose of the study, the content of the questionnaires and focus group interviews, and

• Change in PTSD symptoms (PCL-5) [Time frame: Baseline (pre-treatment), post-treatment (16 weeks), and 6-month follow-up]
• Change in dissociative symptoms (DES) [Time frame: Baseline, post-treatment (16 weeks), and 6-month follow-up]
• Change in general psychological distress and functioning (CORE-OM) [Time frame: Baseline, post-treatment (16 weeks), and 6-month follow-up]
• Change in orienting and self-awareness (Where Self Awareness Scale) [Time frame: Baseline, during treatment (e.g., weekly or at predefined intervals), post-treatment, and 6-month follow-up]
• Change in shock-related vigilance (Shock Induced Vigilance Scale) [Time frame: Baseline, during treatment (e.g., weekly or at predefined intervals), post-treatment, and 6-month follow-up]