Internet and mobile technologies: addressing the mental health of trauma survivors in less resourced communities.

Internet and mobile technologies offer potentially critical ways of delivering mental health support in low-resource settings. Much evidence indicates an enormous negative impact of mental health problems in low- and middle-income countries (LMICs), and many of these problems are caused, or worsened, by exposure to wars, conflicts, natural and human-caused disasters, and other traumatic events. Though specific mental health treatments have been found to be efficacious and cost-effective for low-resource settings, most individuals living in these areas do not have access to them. Low-intensity task-sharing interventions will help, but there is a limit to the scalability and sustainability of human resources in these settings. To address the needs of trauma survivors, it will be important to develop and implement Internet and mobile technology resources to help reduce the scarcity, inequity, and inefficiency of current mental health services in LMICs. Mobile and Internet resources are experiencing a rapid growth in LMICs and can help address time, stigma, and cost barriers and connect those who have been socially isolated by traumatic events. This review discusses current research in technological interventions in low-resource settings and outlines key issues and future challenges and opportunities. Though formidable challenges exist for large-scale deployment of mobile and Internet mental health technologies, work to date indicates that these technologies are indeed feasible to develop, evaluate, and deliver to those in need of mental health services, and that they can be effective.

Recent advances in the detection of specific natural organic compounds as carriers for radionuclides in soil and water environments, with examples of radioiodine and plutonium.

Among the key environmental factors influencing the fate and transport of radionuclides in the environment is natural organic matter (NOM). While this has been known for decades, there still remains great uncertainty in predicting NOM-radionuclide interactions because of lack of understanding of radionuclide interactions with the specific organic moieties within NOM. Furthermore, radionuclide-NOM studies conducted using modelled organic compounds or elevated radionuclide concentrations provide compromised information related to true environmental conditions. Thus, sensitive techniques are required not only for the detection of radionuclides, and their different species, at ambient and/or far-field concentrations, but also for potential trace organic compounds that are chemically binding these radionuclides. GC-MS and AMS techniques developed in our lab are reviewed here that aim to assess how two radionuclides, iodine and plutonium, form strong bonds with NOM by entirely different mechanisms; iodine tends to bind to aromatic functionalities, whereas plutonium binds to N-containing hydroxamate siderophores at ambient concentrations. While low-level measurements are a prerequisite for assessing iodine and plutonium migration at nuclear waste sites and as environmental tracers, it is necessary to determine their in-situ speciation, which ultimately controls their mobility and transport in natural environments. More importantly, advanced molecular-level instrumentation (e.g., nuclear magnetic resonance (NMR) and Fourier-transform ion cyclotron resonance coupled with electrospray ionization (ESI-FTICRMS) were applied to resolve either directly or indirectly the molecular environments in which the radionuclides are associated with the NOM.

Radioiodine Biogeochemistry and Prevalence in Groundwater.

129I is commonly either the top or among the top risk drivers, along with 99Tc, at radiological waste disposal sites and contaminated groundwater sites where nuclear material fabrication or reprocessing has occurred. The risk stems largely from 129I having a high toxicity, a high bioaccumulation factor (90% of all the body's iodine concentrates in the thyroid), a high inventory at source terms (due to its high fission yield), an extremely long half-life (16M years), and rapid mobility in the subsurface environment. Another important reason that 129I is a key risk driver is that there is uncertainty regarding its biogeochemical fate and transport in the environment. We typically can define 129I mass balance and flux at sites, but cannot predict accurately its response to changes in the environment. As a consequence of some of these characteristics, 129I has a very low drinking water standard, which is set at 1 pCi/L, the lowest of all radionuclides in the Federal Register. Recently, significant advancements have been made in detecting iodine species at ambient groundwater concentrations, defining the nature of the organic matter and iodine bond, and quantifying the role of naturally occurring sediment microbes to promote iodine oxidation and reduction. These recent studies have led to a more mechanistic understanding of radioiodine biogeochemistry. The objective of this review is to describe these advances and to provide a state of the science of radioiodine biogeochemistry relevant to its fate and transport in the terrestrial environment and provide information useful for making decisions regarding the stewardship and remediation of 129I contaminated sites. As part of this review, knowledge gaps were identified that would significantly advance the goals of basic and applied research programs for accelerating 129I environmental remediation and reducing uncertainty associated with disposal of 129I waste. Together the information gained from addressing these knowledge gaps will not alter the observation that 129I is primarily mobile, but it will likely permit demonstration that the entire 129I pool in the source term is not moving at the same rate and some may be tightly bound to the sediment, thereby smearing the modeled 129I peak and reducing maximum calculated risk.

Preservation of H2 production activity in nanoporous latex coatings of Rhodopseudomonas palustris†CGA009 during dry storage at ambient temperatures.

To assess the applicability of latex cell coatings as an 'off-the-shelf' biocatalyst, the effect of osmoprotectants, temperature, humidity and O2 on preservation of H2 production in Rhodopseudomonas palustris coatings was evaluated. Immediately following latex coating coalescence (24 h) and for up to 2 weeks of dry storage, rehydrated coatings containing different osmoprotectants displayed similar rates of H2 production. Beyond 2 weeks of storage, sorbitol-treated coatings lost all H2 production activity, whereas considerable H2 production was still detected in sucrose- and trehalose-stabilized coatings. The relative humidity level at which the coatings were stored had a significant impact on the recovery and subsequent rates of H2 production. After 4 weeks storage under air at 60% humidity, coatings produced only trace amounts of H2 (0-0.1% headspace accumulation), whereas those stored at < 5% humidity retained 27-53% of their H2 production activity after 8 weeks of storage. When stored in argon at < 5% humidity and room temperature, R. palustris coatings retained full H2 production activity for 3 months, implicating oxidative damage as a key factor limiting coating storage. Overall, the results demonstrate that biocatalytic latex coatings are an attractive cell immobilization platform for preservation of bioactivity in the dry state.

SU-E-J-13: A Study to Establish the Effect of CBCT Image Rotational Displacement on IGRT and ART Lung SBRT Treatments.

PURPOSE: To determine whether the accuracy of CBCT based IGRT and ART lung SBRT treatments may require extra quality assurance (QA) steps. METHODS: During CBCT Rando phantom acquisition we detected an unexpected ∼2° image rotation when comparing the CW and CCW acquired scans. Misregistered angular coordinates may Result in a rotated reconstructed image and the target localization may lead to an under- or over-dosage of the target volume (TV) and organs at risk (OARs). The effect of image rotation on CBCT-guided lung SBRT was retrospectively examined in a group of six patients treated at our institution. Patient CT sets were rotated by 1,2, and 3°. Treatment plans were recalculated using these rotated images to examine changes of dose-volume histogram indicators for IGRT and ART guided treatments. C++ simulations were run to evaluate the effect of CBCT image rotation. RESULTS: We determined through mathematical analysis that the dose coverage of the TV is dependent on its shape, location and orientation relative to isocenter. Dosimetric evaluation of lung SBRT patients showed that even for 1< Ñ2 <3°, changes in D95 to the PTV were from 2.3 ± 2.1 to 11.5 ± 3.9% for IGRT and from 8.5 ± 8.4 to 16.6 ± 8.0% for ART. Significant changes were also detected at critical structure level. CONCLUSIONS: When IGRT and ART are employed for lung SBRT treatments, significant dosimetric changes may Result from the rotation of CBCT image data sets. The extent of alterations in dose indicators depends on both the shape of the TV and its relative location to isocenter. Based on our results, angular alignment of CBCT to <1° is essential in maintaining accurate dose delivery of IGRT and ART based lung SBRT treatments.

Concentration-dependent mobility, retardation, and speciation of iodine in surface sediment from the Savannah River Site.

Iodine occurs in multiple oxidation states in aquatic systems in the form of organic and inorganic species. This feature leads to complex biogeochemical cycling of stable iodine and its long-lived isotope, (129)I. In this study, we investigated the sorption, transport, and interconversion of iodine species by comparing their mobility in groundwaters at ambient concentrations of iodine species (10(-8) to 10(-7) M) to those at artificially elevated concentrations (78.7 µM), which often are used in laboratory analyses. Results demonstrate that the mobility of iodine species greatly depends on, in addition to the type of species, the iodine concentration used, presumably limited by the number of surface organic carbon binding sites to form covalent bonds. At ambient concentrations, iodide and iodate were significantly retarded (K(d) values as high as 49 mL g(-1)), whereas at concentrations of 78.7 µM, iodide traveled along with the water without retardation. Appreciable amounts of iodide during transport were retained in soils due to iodination of organic carbon, specifically retained by aromatic carbon. At high input concentration of iodate (78.7 µM), iodate was found to be reduced to iodide and subsequently followed the transport behavior of iodide. These experiments underscore the importance of studying iodine geochemistry at ambient concentrations and demonstrate the dynamic nature of their speciation during transport conditions.

A novel approach for the simultaneous determination of iodide, iodate and organo-iodide for 127I and 129I in environmental samples using gas chromatography-mass spectrometry.

In aquatic environments, iodine mainly exists as iodide, iodate, and organic iodine. The high mobility of iodine in aquatic systems has led to (129)I contamination problems at sites where nuclear fuel has been reprocessed, such as the F-area of Savannah River Site. In order to assess the distribution of (129)I and stable (127)I in environmental systems, a sensitive and rapid method was developed which enables determination of isotopic ratios of speciated iodine. Iodide concentrations were quantified using gas chromatography-mass spectrometry (GC-MS) after derivatization to 4-iodo-N,N-dimethylaniline. Iodate concentrations were quantified by measuring the difference of iodide concentrations in the solution before and after reduction by Na(2)S(2)O(5). Total iodine, including inorganic and organic iodine, was determined after conversion to iodate by combustion at 900 °C. Organo-iodine was calculated as the difference between the total iodine and total inorganic iodine (iodide and iodate). The detection limits of iodide-127 and iodate-127 were 0.34 nM and 1.11 nM, respectively, whereas the detection limits for both iodide-129 and iodate-129 was 0.08 nM (i.e., 2pCi (129)I/L). This method was successfully applied to water samples from the contaminated Savannah River Site, South Carolina, and more pristine Galveston Bay, Texas.

Organo-iodine formation in soils and aquifer sediments at ambient concentrations.

One of the key risk drivers at radioactive waste disposal facilities is radioiodine, especially 129I. As iodine mobility varies greatly with iodine speciation, experiments with 129I-contaminated aquifer sediments from the Savannah River Site located in Aiken, SC, were carried out to test iodine interactions with soils and aquifer sediments. Using tracer 125I- and stable 127I- additions, it was shown that such interactions were highly dependent on I- concentrations added to sediment suspensions, contact time with the sediment, and organic carbon (OC) content, resulting in an empirical particle-water partition coefficient (Kd) that was an inverse power function of the added I- concentration. However, Kd values of organically bound 127I were 3 orders of magnitude higher than those determined after 1-2 weeks of tracer equilibration, approaching those of OC. Under ambient conditions, organo-iodine (OI) was a major fraction (67%) of the total iodine in the dissolved phase and by implication of the particulate phase. As the total concentration of amended I- increased, the fraction of detectable dissolved OI decreased. This trend, attributed to OC becoming the limiting factor in the aquifer sediment explains why at elevated I-concentrations OI is often not detected.

Requirement of DNA repair mechanisms for survival of Burkholderia cepacia G4 upon degradation of trichloroethylene.

A Tn5-based mutagenesis strategy was used to generate a collection of trichloroethylene (TCE)-sensitive (TCS) mutants in order to identify repair systems or protective mechanisms that shield Burkholderia cepacia G4 from the toxic effects associated with TCE oxidation. Single Tn5 insertion sites were mapped within open reading frames putatively encoding enzymes involved in DNA repair (UvrB, RuvB, RecA, and RecG) in 7 of the 11 TCS strains obtained (4 of the TCS strains had a single Tn5 insertion within a uvrB homolog). The data revealed that the uvrB-disrupted strains were exceptionally susceptible to killing by TCE oxidation, followed by the recA strain, while the ruvB and recG strains were just slightly more sensitive to TCE than the wild type. The uvrB and recA strains were also extremely sensitive to UV light and, to a lesser extent, to exposure to mitomycin C and H(2)O(2). The data from this study establishes that there is a link between DNA repair and the ability of B. cepacia G4 cells to survive following TCE transformation. A possible role for nucleotide excision repair and recombination repair activities in TCE-damaged cells is discussed.

Molecular and cellular fundamentals of aerobic cometabolism of trichloroethylene.

Cometabolism recognizes that microorganisms can transform non-growth-supporting substrates. The term "cometabolism" was first introduced over 30 years ago and has been redefined, criticized, and used widely ever since. In this review we have examined the aerobic cometabolism of chlorinated solvents, with a particular emphasis on the cometabolism of trichloroethylene. Monooxygenases or dioxygenases with relaxed substrate ranges initiate these transformations. The physiological role of the oxygenases is to initiate the metabolism of growth-supporting substrates (e.g., methane, propane, butane, toluene, ethylene, and ammonia). Diverse enzymes catalyze these oxidative reactions with chlorinated solvents. Synthesis of most of these enzymes is induced by the presence of the growth-supporting substrate and is largely regulated at the level of gene transcription. The genes that code for a given oxygenase are usually clustered together in a single operon and often share homology with counterparts that code for the subunits of related oxygenases in other bacteria. During cometabolism the growth-supporting and non-growth-supporting substrates can both bind to the oxygenase. Transformation of chlorinated solvents by these enzymes presents the cell with a new set of compounds. Some of these compounds are toxic to the cells, others are stable products that are expelled from the cell, and in a few cases the cells utilize the products. The combined effects of cometabolism can have a profound influence on a cell.

Two distinct monooxygenases for alkane oxidation in Nocardioides sp. strain CF8.

Alkane monooxygenases in Nocardioides sp. strain CF8 were examined at the physiological and genetic levels. Strain CF8 can utilize alkanes ranging in chain length from C(2) to C(16). Butane degradation by butane-grown cells was strongly inhibited by allylthiourea, a copper-selective chelator, while hexane-, octane-, and decane-grown cells showed detectable butane degradation activity in the presence of allylthiourea. Growth on butane and hexane was strongly inhibited by 1-hexyne, while 1-hexyne did not affect growth on octane or decane. A specific 30-kDa acetylene-binding polypeptide was observed for butane-, hexane-, octane-, and decane-grown cells but was absent from cells grown with octane or decane in the presence of 1-hexyne. These results suggest the presence of two monooxygenases in strain CF8. Degenerate primers designed for PCR amplification of genes related to the binuclear-iron-containing alkane hydroxylase from Pseudomonas oleovorans were used to clone a related gene from strain CF8. Reverse transcription-PCR and Northern blot analysis showed that this gene encoding a binuclear-iron-containing alkane hydroxylase was expressed in cells grown on alkanes above C(6). These results indicate the presence of two distinct monooxygenases for alkane oxidation in Nocardioides sp. strain CF8.

Cytotoxicity associated with trichloroethylene oxidation in Burkholderia cepacia G4.

The effects of trichloroethylene (TCE) oxidation on toluene 2-monooxygenase activity, general respiratory activity, and cell culturability were examined in the toluene-oxidizing bacterium Burkholderia cepacia G4. Nonspecific damage outpaced inactivation of toluene 2-monooxygenase in B. cepacia G4 cells. Cells that had degraded approximately 0.5 micromol of TCE (mg of cells(-1)) lost 95% of their acetate-dependent O(2) uptake activity (a measure of general respiratory activity), yet toluene-dependent O(2) uptake activity decreased only 35%. Cell culturability also decreased upon TCE oxidation; however, the extent of loss varied greatly (up to 3 orders of magnitude) with the method of assessment. Addition of catalase or sodium pyruvate to the surfaces of agar plates increased enumeration of TCE-injured cells by as much as 100-fold, indicating that the TCE-injured cells were ultrasensitive to oxidative stress. Cell suspensions that had oxidized TCE recovered the ability to grow in liquid minimal medium containing lactate or phenol, but recovery was delayed substantially when TCE degradation approached 0.5 micromol (mg of cells(-1)) or 66% of the cells' transformation capacity for TCE at the cell density utilized. Furthermore, among B. cepacia G4 cells isolated on Luria-Bertani agar plates from cultures that had degraded approximately 0.5 micromol of TCE (mg of cells(-1)), up to 90% were Tol(-) variants, no longer capable of TCE degradation. These results indicate that a toxicity threshold for TCE oxidation exists in B. cepacia G4 and that once a cell suspension has exceeded this toxicity threshold, the likelihood of reestablishing an active, TCE-degrading biomass from the cells will decrease significantly.

Six adoptees who murdered: neuropsychiatric vulnerabilities and characteristics of biological and adoptive parents.

This article is the first to document the perinatal trauma and neuropsychiatric impairment of a sequential sample of male adoptees who committed murder. It also is the first to report objectively verifiable psychopathology and violence in their biological and adoptive parents. It explores the interaction of these variables in the genesis of violence. Subjects were six adopted murderers on whom data regarding biological and adoptive parents could be obtained. In all six cases, central nervous system (CNS) development was compromised in utero or perinatally. In adolescence and/or young adulthood, three met DSM-IV criteria for Bipolar Mood Disorder, one for Schizophrenia, and two for Schizoaffective Disorder. All subjects had at least one psychotic biological parent. In five cases, subjects were adopted into psychotic or violent households. There was no evidence of a specific "bad seed" for violence. Adoptees' intrinsic vulnerabilities to psychoses and to the impulsiveness and emotional lability often associated with early brain trauma, coupled with maltreatment, predisposed them to homicidal violence. As such, these subjects were similar to other extraordinarily violent, nonadopted, offenders. Conscious feelings regarding adoption did not contribute to the subjects' homicidal rages, so much as did conscious rage toward abusive, rejecting adoptive families.

The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction.

This study investigated the extent to which the individual orientations of physicians and patients and the congruence between them are associated with patient satisfaction. A survey was mailed to 400 physicians and 1020 of their patients. All respondents filled out the Patient-Practitioner Orientation Scale, which measures the roles that doctors and patients believe each should play in the course of their interaction. Patients also rated their satisfaction with their doctors. Among patients, we found that females and those who were younger, more educated, and healthier were significantly more patient-centered. However, none of these variables were significantly related to satisfaction. Among physicians, females were more patient-centered, and years in practice was related to satisfaction and orientation in a non-linear fashion. The congruence data indicated that patients were highly satisfied when their physicians either had a matching orientation or were more patient-centered. However, patients whose doctors were not as patient-centered were significantly less satisfied.

Mental illness, neuropsychologic deficits, child abuse, and violence.

This review of the psychiatric, neuropsychological, and familial contributions to aggressive behavior makes clear that conduct disorder is not a single diagnostic entity. It is, rather, the final common pathway of the interaction among a variety of different kinds of intrinsic vulnerabilities and environmental stressors. In every aggressive child all of these vulnerabilities (none of which necessarily meets full criteria for a specific DSM-IV diagnosis) and stressors must be considered and, if present, addressed systematically. We know that psychotic symptomatology, especially paranoia, combined with neuropsychological vulnerabilities and a history of severe abuse become a recipe for violence, and the more impaired the child, if abused, the more violent the child will become as an adolescent and adult. The clinician must, therefore, think of himself or herself as the only knowledgeable adult who will ever take the time to discover these ingredients and deal with the violent child positively and therapeutically.

Diagnostic evaluation of the violent child and adolescent.

The diagnostic evaluation of the violent child and adolescent is a collaborative exercise, requiring diverse expertise. Ironically, after systematic, comprehensive psychiatric, neurologic, psychologic, neuropsychologic, psychoeducational, family, and social evaluations have been completed, the clinician probably will not be able to make a hard and fast DSM-IV diagnosis; that is, unless the clinician is satisfied with fitting the behavioral pieces into the Conduct Disorder category and ignoring the rest of the clinical data. From time to time the clinician will be able to diagnose a bipolar mood disorder underlying a violent youngster's behavior. Occasionally the clinician will recognize paranoid schizophrenia motivating a particularly heinous or bizarre violent act. Most often the clinician will be faced with a variety of different kinds of psychiatric, neurologic, cognitive, and environmental vulnerabilities that have come together and created a violent child or adolescent. That's fine because almost invariably each discovered vulnerability has implications for treatment. The clinician evaluating a violent child or adolescent must overcome his or her initial disgust or anger at the youngster's behaviors and resist the impulse to dismiss the child as conduct disordered, as an incipient psychopath. That diagnosis leads nowhere. The identification of vulnerabilities leads to specific interventions and ultimately to the prevention of future violence.

Inactivation of toluene 2-monooxygenase in Burkholderia cepacia G4 by alkynes.

High concentrations of acetylene (10 to 50% [vol/vol] gas phase) were required to inhibit the growth of Burkholderia cepacia G4 on toluene, while 1% (vol/vol) (gas phase) propyne or 1-butyne completely inhibited growth. Low concentrations of longer-chain alkynes (C5 to C10) were also effective inhibitors of toluene-dependent growth, and 2- and 3-alkynes were more potent inhibitors than their 1-alkyne counterparts. Exposure of toluene-grown B. cepacia G4 to alkynes resulted in the irreversible loss of toluene- and o-cresol-dependent O2 uptake activities, while acetate- and 3-methylcatechol-dependent O2 uptake activities were unaffected. Toluene-dependent O2 uptake decreased upon the addition of 1-butyne in a concentration- and time-dependent manner. The loss of activity followed first-order kinetics, with apparent rate constants ranging from 0.25 min-1 to 2.45 min-1. Increasing concentrations of toluene afforded protection from the inhibitory effects of 1-butyne. Furthermore, oxygen, supplied as H2O2, was required for inhibition by 1-butyne. These results suggest that alkynes are specific, mechanism-based inactivators of toluene 2-monooxygenase in B. cepacia G4, although the simplest alkyne, acetylene, was relatively ineffective compared to longer alkynes. Alkene analogs of acetylene and propyne-ethylene and propylene-were not inactivators of toluene 2-monooxygenase activity in B. cepacia G4 but were oxidized to their respective epoxides, with apparent Ks and Vmax values of 39.7 microM and 112.3 nmol min-1 mg of protein-1 for ethylene and 32.3 microM and 89.2 nmol min-1 mg of protein-1 for propylene.

Feeding ecology of the black howler monkey (Alouatta pigra) in northern Belize.

We studied the feeding ecology of the black howler monkey (Alouatta pigra) from March 1994 to April 1995 in the Community Baboon Sanctuary in northern Belize, Central America. Activity and diet composition were recorded using continuous focal animal sampling. Diet composition was compared with the relative abundance of plant parts eaten by the howlers within the study site. The study animals spent an average of 24.4% of their time feeding, 61.9% resting, and approximately 9.8% traveling. In contrast to previously published reports on A. pigra, we found the diet composition to be similar to that of other Alouatta species (conforming to the folivore/frugivore profile), with 41% of feeding time spent eating fruit, 45% foliage, and 11% flowers. This contrast may indicate a wide degree of dietary flexibility that allows A. pigra to inhabit a variety of habitat types. We suggest that a high level of resource abundance throughout the year makes the Community Baboon Sanctuary excellent habitat for Alouatta pigra.

Effects of topical oral antiseptic rinses on bacterial counts of saliva in healthy human subjects.

Wound infections remain a significant source of morbidity in patients undergoing major head and neck operations that invade the aerodigestive tract. Infection rates have been significantly reduced by the administration of perioperative intravenous antibiotics; however, the incidence of infection remains unacceptably high. This study was undertaken to help identify an oral antiseptic that could significantly reduce the bacterial colony count of human saliva. A randomized, prospective clinical trial was conducted to analyze and compare the effects of Listerine antiseptic and Peridex oral rinse on the aerobic and anaerobic bacterial counts in healthy human subjects. Thirty healthy adult volunteers between the ages of 18 and 61 participated in the study. The patients were randomized to receive normal saline solution, Listerine antiseptic, or Peridex oral rinse. Aerobic and anaerobic bacterial colony counts of saliva were measured before treatment and at 1 and 4 hours after treatment. Both Listerine antiseptic and Peridex oral rinse significantly reduced bacterial counts at 1 hour after treatment in our volunteers. At 4 hours after treatment, Peridex oral rinse showed a further reduction in the bacterial colony count whereas Listerine antiseptic showed no difference compared with normal saline solution. At 4 hours after treatment, Peridex oral rinse reduced the total bacterial colony count by 85%.

Objective documentation of child abuse and dissociation in 12 murderers with dissociative identity disorder.

OBJECTIVE: The skepticism regarding the existence of dissociative identity disorder as well as the abuse that engenders it persists for lack of objective documentation. This is doubly so for the disorder in murderers because of issues of suspected malingering. This article presents objective verification of both dissociative symptoms and severe abuse during childhood in a series of adult murderers with dissociative identity disorder. METHOD: This study consisted of a review of the clinical records of 11 men and one woman with DSM-IV-defined dissociative identity disorder who had committed murder. Data were gathered from medical, psychiatric, social service, school, military, and prison records and from records of interviews with subjects' family members and others. Handwriting samples were also examined. Data were analyzed qualitatively. RESULTS: Signs and symptoms of dissociative identity disorder in childhood and adulthood were corroborated independently and from several sources in all 12 cases; objective evidence of severe abuse was obtained in 11 cases. The subjects had amnesia for most of the abuse and underreported it. Marked changes in writing style and/or signatures were documented in 10 cases. CONCLUSIONS: This study establishes, once and for all, the linkage between early severe abuse and dissociative identity disorder. Further, the data demonstrate that the disorder can be distinguished from malingering and from other disorders. The study shows that it is possible, with great effort, to obtain objective evidence of both the symptoms of dissociative identity disorder and the abuse that engenders it.