CASE REPORT article

Schema therapy for dissociative identity disorder: a case report.

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\r\nNathan Bachrach,

  • 1 Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
  • 2 GGZ-Oost Brabant, Department of Personality Disorders, Helmond, Netherlands
  • 3 Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
  • 4 Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
  • 5 Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, Netherlands

Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group.

Introduction

Dissociative Identity Disorder (DID) is a highly disabling disorder, associated with high levels of impairment, high risk for self-harm, multiple suicide attempts, high mortality, and very high societal costs ( 1 ). The main diagnostic criterion for DID is the perceived presence of two or more distinct identities, accompanied by a marked discontinuity in the sense of self and agency, and alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. Also, patients often report recurrent gaps in the recall of important personal information, everyday events, and traumatic events ( 2 ). The estimated 12-month prevalence of DID is 1.5% in the general American population ( 2 ), and around 5% in psychiatric settings ( 3 ).

Treatment for DID often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation ( 4 ). The percentage of patients who reach the third phase of treatment is relatively low [17–33%, ( 5 )] and treatment duration is long, on average 8.4 years ( 6 ). The effectiveness of this treatment has been examined in several non-controlled studies ( 6 – 8 ) and one Randomized Controlled Trial [RCT; ( 9 )]. The results indicated that, although the general functioning of patients improved, the effects of this treatment on the core symptoms (i.e., dissociative symptoms) are small or absent. Hence, there is ample room for improvement in the treatment of DID.

Schema therapy (ST) has been introduced as a viable alternative treatment for DID ( 10 – 12 ). ST is thought to be applicable to and effective for DID for several reasons. First, ST as a whole, as well as its trauma processing component, Imagery Rescripting (ImRs), are effective for disorders that result from interpersonal trauma in childhood, including complex PTSD and personality disorders [e.g., ( 13 – 17 )]. Secondly, ST was found to reduce dissociative symptoms in patients with Borderline Personality Disorder (BPD) ( 18 ). Thirdly, perceived shifts between identities in people with DID are understood as shifts between modes (temporary states of mind) and compartmentalization is not assumed ( 19 ). Extreme shifts in emotions, cognitions, and behaviors that are present in DID also appear in other disorders that are related to severe and prolonged childhood abuse, such as BPD; ST delivers tools for dealing with these shifts ( 20 ). Fourthly, a recent RCT ( 15 ) investigating the effectiveness of ImRs in people with PTSD as a result of early childhood trauma showed that trauma treatment is highly effective and can be performed safely without a stabilization phase. As a first illustration of this new approach to the treatment of DID, this case report presents an illustration of the application of an adapted form of ST for DID.

Case description

Ella (fictitious name) is a 43-year-old patient with an extensive psychiatric history, who was referred to a specialized mental health center in the Netherlands to participate in a study on the treatment of DID with ST. Ella experienced nightmares and flashbacks about past traumatic experiences, and reported 17 identities, as well as dissociative amnesia (i.e., memory gaps for daily life events and traumas). Several identities were obsessed with self-hatred and self-punishment and repeatedly gave orders to hurt or kill herself. She broke her arm once by force, repeatedly cut herself on her arm, and attempted suicide several times. According to the patient's report, traumatic experiences involved recurrent sexual abuse by her father during her childhood (4–11 years), as well as several times by a teacher and a peer from secondary school. Her mother denied the abuse and behaved in a guilt-inducing way. Moreover, during her training as a dentist assistant after graduating from high school, a manager tried to sexually abuse her, after which she mentally broke down. She was hospitalized numerous times due to parasuicidal behavior and suicide attempts. She also received CBT for 3 years. This treatment focused on depressive and anxiety symptoms, (para)suicidal behaviors, and cannabis addiction. It was delivered in individual as well as group format and did not result in long-lasting results. Previous treatment in this case did not include trauma stabilization therapy. She met her husband 14 years ago and has a son who is 6 years old. She feels insecure about the upbringing of her son and feels unconnected to her partner. At the start of therapy, she was not able to work.

The patient gave informed consent for participation in the study and for the publication of this case report. The Structured Clinical Interview for DSM disorders Dissociative disorders-Revised [SCID-D-R; ( 21 )], SCID-I, and SCID-II ( 22 , 23 ) were used to assess the presence of clinical disorders by an independent experienced clinician. Ella was diagnosed with DID, depressive disorder, PTSD, cannabis use disorder, and BPD, and her Global Assessment of Functioning ( 2 ) score was 25. Table 1 shows the results of the baseline assessment. This case is part of a non-concurrent multiple baseline design study among 10 DID patients ( 10 ).

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Table 1 . Results of baseline measures.

The treatment consisted of 160 sessions twice per week, followed by 40 weekly sessions. Thereafter, she received 6 monthly booster sessions which were aimed at reconsolidation and generalization of ST insights and skills learned during the active treatment. Each session lasted 50 min. ST for DID follows the same theoretical framework and makes use of therapeutic interventions as originally developed by Young et al. ( 25 ), though ST for DID is personalized to each patient as they present with different symptoms. Furthermore, several important adaptations to ST were made to meet the needs of DID patients. These will now be discussed.

Case-conceptualization and establishing a shared definition of problems in schema therapy language

At the start of treatment, the diagnosis of DID as well as the main problems of the patient were discussed. Ella was educated on the rationale of ST for DID with regards to basic needs and how frustration of these needs leads to schemas, modes, and psychopathology. To manage expectations, conditions of treatment were explained, such as treatment length (3.5 years), frequency of sessions, need for active participation, whom to contact in case of crisis, and the availability of the therapist. Much effort was put into building a working alliance throughout treatment by validating thoughts and emotions and being present, available, and consistent. Being really determined in finding solutions to deal with severe and persistent symptoms, not giving up but instead delivering hope and power is very important in working with DID patients. She was educated on how DID is understood in terms of schema theory (as modes), and identity states were thereafter translated into modes by clustering identities by their function and reformulating and merging them into a mode (see Table 2 ). There was no pressure to share all identities; the therapist worked with states that were present. Together with Ella a mode model was made (see Figure 1 ), containing the most prevalent modes: punitive and demanding mode (e.g., internal demanding and punitive messages), the vulnerable child mode (painful feelings, PTSD symptoms), the detached protector (e.g., withdrawing and disconnecting), avoidant protector (active avoidance behaviors), and self-soother (using cannabis and auto-mutilation to deal with painful feelings). This idiosyncratic model was consistent with the results of a recent empirical study into the most prevalent modes in patients suffering from DID ( 26 ). Moreover, (para)suicidal behaviors, coping mechanisms, and supportive relatives were assessed (level of parasuicidal behaviors was high and healthy coping mechanisms low), after which a basic safety plan was made in which Ella agreed to try to perform helpful behaviors (e.g., talking to my neighbor, talking to my husband, talking with my therapists) before harming herself (see Figure 2 ). This plan was used whenever basic safety became an issue, evident for example by the patient sending an appeal for help by e-mail or phone. She e-mailed texts like “ Death must be met with dignity. It is the only dignified thing left to do. I am never going to recover and if you really get to know me you would see how bad we are. I don't deserve to live .” Yet, it was possible to reassure her and prevent self-harm through email and short phone calls.

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Table 2 . Overview of parts and the corresponding modes.

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Figure 1 . Schema mode model of the patient.

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Figure 2 . Safety plan of the patient.

Dealing with dissociation and working with the detached protector

Specific adaptations in ST were made to address dissociative responses. Ella was educated on dissociation, stressing that it is a natural reaction to extreme and ongoing stress, especially when (biologically) sensitive to stressors. Furthermore, dissociative behaviors such as detachment or being unresponsive to stimuli from the environment were framed as behaviors that once had a clear survival function, but at present were mainly maladaptive. A strip of fleece was used to make a literal connection between Ella and the therapist, and to gain control over what was happening during the session. Whenever Ella zoned out or started to dissociate, the therapist gave the fleece a slight tug to have her stay connected and more present. Also, Ella could tug the fleece whenever she was in need, e.g., when the pace of the therapist was too high. At the beginning, the tugging and exploration of what triggered the disconnection was mainly initiated by the therapist, but gradually Ella became more active in tugging and exploring. Other techniques that were used to stop disconnection were grounding, such as the “Stop, Freeze, and Breathe” exercise ( 27 ), naming five things you see, throwing a small ball, or pinching some things hard (a shell or a sharp wooden stick). Also, the therapist and Ella found out that a dog clicker helped Ella to orient in the present whenever she got overwhelmed by flashbacks. She used the clicker when she sensed that she was (about to) reexperience traumatic events. The clicker helped her to feel in control over flashbacks and reorient to the present. Moreover, chair exercises, such as interviews with the detached protector, validating its protective function in the past, asking it to be less present, and setting the chair more aside in order to connect and reparent the vulnerable child, were used to reduce detachment.

Working with the avoidant protector

Avoidance behaviors are highly prevalent in DID patients and are a strong maintaining factor. Therefore, in ST for DID there is a constant alertness for avoidance behavior shown by the various identities. Dependent on their function they are reframed as a coping mode. Because the avoidance behavior can be intense and strong, creative solutions on how to deal with it are needed.

Ella had a strong avoidant protector (interpersonal and situational avoidance). She tended to avoid multiple situations (e.g., talking to other mothers at the schoolyard, attending other social situations, or discussing shameful past situations with the therapist). Her awareness of avoidance increased by teaching her to identify the behaviors of the avoidant protector and turn her attention toward avoidance behaviors in and outside the sessions via homework assignments (mode awareness work sheets). Avoidance patterns were targeted by chair work [dialogue with the avoidant protector, validation of the protective function in the past, asking the mode to make space for healing of the vulnerable part, and empathic confrontation (e.g., confronting her with the fact that avoiding trauma processing maintains PTSD, and not going along with avoidance)]. Creative solutions were used to break through her avoidance (e.g., picking her up from the parking lot and outside the building when she was afraid to enter the health center building and using telehealth when she wanted to cancel a therapy session combined with discussing her avoidance). In addition to cognitive interventions such as exploring the pros and cons of avoidance, she was stimulated to exercise approach behaviors at home (e.g., sharing feelings with partner or talking to other moms). Gradually, Ella became more able to diminish her tendency to avoid in therapy, as well as in daily life situations.

Working with the self-soother

DID patients frequently use alcohol, drugs, or medication to avoid dealing with intense negative emotions. In ST for DID these behaviors are reframed as the self-soother mode. The patient is made responsible for her behavior instead of going along with her tendency to attribute her behavior to an identity over which she has no control.

In the case of Ella, her cannabis use was framed as an avoidance strategy; she used cannabis daily to avoid painful feelings from past traumatic experiences. After several attempts to reach abstinence of cannabis through CBT techniques for addiction used in the context of ST, an additional clinical detox at her request helped Ella to stop her cannabis use completely. During this detox she expressed that she did not get overwhelmed by flashbacks and painful feelings, which helped her to continue abstinence, because sedation was not necessary anymore.

Trauma processing

In ST for DID, trauma processing is seen as a crucial part of therapy, which needs to start as soon as possible (usually several weeks to a few months). In ST for DID there is no stabilization phase in which skill and emotion regulation strategies are taught nor is stabilization of symptoms a prerequisite for trauma processing, whilst trauma processing in itself is found to have a stabilizing effect in patients suffering from severe childhood traumas [e.g., ( 17 )]. Trauma processing is done by ImRs, a technique that aims to change the dysfunctional meaning of early aversive experiences. It consists of prompting patients to rescript painful autobiographical memories in line with their unmet needs ( 28 ). To adapt ST to the specific needs of DID patients, the use of ImRs has been broken down in steps, to customize the pace of trauma processing and level of trauma exposure to what patients are able to deal with, gradually increasing the level of exposure and the involvement of the healthy adult part of the patient. In the case of Ella, trauma processing started after 8 weeks. This was possible due to several factors such as raising her commitment, the good working alliance, not avoiding trauma work but carrying it out at a level that was manageable for her, performing it in small steps, and the high frequency of treatment sessions. Imagery work was built up slowly, starting with a neutral experience (imagining skiing together with the therapist), whereafter mild negative (soothing of her crying as a child or being excluded at school) and more adverse negative experiences were processed (neglect and abuse experiences by father, teacher, and peer). ImRs was performed in small steps in which first the therapist rescripted, whereafter Ella was motivated to gradually participate in the rescripting (“ what would you like to say to him, okay just say that ”), and finally carrying out the rescripting herself. In the first 2 years, trauma work often disrupted her, because it activated the punitive part, sometimes leading to (para)suicidal behaviors. Therefore, in ST for DID one frequently oscillates between trauma work and working with the punitive part. At these moments, the safety plan was used and if necessary we worked with the punitive mode in the next session. In Ella, the punitive part told her she was bad and faulty and it was not worth living, making it very difficult to take care of the needs of the vulnerable child. The therapist interspersed ImRs with punitive mode work (see next paragraph) and stimulating adult healthy perspectives on feelings and needs of people. At the start the therapist kept the trauma work short (5 min) and gradually increased the duration of trauma processing (to about 30–40 min in one session). Over time, Ella thus increasingly tolerated trauma work and gained power over the traumatic experiences.

It took a long time and many repetitions before she was able to comfort and fulfill the needs of her vulnerable child. Only in the 3rd year she was able to adopt a healthier perspective on who was guilty and responsible for the abuse. In the last year she was able to rescript on her own. As a tool for performing the rescripting at home, she made a collage for each individual person who abused her to visualize the rescripting. It contained pictures of actions to stop the abuser (hitting him with a baseball bat, stabbing him with a knife, or setting fire to the house/school where the abuse took place). Additionally, it contained messages to say to the abuser ( shame on you, you're bad ), actions to bring the vulnerable child to safety (bring her to the hospital, wrapping her in warm blankets, or bringing her to a new safe home), and sentences to emphasize the innocence of the child and to build her self-worth (“ it is not your fault, there is nothing wrong with you ”).

Banishing the punitive part

In ST for DID, aggressive, punitive, and highly demanding identities are reframed as the punitive and demanding mode. Repeated, persistent, and creative ways of fighting their messages and banishment are needed to reduce the impact on the patient. ST aims to stop these messages and to increase control over them by replacing them with realistic, healthier messages.

In Ella the punitive and demanding modes (e.g., telling her she was bad, guilty, worthless, and incapable) were highly prevalent and persistent, and had a profound impact on her quality of life. They played an important role in eliciting and maintaining strong negative feelings and thoughts, self-harm (e.g., damaging her arm), and suicide attempts (by auto-intoxication). In those moments, the safety plan was initially used, followed by punitive mode work. Early in therapy, Ella felt that getting rid of the punitive mode was invalidating, because she felt that it was a part of her, and she was afraid of losing other identities as well. Repeated education and exploration of the impact of the punitive and demanding modes was necessary to work on banishing the punitive and demanding modes. Through time, and after numerous repetition of these exercises, the impact of the punitive mode was diminished. Numerous ST techniques were used in this process, such as balloon techniques (e.g., putting an imaginative protective balloon around herself to shield her from the negative messages and blowing punitive messages into a balloon after which the balloon was released). Other techniques used were imaginative muting of the mode (using a remote control to diminish the volume or using duct tape to silence the voice), shrinking the punitive mode to a smaller size, incarcerating it, chair work (e.g., putting the punitive mode on a chair, ordering it to stop, and placing it outside the room), and rituals such as burying and burning the images and messages of the punitive mode. A major breakthrough was achieved during a clinical admission due to a suicide attempt induced by the punitive mode. At this moment in time, the therapist had become really fed up with the punitive mode, and authentically and very strongly directly addressed this mode: “ I want you to get out of Ella's life, you are making her life miserable. You must leave .” Thereafter, the therapist motivated Ella to take back control and to bid farewell to the punitive mode once and for all. During an imagery exercise that followed, she imagined the punitive mode to change into a statue whereafter she shrank it, and chopped it into a thousand pieces. In the sessions that followed, Ella reported that the punitive part did not return, but she felt an empty hole within herself. The therapist and patient filled this hole with helpful messages for her vulnerable child.

Healing the vulnerable child mode

In ST for DID, child identities are conceptualized as vulnerable child modes. The therapist frequently and repeatedly reparents the vulnerable child, using imagination exercises to fulfill the needs of the vulnerable child, and gradually stimulating the healthy adult part of the patient to participate in healing the vulnerable child. Ella did not show her vulnerable side during the first treatment sessions. She feared maltreatment by the therapist. It was possible to gain her trust by creating a sense of safety within the therapy, after which she was able to let the therapist get in contact with the vulnerable child. The high treatment frequency, repeated validation of feelings and needs, and availability of the therapist might have all contributed to the relatively quick formation of a good working alliance. The therapist reparented the vulnerable child by validating and comforting Ella, but also by educating her on universal basic rights and needs of children, and responsibilities of parents as well as by recurrent rescripting of traumatic events that contributed to her negative self-image and guilt and shame feelings.

Stimulating autonomy

In ST for DID there is a strong focus on the stimulation of autonomy and taking responsibility for changing lifelong patterns throughout the treatment, because of the high levels of learned helplessness in DID patients. Ella often felt overwhelmed by her symptoms and unable to cope with most aspects of her life. Right at the start of treatment, personal goals were formulated to increase commitment and take responsibility for direction of the treatment. Also, homework exercises were given, in which Ella was asked to make summaries of each session, and was stimulated to express feelings and needs within sessions and at home (“ What does your little child mode think, feel, and need, and what does your healthy adult mode want to say to your father? ”). Especially in the last year of therapy, instead of doing the work for her, the therapist stimulated Ella to become more personally active in interventions. Autonomy and mastery were also stimulated by building a clear identity, figuring out what her likes and dislikes were, and which societal goals she wanted to pursue. In the last few months of treatment, the therapist and patient made a mode management plan together, in which all the helping interventions were included.

Review of successes

Because of a persistence of symptoms and strong feelings of helplessness, continuous focusing on the strengths of the patients and the progress they make is very important. Every 6 months, successes were reviewed by both the therapist and Ella by looking back at the positive steps she made (e.g., “ You completely stopped using cannabis for 6 months now ”, “ Lately, you were able to stay present during each entire session ”, and “ You were able to rescript yourself ”), and by looking at changes in the Mode Pie Chart [a pie chart in which the relative attendance of each mode is estimated; see ( 27 )].

The effectiveness of ST for DID is currently being investigated in two non-concurrent multiple baseline design studies in the Netherlands ( 10 ). This case report is one of the first descriptions of the practical application of ST for DID [also see ( 12 , 29 )], and illustrates that ST might be a viable and effective treatment for DID. Ella reported dissociative amnesia for traumatic experiences at the start of treatment. However, during therapy she shared that she was able to access traumatic experiences but feared confrontation and thus tried to avoid them. ImRs helped her to gradually process these traumas. ImRs was adapted to the limitations of Ella; it started as soon as possible (after several weeks), was built up gradually, and was performed continuously during the course of treatment. Furthermore, she was able to go along with a new conceptualization of the self in terms of modes instead of identities.

Ella showed strong improvement in psychiatric symptoms; there was a strong reduction of dissociative symptoms, PTSD, and depression symptoms including absence of suicidal behaviors, and abstinence from cannabis. She improved in social interaction and societal participation: she now takes care of her son and dog, her relationship with her husband has improved, she is meeting with friends, and sings in a choir. She also works as a volunteer for a needy elderly person and is applying for a job as a dentist assistant. These results are in line with studies into the effectiveness of ST and ImRs in adjacent populations ( 17 , 30 ). Ella found the termination of treatment very difficult, especially saying farewell to her therapist. Working so closely together during several years created a strong attachment bond, and ending of treatment can be difficult for both therapist and patient. Furthermore, because of the descriptive nature of this case report, no conclusion can be drawn about the evidence base of ST for DID; follow-up assessments were performed but cannot be presented because this case is part of a non-concurrent multiple baseline design study amongst 10 DID patients which is not yet finalized, so the results of individual participants cannot be shared ( 10 ).

This case report shows how ST can be applied to DID and suggests the possible effectiveness of ST for DID in general. An important next step is to systematically investigate the effectiveness of ST for DID in methodologically well-designed treatment studies, possibly leading to evidence-based treatments that go beyond stabilization of symptoms.

Patient perspective

Ella reported that ST for DID was and still is hard work. She has learned tools with which she can take and keep more control over modes and flashbacks. Where she used to avoid many situations and places, she now has the confidence to know that she can manage these on her own.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

The studies involving human participants were reviewed and approved by the Ethics Committee of the Faculty of Behavioral and Social Sciences of the University of Groningen (EC-GMW). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

NB wrote the first draft of the manuscript. All authors read, commented on, and approved the manuscript.

Acknowledgments

We thank Ella for her participation in the study and her consent for the publication of this case report. We also thank Ida Shaw for her supervision of this ST trajectory.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: schema therapy, Dissociative Identity Disorder, case report, PTSD, personality disorder

Citation: Bachrach N, Rijkeboer MM, Arntz A and Huntjens RJC (2023) Schema therapy for Dissociative Identity Disorder: a case report. Front. Psychiatry 14:1151872. doi: 10.3389/fpsyt.2023.1151872

Received: 26 January 2023; Accepted: 04 April 2023; Published: 21 April 2023.

Reviewed by:

Copyright © 2023 Bachrach, Rijkeboer, Arntz and Huntjens. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nathan Bachrach, n.bachrach@tilburguniversity.edu

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Dissociative Identity Disorder Cases: Famous and Amazing

Famous cases of dissociative identity disorder include those seen in court and in books. Check these out, plus DID case studies.

There are many famous dissociative identity disorder (DID) cases, probably because people are so fascinated by the disorder. While DID is rare, detailed reports of DID have existed since the 18th century. Famous cases of dissociative identity disorder have been featured on the Oprah Winfrey show, in books and have been seen in criminal trials. (See Real Dissociative Identity Disorder Stories and Videos and Celebrities and Famous People with DID )

A Dissociative Identity Disorder Case in Court: Billy Milligan

In 1977, Billy Milligan was arrested for kidnapping, robbing and raping three women around Ohio State University. After being arrested, he saw a psychiatrist who diagnosed him with DID (See how DID is diagnosed ). It was argued in court that Milligan wasn't guilty as, at the time of the crimes, two other personalities were in control -- Ragen, a Yugoslavian man and Adalana, a lesbian ( Understanding Dissociative Identity Disorder Alters ).

The jury agreed with the defense and Milligan became the first person ever to be found not guilty due to dissociative identity disorder . Milligan was confined to a mental hospital until 1988 when psychiatrists felt that all the personalities had melded together.

An upcoming film, The Crowded Room , will be based on his famous case of dissociative identity disorder.

Famous Cases of DID: Kim Noble

Kim Noble was born in 1960 and, from a young age, was physically abused. As a teenager, she suffered many mental problems and overdosed several times.

It wasn't until her 20s that other personalities began to appear. "Julie" was a very destructive personality that ran Noble's van into a bunch of parked cars. "Hayley," another personality, was involved in a pedophile ring.

In 1995, Noble received a DID diagnosis and has been getting psychiatric help ever since. It's not known how many personalities Noble has as she goes through four or five personalities a day, but it is thought to be around 100. "Patricia" is Noble's most dominant personality and she is a calm and confident woman.

Noble (as Patricia) and her daughter appeared on The Oprah Winfrey Show in 2010. In 2012, she published a book about her experiences: All of Me: How I Learned to Live with the Many Personalities Sharing My Body.

A Dissociative Disorder Case Study

In 2005, a dissociative identity disorder case study of a woman named "Kathy" (not her real name) was published in Journal of the Islamic Medical Association of North America.

Kathy's traumas began when she was three. At that age, she would have terrible nightmares during which her parents would often entertain leaving the child to cry for hours before falling asleep only to awake a few hours later frightened and screaming.

At age four, Kathy found her father in bed with a five-year-old neighbor. At that time, her father convinced her to join in on the sexual activity. Kathy felt guilty and cried for several hours only stopping once she began to attribute what had happened to an alternate personality, Pat. Kathy would insist on being called Pat during the abuse the father committed for the next five years.

At age nine, Kathy's mother discovered Kathy and her father in bed together. Her mother insisted on the child sleeping in her bed every night thereafter leading to a sexual relationship with the child. Kathy could not accept this and created another identity, Vera, who continued the relationship for another five years.

At age 14, Kathy was raped by her father's best friend and began calling herself Debbie. At that time, she became very depressed and mute and was admitted to a hospital (read why some go to dissociative identity (DID) treatment centers ).

According to the case study, "she showed a mixture of depression, dissociation and trance-like symptoms, with irritability and extensive manipulation which caused confusion and frustration among the hospital staff."

At age 18, Kathy became very attached to her boyfriend but her parents forbid her to see him. Kathy then ran away from home to a new town. However, she could not find a job and her need of money drove her to prostitution. She began to call herself Nancy at this point.

The alternate personality Debbie rejected Nancy and forced her to overdose on sleeping pills. It was then that Kathy was admitted to a psychiatric hospital and given the diagnosis of multiple personality disorder (as it was known at the time). (More on the history of dissociative identity disorder here.)

Kathy is now 29, married, and continues to struggle with mental health problems including dissociative episodes.

article references

APA Reference Tracy, N. (2022, January 4). Dissociative Identity Disorder Cases: Famous and Amazing, HealthyPlace. Retrieved on 2024, February 20 from https://www.healthyplace.com/abuse/dissociative-identity-disorder/dissociative-identity-disorder-cases-famous-and-amazing

Medically reviewed by Harry Croft, MD

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There are celebrities and famous people with dissociative identity disorder. We have the story of Sybil, pro football star, Herschel Walker and others.

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  • What Is a Case Study? | Definition, Examples & Methods

What Is a Case Study? | Definition, Examples & Methods

Published on May 8, 2019 by Shona McCombes . Revised on November 20, 2023.

A case study is a detailed study of a specific subject, such as a person, group, place, event, organization, or phenomenon. Case studies are commonly used in social, educational, clinical, and business research.

A case study research design usually involves qualitative methods , but quantitative methods are sometimes also used. Case studies are good for describing , comparing, evaluating and understanding different aspects of a research problem .

Table of contents

When to do a case study, step 1: select a case, step 2: build a theoretical framework, step 3: collect your data, step 4: describe and analyze the case, other interesting articles.

A case study is an appropriate research design when you want to gain concrete, contextual, in-depth knowledge about a specific real-world subject. It allows you to explore the key characteristics, meanings, and implications of the case.

Case studies are often a good choice in a thesis or dissertation . They keep your project focused and manageable when you don’t have the time or resources to do large-scale research.

You might use just one complex case study where you explore a single subject in depth, or conduct multiple case studies to compare and illuminate different aspects of your research problem.

Prevent plagiarism. Run a free check.

Once you have developed your problem statement and research questions , you should be ready to choose the specific case that you want to focus on. A good case study should have the potential to:

  • Provide new or unexpected insights into the subject
  • Challenge or complicate existing assumptions and theories
  • Propose practical courses of action to resolve a problem
  • Open up new directions for future research

TipIf your research is more practical in nature and aims to simultaneously investigate an issue as you solve it, consider conducting action research instead.

Unlike quantitative or experimental research , a strong case study does not require a random or representative sample. In fact, case studies often deliberately focus on unusual, neglected, or outlying cases which may shed new light on the research problem.

Example of an outlying case studyIn the 1960s the town of Roseto, Pennsylvania was discovered to have extremely low rates of heart disease compared to the US average. It became an important case study for understanding previously neglected causes of heart disease.

However, you can also choose a more common or representative case to exemplify a particular category, experience or phenomenon.

Example of a representative case studyIn the 1920s, two sociologists used Muncie, Indiana as a case study of a typical American city that supposedly exemplified the changing culture of the US at the time.

While case studies focus more on concrete details than general theories, they should usually have some connection with theory in the field. This way the case study is not just an isolated description, but is integrated into existing knowledge about the topic. It might aim to:

  • Exemplify a theory by showing how it explains the case under investigation
  • Expand on a theory by uncovering new concepts and ideas that need to be incorporated
  • Challenge a theory by exploring an outlier case that doesn’t fit with established assumptions

To ensure that your analysis of the case has a solid academic grounding, you should conduct a literature review of sources related to the topic and develop a theoretical framework . This means identifying key concepts and theories to guide your analysis and interpretation.

There are many different research methods you can use to collect data on your subject. Case studies tend to focus on qualitative data using methods such as interviews , observations , and analysis of primary and secondary sources (e.g., newspaper articles, photographs, official records). Sometimes a case study will also collect quantitative data.

Example of a mixed methods case studyFor a case study of a wind farm development in a rural area, you could collect quantitative data on employment rates and business revenue, collect qualitative data on local people’s perceptions and experiences, and analyze local and national media coverage of the development.

The aim is to gain as thorough an understanding as possible of the case and its context.

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In writing up the case study, you need to bring together all the relevant aspects to give as complete a picture as possible of the subject.

How you report your findings depends on the type of research you are doing. Some case studies are structured like a standard scientific paper or thesis , with separate sections or chapters for the methods , results and discussion .

Others are written in a more narrative style, aiming to explore the case from various angles and analyze its meanings and implications (for example, by using textual analysis or discourse analysis ).

In all cases, though, make sure to give contextual details about the case, connect it back to the literature and theory, and discuss how it fits into wider patterns or debates.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

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  • Published: 12 February 2024

Plasma proteomic profiles predict future dementia in healthy adults

  • Yu Guo 1   na1 ,
  • Jia You   ORCID: orcid.org/0000-0002-7079-8041 1 , 2   na1 ,
  • Yi Zhang 1   na1 ,
  • Wei-Shi Liu 1 ,
  • Yu-Yuan Huang 1 ,
  • Ya-Ru Zhang 1 ,
  • Wei Zhang 2 ,
  • Qiang Dong   ORCID: orcid.org/0000-0002-3874-0130 1 ,
  • Jian-Feng Feng   ORCID: orcid.org/0000-0001-5987-2258 2 , 3 ,
  • Wei Cheng   ORCID: orcid.org/0000-0003-1118-1743 1 , 2 , 3 &
  • Jin-Tai Yu   ORCID: orcid.org/0000-0002-2532-383X 1  

Nature Aging volume  4 ,  pages 247–260 ( 2024 ) Cite this article

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  • Neurodegeneration
  • Predictive markers

The advent of proteomics offers an unprecedented opportunity to predict dementia onset. We examined this in data from 52,645 adults without dementia in the UK Biobank, with 1,417 incident cases and a follow-up time of 14.1 years. Of 1,463 plasma proteins, GFAP, NEFL, GDF15 and LTBP2 consistently associated most with incident all-cause dementia (ACD), Alzheimer’s disease (AD) and vascular dementia (VaD), and ranked high in protein importance ordering. Combining GFAP (or GDF15) with demographics produced desirable predictions for ACD (area under the curve (AUC) = 0.891) and AD (AUC = 0.872) (or VaD (AUC = 0.912)). This was also true when predicting over 10-year ACD, AD and VaD. Individuals with higher GFAP levels were 2.32 times more likely to develop dementia. Notably, GFAP and LTBP2 were highly specific for dementia prediction. GFAP and NEFL began to change at least 10 years before dementia diagnosis. Our findings strongly highlight GFAP as an optimal biomarker for dementia prediction, even more than 10 years before the diagnosis, with implications for screening people at high risk for dementia and for early intervention.

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did case study pdf

Data availability

The data used in the present study are available from UK Biobank with restrictions applied. Data were used under license and are thus not publicly available. Access to the UK Biobank data can be requested through a standard protocol ( https://www.ukbiobank.ac.uk/register-apply/ ). Data used in this study are available in the UK Biobank under application number 19542. All data supporting the findings described in this manuscript are available in the article and in the supplementary materials and from the corresponding author upon request. Source data are provided with this paper.

Code availability

All software used in this study is publicly available. The code used in this study can be accessed at https://github.com/jasonHKU0907/DementiaProteomicPrediction .

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Acknowledgements

We thank all the participants and researchers from the UK Biobank. W.C. was funded by National Key Research and Development Program of China (grant no. 2023YFC3605400). J.T.-Y. was funded by grants from the Science and Technology Innovation 2030 Major Projects (grant no. 2022ZD0211600), National Natural Science Foundation of China (grant nos. 82071201, 92249305), Research Start-up Fund of Huashan Hospital (grant no. 2022QD002) and Excellence 2025 Talent Cultivation Program at Fudan University (grant no. 3030277001). J.F.-F. was funded by National Key R&D Program of China (grant nos. 2018YFC1312904, 2019YFA0709502), Shanghai Municipal Science and Technology Major Project (grant no. 2018SHZDZX01) and the 111 Project (no. B18015). J.Y. was funded by Shanghai Pujiang Talent Program (grant no. 23PJD006). The funders had no role in study design, data collection and analysis; decision to publish or preparation of the manuscript. Further, we would like to thank the support from the ZHANGJIANG LAB, Tianqiao and Chrissy Chen Institute, and the State Key Laboratory of Neurobiology and Frontiers Center for Brain Science of Ministry of Education, Fudan University.

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These authors contributed equally: Yu Guo, Jia You, Yi Zhang.

Authors and Affiliations

Department of Neurology and National Center for Neurological Disorders, Huashan Hospital, State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Shanghai Medical College, Fudan University, Shanghai, China

Yu Guo, Jia You, Yi Zhang, Wei-Shi Liu, Yu-Yuan Huang, Ya-Ru Zhang, Qiang Dong, Wei Cheng & Jin-Tai Yu

Institute of Science and Technology for Brain-inspired Intelligence, Fudan University, Shanghai, China

Jia You, Wei Zhang, Jian-Feng Feng & Wei Cheng

Key Laboratory of Computational Neuroscience and Brain-inspired Intelligence, Fudan University, Ministry of Education, Shanghai, China

Jian-Feng Feng & Wei Cheng

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J.-T.Y. undertook conceptualization and design of the study, interpretation of the data and revision of the manuscript. Y.G., J.Y. and Y.Z. collected, analyzed and interpreted the data, and drafted and revised the manuscript. J.-F.F., W.C. and J.-T.Y. were responsible for funding, administrative, technical or material support. All authors carried out revision of the manuscript. All authors had full access to all the study data and accepted responsibility for submitting it for publication.

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Correspondence to Jian-Feng Feng , Wei Cheng or Jin-Tai Yu .

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Extended data

Extended data fig. 1 flowchart for participants’ enrollment..

From the UK Biobank cohort, we excluded individuals with dementia at baseline or with self-reported dementia and those who did not undergo plasma proteomic assay. The remaining participants were classified based on their first reported years of ACD or AD or VaD after baseline. Abbreviations: ACD, all-cause dementia; AD, Alzheimer’s disease; VaD, vascular dementia.

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Supplementary Figs. 1–6.

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Guo, Y., You, J., Zhang, Y. et al. Plasma proteomic profiles predict future dementia in healthy adults. Nat Aging 4 , 247–260 (2024). https://doi.org/10.1038/s43587-023-00565-0

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did case study pdf

The Cases Against Trump: A Guide

Fraud. Hush money. Election subversion. Mar-a-Lago documents. One place to keep track of the presidential candidate’s legal troubles.

Arrows pointing at Donald Trump

Not long ago, the idea that a former president—or major-party presidential nominee—would face serious legal jeopardy was nearly unthinkable. Today, merely keeping track of the many cases against Donald Trump requires a law degree, a great deal of attention, or both.

In all, Trump faces 91 felony counts across two state courts and two different federal districts, any of which could potentially produce a prison sentence. He’s also dealing with a civil suit in New York that could force drastic changes to his business empire, including closing down its operations in his home state. Meanwhile, he is the leading Republican candidate in the race to become the next president—though the Supreme Court has now heard a case seeking to disqualify him. If the criminal and civil cases unfold with any reasonable timeliness, he could be in the heat of the campaign at the same time that his legal fate is being decided.

David A. Graham: The end of Trump Inc.

Here’s a summary of the major legal cases against Trump, including key dates, an assessment of the gravity of the charges, and expectations about how they could turn out. This guide will be updated regularly as the cases proceed.

New York State: Fraud

In the fall of 2022, New York Attorney General Letitia James filed a civil suit against Trump, his adult sons, and his former aide Allen Weisselberg, alleging a years-long scheme in which Trump fraudulently reported the value of properties in order to either lower his tax bill or improve the terms of his loans, all with an eye toward inflating his net worth.

When? Justice Arthur Engoron ruled against Trump and his co-defendants in late September 2023, concluding that many of the defendants’ claims were “clearly” fraudulent—so clearly that he didn’t need a trial to hear them. (He also sanctioned Trump’s lawyers for making repeated frivolous arguments.) Engoron has also fined Trump a total of $15,000 for violating a gag order in the case. The trial ended in January, and a ruling is currently expected in mid-February .

How grave is the allegation? Fraud is fraud, and in this case, the sum of the fraud stretched into the millions—but compared with some of the other legal matters in which Trump is embroiled, this is pretty pedestrian. The case is also civil rather than criminal. But although the stakes are lower for the nation, they remain high for Trump: Engoron could bar Trump’s famed company from business in New York, strip it of several key properties, and fine Trump hundreds of millions of dollars.

How plausible is a guilty verdict? Engoron has already ruled that Trump committed fraud. The outstanding questions are what damages he might have to pay and what exactly Engoron’s ruling means for Trump’s business and properties in New York.

Manhattan: Defamation and Sexual Assault

Although these other cases are all brought by government entities, Trump also faced a pair of defamation suits from the writer E. Jean Carroll, who said that Trump sexually assaulted her in a department-store dressing room in the 1990s. When he denied it, she sued him for defamation and later added a battery claim.

When? In May 2023, a jury concluded that Trump had sexually assaulted and defamed Carroll, and awarded her $5 million. A second defamation case produced an $83.3 million judgment in January 2024.

How grave was the allegation? Although these cases don’t directly connect to the same fundamental issues of rule of law and democratic governance that some of the criminal cases do, they were a serious matter, and a federal judge’s blunt statement that Trump raped Carroll has gone underappreciated.

What happens now? Trump has appealed both cases. During the second trial, he also continued to insult Carroll, which may have courted additional defamation suits.

Manhattan: Hush Money

In March 2023, Manhattan District Attorney Alvin Bragg became the first prosecutor to bring felony charges against Trump, alleging that the former president falsified business records as part of a scheme to pay hush money to women who said they had had sexual relationships with Trump.

When? The case is set to go to trial on March 25, Judge Juan Merchant said on February 15.

How grave is the allegation? Falsifying records is a crime, and crime is bad. But many people have analogized this case to Al Capone’s conviction on tax evasion: It’s not that he didn’t deserve it, but it wasn’t really why he was an infamous villain. That this case alleges behavior that didn’t directly attack elections or put national secrets at risk makes it feel more minor—in part because other cases have set a grossly high standard for what constitutes gravity.

How plausible is a guilty verdict? Bragg’s case faces hurdles including arguments over the statute of limitations, a questionable key witness in the former Trump fixer Michael Cohen, and some fresh legal theories. In short, the Manhattan case seems like perhaps the least significant and most tenuous criminal case. Some Trump critics were dismayed that Bragg was the first to bring criminal charges against the former president.

Department of Justice: Mar-a-Lago Documents

Jack Smith, a special counsel in the U.S. Justice Department, has charged Trump with 37 felonies in connection with his removal of documents from the White House when he left office. The charges include willful retention of national-security information, obstruction of justice, withholding of documents, and false statements. Trump took boxes of documents to properties where they were stored haphazardly, but the indictment centers on his refusal to give them back to the government despite repeated requests.

David A. Graham: This indictment is different

When? Smith filed charges in June 2023. Judge Aileen Cannon has set a trial date of May 20, 2024. In November, she rejected Trump’s request to push that back but said she would reconsider timing in March . Smith faces a de facto deadline of January 20, 2025, at which point Trump or any Republican president would likely shut down a case.

How grave is the allegation? These are, I have written, the stupidest crimes imaginable , but they are nevertheless very serious. Protecting the nation’s secrets is one of the greatest responsibilities of any public official with classified clearance, and not only did Trump put these documents at risk, but he also (allegedly) refused to comply with a subpoena, tried to hide them, and lied to the government through his attorneys.

How plausible is a guilty verdict? This may be the most open-and-shut case, and the facts and legal theory here are pretty straightforward. But Smith seems to have drawn a short straw when he was randomly assigned Cannon, a Trump appointee who has sometimes ruled favorably for Trump on procedural matters. Some legal commentators have even accused her of “ sabotaging ” the case.

Fulton County: Election Subversion

In Fulton County, Georgia, which includes most of Atlanta, District Attorney Fani Willis brought a huge racketeering case against Trump and 18 others, alleging a conspiracy that spread across weeks and states with the aim of stealing the 2020 election.

When? Willis obtained the indictment in August 2023. The number of people charged makes the case unwieldy and difficult to track. Several of them, including Kenneth Chesebro , Sidney Powell , and Jenna Ellis, struck plea deals in the fall. Willis has proposed a trial date of August 5, 2024, for the remaining defendants.

How grave is the allegation? More than any other case, this one attempts to reckon with the full breadth of the assault on democracy following the 2020 election.

How plausible is a guilty verdict? Expert views differ. This is a huge case for a local prosecutor, even in a county as large as Fulton, to bring. The racketeering law allows Willis to sweep in a great deal of material, and she has some strong evidence—such as a call in which Trump asked Georgia Secretary of State Brad Raffensperger to “find” some 11,000 votes. Three major plea deals from co-defendants may also ease Willis’s path, but getting a jury to convict Trump will still be a challenge. Complicating matters, Willis is now under fire for a romantic relationship with an attorney she hired as a special prosecutor.

Department of Justice: Election Subversion

Special Counsel Smith has also charged Trump with four federal felonies in connection with his attempt to remain in power after losing the 2020 election. This case is in court in Washington, D.C.

When? A grand jury indicted Trump on August 1, 2023. The trial was originally schedule for March 4, but Judge Tanya Chutkan said in early February that the date would change, as an appeals court deliberated on Trump’s claim of absolute immunity. A three-judge panel roundly rejected that claim on February 6, but no new trial date has been announced yet. As with the other DOJ case, Smith will need to move quickly, before Trump or any other Republican president could shut down a case upon taking office in January 2025. Other tangential legal skirmishes continue: In October, after verbal attacks by Trump on witnesses and Smith’s wife, Chutkan issued an order limiting what Trump can say about the case.

David A. Graham: Trump attempted a brazen, dead-serious attack on American democracy

How grave is the allegation? This case rivals the Fulton County one in importance. It is narrower, focusing just on Trump and a few key elements of the paperwork coup , but the symbolic weight of the U.S. Justice Department prosecuting an attempt to subvert the American election system is heavy.

How plausible is a guilty verdict? It’s very hard to say. Smith avoided some of the more unconventional potential charges, including aiding insurrection, and everyone watched much of the alleged crime unfold in public in real time, but no precedent exists for a case like this, with a defendant like this.

Additionally …

In more than 30 states , cases have been filed over whether Trump should be thrown off the 2024 ballot under a novel legal theory about the Fourteenth Amendment. Proponents, including J. Michael Luttig and Laurence H. Tribe in The Atlantic , argued that the former president is ineligible to serve again under a clause that disqualifies anyone who took an oath defending the Constitution and then subsequently participated in a rebellion or an insurrection. They said that Trump’s attempt to steal the 2020 election and his incitement of the January 6 riot meet the criteria.

Cases were brought in many states, and state authorities issued conflicting opinions. Several states ruled against removing Trump from the ballot, but the Colorado Supreme Court and the Maine secretary of state both disqualified him, ruling that he had engaged in an insurrection—a remarkable legal finding. Trump then appealed to the U.S. Supreme Court.

When? The U.S. Supreme Court heard arguments in the case on February 8. The timing for a decision is not clear.

How grave is the allegation? In a sense, the claim made here is even graver than the criminal election-subversion cases filed against Trump by the U.S. Department of Justice and in Fulton County, Georgia, because neither of those cases alleges insurrection or rebellion. But the stakes are also much different—rather than criminal conviction, they concern the ability to serve as president.

How plausible is a disqualification? Though there is a robust debate among legal scholars on this question, the nine who matter are the ones on the Supreme Court, and they appeared very skeptical of arguments in favor of disqualification during the February 8 hearing.

Judge fines Donald Trump more than $350 million, bars him from running businesses in N.Y. for three years

The judge who presided over a civil business fraud trial against Donald Trump on Friday ordered the former president, his sons, business associates and company to pay more than $350 million in damages and temporarily limited their ability to do business in New York.

Judge Arthur Engoron ordered the former president and the Trump Organization to pay over $354 million in damages , and barred Trump “from serving as an officer or director of any New York corporation or other legal entity in New York for a period of three years,” including his namesake company.

New York Attorney General Letitia James, whose office brought the case, said that with pre-judgment interest, the judgment totals over $450 million, an amount “which will continue to increase every single day” until the judgment is paid.

“Donald Trump is finally facing accountability for his lying, cheating, and staggering fraud. Because no matter how big, rich, or powerful you think you are, no one is above the law,” James said in a statement, calling the ruling “a tremendous victory for this state, this nation, and for everyone who believes that we all must play by the same rules — even former presidents.”

The ruling also bars Trump and his company from applying for any bank loans for three years.

In his first public remarks after the ruling, Trump said, “We’ll appeal and we’ll be successful.”

Speaking to reporters at Mar-a-Lago on Friday night, Trump bashed the ruling as “a fine of 350 million for a doing a perfect job.” He also repeated previous attacks by calling the judge “crooked” and the attorney general “corrupt.”

Trump did not take any questions from reporters after speaking for about six minutes.

The judge’s decision is a potential blow to both Trump’s finances and persona — having built his brand on being a successful businessman that he leveraged in his first run for president. Trump is currently running for the White House for a third time. This case is just one of many he is currently facing, including four separate pending criminal trials, the first of which is scheduled to begin on March 25.

Engoron also ordered the continued “appointment of an Independent Monitor” and the “the installation of an Independent Director of Compliance” for the company.

In posts on his social media platform Truth Social, Trump called the ruling “an illegal, unAmerican judgment against me, my family, and my tremendous business.”

“This ‘decision’ is a complete and total sham,” he wrote.

During the trial, Trump and executives at his company, including his sons Donald Trump Jr. and Eric Trump, attempted to blame exaggerated financial statements that were the heart of New York Attorney General Letitia James’ fraud case on the accountants who compiled them. Engoron disagreed.

“There is overwhelming evidence from both interested and non-interested witnesses, corroborated by documentary evidence, that the buck for being truthful in the supporting data valuations stopped with the Trump Organization, not the accountants,” he wrote.

In explaining the need for a monitor, the judge cited the lack of remorse by Trump and his executives after the fraud was discovered.

“Their complete lack of contrition and remorse borders on pathological. They are accused only of inflating asset values to make more money. The documents prove this over and over again. This is a venial sin, not a mortal sin. Defendants did not commit murder or arson. They did not rob a bank at gunpoint. Donald Trump is not Bernard Madoff. Yet, defendants are incapable of admitting the error of their ways,” Engoron wrote.

“Defendants’ refusal to admit error — indeed, to continue it, according to the Independent Monitor — constrains this Court to conclude that they will engage in it going forward unless judicially restrained,” he added.

The ruling also bars the Trump sons — who’ve been running the company since their father went to the White House — “from serving as an officer or director of any New York corporation or other legal entity in New York for a period of two years.” Both were fined over $4 million, plus interest, for their roles in the scheme.

Donald Trump Jr. posted on the social media site X that “We’ve reached the point where your political beliefs combined with what venue your case is heard are the primary determinants of the outcome; not the facts of the case! It’s truly sad what’s happened to our country.”

In a statement, Eric Trump called the judge “a cruel man.”

“He knows that every single witness testified to that fact that I had absolutely NOTHING to do with this case (as INSANE as the case truly is),” Eric Trump said.

He also attacked the ruling as “political vengeance by a judge out to get my father.”

 Trump attorney Alina Habba called the verdict “a manifest injustice — plain and simple.”

“Given the grave stakes, we trust that the Appellate Division will overturn this egregious verdict and end this relentless persecution against my clients,” she said in a statement.

A spokesperson for Trump Organization called the ruling “a gross miscarriage of justice. The Trump Organization has never missed any loan payment or been in default on any loan.”

High legal costs

An appeal in the case would likely take years, but Trump could have to post a bond for the full amount if he does so.

Read more: Trump faces about $400 million in legal penalties. Can he afford it?

The judgment is the second this year against Trump after he was hit last month with an $83.3 million verdict in writer E. Jean Carroll’s defamation case against him. Trump has said he plans to appeal that verdict as well, but would have to post a bond for that amount as well.

James had been seeking $370 million from Trump, his company and its top executives, alleging “repeated and persistent fraud ” that included falsifying business records and financial statements. James had argued those financial statements were at times exaggerated by as much as $2.2 billion.

James contended the defendants used the inflated financial statements to obtain bank loans and insurance policies at rates he otherwise wouldn’t have been entitled to and “reaped hundreds of millions of dollars in ill-gotten gains.”

Trump had maintained his financial statements were conservative, and has called the AG’s allegations politically motivated and a “fraud on me.”

“This is a case that should have never been brought, and I think we should be entitled to damages,” Trump told reporters when he attended closing arguments in the case on Jan. 11.

Trump testimony knocked

The monthslong civil trial included testimony from Trump and his oldest children . The former president was combative in his day on the stand, blasting James as a “hack” and calling the judge “extremely hostile.”

Trump repeatedly complained about Engoron before and throughout the trial, and the judge slapped him with a partial gag order after he started blasting the judge’s law clerk as well. Trump’s complaints led to a flood of death threats against the clerk, as well as Engoron, court officials said, and Trump was fined $15,000 for twice violating the order.

Among the examples cited as fraud by the attorney general’s office during the trial was Trump valuing his triplex home in Trump Tower in New York City at three times its actual size and value, as well as including a brand value to increase the valuation of his golf courses on the financial statements, which explicitly said brand values were not included.

Another example pointed to by the attorney general clearly got under his skin — a dispute over the value of Mar-a-Lago, his social club and residence in Florida. Trump’s financial statements from 2011 to 2021 valued Mar-a-Lago at $426 million to $612 million, while the Palm Beach County assessor appraised the property’s market value to be $18 million to $27 million during the same time frame. Trump had also fraudulently puffed up the value of the property by saying it was a private residence, despite having signed an agreement that it could only be used as a social club to lower his tax burden.

Trump maintained during the trial the property was worth much, much more .

“The judge had it at $18 million, and it is worth, say, I say from 50 to 100 times more than that. So I don’t know how you got those numbers,” Trump testified, adding later that he thinks it’s actually worth “between a billion and a billion five.”

In his ruling Friday, Engoron said he didn’t find Trump to be a credible witness.

“Overall, Donald Trump rarely responded to the questions asked, and he frequently interjected long, irrelevant speeches on issues far beyond the scope of the trial. His refusal to answer the questions directly, or in some cases, at all, severely compromised his credibility,” the judge wrote.

Michael Cohen testimony ‘credible’

James’ investigation into the former president’s business began in 2019 as a result of congressional testimony from his former personal lawyer Michael Cohen , who told the House Oversight Committee that Trump would improperly expand and shrink values to fit whatever his business needs were.

Cohen testified during the trial about his role in the scheme, and said while Trump didn’t explicitly tell him and then-Chief Financial Officer Allen Weisselberg to inflate the numbers in the financial statement, he was like a “mob boss” who tells you what he wants without directly telling you.

Trump claimed Cohen’s testimony exonerated him while also painting him as an untrustworthy liar because he admitted having previously lied under oath.

In his ruling, Engoron called Cohen an “important witness” and said he found his testimony “credible.” “This factfinder does not believe that pleading guilty to perjury means that you can never tell the truth. Michael Cohen told the truth,” the judge wrote.

Former CFO ‘evasive’

Engoron was less forgiving about former Trump CFO Weisselberg, who previously pleaded guilty to carrying out tax fraud at the company.

Weisselberg’s “testimony in this trial was intentionally evasive, with large gaps of ‘I don’t remember.’”

“There is overwhelming evidence that Allen Weisselberg intentionally falsified hundreds of business records during his tenure” at the company, the judge wrote. “Weisselberg understood that his assignment from Donald Trump was to have his reported assets increase every year irrespective of their actual values. The examples of Weisselberg’s intent to falsify business records are too numerous to itemize,” he added.

The judge permanently barred Weisselberg “from serving in the financial control function of any New York corporation or similar business entity operating in New York State,” and ordered him to pay the $1 million he’s already received from his $2 million separation agreement from the company as “ill-gotten gains.”

AG initially sought less

James filed her suit seeking $250 million in damages from Trump in 2022, and the judge appointed a monitor to oversee the company’s finances that November.

In a summary judgment  ruling the week before the trial started, Engoron found Trump and his executives had repeatedly engaged in fraud. The “documents here clearly contain fraudulent valuations that defendants used in business, satisfying [the attorney general’s] burden to establish liability as a matter of law against defendants,” the judge wrote, while denying Trump’s bid to dismiss the case.

Engoron summarized the Trump defense as “the documents do not say what they say; that there is no such thing as ‘objective’ value; and that, essentially, the Court should not believe its own eyes.”

The order, which Trump appealed, held that Trump’s business certificates in New York should be canceled, which could have wreaked havoc on Trump’s company and forced the sell-off of some assets.

Engoron backed off of that decision in his ruling Friday, saying the addition of the “two-tiered oversight” of the monitor and the compliance director makes that move “no longer necessary.”

Trump had complained about the summary judgment ruling while he was on the witness stand. “He said I was a fraud before he knew anything about me, nothing about me,” Trump said. “It’s a terrible thing you did.”

did case study pdf

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College of Nursing

Driving change: a case study of a dnp leader in residence program in a gerontological center of excellence.

View as pdf A later version of this article appeared in Nurse Leader , Volume 21, Issue 6 , December 2023 . 

The American Association of Colleges of Nursing (AACN) published the Essentials of Doctoral Education for Advanced Practice Nursing in 2004 identifying the essential curriculum needed for preparing advanced practice nurse leaders to effectively assess organizations, identify systemic issues, and facilitate organizational changes. 1 In 2021, AACN updated the curriculum by issuing The Essentials: Core Competencies for Professional Nursing Education to guide the development of competency-based education for nursing students. 1 In addition to AACN’s competency-based approach to curriculum, in 2015 the American Organization of Nurse Leaders (AONL) released Nurse Leader Core Competencies (updated in 2023) to help provide a competency based model to follow in developing nurse leaders. 2

Despite AACN and AONL competency-based curriculum and model, it is still common for nurse leaders to be promoted to management positions based solely on their work experience or exceptional clinical skills, rather than demonstration of management and leadership competencies. 3 The importance of identifying, training, and assessing executive leaders through formal leadership development programs, within supportive organizational cultures has been discussed by national leaders. As well as the need for nurturing emerging leaders through fostering interprofessional collaboration, mentorship, and continuous development of leadership skills has been identified. 4 As Doctor of Nursing Practice (DNP) nurse leaders assume executive roles within healthcare organizations, they play a vital role within complex systems. Demonstration of leadership competence and participation in formal leadership development programs has become imperative for their success. However, models of competency-based executive leadership development programs can be hard to find, particularly programs outside of health care systems.

The implementation of a DNP Leader in Residence program, such as the one designed for The Barbara and Richard Csomay Center for Gerontological Excellence, addresses many of the challenges facing new DNP leaders and ensures mastery of executive leadership competencies and readiness to practice through exposure to varied experiences and close mentoring. The Csomay Center , based at The University of Iowa, was established in 2000 as one of the five original Hartford Centers of Geriatric Nursing Excellence in the country. Later funding by the Csomay family established an endowment that supports the Center's ongoing work. The current Csomay Center strategic plan and mission aims to develop future healthcare leaders while promoting optimal aging and quality of life for older adults. The Csomay Center Director created the innovative DNP Leader in Residence program to foster the growth of future nurse leaders in non-healthcare systems. The purpose of this paper is to present a case study of the development and implementation of the Leader in Residence program, followed by suggested evaluation strategies, and discussion of future innovation of leadership opportunities in non-traditional health care settings.

Development of the DNP Leader in Residence Program

The Plan-Do-Study-Act (PDSA) cycle has garnered substantial recognition as a valuable tool for fostering development and driving improvement initiatives. 5 The PDSA cycle can function as an independent methodology and as an integral component of broader quality enhancement approaches with notable efficacy in its ability to facilitate the rapid creation, testing, and evaluation of transformative interventions within healthcare. 6 Consequently, the PDSA cycle model was deemed fitting to guide the development and implementation of the DNP Leader in Residence Program at the Csomay Center.

PDSA Cycle: Plan

Existing resources. The DNP Health Systems: Administration/Executive Leadership Program offered by the University of Iowa is comprised of comprehensive nursing administration and leadership curriculum, led by distinguished faculty composed of national leaders in the realms of innovation, health policy, leadership, clinical education, and evidence-based practice. The curriculum is designed to cultivate the next generation of nursing executive leaders, with emphasis on personalized career planning and tailored practicum placements. The DNP Health Systems: Administration/Executive Leadership curriculum includes a range of courses focused on leadership and management with diverse topics such as policy an law, infrastructure and informatics, finance and economics, marketing and communication, quality and safety, evidence-based practice, and social determinants of health. The curriculum is complemented by an extensive practicum component and culminates in a DNP project with additional hours of practicum.

New program. The DNP Leader in Residence program at the Csomay Center is designed to encompass communication and relationship building, systems thinking, change management, transformation and innovation, knowledge of clinical principles in the community, professionalism, and business skills including financial, strategic, and human resource management. The program fully immerses students in the objectives of the DNP Health Systems: Administration/Executive Leadership curriculum and enables them to progressively demonstrate competencies outlined by AONL. The Leader in Residence program also includes career development coaching, reflective practice, and personal and professional accountability. The program is integrated throughout the entire duration of the Leader in Residence’s coursework, fulfilling the required practicum hours for both the DNP coursework and DNP project.

The DNP Leader in Residence program begins with the first semester of practicum being focused on completing an onboarding process to the Center including understanding the center's strategic plan, mission, vision, and history. Onboarding for the Leader in Residence provides access to all relevant Center information and resources and integration into the leadership team, community partnerships, and other University of Iowa College of Nursing Centers associated with the Csomay Center. During this first semester, observation and identification of the Csomay Center Director's various roles including being a leader, manager, innovator, socializer, and mentor is facilitated. In collaboration with the Center Director (a faculty position) and Center Coordinator (a staff position), specific competencies to be measured and mastered along with learning opportunities desired throughout the program are established to ensure a well-planned and thorough immersion experience.

Following the initial semester of practicum, the Leader in Residence has weekly check-ins with the Center Director and Center Coordinator to continue to identify learning opportunities and progression through executive leadership competencies to enrich the experience. The Leader in Residence also undertakes an administrative project for the Center this semester, while concurrently continuing observations of the Center Director's activities in local, regional, and national executive leadership settings. The student has ongoing participation and advancement in executive leadership roles and activities throughout the practicum, creating a well-prepared future nurse executive leader.

After completing practicum hours related to the Health Systems: Administration/Executive Leadership coursework, the Leader in Residence engages in dedicated residency hours to continue to experience domains within nursing leadership competencies like communication, professionalism, and relationship building. During residency hours, time is spent with the completion of a small quality improvement project for the Csomay Center, along with any other administrative projects identified by the Center Director and Center Coordinator. The Leader in Residence is fully integrated into the Csomay Center's Leadership Team during this phase, assisting the Center Coordinator in creating agendas and leading meetings. Additional participation includes active involvement in community engagement activities and presenting at or attending a national conference as a representative of the Csomay Center. The Leader in Residence must mentor a master’s in nursing student during the final year of the DNP Residency.

Implementation of the DNP Leader in Residence Program

PDSA Cycle: Do

Immersive experience. In this case study, the DNP Leader in Residence was fully immersed in a wide range of center activities, providing valuable opportunities to engage in administrative projects and observe executive leadership roles and skills during practicum hours spent at the Csomay Center. Throughout the program, the Leader in Residence observed and learned from multidisciplinary leaders at the national, regional, and university levels who engaged with the Center. By shadowing the Csomay Center Director, the Leader in Residence had the opportunity to observe executive leadership objectives such as fostering innovation, facilitating multidisciplinary collaboration, and nurturing meaningful relationships. The immersive experience within the center’s activities also allowed the Leader in Residence to gain a deep understanding of crucial facets such as philanthropy and community engagement. Active involvement in administrative processes such as strategic planning, budgeting, human resources management, and the development of standard operating procedures provided valuable exposure to strategies that are needed to be an effective nurse leader in the future.

Active participation. The DNP Leader in Residence also played a key role in advancing specific actions outlined in the center's strategic plan during the program including: 1) the creation of a membership structure for the Csomay Center and 2) successfully completing a state Board of Regents application for official recognition as a distinguished center. The Csomay Center sponsored membership for the Leader in Residence in the Midwest Nurse Research Society (MNRS), which opened doors to attend the annual MNRS conference and engage with regional nursing leadership, while fostering socialization, promotion of the Csomay Center and Leader in Residence program, and observation of current nursing research. Furthermore, the Leader in Residence participated in the strategic planning committee and engagement subcommittee for MNRS, collaborating directly with the MNRS president. Additional active participation by the Leader in Residence included attendance in planning sessions and completion of the annual report for GeriatricPain.org , an initiative falling under the umbrella of the Csomay Center. Finally, the Leader in Residence was involved in archiving research and curriculum for distinguished nursing leader and researcher, Dr. Kitty Buckwalter, for the Benjamin Rose Institute on Aging, the University of Pennsylvania Barbara Bates Center for the Study of the History of Nursing, and the University of Iowa library archives.

Suggested Evaluation Strategies of the DNP Leader in Residence Program

PDSA Cycle: Study

Assessment and benchmarking. To effectively assess the outcomes and success of the DNP Leader in Residence Program, a comprehensive evaluation framework should be used throughout the program. Key measures should include the collection and review of executive leadership opportunities experienced, leadership roles observed, and competencies mastered. The Leader in Residence is responsible for maintaining detailed logs of their participation in center activities and initiatives on a semester basis. These logs serve to track the progression of mastery of AONL competencies by benchmarking activities and identifying areas for future growth for the Leader in Residence.

Evaluation. In addition to assessment and benchmarking, evaluations need to be completed by Csomay Center stakeholders (leadership, staff, and community partners involved) and the individual Leader in Residence both during and upon completion of the program. Feedback from stakeholders will identify the contributions made by the Leader in Residence and provide valuable insights into their growth. Self-reflection on experiences by the individual Leader in Residence throughout the program will serve as an important measure of personal successes and identify gaps in the program. Factors such as career advancement during the program, application of curriculum objectives in the workplace, and prospects for future career progression for the Leader in Residence should be considered as additional indicators of the success of the program.

The evaluation should also encompass a thorough review of the opportunities experienced during the residency, with the aim of identifying areas for potential expansion and enrichment of the DNP Leader in Residence program. By carefully examining the logs, reflecting on the acquired executive leadership competencies, and studying stakeholder evaluations, additional experiences and opportunities can be identified to further enhance the program's efficacy. The evaluation process should be utilized to identify specific executive leadership competencies that require further immersion and exploration throughout the program.

Future Innovation of DNP Leader in Residence Programs in Non-traditional Healthcare Settings

PDSA Cycle: Act

As subsequent residents complete the program and their experiences are thoroughly evaluated, it is essential to identify new opportunities for DNP Leader in Residence programs to be implemented in other non-health care system settings. When feasible, expansion into clinical healthcare settings, including long-term care and acute care environments, should be pursued. By leveraging the insights gained from previous Leaders in Residence and their respective experiences, the program can be refined to better align with desired outcomes and competencies. These expansions will broaden the scope and impact of the program and provide a wider array of experiences and challenges for future Leaders in Residency to navigate, enriching their development as dynamic nurse executive leaders within diverse healthcare landscapes.

This case study presented a comprehensive overview of the development and implementation of the DNP Leader in Residence program developed by the Barbara and Richard Csomay Center for Gerontological Excellence. The Leader in Residence program provided a transformative experience by integrating key curriculum objectives, competency-based learning, and mentorship by esteemed nursing leaders and researchers through successful integration into the Center. With ongoing innovation and application of the PDSA cycle, the DNP Leader in Residence program presented in this case study holds immense potential to help better prepare 21 st century nurse leaders capable of driving positive change within complex healthcare systems.

Acknowledgements

         The author would like to express gratitude to the Barbara and Richard Csomay Center for Gerontological Excellence for the fostering environment to provide an immersion experience and the ongoing support for development of the DNP Leader in Residence program. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

  • American Association of Colleges of Nursing. The essentials: core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf . Accessed June 26, 2023.
  • American Organization for Nursing Leadership. Nurse leader core competencies. https://www.aonl.org/resources/nurse-leader-competencies . Accessed July 10, 2023.
  • Warshawsky, N, Cramer, E. Describing nurse manager role preparation and competency: findings from a national study. J Nurs Adm . 2019;49(5):249-255. DOI:  10.1097/NNA.0000000000000746
  • Van Diggel, C, Burgess, A, Roberts, C, Mellis, C. Leadership in healthcare education. BMC Med. Educ . 2020;20(465). doi: 10.1186/s12909-020-02288-x
  • Institute for Healthcare Improvement. Plan-do-study-act (PDSA) worksheet. https://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx . Accessed July 4, 2023.
  • Taylor, M, McNicolas, C, Nicolay, C, Darzi, A, Bell, D, Reed, J. Systemic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety. 2014:23:290-298. doi: 10.1136/bmjqs-2013-002703

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Trump Fraud Trial Penalty Will Exceed $450 Million

The ruling in Donald J. Trump’s civil fraud case could cost him all his available cash. The judge said that the former president’s “complete lack of contrition” bordered on pathological.

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Donald Trump, wearing a blue suit and blue tie, sits at the defendant’s table in a courtroom.

By Jonah E. Bromwich and Ben Protess

A New York judge on Friday handed Donald J. Trump a crushing defeat in his civil fraud case , finding the former president liable for conspiring to manipulate his net worth and ordering him to pay a penalty of nearly $355 million plus interest that could wipe out his entire stockpile of cash .

The decision by Justice Arthur F. Engoron caps a chaotic, yearslong case in which New York’s attorney general put Mr. Trump’s fantastical claims of wealth on trial. With no jury, the power was in Justice Engoron’s hands alone, and he came down hard: The judge delivered a sweeping array of punishments that threatens the former president’s business empire as he simultaneously contends with four criminal prosecutions and seeks to regain the White House.

Justice Engoron barred Mr. Trump for three years from serving in top roles at any New York company, including portions of his own Trump Organization. He also imposed a two-year ban on the former president’s adult sons and ordered that they pay more than $4 million each. One of them, Eric Trump, is the company’s de facto chief executive, and the ruling throws into doubt whether any member of the family can run the business in the near term.

The judge also ordered that they pay substantial interest, pushing the penalty for the former president to $450 million, according to the attorney general, Letitia James.

In his unconventional style, Justice Engoron criticized Mr. Trump and the other defendants for refusing to admit wrongdoing for years. “Their complete lack of contrition and remorse borders on pathological,” he said.

He noted that Mr. Trump had not committed violent crimes and also conceded that “Donald Trump is not Bernard Madoff.” Still, he wrote, “defendants are incapable of admitting the error of their ways.”

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The Civil Fraud Ruling on Donald Trump, Annotated

Former President Donald J. Trump was penalized $355 million plus interest and banned for three years from serving in any top roles at a New York company, including his own, in a ruling on Friday by Justice Arthur F. Engoron.

Mr. Trump will appeal the financial penalty but will have to either come up with the money or secure a bond within 30 days. The ruling will not render him bankrupt, because most of his wealth is in real estate, which altogether is worth far more than the penalty.

Mr. Trump will also ask an appeals court to halt the restrictions on him and his sons from running the company while it considers the case. In a news conference from his Palm Beach, Fla., home, Mar-a-Lago, on Friday evening, he attacked Ms. James and Justice Engoron, calling them both “corrupt.”

Alina Habba, one of Mr. Trump’s lawyers, described the ruling in her own statement as “a manifest injustice — plain and simple.” She added that “given the grave stakes, we trust that the Appellate Division will overturn this egregious verdict.”

But there might be little Mr. Trump can do to thwart one of the judge’s most consequential punishments: extending for three years the appointment of an independent monitor who is the court’s eyes and ears at the Trump Organization. Justice Engoron also strengthened the monitor’s authority to watch for fraud and second-guess transactions that look suspicious.

Mr. Trump’s lawyers have railed against the monitor, Barbara Jones, saying that her work had already cost the business more than $2.5 million; the decision to extend her oversight of the privately held company could enrage the Trumps, who see her presence as an irritant and an insult.

Ms. James had sought an even harsher penalty, asking for Mr. Trump to be permanently barred from New York’s business world. In the 2022 lawsuit that precipitated the trial, she accused Mr. Trump of inflating his net worth to obtain favorable treatment from banks and other lenders, attacking the foundation of his public persona as a billionaire businessman.

Even though the lenders made money from Mr. Trump, they were the purported victims in the case, with Ms. James arguing that without his fraud, they could have made even more.

The financial penalty reflects those lost profits, with nearly half of the $355 million — $168 million — representing the interest that Mr. Trump saved, and the remaining sum representing his profit on the recent sale of two properties, money that the judge has now clawed back from Mr. Trump and corporate entities he owns.

Before the trial began, Justice Engoron ruled that the former president had used his annual financial statements to defraud the lenders, siding with the attorney general on her case’s central claim. The judge’s Friday ruling ratified almost all of the other accusations Ms. James had leveled against Mr. Trump, finding that the former president had conspired with his top executives to violate several state laws.

The judge’s decision for now grants Ms. James, a Democrat, a career-defining victory. She campaigned for office promising to bring Mr. Trump to justice, and sat calmly in the courtroom as the former president attacked her, calling her a corrupt politician motivated solely by self-interest.

“This long running fraud was intentional, egregious, illegal,” Ms. James said during a Friday evening news conference, adding that “there cannot be different rules for different people in this country, and former presidents are no exception.”

New York Attorney General Speaks on Trump Fraud Case Decision

“today we are holding donald trump accountable,” said the attorney general, letitia james, after a new york judge found donald j. trump’s claims of wealth fraudulent..

No matter how rich, powerful or politically connected you are, everyone must play by the same rules. We have a responsibility to protect the integrity of the marketplace. And for years, Donald Trump engaged in deceptive business practices and tremendous fraud. Donald Trump falsely, knowingly, inflated his net worth by billions of dollars to unjustly enrich himself, his family, and to cheat the system. After 11 weeks of trial, we showed the staggering extent of his fraud and exactly how Donald Trump and the other defendants deceived banks, insurance companies and other financial institutions for their own personal gain. We prove just how much Donald Trump, his family and his company unjustly benefited from his fraud. White-collar financial fraud is not a victimless crime. When the powerful break the law and take more than their fair share, there are fewer resources available for working people, small businesses and families. Today we are holding Donald Trump accountable.

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Her win is Mr. Trump’s second major courtroom loss in two months, following a January jury verdict in a defamation case brought by E. Jean Carroll, a writer whom he was found liable of sexually abusing. The jury penalized him $83.3 million.

Friday’s ruling comes as Manhattan prosecutors are set to try Mr. Trump on criminal charges late next month . He is also contending with 57 more felony counts across three other criminal cases.

But none of his legal troubles seem to have anguished Mr. Trump quite like the fraud case. During the trial, he protested its premise, pleading, “This has been a persecution of somebody that’s done a good job in New York.”

Mr. Trump’s lawyers argued that the fraud did not have a victim in the traditional sense , daring the attorney general to find someone who was harmed. And in a statement on Friday, a Trump Organization spokeswoman noted that the company had “never missed any loan payment or been in default on any loan” and that the lenders “performed extensive due diligence prior to entering into these transactions.”

At trial, Mr. Trump’s lawyers called as witnesses the president’s former bankers, who testified that they had been delighted to have Mr. Trump as a client.

Eric Trump and his brother Donald Trump Jr. also testified, but their efforts to distance themselves from their father’s financial statements fell flat with the judge. Justice Engoron’s decision to bar them from running any New York business for two years — and Mr. Trump for three — will likely strike a nerve with the Trump family.

Before the trial, the fallout from the case seemed to threaten the Trump Organization’s very existence. When Justice Engoron first ruled that Mr. Trump had committed fraud, he ordered the dissolution of much of the former president’s New York empire.

But legal experts had questioned the judge’s ability to do that , and in his ruling on Friday, Justice Engoron pulled back. Instead, the judge said any “restructuring and potential dissolution” would be up to Ms. Jones, the independent monitor.

The judge also granted Ms. Jones new authority as part of an “enhanced monitorship,” and asked her to recommend an independent compliance director who will oversee the company’s financial reporting from within its ranks.

The monitorship and other penalties, including a three-year ban on Mr. Trump and his company seeking loans from banks registered in New York, could hamstring the company as it seeks to compete in the state’s crowded real estate market.

However, nothing will hurt quite as much as the financial penalty. If upheld on appeal, it could erase the cushion of liquidity — cash, stocks and bonds — that Mr. Trump built in his post-presidential life.

Mr. Trump claimed under oath last year that he was sitting on more than $400 million in cash, but between Justice Engoron’s $355 million punishment, the interest Mr. Trump owes and the $83.3 million payout to Ms. Carroll, that might all be gone. If so, Mr. Trump might have to sell one of his properties or another asset to cover the payouts.

The symbolism of the punishments cannot be overlooked, either. Mr. Trump is synonymous with the company he ran for decades, and by severing him from its operations, the judge has written an embarrassing epilogue to the former president’s story of his career as a New York mogul.

For now, Mr. Trump has spun his legal misfortunes into what he sees as political gold. He has used the cases to falsely portray himself as a victim of a Democratic cabal led by President Biden, and he has campaigned at every courthouse he has visited.

In Justice Engoron’s courtroom, Mr. Trump delivered a rally-made rant from the witness stand, marking the climax of a monthslong proceeding that was alternately stultifying and scintillating. The former president attacked one of Ms. James’s lawyers, saying: “You and about every other Democrat, district attorney, A.G. and U.S. attorney were coming after me from 15 different sides. All Democrats, all Trump haters.”

He did not spare Ms. James herself, or the judge, calling the attorney general a “political hack” and Justice Engoron an “extremely hostile judge.”

Mr. Trump later delivered his own closing statement, calling Ms. James’s fraud accusation a “fraud on me” and saying that the attorney general was the one who “should pay me.”

He generated drama even when not in the spotlight, rolling his eyes at the defense table and muttering to his lawyers. He was particularly enraged by the testimony of his former fixer, Michael D. Cohen , who linked Mr. Trump directly to the fraud scheme.

Mr. Trump’s lawyers succeeded in rattling Mr. Cohen, and asked, based on apparent contradictions in his testimony, that Justice Engoron throw out the case. When the judge declined, Mr. Trump abruptly stood up and stormed out of the courtroom.

The judge largely tolerated Mr. Trump’s behavior, but early on, he barred the former president from attacking his staff members, most prominently his law clerk, who sat near the judge throughout the trial so they could confer. Mr. Trump twice violated that order, prompting $15,000 in fines from the judge.

Courtroom theatrics notwithstanding, the evidence presented was often tedious, consisting of years-old emails and spreadsheets. Through that documentary evidence, Ms. James’s lawyers showed that Mr. Trump’s company had ignored appraisals and manipulated numbers to inflate the value of properties such as golf clubs and office buildings, sometimes to absurd heights.

The most blatant exaggeration was the listed size of Mr. Trump’s triplex apartment in Trump Tower on Fifth Avenue. For years, the former president had valued it as if it were 30,000 square feet, when it was actually 10,996.

In his ruling, Justice Engoron blasted Mr. Trump and the other defendants, saying that misstating the apartment’s size was the only error to which they would admit.

Justice Engoron wrote that he was not looking to “judge morality” — only to find facts and apply the law.

“The court intends to protect the integrity of the financial marketplace and, thus, the public as a whole,” he wrote.

Justice Engoron added that Mr. Trump’s refusal to admit error left him with no choice but to conclude that the former president would continue to commit fraud unless he was stopped.

William K. Rashbaum , Claire Fahy and Maggie Haberman contributed reporting.

Jonah E. Bromwich covers criminal justice in New York, with a focus on the Manhattan district attorney's office, state criminal courts in Manhattan and New York City's jails. More about Jonah E. Bromwich

Ben Protess is an investigative reporter at The Times, writing about public corruption. He has been covering the various criminal investigations into former President Trump and his allies. More about Ben Protess

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99 million people included in largest global vaccine safety study

19 February 2024

Health and medicine , Faculty of Medical and Health Sciences

The Global Vaccine Data Network, hosted at the University of Auckland, utilises vast data sets to detect potential vaccine safety signals

Global Vaccine Data Network co-director Dr Helen Petousis-Harris: Latest study uses vast data sets to ensure vaccine safety.

The Global Vaccine Data Network (GVDN) assessed 13 neurological, blood, and heart related medical conditions to see if there was a greater risk of them occurring after receiving a Covid-19 vaccine in the latest of eight studies in the Global COVID Vaccine Safety (GCoVS) Project.

Recently published in the journal Vaccine , this observed versus expected rates study included 99 million people (over 23 million person-years of follow-up) from 10 collaborator sites across eight countries. The study identified the pre-established safety signals for myocarditis (inflammation of the heart muscle) and pericarditis (inflammation of the thin sac covering the heart) after mRNA vaccines, and Guillain-Barré syndrome (muscle weakness and changed sensation (feeling)), and cerebral venous sinus thrombosis (type of blood clot in the brain) after viral vector vaccines.

Possible safety signals for transverse myelitis (inflammation of part of the spinal cord) after viral vector vaccines and acute disseminated encephalomyelitis (inflammation and swelling in the brain and spinal cord) after viral vector and mRNA vaccines were identified.

So far, these findings were further investigated by the GVDN site in Victoria, Australia. Their study and results are described in the accompanying paper. Results are available for public review on GVDN’s interactive data dashboards .

Observed versus expected analyses are used to detect potential vaccine safety signals. These studies look at all people who received a vaccine and examine if there is a greater risk for developing a medical condition in various time periods after getting a vaccine compared with a period before the vaccine became available.

Lead author Kristýna Faksová of the Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark, remarked that use of a common protocol and aggregation of the data through the GVDN makes studies like this possible. “The size of the population in this study increased the possibility of identifying rare potential vaccine safety signals,” she explains. “Single sites or regions are unlikely to have a large enough population to detect very rare signals.”

By making the data dashboards publicly available, we are able to support greater transparency, and stronger communications to the health sector and public.

Associate Professor Helen Petousis-Harris Co-Director, Global Vaccine Data Network hosted at University of Auckland

GVDN Co-Director Dr. Steven Black said, “GVDN supports a coordinated global effort to assess vaccine safety and effectiveness so that vaccine questions can be addressed in a more rapid, efficient, and cost-effective manner. We have a number of studies underway to build upon our understanding of vaccines and how we understand vaccine safety using big data.”

GVDN Co-Director Dr. Helen Petousis-Harris said, “By making the data dashboards publicly available, we are able to support greater transparency, and stronger communications to the health sector and public.”

The GCoVS Project was made possible with support by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) to allow the comparison of the safety of vaccines across diverse global populations.  

About the Global Data Vaccine Network

Established in 2019 and with data sourced from millions of individuals across six continents, the GVDN collaborates with renowned research institutions, policy makers, and vaccine related organisations to establish a harmonised and evidence-based approach to vaccine safety and effectiveness.

The GVDN is supported by the Global Coordinating Centre based at Auckland UniServices Ltd, a not-for-profit, stand-alone company that provides support to researchers and is wholly owned by the University of Auckland. Aiming to gain a comprehensive understanding of vaccine safety and effectiveness profiles, the GVDN strives to create a safer immunisation landscape that empowers decision making for the global community. For further information, visit globalvaccinedatanetwork.org.

Disclaimer: This news release summarises the key findings of the GVDN observed versus expected study. To view the full publication in Vaccine, visit doi.org/10.1016/j.vaccine.2024.01.100.

This project is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totalling US$10,108,491 with 100% percentage funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS, or the U.S. Government. For more information, please visit cdc.gov

Media inquiries: gvdn@auckland.ac.nz and communications@univervices.co.nz

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  25. Fani Willis Testifies, With Everything on the Line, in the Trump

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  26. (PDF) The case study as a type of qualitative research

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