AN UPDATE
ON THE
DISSOCIATIVE
EXPERIENCES SCALE
Ere Bernstein Carlson, Ph.D.
Frank W. Putnam, M.D.
Eve Bernstein Carlson, Ph.D., is Assistant Professor of
Psychology at Beloit College in Beloit, Wisconsin. Frank W.
Putnam, M.D., is Chief, Unit on Dissociative Disorders,
Developmental Psychology Laboratory, National Institute of
Mental Health, Bethesda, MD.
For reprints write Eve B. Carlson, Ph.D., Department of
Psychology. Beloit College, 700 College Street, Beloit, WI
53511.
ABSTRACT
The authors review a wide range of studies that relate to the norms,
reliability, and validity of the DissociativeExperiences Scale (DES).
Appropriate clinical and research use of the scale are discussed togeth-
er with factor analytic studies and fruitful statistical analysis meth-
ods. Current research with the DES is described and promising new
research questions are highlighted. Suggestions are made for trans-
lating and using the DES in other cultures. A second version of the
DES, which is easier to score, is included as an appendix.
INTRODUCTION
Our understanding of the role of dissociative symptoms
in psychological disorders has changed significantly over the
last decade. Previously, dissociative disorders were thought
to be rare and the role of dissociation in other mental dis-
orders was not given much consideration. But recent stud-
ies have found prevalence rates for multiple personality dis-
order (the most severe of the dissociative disorders) that
range from 2.4 to 11.3 percent of inpatient psychiatric sam-
ples (Bliss & Jeppsen, 1985; Graves, 1989; Ross, 1991; Ross,
Anderson, Fleisher, & Norton, 1991). Furthermore, high
rates of dissociative symptoms have been found in samples
of subjects with posttraumatic stress disorder (Branscomb,
1991; Bremner, Southwick, Brett, Fontana, Rosenheck, &
Charney, 1992; Carlson & Rosser-Hogan, 1991; Kulka,
Schlenger, & Fairbank, 1988; Wald, 1988) and in subjects
with histories of childhood abuse (Anderson, Yasenik, & Ross,
in press; Chu & Dill, 1990; Coons, Bowman, Fellow, &
Schneider, 1989; Coons, Cole, Pellow, & Milstein, 1990;
Goodwin, Cheeves, & Connell, 1990; Herman, Perry, & van
der Kolk, 1989; Ross, Anderson, Heber, & Norton, 1990a;
Sanders & Giolas, 1991; Sanders, McRoberts, & Tollefson,
1989; van der Kolk, Perry, & Herman, 1991). These and
other findings reviewed below indicate that dissociation may
be an important process for a large number of psychiatric
patients.
16
The Dissociative Experiences Scale (DES) was developed
to serve as a clinical tool to help identify patients with dis-
sociative psychopathology and as a research tool to provide
a means of quantifying dissociative experiences. Though its
development and initial validation have been described else-
where (Bernstein & Putnam, 1986), considerable new
research has provided extensive norms for the scale and new
information on the scale's reliability and validity. We pre-
sent here information that should be pertinent to a wide
variety of contexts in which the scale is used.
DESCRIPTION AND APPROPRIATE USE
OF THE SCALE
The Dissociative Experiences Scale is a brief, self-report
measure of the frequency of dissociative experiences. The
scale was conceptualized as a trait measure (as opposed to
a state measure) and it inquires about the frequency of dis-
sociative experiences in the daily lives of subjects. The scale
was developed to provide a reliable, valid, and convenient
way to quantify dissociative experiences. It was designed to
be useful in determining the contribution of dissociation to
various psychiatric disorders and as a screening instrument
for dissociative disorders (or disorders with a significant dis-
sociative component such as posttraumatic stress disorder).
A response scale that allows subjects to quantify their expe-
riences for each item was used so that scores could reflect a
wider range of dissociative symptomatology than possible
using a dichotomous (yes/no) format.
Though the scale has been used to measure dissocia-
tion in non-clinical (normal) populations, this was not its
intended purpose and users should be aware of this. Since
non-clinical subjects typically score in a fairly narrow range
at the low end of the scale on the DES, small differences
among these subjects may not be meaningful.
Similarly, since the DES was developed for use with adults
(persons 18 or older), the language used and the experi-
ences described are appropriate for adults, but may not be
appropriate for younger persons. Though the scale has been
used in research on persons between 12 and 17 from both
the general population and from a psychiatric sample (Ross,
Ryan, Anderson, Ross, & Hardy, 1989; Sanders et al., 1989),
the validity of scores for persons under 18 has not yet been
investigated. The scores may have a different meaning for
younger persons because they may interpret the questions
differently. We are now in the process of developing a DES
suitable for use with adolescents.
Finally, the DES was not intended as a diagnostic instru-
DISSOCL1TION. No, 1. March 1993
CARLSON/PUTNAM
rent. High DES scores should not be construed as an indi- should consider using a diagnostic interview for dissociative
cator of a dissociative disorder diagnosis. The section on the disorders (see Clinical Use section, below) .
use of cutoff scores provides information about the use of
the DES in detecting patients with dissociative disorders.
Researchers or clinicians who want a diagnostic instrument
TABLE 1
Mean or median DES scores across populations for various studies.
Study Number
Population
Sampled 1 2 3 4 5 6 7 8 9 10
General Population 4.4
(Adults) (34)
4.9
(28)
7.8
(415)
6.4
(30)
3.7
(25)
Anxiety Disorders 6.7
(53)
3.9
(13)
10.4
(97)
Affective Disorders 12.7
(102)
6.0
(14)
Eating Disorders 16.1
(120)
12.7
(30)
16.7
(30)
17.8
(25)
Late Adolescents 14.1
(31)
23.8
(259)
11.8
(108)
Schizophrenia 20.6
(20)
12.6
(20)
17.7
(61)
10.5
(15)
Borderline Personality
Disorder
20.1
(19)
18.2
(13)
Inpatient/Childhood Abuse 19.9
(62)
PTSD 31.3
(10)
30.0
(116)
26.1
(26)
41.1
(35)
27
(53)
DDNOS 40.8
(29)
29.8
(99)
38.3
(6)
MPD 57.1
(20)
40.7
(17)
55
(33)
42.8
(228)
45.2
(20)
 Denotes median scores shown; Studies numbered as follows: 1 = Bernstein Putnam, 1986; 2 = Ross, Norton, 
Anderson, 1988; 3 = Frischholz et al., 1990; 4 = Carlson et al., unpublished data; 5 = Coons et al., 1989;
6 = Branscomb, 1991; 7 = Bremner, Southwick, Brett, Fontana, Rosenheck, Charney, 1992; 8 = Chu Dill, 1990;
9 = Demitrack et al., 1990; 10 = Goldner et al., 1991.
17
DISSOCUTION.1"ul CI, \o. I. Mardi 1993
UPDATE ON THE DES
DEVELOPMENT OF THE SCALE
The items for the DES were developed from interviews
with persons with DSM-III diagnoses for dissociative disor-
ders and in consultation with experts in the diagnosis and
treatment of dissociative disorders. Items were developed
that included experiences of disturbance in memory, iden-
tity, awareness, and cognition. These included experiences
usually labeled amnesia, depersonalization, derealization,
absorption, and imaginative involvement. Experiences of the
dissociation of moods or impulses were excluded from the
scale so that the items would not overlap with alterations in
mood and impulses associated with affective disorders. In
other words, it was thought desirable to avoid having. a dis-
sociation scale on which some subjects might have high scores
resulting only from frequent experiences of alterations in
mood or impulses. Items were worded to be comprehensi-
ble to the widest possible range of individuals and to avoid
implications of any social undesirability of the experiences.
A discussion of the response scale used on the original
version of the scale is provided in Bernstein & Putnam (1986) .
[A second version of the scale was recently developed to pro-
vide a scale which is easier to score, but still provides some
precision in quantification (see section on DES II below).]
Pilot testing of the scale was completed on two prelim-
inary forms of the scale using normal and schizophrenic sub-
jects. These samples were chosen so that we could insure
that questions were understood by a wide range of subjects,
including those with severe psychiatric disorders. Comments
were also solicited from clinicians treating patients with dis-
sociative disorders.
ADMINISTRATION AND SCORING OF THE SCALE
The scale is a self-report measure, so it is self-adminis-
tered. Through directions on the cover sheet of the scale,
subjects are instructed to only consider those experiences
not occurring under the influence of drugs or alcohol when
marking answers. In cases when the subject is illiterate or
has difficulty reading, the instructions and questions can be
read aloud and repeated and the subject can be assisted in
marking the appropriate question. If a subject does not under-
stand the response scale line, he or she can be told that the
0% end means, "This never happens to you," and the 100%
end means that, "This is always happening to you."
The scale is scored by measuring the mark made by the
subject to the nearest 5 millimeters for each item. Thus,
scores on each item can range from 0 to 100 and can be any
multiple of five (0, 5, 10, 15, 20, etc.). A total score for the
entire scale is determined by calculating the average score
for all items (add all item scores and divide by 28). An alter-
native form of the scale is available that is easier to score as
it has a response scale that involves circling an answer (see
section on DES II below).
It is important to obtain a copy of the original DES rather
than copy the appendix of the Journal of Nervous and Mental
Disease article. Because the article is reduced in size, the
response line is not 100 mm in the appendix. In addition,
18
item 25 was left out of the scale when it was printed in the
article appendix.
NORMS
Numerous studies have collected DES data on a wide
range of clinical and non-clinical populations. The means
and standard deviations (or medians) and the number of
subjects (in parentheses) for a selection of samples from var-
ious studies are shown in Table 1. The table is arranged with
low-scoring groups toward the top and high-scoring groups
toward the bottom. Studies are arranged in the table for ease
of comparison across groups, not in chronological order.
Though there is some variation in scoring across samples,
the mean scores and the ranking of group scores within stud-
ies are extremely consistent across studies.
It should be noted that scores do not necessarily reflect
level of psychopathology since many DES items ask about
non-pathological forms of dissociation (such as day-dream-
ing). Consequently, DES scores may have different mean-
ings across clinical and non-clinical samples. For example,
late adolescents score relatively high on the DES (at a level
similar to eating disorder subjects) , but they tend to endorse
mild to moderate experiences of dissociation.
RELIABILITY
As described above, the DES was designed as a trait mea-
sure of dissociation. We have discussed elsewhere how the
DES might be conceptualized as measuring dissociativity
(Carlson & Putnam, 1989). We expect, then, stable scores
over shorter periods of time and consistency in scores across
items.
Results of studies of the reliability of the DES are shown
in Table 2 (Bernstein & Putnam, 1986; Frischholz, et. al.,
1990; Pitblado & Sanders, 1991) . These results show that the
DES has good test-retest reliability and internal reliability
(split half and Kuder Richardson). According to Rosenthal
and Rosnow (1991), "For purposes of clinical testing, relia-
bility coefficients of approximately .85 or higher may be con-
sidered as indicative of dependable psychological tests." (p.50).
The lower reliability coefficient reported by Pitblado and
Sanders (1991) no doubt reflects the homogeneity of their
college student sample as a restriction of range in scores will
result in a reduced correlation coefficient. In addition, inter-
rater reliability for the scoring of the DES was studied by
Frischholz et al. (1990) who found a coefficient of relative
agreement of .99 across scorers (n=20).
VALIDITY
The validity of the DES has been established by studies
which collected data relevant to the construct validity and
the criterion validity of the scale.
Construct Validity
Constructvalidity refers to an instrument's ability to accu-
rately measure a construct, in this case dissociation. According
DISSOCIATION, Vol. VI. No, 1, Mardi 1993
CARLSON/PUTNAM
TABLE 2
Reliability of the DES
Test-Retest Reliability
N
Bernstein & Putnam (1986) 26
Frischholz et al. (1990) 30
Pitblado & Sanders (1991) 46
r p test/retest interval
.84 <.0001 4 to 8 weeks
.96 <.0001 4 weeks
.79 <.0001 6 to 8 weeks
Internal Reliability
N
Bernstein & Putnam (1986) 73
Pitblado & Sanders (1991) 46
Cronbach's Alpha
Frischholz et al. (1990) 321 .95 <.0001
Split-Half
r p
.83 <.0001
.93 <.0001
to Anastasi (1988), all information about the validity and
reliability of a test contributes to its construct validity.
The most obvious evidence of the construct validity of
the DES is the fact that those who are expected to score high
on the test do score high and those who are expected to
score low do score low. Table 1 shows that those with PTSD,
DDNOS, and MPD score very high on the scale. It is appro-
priate that the highest scores on the DES would be earned
by subjects with dissociative disorders. The high scores of
PTSD subjects are consistent with previous descriptions in
the literature of high dissociative symptomatology in this
population (Blank, 1985; Kolb, 1985). General population
adults earn very low scores, as expected. The moderately
high scores earned by subjects who were late adolescents is
consistent with prior research showing high levels of disso-
ciation in college students (e.g. Dixon, 1963; Myers & Grant,
1970). High scores in subjects with eating disorders is con-
sistent with a wide range of findings in that area (see
Demitrack, et al., 1990.)
Two specific methods of assessing construct validity include
convergent validity and discriminant validity. To establish
convergent validity, one shows that the new instrument cor-
relates well with other measures of the same construct. While
there are no measures of dissociation available with estab-
lished reliability and validity with which to compare the DES,
convergent validity can be studied by comparing the scale
to not-yet validated dissociation scales and to measures of
related constructs. Frischholz, Braun, Sachs, Schwartz, Lewis,
Schaeffer, et a!. (1991) reported a Pearson correlation of
.52 between the DES and the Perceptual Alteration Scale (a
not-yet validated dissociation scale) and Nadon, Hoyt,
Register, and Kihlstrom (1991) reported a Pearson correla-
tion of .82 between the two measures. Both of these validi-
ty coefficients compare favorably to the average validity coef-
ficient of .46 reported for the MMPI in a meta-analytic study
of its validity (Rosenthal & Rosnow, 1991).
Frischholz et al. (1991) also correlated DES scores with
scores on measures of constructs related to dissociation includ-
ing the Tellegan Absorption Scale (TAS) and the Ambiguity
Intolerance Scale (AIS). They found correlations of .39 and
.24 between the total DES scores and the TAS and AIS (respec-
tively) in a sample of 311 college students. While the coef-
ficients may be diminished by the narrow range of scores in
this homogenous sample, there do appear to be moderate
sized relationships between the DES and measures of relat-
ed constructs. Frischholz et al. conclude that these levels of
convergent validity support the premise that the DES is a
valid measure of dissociation. A different study found small
19
DISSOCLITION. Vol. VI, No. 1, March 1993
UPDATE ON THE DES
correlations between DES scores and measures of hypnotiz-
ability (Frischholz et al., 1992). Those interested in a more
in-depth discussion of the relationship between dissociation
and hypnotizability should see Carlson (in press), Carlson
and Putnam (1989), and Frischholz et al. (1992).
Discriminant validity is established by showing that
scores on the new instrument do not correlate highly with
variables thought to be unrelated to the construct of inter-
est. Bernstein and Putnam (1986) found no significant rela-
tionship between DES scores and socioeconomic status or
DES scores and sex. These results were replicated by Ross,
Joshi, and Currie (1990) who found no differences in DES
scores across sex, income level, employment status, educa-
tion, or religious affiliation in a general population sample
of 1055 adults. In a sample of 35 PTSD Vietnam combat vet-
eran subjects, Branscomb (1991) found no difference inDES
scores when comparing across race (Caucasian and African
American). Both the Bernstein and Putnam (1986) and the
Ross et al. (1990) study found low, negative correlations
between DES scores and age. There are several possible rea-
sons why younger people score higher on the DES. It may
be because they have more dissociative experiences, because
they are more willing or prone to report the experiences,
or because they are more likely to interpret their experi-
ences as matching those described in the DES items. All three
of these possibilities seem likely.
In summary, studies of DES scores for different diag-
nostic groups and studies of the convergent and discrimi-
nant validity of the DES all provide evidence for the con-
structvalidity of the scale. Additional evidence for the construct
validity of theDES is provided by factor analyses of the scale
(see section on Factor Analyses and Subscales below).
Criterion Validity
Evidence for the criterion validity of the DES is provid-
ed by several studies. Criterion validity is an index of how
well a measure agrees with some criterion related to the con-
struct being measured. In the case of the DES, criterion valid-
ity would be established by providing evidence thatDES scores
agree with the criteria of DSM dissociative disorder diagnoses.
The first evidence for criterion validity is the high scores
obtained across studies by subjects with dissociative disor-
ders as shown in Table 1. Clearly, subjects with diag-
noses of dissociative disorders obtain higher scores than sub-
jects in any other group.
The concurrent validity (or predictive capacity) of the
DES was studied to further establish its criterion validity.
Concurrent validity compares the results of the measure to
some other criterion measured at the same time. In a large
multicenter study (N=1051), a cutoff score was used to clas-
sify subjects from a psychiatric sample as or not-MPD.
The criterion used in this study was either or DSM-
III-R diagnosis of MPD. Since psychiatric diagnosis in gen-
eral is not very reliable, some error was introduced into the
results because of inconsistency in diagnosis. It is quite like-
ly, that many subjects with MPD were misdiagnosed as not
having MPD. Despite these sources of error, the analysis yield-
ed a sensitivity rate (proportion of MPD subjects correctly
20
identified) of 74% and a specificity rate (proportion of not-
MPD subjects correctly identified) of 80% (Carlson et al.,
1993). Two other studies of the predictive capacity of the
DES have produced similar results (Frischholz et al., 1990;
Steinberg, Rounsaville, Cicchetti, 1991). These findings
indicate that the scale has good concurrent and criterion-
related validity.
FACTOR ANALYSES AND SUBSCALES
Factor analytic studies of the DES have been done to
clarify the nature of the underlying constructs being mea-
sured by the scale. One factor analysis was completed on
DES scores from a wide range of psychiatric and non-clini-
cal subjects (N=1574) (Carlson, Putnam, Ross, Anderson,
Clark, Torem, et al., 1991). Three main factors emerged
from the analysis and accounted for a total of 49% of the
variance among item scores. The first factor was thought to
reflect amnestic dissociation and included items 3, 4, 5, 6,
8, 10, 25, and 26. A second factor seemed to represent absorp-
tion and imaginative involvement and included items 2, 14,
15, 16, 17, 18, 20, 22, 23. The third factor was comprised of
experiences of depersonalization and derealization and includ-
ed items 7, 11, 12, 13, 27, 28. The factors seem to represent
cohesive and relatively independent constructs. This basic
factor structure was replicated in a confirmatory factor anal-
ysis study by Schwartz and Frischholz (1991).
A factor analysis performed on data from non-clinical
subjects only yielded a somewhat different pattern of fac-
tors. In this analysis, three factors emerged, accounting for
40% of the variance in scores. For non-clinical subjects, the
most variance in scores was attributable to items loading on
an absorption and changability factor (Carlson et al., 1991).
This factor accounted for 18% of the variance in scores and
included items 12, 14, 15, 16, 17, 18, 20, 22, 23, and 24. A
second factor comprised of derealization and depersonal-
ization items (3, 4, 7, 11, 12, 13, and 28) accounted for 13%
of the variance in scores. A third factor comprised of amnes-
tic experiences contained only 3 items (5, 6, and 8) and
accounted for 9% of the variance in scores. A separate fac-
tor analysis study of data from a non-clinical population yield-
ed similar results (Ross, Joshi, Currie, 1991). Three fac-
tors accounted for 47% of the variance in scores, with eight
of the ten items listed above loading onto the first factor.
Researchers and clinicians have used the findings above
to make subscales for measuring subcomponents of disso-
ciation. Some clinicians have indicated that they find the
subscales clinically useful for making diagnostic decisions
such as the differential diagnosis between MPD and DDNOS.
But recent statistical analyses have indicated that the sub-
scales derived from factor analyses like those described above
may not actually measure the subcomponents of dissocia-
tion that they were thought to. Waller (in press) reviewed
the DES for the twelfth edition ofBuros Mental Measurements
Yearbook and noted that DES items are skewed in non-clin-
ical and many clinical samples and that the Pearson corre-
lations (which form the matrix for a factor analysis) are dis-
torted by skewness. He also points out that a common factor
DISSOCIATION, Vol. VI. No. I, March 1993
CARLSON/PUTNAM
analysis of skewed data may produce spurious factors.
Waller performed a reanalysis of the data used for the
Carlson et al. (1991) factor analyses and controlled for skew-
ness of the items. He found that, when skewness is controlled
for, only one general factor for dissociation emerges from
the analysis. This general factor underlies all of the items of
the DES. The three factors found above seem to reflect the
frequency which which subjects endorse particular items.
Thus, the "absorption" factor may be a" high endorsement
frequency" factor, the "derealization and depersonalization"
factor may be a "moderate endorsement frequency" factor,
and the "amnestic dissociation" factor may be a "low endorse-
ment frequency" factor. It seems, then, that the content of
DES items are confounded with the frequency or rarity of
experiences. At present, it is impossible to tell whether sub-
scale scores for a particular subject or group really measure
subcomponents of dissociation, or whether they just mea-
sure endorsement frequency. It appears that the scale will
reliably measure only the general dissociation factor.
Researchers and clinicians should keep these findings in
mind if they wish to use subscale scores derived from past
factor analytic studies.
USE OF CUTOFF SCORES WITH THE DES
The use of a cutoff score to identify those who might
have a dissociative disorder or a disorder with a consider-
able dissociative component is discussed in detail in Carlson
et al. (1993). As described above, using a total score of 30
or above to identify those who may be severely dissociative
will result (on the average) in the correct identification of
74% of those who areMPD and correct identification of 80%
of those who are notMPD (Carlson et al., 1993). In this anal-
ysis, 61% of those who scored 30 or above who were not MPD
had posttraumatic stress disorder or a dissociative disorder
other than MPD. This means that a very high proportion of
those who score 30 or over will probably have a disorder
other than MPD that has a considerable dissociative com-
ponent. A receiver operating characteristics analysis described
in Carlson et al. (1993) indicated that 30 was the optimal
cutoff score in terms of maximizing the accuracy of predic-
tions.
By applying Bayes theorem (Meehl Rosen, 1955) to
the cutoff analysis, we can see what effect the low base rates
for MPD have on the accuracy of predictions made fromDES
scores. The application of Baye theorem to the general
psychiatric population shows that the probability of a per-
son withMPD scoring under 30 is quite low: If the analysis
described above is representative, only 1% of those scoring
under 30 will be MPD. But it is quite probable that those
scoring 30 or over are not actuallyMPD. This is because the
frequency of MPD is quite low, even in a psychiatric popu-
lation (see Introduction for estimates of prevalence). In fact,
projections from one analysis indicate that only 17% of those
in a given psychiatric sample who score 30 or over on the
DES will actually be MPD psychiatric (Carlson et al., 1993).
The other 83% of the "high scorers" will be people who do
not have MPD, though many of these will have PTSD or a dis-
sociative disorder other than MPD. Clinical users of the DES
need to keep these findings in mind and remember that the
DES is not a definitive tool for diagnosing patients with
but is a screening tool to identify those who may have high
levels of dissociation. Reliable and valid structured clinical
interviews for dissociative disorders are available to aid clin-
icians in making diagnoses (see Clinical Use section, below).
CLINICAL USE OF THE DES
Many clinicians have used the DES as a screening device
to identify high dissociators, but are unsure how to proceed
when someone obtains a high score on the scale. Most times
that a client scores over 20 or 30 on theDES, the clinician
will want to know more about the dissociative experiences
that contributed to the high score One approach at further
investigation would be to use the completed scale to inter-
view the client. For each item with a score of 20 or more,
the clinician could ask the client for an example of the dis-
sociative experience (e.g., Can you give me an example of
a time when you found something among your possessions
that you didn remember buying?"). With this method, it
is possible to find out if a client has understood a question
differently than it was intended. For example, a client might
answer the above question with, "Sometimes my wife buys
me new shirts and I find them in my closet." Clearly, this
experience is not an example of dissociation and the high
score is misleading.
Another approach would be to use one of two available
structured clinical interviews for dissociative disorders. The
Dissociative Disorders Interview Schedule developed by
(Ross et al., 1989) and the Structured Clinical Interview for
.DSM-III-R Dissociative Disorders developed by Steinberg
(Steinberg et al., 1990) can both be used to make or rule
out a dissociative disorder diagnosis.
USE OF THE DES IN TRANSLATION
The DES has been translated for use in several other lan-
guages and is available from the authors in French, Spanish,
Italian, Hindi, Cambodian, Hebrew, Japanese, Swedish,
Norwegian, and Czech. Translations are currently in progress
for a version of the DES in German. Translations of the DES
have allowed comparison of Dutch, French, and American
dissociative subjects (Ensink an Otterloo, 1989; Malarewitz,
1990). In the Ensink and van Otterloo study, subjects with
MPD obtained scores quite similar to those found in the
Bernstein and Putnam (1986) study. The DES has also been
translated into Cambodian and has been used to measure
levels of dissociation in Cambodian refugees living in the
United States (Carlson Rosser-Hogan, 1991).
There are several important issues to be aware of when
translating psychological measures across languages and cul-
tures. Some of the most important guidelines for transla-
tion of research instruments are described by Brislin (Brislin,
1986). First, scale items should be translated conceptually,
not literally. This is to insure that colloquial expressions are
not translated literally and that terms and concepts unfa-
21
DISSOCI.AT10N, Vol VI. N. I. March 1993
UPDATE ON THE DES
miliar in another culture do not appear in the translated
items. Second, it is sometimes wise to eliminate items that
do not make sense conceptually in another culture or pop-
ulation. For example, in translating the DES into Japanese,
it was sensible to add "riding a bicycle" to the other modes
of transportation listed in item one. Third, it is important
to include new items that represent experiences that do occur
in the second culture, but were not part of the cultural expe-
rience of those for whom the measure was originally devel-
oped (A. Kleinman, personal communication, October
1991). Fourth, it is crucial to perform a blind backtransla-
tion of the translated measure so that the backtranslation
can be compared and reconciled with the original version.
This process provides a necessary check on the accuracy of
the translation.
When interpreting DES scores from a translated version
of the DES, it is important to remember that the DES will not
necessarily have the same level of reliability or validity when
it is used in another language or culture. The reliability and
validity of the scale in any new culture must be established
independently. Similarly, DESscores do not necessarily have
the same meaning across cultures. For example, a score of
30 on the DES may have a different meaning outside of the
United States or in subcultures within the United States.
This means the cutting score suggested here for screening
for dissociative pathology is not necessarily an appropriate
cutting score when the scale is given to people from anoth-
er culture.
THE DES II
A second version of the DES has been developed that is
easier to score than the original version. The response scale
has been changed from a visual analog scale to a format of
numbers from 0 to 100 (by 10s). The subject is instructed
to circle a number for each item that best describes the per-
centage of time they have the experience. A copy of this
measure can be found in Appendix A and researchers and
clinicians are welcome to reproduce the scale for their use
without specific permission. The DES II was tested and found
to produce scores very similar to those on the original DES.
We collected data with the DES II on 40 MPD subjects, 36 late
adolescents, and 42 general population adults. We compared
total scores for the groups on the new DES to total scores on
the old DES (using data from a large multicenter study) and
found no significant difference between group means for
any group. More research should be done to further estab-
lish the equivalence of this new form of the DES, but we con-
sider the change in the scale to be so minor that we feel con-
fident that the new version will yield results comparable to
those of the old version.
STATISTICAL ANALYSIS OF DES SCORES
In the years since the DES was first published, some issues
related to the statistical analysis of DES scores have been
raised. First, though we initially suggested that only non-
parametric statistics be used to analyze DES data, we now
22
advocate use of parametric statistics for moderate sized sam-
ples (N>30). We have come to this conclusion after observ-
ing that for moderate sized samples, mean scores are gen-
erally equivalent to median scores. Furthermore, since
sampling distributions of means for DES scores are gener-
ally normally distributed, there is less concern about violat-
ing the assumption of parametric statistics.
A second issue is that too many researchers report only
mean DES scores to describe dissociation levels of research
samples. This kind of report is usually not an adequate char-
acterization of the dissociation tendencies of subjects in a
sample. In addition to calculating group means, researchers
should plot score distributions to find out how many sub-
jects show different levels of dissociation. As an alternative,
researchers can calculate the percentage of subjects who
score 30 or higher on the DES. As described in the section
of cutoff scores, a score of 30 provides a empirically derived
breakpoint for dividing a sample into high and low dissoci-
ators. In addition, it is often useful to examine item scores
of groups when expected group differences in means are
not found. In other words, researchers need to examine their
date for more subtle patterns than group mean differences.
CURRENT RESEARCH WITH DES
The DES has been used in awide variety of research stud-
ies. We will briefly describe a few research approaches that
we believe are particularly useful. First, the scale has been
used to determine the level of dissociation in samples of
patients with various psychiatric diagnoses. For example, the
DES has been used to measure the level of dissociation in
samples of posttraumatic stress disorder patients (Branscomb,
1991; Bremner et al., 1992), eating disorder patients
(Demitrack et al., 1990; Goldner et al., 1991), and border-
line personality disorder patients (Herman etal.,1989). The
scale has also been used to measure dissociation levels in
non-clinical populations such as the general population (Ross
et al., 1990), college students (Sanders & Giolas, 1991), and
adolescents (Ross et al., 1989).
Another fruitful use of the DES has been to screen for
dissociative patients or subgroups within a non-dissociative
diagnostic group. In this type of study, the DES is used to
identify high dissociators in a particular non-dissociative sam-
ple. The high dissociators are then studied more closely,
often by means of a structured interview for dissociative dis-
orders. in this way, a particular subgroup can be identified
that is distinctive in regard to its level of dissociation. The
distinctive level of dissociation may be important in diag-
nosing, understanding, and treating this subgroup of patients.
An example of this type of use includes Ross's study of high
and low dissociators in a college student sample (Ross, Ryan,
Voigt, & Eide, 1991).
The DES has also been used to study the relationship of
dissociation to specific clinical features in general popula-
tion, psychiatric, and medical samples (see Carlson [in press],
for a review of this research) . Clinical features that have been
studied to date in relation to dissociation include suicidali-
ty, self-mutilation, somatization, chronic pelvic pain, pre-
DISSOCIATION, vol.
CARLSON/PUTNAM
menstrual syndrome, epilepsy, aggression, and paranormal
experiences (Devinsky, Putnam, Grafman, Bromfield, &
Theodore, 1989; Jensvold, Putnam, Schmidt, Muller, &
Rubinow, 1989; Loewenstein & Putnam, 1988; Quimby &
Putnam, 1991; Richards, 1991; Ross, Fast, Anderson, Auty,
Todd, 1990b; Ross oshi,1992; van der Kolk et al., 1991;
Walker, Katon, Neraas,Jemelka, Massoth, 1992). Similarly,
the scale has been used to study the relationship of dissoci-
ation to childhood experiences such as sexual and physical
abuse (Anderson et al., in press; Chu & Dill, 1990; Strick &
Wilcoxon, 1991).
A third area of research that looks promising is the study
of the relationship between dissociation levels and biologi-
cal processes. One such study has found a significant posi-
tive correlation between DES scores and cerebrospinal fluid
levels of homovanillic acid and a significant negative corre-
lation between DES scores and cerebrospinal fluid levels of
Beta-endorphin in a sample of eating disorder patients
(Demitrack et al., unpublished manuscript). A study using
a less direct measure of biological processes has found a rela-
tionship between DES scores and pain tolerance (Giolas &
Sanders, 1991). Giolas and Sanders (1991) also found that
those with higher DES scores reported suffering less even
when they perceived a similar level of pain.
FUTURE DIRECTIONS
There are several areas of research that, as far as we
know, have not yet been explored, but seem to have great
potential. First, the use of the DES to identify a subgroup of
subjects in a particular population seems particularly well-
suited to the study of some populations not yet investigated
in this way. Two populations that would be particularly inter-
esting to study would be criminals and sex offenders. Many
have speculated that males who have histories of physical
and/or sexual abuse and who have frequent dissociative symp-
toms may end up in the criminal justice system rather than
the mental health system. One could study this question by
identifying subgroups of criminals and sex offenders who
are highly dissociative and investigating whether the rates
of childhood abuse are higher for the high dissociators than
the low dissociators in the population.
Another population that has not yet been studied for
dissociative subgroups is that of substance abusers. It is com-
monly hypothesized that some people abuse substances in
an effort to escape from unpleasant feelings (such as anxi-
ety) . There may be a subgroup of this population who abuse
substances to escape from unpleasant feelings such as deper-
sonalization or derealization or from anxiety caused by amne-
sia for periods of time. To study this question, one could
attempt to identify a subgroup of high dissociators and inves-
tigate their motivations for substance abuse.
Another quite obvious use of the DES, which no pub-
lished study has yet described, is the use of the scale in a
treatment outcome study. Treatment of dissociative disor-
ders should surely result in the reduction of the frequency
and intensity of dissociative experiences. Simple pre and
posttest measures of dissociation with the DES could estab-
lish whether a particular treatment is effective at reducing
dissociative symptomatology.
Further research on dissociation scale development might
include studies to establish the equivalence of the DES and
the DES II. Studies of the reliability and validity of the DES
II would also be useful to confirm that the scale performs as
well as the original DES. Also, it is likely that others will try
to develop dissociation scales that will perform even better
than the DES. New dissociation instruments should be based
on a clearly defined construct of dissociation and should
perform at least as well as the DES in terms of reliability and
validity. High levels of internal as well as test-retest reliabil-
ity should be demonstrated. Validity should be established
byawide range of methods, including criterion-relatedvalid-
ity, convergent validity, and discriminant validity. In addi-
tion, there are several ways in which a new measure could
improve upon the DES. It would be very valuable if a new
measure could distinguish among subjects with various diag-
nostic groups who show high levels of dissociation such as
MPD, dissociative disorder not otherwise specified, psy-
chogenic amnesia, psychogenic fugue, and posttraumatic
stress disorder. In addition, items for a new scale could be
developed in a more systematic way than were those of the
DES. The number of items in each content area (e.g., armies-
tic dissociation, depersonalization, derealization, absorption)
could be balanced to represent the proportions theoreti-
cally expected or could simply be made equal. Some items
could be made more specific or more clearly focused to rep-
resent a particular content area. Amnesia items could be
designed to separately measure retrieval failures for explic-
it (context dependent) and implicit (context independent)
memories. These are just a few examples of ways in which a
new scale could measure dissociation in a way that the DES
does not.
CONCLUSION
In conclusion, the DES has proved a valuable aid to those
interested in measuring and studying dissociation. It is being
used quite widely to study rates of dissociation in various
groups, to screen for persons who are highly dissociative,
and to study relationships between dissociation and other
variables. Because dozens of studies that use the DES to mea-
sure dissociation are in the planning stages or are now in
progress, those interested in dissociation can look forward
to many new developments in the area in the coming years.

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25
DISSOCIATION, Vol. VI. X. 1, Vascii 4993
APPENDIX A
DES
Eve Bernstein Carlson, Ph.D. Frank W. Putnam, M.D.
Directions: This questionnaire consists of twenty-eight questions about experiences that you may have in your daily life. We are inter-
ested in how often you have these experiences. It is important, however, that your answers show how often these experiences happen to
you when you are notunder the influence of alcohol or drugs. To answer the questions, please determine to what degree the experi-
ence described in the question applies to you and circle the number to show what percentage of the time you have the experience.
Example:
0% I0 20 30 40 50 60 70 80 90 100%
(never) {always)
Date Age Sex: M F
1. Some people have the experience of driving or riding in a car or bus or subway and suddenly realizing that they don remember
what has happened during all or part of the trip. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
2. Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of
what was said. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
3. Some people have the experience of finding themselves in a place and having no idea how they got there. Circle a number to show
what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
4. Some people have the experience of finding themselves dressed in clothes that they don remember putting on. Circle a number
to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
5. Some people have the experience of finding new things among their belongings that they do not remember buying. Circle a num-
ber to show what percentage of the time this happensto you.
0% 10 20 30 40 50 60 70 80 90 100%
6. Some people sometimes find that they are approached by people who they do not know who call them by another name or insist
that they have met them before. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
7. Some people sometimes have the experience of feeling as though they are standing next to themselves or watching themselves do
something and they actually see themselves as if they were looking at another person. Circle a number to show what percentage of
the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
8. Some people are told that they sometimes do not recognize friends or family members. Circle a number to show what percentage
of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
9. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation). Circle
a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
10. Some people have the experience of being accused of lying when they do not think that they have lied. Circle a number to show
what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
11. Some people have the experience of looking in a mirror and not recognizing themselves. Circle a number to show what percent-
age of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
12. Some people have the experience of feeling that other people, objects, and the world around them are not real. Circle a number
to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
13. Some people have the experience of feeling that their body does not seem to belong to them. Circle a number to show what per-
centage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
DISSOCIATION, Vol. \1, No.1, March 1993
26
14. Some people have the experience of sometimes remembering a past event so vividly that they feel as if they were reliving that event,
Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
15. Some people have the experience of not being sure whether things that they remember happening really did happen or whether
they just dreamed them. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
16. Some people have the experience of being in a familiar place but finding it strange and unfamiliar. Circle a number to show what
percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
17. Some people find that when they are watching television or a movie they become so absorbed in the story that they are unaware of
other events happening around them. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
18. Some people find that they become so involved in a fantasy or daydream that it feels as though it were really happening to them.
Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
19. Some people find that they sometimes are able to ignore pain. Circle a number to show what percentage of the time this happens
to you.
0% 10 20 30 40 50 60 70 80 90 100%
20. Some people find that they sometimes sit staring off into space, thinking of nothing, and are not aware of the passage of time. Circle
a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
21. Some people sometimes find that when they are alone they talk out loud to themselves. Circle a number to show what percentage
of the time this happensto you.
0% 10 20 30 40 50 60 70 80 90 100%
22. Some people find that in one situation they may act so differently compared with another situation that they feel almost as if they
were two different people. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
23. Some people sometimes find that in certain situations they are able to do things with amazing ease and spontaneity that would usu-
ally be difficult for them (for example, sports, work, social situations, etc.). Circle a number to show what percentage of the time
this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
24. Some people sometimes find that they cannot remember whether they have done something or have just thought about doing that
thing (for example, not knowing whether they have mailed a letter or have just thought about mailing it). Circle a number to
show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
25. Some people find evidence that they have done things that they do not remember doing. Circle a number to show what percentage
of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
26. Some people sometimes find writings, drawings, or notes among their belongings that they must have done but cannot remember
doing. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
27. Some people sometimes find that they hear voices inside their head that tell them to do things or comment on things that they are
doing. Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
28. Some people sometimes feel as if they are looking at the world through a fog so that people and objects appear far away or unclear.
Circle a number to show what percentage of the time this happens to you.
0% 10 20 30 40 50 60 70 80 90 100%
Reprinted with permission from Bernstein, E.M., and Putnam, F.W., Development, reliability and validity of a dissociation scale.journal
of Nervous & Mental Disease, 174, 727-735. Williams Wilkins, 1986.
27
DISSOCIATION,