CLINICAL ASSESSMENT OF
DISSOC[ATIVE SYMPTOMS
AND DISORDERS:
Tl STRUM RED
CLLVICILINTER 67E1V
FOR DS,II-IVDISSOCLI TWE
DISORDERS (SCID-D)
Marlene Steinberg, M.D.
Domenic Cicchetti, Ph.D.
Jospehine Buchanan, B.S.
Pamela Hall, Pse.D.
Bruce Rounsav tile, M.D.
Marlene Steinberg, M.D., is Associate Research Scientist at
Yale University School of Medicine, New Haven, Connecticut.
Domenic Cicchetti, Ph.D., is Senior Research Scientist at
Yale University School of Medicine, and Senior Research
Psychologist and Biostatistician at VA Medical Center, West
Haven, Connecticut. Josephine Buchanan, B.S., is Project
Supervisor, SCID-D Program, Yale University School of
Medicine. Pamela Hall, Psy.D., isAdjunctAssociate Professor
in the Graduate Psychology Department, Pace University,
New York, NY, and is in private practice in Summit and Perth
Amboy, New Jersey. Bruce Rounsaville, M.D., is Associate
Professor of Psychiatry, Director of Research at the Substance
Abuse and Treatment Unit, at Yale University School of
Medicine.
For reprints write Marlene Steinberg, M.D., 100 Whitney
Avenue, New Haven, Connecticut 06510.
Supported by NIMH First Independent Research Support
and Transition Award MH-43352 and 2 RO1-43352 - 04 (Dr.
Steinberg), grants DA 00089 and DA 04060 from the National
Institute on Drug Abuse (Dr. Rounsaville) , and by VA Merit
Review Grant MRIS 1416 (Dr. Cicchetti).
The authors thank Betsy Frey, M.Div., M. Phil; and Jonathan
Lovins, B.A., for reviewing this manuscript.
ABSTRACT
Early detection of dissociative symptoms is essential for effective ini-
tiation of appropriate treatment. The author reviews a new diag-
nostic tool, the Structured Clinical Interview for DSM-IV
Dissociative Disorders (SCID-D)(Steinberg, 1993), which com-
prehensively evaluates the severity of five posttraumatic dissociative
symptoms (amnesia, depersonalization, derealization, identity con-
fusion, identity alteration) and the dissociative disorders. Several
investigations have reported good-to-excellent reliability and valid-
ity of the SCID-D. This article describes the clinical assessment of dis-
sociative symptoms, as well as the diagnosis of dissociative disorders
using the SCIDD, based upon research at Yale University involv-
ingover 400 interviews over a 10 year time period. It is recommended
that screening for dissociative disorders, as described in the SCID-D
and the Interviewer Guide to the Structured Clinical
Interview forDSM-IV Dissociative Disorders(SCID-D) (Steinberg,
1993), be included in the diagnostic evaluation of patients with
either dissociative symptoms or with suspected/documented histories
of trauma.
Dissociation is definedbyDSM-III-R (American Psychiatric
Association, 1987) as "a disturbance or alteration in the nor-
mally integrative functions of identity, memory or con-
sciousness." Severe dissociative symptoms and the dissocia-
tive disorders are recognized as posttraumatic (Braun, 1990;
Coons, et al., 1990; Fine, 1990; Goodwin,1990; Kluft, 1985c;
1988; Kluft, Braun Sachs, 1984; Putnam, 1985; Ross, Norton
Wozney, 1989; Spiegel, 1984, 1991; Spiegel Gardena,
1991; Ten-, 1991). Dissociation, as a psychological defense,
is used by survivors of abuse and trauma to cope with over-
whelming anxiety and pain. Victims of recurrent child abuse
develop chronic dissociative symptoms or disorders, which
include dissociative (psychogenic) amnesia, dissociative
(psychogenic) fugue, depersonalization disorder, multiple
personality disorder (MPD) (dissociative identity disorder,
DSM-IV proposed name change), and dissociative disorder
not otherwise specified (DDNOS). Studies of the dissocia-
tive disorders have noted reported histories of abuse in 85%
to 97% of cases of MPD (Coons Milstein, 1986; Kluft, 1988,
1991; Putnam, et al., 1986; Ross, Norton Wozney, 1989;
Schultz, Braun Kluft, 1989).
Investigators report that individuals with MPD are fre-
quently misdiagnosed for many years (Kluft, 1987b).
Recent investigations indicate that MPD is much more com-
mon than previously recognized, and estimates of its preva-
lence range from 1% to 10% of psychiatric patients (Bliss 
Jeppsen, 1985; Kluft, 1991; Putnam, Guroff, Silberman, Barban,
Post, 1986; Ross, Norton Wozney, 1989). Furthermore,
the occurrence of dissociative symptoms has been documented
in numerous psychiatric disorders, including personality dis-
orders (such as borderline personality), eating disorders,
anxiety disorders (including obsessive-compulsive disorder
and post-traumatic stress disorder), (depression, and schi-
zophrenia (Clary, Burstin Carpenter, 1984; Fine, 1990;
Fink Golinkoff, 1990; Goff, et al., 1992; Havenaar, Boon
Tordoir, 1992; Kluft, 1988; Marcum, Wright Bissell, 1985;
Roth, 1959; Schultz, Braun Kluft, 1989; Torem, 1986).
For much of this century, patients with dissociative dis-
orders have been misdiagnosed as having schizophrenia, manic
depressive illness, hysteria, epilepsy, or a variety of other psy-
chiatric disorders (Coons, 1984; Kluft, 1991; Putnam, et al.,
1986; Rosenbaum, 1980; Ross Norton, 1988; Schenck 
Bear, 1981). The neglect of dissociative symptoms and dis-
orders by the medical establishment has resulted from sev-
eral factors, including the reluctance to discuss issues relat-
ed to child abuse and the concealed nature of dissociative
symptoms themselves. Assessment is often complicated
because patients with dissociative disorders may deny or be
DISSOCIATION, Vol, V'I. No. I, March 1993
3
CLINICAL ASSESSMENT: SCID-D
amnestic for both their abuse history and/or their disso-
ciative symptoms; and may experience "amnesia for amne-
sia" (Kluft, 1988).
Early identification of patients who suffer from disso-
ciative symptoms and disorders is essential to successful treat-
ment. The recent development of screening (Bernstein 
Putnam, 1986; Riley, 1988; Sanders, 1986) and diagnostic
tools (Ross, et al., 1989; Steinberg, 1985, 1993a, 1993b) for
dissociative symptoms and disorders permits early detection
of patients suffering from dissociative symptoms and disor-
ders.
This article is intended to help familiarize clinicians with
the systematic assessment of dissociative symptoms and dis-
orders. A review of five core dissociative symptom areas and
the differential diagnosis of the dissociative disorders are
presented in the context ofa new diagnostic tool, the
Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) .
Excerpts from SCID-D interviews illustrate the semistructured
format of the SCID-D, the multifaceted nature of dissocia-
tive symptoms, and relevant clinical information that can be
gathered by this tool. A sample SCID-D protocol for chart
documentation and psychological reports is also included.
THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV
DISSOCIATIVE DISORDERS (SCID-D)
The Structured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D) (Steinberg, 1985; Steinberg, 1993b) is a
semistructured diagnostic interview that systematically assess-
es the severity of five dissociative symptoms (amnesia, deper-
sonalization, derealization, identity confusion, and identity
alteration) in all psychiatric patients; and diagnoses the dis-
sociative disorders according toDSM-IVcriteria. The SCID-D
evaluates the severity of five specific dissociative symptoms
in patients with all DSM Axis I and II diagnoses, and assess-
es the presence of Dissociative (Psychogenic) Amnesia,
Dissociative (Psychogenic) Fugue, Depersonalization Disorder,
Multiple Personality Disorder (MPD; Dissociative Identity
Disorder, proposed name change) , and Dissociative Disorder
Not Otherwise Specified (DDNOS), according toDSM-IV cri-
teria.
The SCID-D systematizes the assessment of dissociative
symptoms by defining the 5 core symptoms of dissociation
and the dissociative disorders as follows: amnesia, deper-
sonalization, derealization, identity confusion, and identity
alteration, each representing basic disturbances in the pro-
cesses of memory, identity or consciousness. This concep-
tualization of dissociation was derived from a critical syn-
thesis of the literature on dissociation, together with clinical
experience with patients that suffer from abuse and disso-
ciative disorders. Major contributors to this written and" oral"
literature include pioneers in the field of dissociation, such
as the late David Caul and the late Cornelia Wilbur, as well
as Ralph Allison, Bennett Braun and Richard Kluft. In addi-
tion, Drs. Cicchetti and Rounsaville at Yale School of
Medicine have generously contributed over a decade of exper-
tise in methodology and diagnostic testing in the field trials
of the SCID-D. Finally, critical contributions to the multi-
center field trials of the reliability of the SCID-D were made
by expert investigators, Drs. Bowman, Cicchetti, Coons, Fine,
Fink, Hall, Kluft, and Rounsaville.
Originally developed to incorporate DSM-III-R criteria,
the SCID-D was updated for publication in 1993 to incorpo-
rate DSM-IVcriteria for the Dissociative Disorders. NIMH-
funded field trials of the SCID-D at Yale have indicated good-
to-excellent reliability and discriminant validity for each of
the five dissociative symptoms, as well as for the dissociative
disorders (Steinberg, Buchanan, Cicchetti, Hall Rounsaville,
1989-1992; Steinberg, Rounsaville Cicchetti , 1990) . These
results have been replicated by Goff, Olin, Jenike, Baer,
Buttolph (1992) at Harvard, and by Boon and Draijer (1991)
in a cross-national replication study in Amsterdam. In addi-
tion, preliminary findings from 3 of the 4 sites in the mul-
ticenter field trials of the SCID-D (involving expert researchers
from New Haven, Philadelphia, Indianapolis, and Summit,
New jersey) also indicate good-to-excellent reliability and
validity (Steinberg, Kluft, Coons, et al., 1989-1993).
The clinician-administered SCID-D interview assesses the
phenomenology and severity of dissociative symptoms using
open-ended questions, with individualized follow-up ques-
tions for exploring endorsed symptoms, as well as 9 addi-
tional sections for exploration of specific aspects of identi-
ty disturbances, such as feelings of possession, sudden mood
changes, etc. This format elicits informative descriptions of
dissociative experiences, rather than mere yes or no respons-
es. As the reader will discover in the course of this article,
patients frequently spontaneously elaborate on histories of
trauma while describing their dissociative experiences. This
feature of the SCID-D allows clinicians to obtain information
regarding traumatic histories, without the use of leading or
intrusive questions.
Another advantage of the SCID-D specific design is its
long-term utility. The SCID-D allows interviewers to evalu-
ate dissociative symptoms in various psychiatric and nonpsy-
chiatric populations, independent of changes in DSM cri-
teria for the dissociative disorders. The organization of the
SCID-D also allows the clinician to evaluate new disorders
that may be defined by future revisions For instance,
Dissociative Trance Disorder (a subcategory of DDNOS) can be
evaluated with the SCID-D interview through specific ques-
tions regarding feelings of possession in the follow-up sec-
tion on possession symptoms.
Although administration of the full SCID-D requires two
to three hours of the interviewer s time, the instrument is
highly cost-effective in terms of its demonstrated ability to
detect previously undiagnosed cases of dissociative disorder.
Given present figures regarding the average dissociative
patient length of time in misdirected therapy prior to estab-
lishment of the correct diagnosis (7-10 years; Coons, Bowman
Milstein, 1988; Kluft, 1987; Putnam, et al., 1986), earlier
detection of a dissociative disorder using the SCID-D allows
for rapid implementation of appropriate treatment strate-
gies.
THE FIVE SCID-D DISSOCIATIVE SYMPTOMS
Amnesia can be defined as the inability to recall a sig-
nificant block of time that has passed, and/or the inability
4
DISSOCIATION. Vol. CI. No.1, (larch 1993
STEINBERG/CICCHETTI/BUCHANAN/HALL/ROUNSAVILLE
to recall important personal information (Steinberg, et al.,
1990). It is endorsed by patients as "gaps" in their memory
or "lost time", ranging from seconds to years. Patients may
describe episodes of forgetting their name, age or address.
Patients with severe amnesia are often unable to recall the
frequency or duration of their amnestic episodes (Kluft, 1988;
Steinberg, et al., 1990). Individuals with chronic amnesia
often confabulate or rely on reports from relatives or friends
in attempts to fill the gaps in their memory (Kluft, 1991).
Amnesia of psychogenic etiology mustbe distinguished from
that found in organic brain dysfunction or secondary to sub-
stance abuse.
Depersonalization involves the experience of detachment
from one body or self; for example, feeling the self to be
strange or unreal, feeling a sense of physical separation from
the body, detachment from emotions, or feeling like a life-
less robot. Depersonalization experiences are frequently
described in " as if" terms, reflecting intact reality testing
(Ackner, 1954). SCID-D research has found that patients
with dissociative disorders often experience depersonaliza-
tion within the context of ongoing, coherent dialogues with
the self (Steinberg, 1991; Steinberg, et aI., 1990).
Depersonalization is particularly difficult for patients to
describe, and can sometimes go unnoticed or can be expe-
rienced by patients habituated to it as "normal."
Depersonalization occurs as an isolated symptom in a vari-
ety of psychiatric disorders (Brauer, HarrowTucker, 1970;
Noyes, et al., 1977). Additionally, transient depersonaliza-
tion is a common response to alcohol and drug use, sleep
and sensory deprivation, severe emotional stressors; and also
occurs as a side effect of medications (Roberts, 1960;
Trueman, 1984b).
Derealization involves the sense that the physical and/or
interpersonal environment has lost its sense of familiarity
or reality. During derealization episodes, the patient expe-
riences friends and relatives as strange and unfamiliar, as
may also be the patient home, place of work, or personal
belongings. Derealization often occurs in the context of flash-
backs, in which a person regresses in age and re-enters a past
experience, as if it were current reality. During the flash-
back, the present feels unreal to the person. Derealization
involves the loss of an affective link between the individual
and another person or object that seems unfamiliar or unre-
al (Siomopoulos, 1972). Isolated episodes of derealization
may occur in subjects without psychiatric disorders, in
response to substance use, sensory and sleep deprivation,
and significant social stressors (e.g., bereavement).
Identity confusion, as assessed in the SCID-D, is defined as
a sense of uncertainty, puzzlement or conflict regarding per-
sonal identity (Steinberg, et al., 1990; Steinberg, 1993b).
Patientswho experience dissociative symptoms often express
confusion as to who they really are. They feel that they have
little sense of self and have difficulty maintaining a feeling
of inner coherence, stability, or continuity. They experience
conflicting wishes and opinions. In dissociative disorders,
identity confusion often manifests as a fierce battle for inner
survival,where the subject experiences conflicting and
opposing attitudes regarding issues and events in his or her life.
In MPD, identity confusion assumes the form of alternate
personalities fighting for control of the person thoughts
and behavior. Although identity confusion may occur tran-
siently during adolescence or life crises, the symptom tends
to be more chronic and distressing in patients with disso-
ciative disorders.
Identity alteration, as assessed by the refers toobjec-
tive behavior that indicates the assumption of different iden-
tities (Steinberg, et al., 1990; Steinberg, 1993a). Examples
of identity alteration include: the use of different names,
finding possessions that one cannot remember acquiring,
and possessing a skill that one cannot remember having
learned. Patients with multiple personality disorder some-
times refer to themselves as "we" or "us" (Kluft, 1991) . Severe
identity alteration that occurs in dissociative disorders is
accompanied by amnesia for events experienced under alter-
nate personality states. Identity alteration in MPD is charac-
terized by its complexity, distinctness, the ability of the states
to take control of behavior, and interconnection with other
dissociative symptoms. research has found that iden-
tity switches often occur in conjunction with experiences of
severe depersonalization and derealization.
Severity Rating Definitions found Interviewer's Guide
to theSCID-Dallow the interviewer to rate the severity of each
of the five dissociative symptoms based on standardized cri-
teria of duration, frequency, distress and dysfunction
(Steinberg, 1993a) . These definitions provide guidelines for
rating the severity of the five dissociative symptoms based
on specific SCID-D responses. Table 1 presents the severity
rating definitions for depersonalization. For further infor-
mation on these symptoms and severity ratings, the reader
is referred to the Interviewer 's Guide to the SCID-D (Steinberg,
1993b).
DSM-IV DISSOCIATIVE DISORDERS
Evaluation of the five dissociative symptoms is essential
for accurate differential diagnosis of the dissociative disor-
ders. Each of the dissociative disorders is characterized by a
specific constellation of the five symptoms described above.
A brief review of the dissociative disorders is presented, fol-
lowed by a review of their specific dissociative symptom pro-
files (see Figure 1).
DissociativeAmnesia (Psychogenic Amnesia) isacommon
disorder, regularly encountered in hospital emergency
rooms (Nemiah, 1985). Dissociative Amnesia is character-
ized by the inability to recall important personal informa-
tion (American Psychiatric Association Task Force onDSM-
IV, 1993). The forgotten information is often related to a
traumatic event. The amnesia must be too extensive to be
explained by ordinary forgetfulness, and must not be due
to organic mental disorder, such as alcoholic blackout, drug
intoxication, or seizure disorder; and must not be due to
the activities of alternate personalities (i.e., multiple per-
sonality disorder). Due to similarities with organic memory
loss, Dissociative Amnesia can be easily overlooked
(Loewenstein, 1991). Dissociative Amnesia often manifests
in combat veterans and in the victims of single severe trau-
5
1)1SS0CI 010\.101.11. Nu.1. ll.arrh I!I93
CLINICAL ASSESSMENT: SCID-D
mas such as an automobile accident, witnessing a murder,
natural disaster, or near-death experience. In contrast to
MPD, the course of Dissociative Amnesia is usually marked
by sudden onset and resolution.
DissociativeFugue (Psychogenic Fugue) involves sudden,
unplanned wandering away from home or work. It includes
amnesia for one past; and the assumption of a new iden-
tity, or confusion about personal identity (American Psychiatric
Association Task Force on 1993). The patient remains
alert and oriented, and is capable of performing sophisti-
cated tasks. This disorder is distinguished from Multiple
Personality Disorder by its sudden, acute onset, the pres-
ence of a single severe stressor or trauma, and the absence
of the recurrent appearance of distinct personalities. To meet
the criteria for Dissociative Fugue, the memory and identi-
ty disturbances cannot occur as part of Multiple Personality
Disorder or as part of a substance-induced disorder.
Depersonalization Disorder involves persistent and recur-
rent experiences of severe depersonalization that lead to
distress and dysfunction (American Psychiatric Association
Task Force on DSM-IV, 1993) (Steinberg, 1991). A patient
suffering from Depersonalization Disorder retains in tact real-
ity testing. For a diagnosis of Depersonalization Disorder,
the depersonalization must occur independently of
Schizophrenia, Multiple Personality Disorder, or a sub-
stance abuse disorder.
Dissociative Disorder Not Otherwise Specified (DDNOS)
includes dissociative syndromes that do not meet the full
criteria of any of the other dissociative disorders. DDNOS
includes variants of Multiple Personality Disorder in which
TABLE 1
Severity Rating Definitions of Depersonalization
Depersonalization Detachment from one 's self, e.g., a sense of looking at one's self as if one is an outsider.
MILD
 Single episode or rare (total of 1-4) episodes of depersonalization which are brief (less than
4 hours) and are usually associated with stress or fatigue.
MODERATE (One of the following)
 Recurrent (more than 4) episodes of depersonalization.
(May be brief or prolonged. May be precipitated by stress.)
 Episodes (14) of depersonalization which (One of the following)
- produce impairment in social or occupational functioning.
- are not precipitated by stress.
- are prolonged (over 4 hours).
- are associated with dysphoria.
SEVERE (One of the following)
 Persistent episodes of depersonalization (24 hours and longer).
 Episodes of depersonalization occur daily or weekly. May be brief or prolonged.
 Frequent (more than 4) episodes of depersonalization that (One of the following)
- produce impairment in social or occupational functioning.
- do not appear to be precipitated by stress.
-- are prolonged (over 4 hours).
- are associated with dysphoria.
*Note: The Severity Rating Definitions are not an inclusive list. The purpose of these definitions is to give
the rater a general description of the parameters of the spectrum of dissociative symptoms and their severity.
Reprinted with permission from: Steinberg,M: Interviewer's Guide to the Structured Clinical Interview forDSM-IV
Dissociative Disorders (SCIDD),
6
DISSOCIATION, Vol. VI, No. 1, March 1993
STEINBERG/CICCHETTI/BUCHANAN/HALL/ROUNSAVILLE
Q. 38. Have you ever felt that you
were watching yourself from a point
outside of your body, as if you were see-
ing yourselffrom a distance (or watch-
ing a movie of yourself?) (Have you
ever had an "out of body" experience?"
DEPERSONALIZATION
An alteration in the perception or
experience of the self so that the feeling
of one's own reality is temporarily lost.
This is manifested in a sense of self-
estrangement or unreality, which may
include the feeling that one's extremities
have changed in size, or a sense of seeming
to perceive oneself from a distance (usually
from above) (DSM-III-R, p. 397).
? 1 3 4
Patients feel that their point of conscious
"I-ness" is outside their bodies, commonly
a few feet overhead, from where they actually
observe themselves as if they were a totally
other person (Nemiah, I989a, p 1042)
? = inadequate information 1 = absent 3 = present 4 = inconsistent information
Reprinted with permission from: Steinberg, Washington, DC,
American Psychiatric Press, 1993.
personality" states" may take over consciousness and behav-
ior but are not sufficiently distinct, and variants of Multiple
Personality Disorder in which there is no amnesia for per-
sonal information. Other forms of DDNOS include posses-
sion and trance states, derealization unaccompanied by deper-
sonalization, dissociated states in people who have undergone
intense coercive persuasion (e.g., brainwashing, kidnapping) ,
and loss of consciousness not attributed to a medical con-
dition.
Multiple Personality Disorder (MPD) (Dissociative Identity
Disorder, DSM-IV proposed name change) isthe most chronic and
severe manifestation of dissociation (Kluft, Steinberg Spitzer,
1988). MPD is believed to follow severe and persistent sexu-
al, physical, and/or psychological child abuse (American
Psychiatric Association, 1987; Braun Sachs, 1985; Coons,
Bowman Milstein, 1988; Fine, 1990; Kluft, 1985a; Kluft,
1991; Putnam, 1985 #50; Wilbur, 1984a). In this disorder,
distinct, coherent identities exist within one individual and
are able to assume control of the person behavior and
thought. In MPD, the patient experiences amnesia for per-
sonal information, including some of the identities and activ-
ities of alternate personalities. MPD may mimic a spectrum
of psychiatric conditions, including the psychotic, affective,
and character disorders (Bliss, 1980; Braun Sachs, 1985;
Coons, 1984; Greaves, 1980; Kluft, 1984a; 1987; Putnam, et
al., 1986; Ross Norton, 1988).
THE STRUCTURED CLINICAL INTERVIEW FOR DSM-IV
DISSOCIATIVEDISORDERS (SCID-D)
In addition to the evaluation of the severity of five dis-
sociative symptoms, the SCID-D also assesses the dissociative
disorders according to DSM-IVcriteria. Follow-up questions
within these sections elicit descriptions of the endorsed symp-
toms, as well as reports of frequency and duration. Since dis-
sociative symptoms are often multifaceted, the SCID-D uses
multiple open-ended questions to explore each of the dis-
sociative symptoms. This semi-structured format is advanta-
geous because patients tend to describe dissociative symp-
toms in varied ways that are ignored or overlooked by shorter
or highly structured interviews.
The 3-column format of the SCID-D ismodeled on that
of the Structured Clinical Interview forDSM-III-R (SCID) (1990) ,
developed by Spitzer, Williams, Gibbon, and First. The
is a widely used diagnostic interview for the evaluation of a
variety of major psychiatric disorders including the mood,
psychotic, anxiety, and substance use disorders and has report-
ed good reliability. However, the SCID does not evaluate the
dissociative disorders. TheSCID-D can be used in conjunc-
tion with the SCID or independently.
An example of the SCID-D multicolumn format is shown
above.
The SCID-D also assesses associated features of and
Dissociative Disorder, Not Otherwise Specified, such as inter-
nal dialogues, mood changes and flashbacks. Finally, the
interviewer has the option of administering one or two fol-
low-up sections to further assess the severity of identity con-
fusion and identity alteration. After the interview, the clin-
ician rates the presence of intra-interview dissociative cues,
including intra-interview amnesia, changes in demeanor, and
trance-like appearance. In theSCID-D,both verbal and non-
verbal responses of patients are examined to obtain an accu-
rate assessment of dissociative symptoms and disorders, thus
approximating an experienced clinician diagnostic judg-
ment.
7
DISSOCIATION, Vol. VI, March 11193
CLINICAL ASSESSMENT: SCID-D
ASSESSMENT OF THE FIVE DISSOCIATIVE SYMPTOMS:
EXAMPLES OF SCID-D RESPONSES
Below are examples of SCID-D questions regarding dis-
sociative symptoms and characteristic responses from patients
with dissociative disorders.
Assessing Amnesia
Questions in this section explore the multifaceted nature
of amnesia and assess both the subjects awareness of lost
time, as well as behavioral manifestations such as finding
oneself in a place and not knowing how one got there. Intra-
interview dissociative cues suggestive of amnesia include the
patient seeming disoriented during the interview or having
difficulty recalling the frequency of endorsed symptoms.
The first question of the amnesia section asks: "Have
you ever felt as if there were large gaps in your memory?"
One patient responded:
Yes. My childhood. I not able to do math. I mean
I can tdo it, but Ie gone back and Ie looked at
my test scores in school and I did fine in math...Or
I won remember that we [the patient and her hus-
band] went someplace, but if it said I can then
remember it. I have to be told. I have like a blank.
(SCID-D interview, unpublished transcript.)
Many patients with dissociative disorders understand
their amnesia as "blank spells" or as "spaciness." Many are
not aware that their inability to remember is a psychiatric
symptom that may have resulted from trauma. The previous
patient, like many others, relies on information from oth-
ers to fill in the lacunae in her memory. This is a form of
compensation that allows the patient to retain some sense
of temporal continuity in her life.
Question # 7 asks, "Have you ever found yourself in a
place and been unable to remember how or why you went
there?" One patient replied:
Yeah. When I disappeared for four hours and I didn
know where I was and I ended up on a neighbor
front doorstep...I was covered with bruises at that
point and I thought it was `cause I had fallen down
and stumbled. In retrospect, I think that was the
first punching out I got from my husband and I
stumbled around for several hours. (SCID-D inter-
view, unpublished transcript.)
In response to this item, the patient endorsed an amnes-
tic episode lasting hours, for recent events. The amnesia was
related to physical abuse from her husband. Often, severe
stress or trauma, occurring in the present, triggers memo-
ries of childhood abuse and dissociation.
Assessing Depersonalization
Depersonalization is also a complex dissociative symp-
tom, and patients experience it in a number of ways. These
can include out-of-body experiences, numbing of emotions,
a feeling of strangeness, and the sense that parts of thebody
are changing in size. Nonverbal cues such as a trance-like
state may suggest depersonalization during an interview.
Question # 38 asks: "Have you ever felt that you were
watching yourself from a point outside of your body, as if
you were seeingyourselffrom a distance (or watching a movie
of yourself)?" One patient responded:
I can remember when I was delivering my daugh-
ter, of being up on the ceiling and watching the
whole process of labor and delivery while she was
born...and Ie had the same experience when Ie
finally remembered my husband raping me and I
had the same experience when my father sexually
assaulted me when I went down to visit my mother
after she had a hysterectomy, and I remember being
in the corner of the bedroom ceiling when that
happened.(SCID-D interview, unpublished tran-
script.)
In addition to endorsing symptoms of depersonaliza-
tion this patient response is an illustrative example of the
SCID-D ability to elicit a history of abuse without asking
direct or intrusive questions about trauma.
Another patient described depersonalization related
to body perception in a different way.In contrast to out-of-
body experiences, the following episode involves a part of
the body feeling foreign. Question # 41 asks, "Have you ever
felt as if a part of your body or your whole being was foreign
to you?" One patient responded:
(Pauses) Yeah. Sometimes my hands don seem like
my hands. Ie always hated my legs and they
don...sometimes theye not mine. This is very
weird (sighs).
Depersonalization may also involve the feeling that one
hands or feet are separated from the rest of one body.
Additionally, this patient expressed confusion and disbelief
at the experience of depersonalization, reflecting intact real-
ity testing. Finally, the lengthy pause and sigh in her response
reflect an emotional response to the questions, common-
place in patients who experience recurrent dissociative symp-
toms.
A common, perceptual form of depersonalization
involves the individuals "splitting" into a participator and
an observer. This experience often contains elements of iden-
tity alteration.Question # 47 asks: "Have you ever felt as if
you were two different people, one person going through
the motions of life, and the other part observing quietly?"
One patient responded:
[There is] this body that walks around and some-
body else just watches. But there are others. It so
complicated I don know how to explain it...Like
I know I here and I won remember a lot of it.
Like Il leave here and I ll have a lot of guilt and
8
DISSOCIATION, Vol. VI, No. 1, 166 I99:i
STEINBERG/CICCHETTI/BUCHANAN/HALL/ROUNSAVILLE
Il worry and it probably will take me two days to
remember what went on...It like you have to fil-
ter through the ranks-layers-I don t know.
This patient depersonalization is connected to symp-
toms of amnesia, identity confusion and identity alteration
(a common occurrence in patients withMPD). Additionally,
like many patients with dissociative disorders, she has diffi-
culty putting her experiences into precise terms.
The experience of ongoing internal dialogues in the
context of depersonalization occurs in patients with disso-
ciative disorders (Steinberg, 1991). One patientwith DDNOS
provided this example of an internal dialogue:
I start to argue with somebody that in that chair,
but I see that person in that chair and I see it
me...he looking at me and he laughing at me,
and he calling me on to fight him...and I don
want to fight him...I see me outside myself, in other
words, and he laughing at me, calling out saying,
" Come on punk, fight me, come on punk, fight me.
(SCID-D interview, unpublished transcript)
Thus this patient experiences severe depersonalization
in conjunction with identity confusion.
Assessing Derealization
The SCID-D allows the interviewer to explore the sub-
ject experiences of feeling that friends or family members
are unfamiliar or unreal. Patients who experience severe
derealization during the interview may comment that the
therapist or the interview experience does not seem real.
Question # 79 asks: "Have you ever felt as if familiar sur-
roundings or people you knew seemed unfamiliar or unre-
al?" One patient answered:
Sometimes people will feel unreal to me, like, you
know, what am I doing with this person. I don
even know this person. (SCID-D interview, unpub-
lished transcript.)
Positive responses to this question often involve dere-
alization of a patient parents or spouse. Commonly, dere-
alization occurs in the context of a flashback, in which a
friend or parent reminds the patient of a past abuser, and
the patient consequently feels that the person they are with
is unreal. For instance, one patient experienced derealiza-
tion when she had flashbacks involving her abusive father.
Question # 84 asks: "Have you ever felt puzzled as to what is
real and what unreal in your surroundings?"
Yes.When I have flashbacks. That what I call them.
It s like I be out on a date with a boyfriend and
see a totally different guy. It like really weird. That
happened where it a flashback of one of the guys
that raped me. You know, I be with him, and then,
oh my god, I run out of the theater or something.
(SCID-D interview, unpublished transcript.)
The next question, # 81 asks: "Have you ever felt as if
your surroundings or other people were fading away? One
patient responded:
I have had that experience when I visit my family.
They become blurry, they become almost invisible.
Their voices all melt together. I have a wonderful
time by myself...I had no idea what the conversa-
tions were about, what was said, who was there or
anything." (SCID-D interview, unpublished tran-
script.)
As seen in the previous example, derealization can involve
perceptual distortions. Derealization is often a necessary
defense during traumatic experiences, in which avictim may
need to detach his or her consciousness from the painful
reality of the trauma. Derealization may be triggered when
the individual is reminded of a past trauma or when con-
fronted with a stressful situation in the present.
Assessing Identity Confusion
In response toSCID-D questions regarding identity con-
fusion, subjects with dissociative disorders often describe a
battle for inner survival and use metaphors of war. Moreover,
patients with MPD often elaborate spontaneously on symp-
toms of identity alteration in their responses. Question #
101 asks: "Have you ever felt as if there was a struggle going
on inside of you?" One patient responded:
Oh God. Yes. That like daily, hourly. I feel like an
amoeba with fifteen thousand different ideas about
where it wants to go. And it like literally a being
pulled in every direction possible until there
nothing left, and it s like split in half. That s a con-
stant battle.
Patients with dissociative disorders typically feel confused
about their identity. This experience is compounded by the
inability to recall significant portions of time and conflict-
ing states of consciousness. Question # 105 asks:" Have you
ever felt confused as to who you are? One patient who pre-
sented with global amnesia responded:
I was confused. Confused is a mild word. I just didn t
know. I think confused is too mild. I just did not
have any idea of what happened to me, like how
could I go from wherever I was to now...I didn
know who I was, I didn know basically where I
was...I was terrified. I can still remember myself
crawling on one side of the bed. I could have been
in a ball this big, all crunched up scared to death.
Felt like a baby in a crib. (SCID-D interview, unpub-
lished transcript.)
This patient spontaneously elaborated on an episode of
identity alteration involving age regression.
9
DISSOCIATION, Vol. VI. No.1, March 1993
CLINICAL ASSESSMENT: SCID-D
Assessing Identity Alteration
Because amnesia for altered identity states can mask the
assessment of identity alteration, the SCID-D explores both
direct and indirect evidence of this symptom. Indirect evi-
dence for identity alteration comes from two sources: feed-
back from relatives or friends and behavioral indications,
such as finding objects in one possession for which one
cannot account. For instance, the SCID-D asks if others have
noted the patient acting like a child, acting like a different
person, or answering to a different name. Direct informa-
tion includes the patient awareness of referring to himself
by different names, acting like a child or like a different per-
son, or feeling possessed. Nonverbal cues during the inter-
view can also help the clinician assess the extent of identity
alteration. Severe mood change, particularly in conjunction
with amnesia, change ofvoice, and other intra-interview cues
during the interview, may also indicate different manifesta-
tions of identity alteration.
Question # 114 asks: "Have you ever acted as if you were
a completely different person?" One patient answered:
Yeah...It can be kind of funny, when I m Paula or
Judy. It can be funny if I look at it a certain way.
You would love Paula. She is the biggest clean freak
in the universe. I mean you couldn tolerate her
really, but if you wanted your house cleaned, you d
love her. And Judy can be funny too. If I look at
her as funny rather than embarrassing. I don like
Jill, because Jill screams at me if I spill milk on the
floor.(SCID-D interview, unpublished transcript.)
This patient, who had multiple personality disorder, list-
ed a series of different names, and the coexistence of the
personalities in ongoing dialogues. This would be consid-
ered severe identity alteration according to the guidelines
of theSeverityRatingDefinitions (Steinberg, 1993a) . For instance,
question # 116 asks: "Have you ever been told by others that
you seem like a different person?" One patient responded:
Yes. Guys that Ie dated, my family, people that I
work with...some of them even said that, it like,
different ways, different opinions, my opinion
might change right in the middle of a conversa-
tion. One way definitely over here, and then the
next time, just within seconds, over here. (SCID-D
interview, unpublished transcript.)
Other types of indirect evidence for identity alteration
include finding objects that were purchased by an alternate
personality. Question # 122 asks: "Have you ever found things
in your possession that seemed to belong to you, but you
could not remember how you got them?" One patient with
MPD replied:
Yes...Weekly. Like I go shopping. I buy things.
I remember that I purchased it. I had the receipt.
So I know I didn steal it or something. But why I
bought it, where I bought it - I buy things that I
don even wear - wouldn be caught dead wear-
10
ing. Totally strange items- a thousand scarves, pon-
chos and shawls. And Ie never wornone of them.
But I have a whole mess of them. My Mom says I
wear them a lot, but I don know of ever wearing
one of them. It odd. (SCID-D interview, unpub-
lished transcript.)
These responses demonstrate that patients with severe
identity alteration experience subjective confusion result-
ing from their identity changes. This patient was markedly
perplexed by the unexpected occurrences. The patient also
mentioned external verification of her identity alteration
(i.e., her mother told her about the different clothing she
wears).
FOLLOW-UP SECTIONS
The SCID-D allows a trained clinician to administer up
to 2 of 9 individualized follow-up sections to explore previ-
ously reported dissociative symptoms. Each of the follow-up
modules consists of 9-13 questions that provide further infor-
mation regarding the severity of identity disturbance. Some
of the follow-up sections include: rapid mood changes, the
use of different names, internal dialogues, the presence of
a childlike part, acting like a different person, and feelings
of possession. Each follow-up section assesses the degree of
complexity and volition associated with personality states
that the subject had previously endorsed.
SCORING OF THE SCID-D INTERVIEW:
THE SCID-D SUMMARY SCORE SHEET
Following the interview, the clinician is able to rate the
severity of each of the 5 symptoms using the Severity Rating
Definitions found in the Interviewer's Guide to the SCID-D
(Steinberg, 1993a). The severity of dissociative symptoms is
evaluated in terms of distress, dysfunctionality, frequency,
duration and course of the symptom. The severity ratings of
the dissociative symptoms receive numeric codes; A score
of "absent" is rated as 1, "mild" is rated as 2," moderate" is
rated as 3, and "severe" is rated as 4, the maximum. The indi-
vidual symptom severity scores are added together to yield
a totalSCID-Dsymptom score, which ranges from 5 (no symp-
tomatology) to 20 (severe manifestations of all five disso-
ciative symptoms) . Table 1 lists the severity rating definitions
of the symptom of depersonalization.
DIFFERENTIAL DIAGNOSIS BASED ON SYSTEMATIC
ASSESSMENT OF DISSOCIATIVE SYMPTOMS
Diagnosis proceeds from the consideration of the full
constellation of dissociative symptoms. If the subject received
ratings of none-to-mild on all symptoms, dissociative disor-
der may be ruled out. If, however, one or more symptoms
were found to be severe, the presence of a dissociative dis-
order should be considered.Diagnostic Worksheets are includ-
ed in the Interviewer's Guide to the SGID-D to assist systematic
assessment of a dissociative disorder. Diagnosis of dissocia-
tive disorder is based on a specific pattern of SCID-D items
DISSOCIATION. Vol. VI, No.l.1!arch 1993
FIGURE 1
SCID-D Symptom Profiles of the Dissociative Disorders
Depersonalization Disorder Dissociative Amnesia
Severe (4)
Moderate (3)
Mild (2)
None (1)
Severe (41
Moderate (3)
Mild(2)
None(1)
1 I
Deperson- Dereal-
alization ization
I I
Identity Identity
Confusion Alteration
I 1 1 I I
Amnesia Deperson- Dereal- Identity Identity
alization ization Confusion Alteration
1
Amnesia
Multiple Personality Disorder (MPD) and Dissociative Dissociative Fugue
Disorder Not Otherwise Specified (DDNOS)
Severe (4)
Severe (4)
Moderate (3)
Mild (2)
MPD Moderate (3)
DDNOS
Mild (2)
None (1)
I I I I 1
None (1) Amnesia Deperson- Dereal- Identity Identity
araation ization Confusion AlterationI I I I 1
Amnesia Deperson- Dereal- Identity Identity
alization ization cordusion alteration
Reprinted with permission from: Steinberg, M: Interoieruer's Guide to the Structured Clinical Interview for
DSM-IVDissociative Disorders (SOD-D). Washington, DC: American Psychiatric Press, 1993.
11
FIGURE 2
SCID-D Symptom Profiles in Psychiatric Patients and Normal Controls
Severe 4.0
Dissociative
Disorders
Mixed
Psychiatric
Disorders
Identity
Confusion
Identity
Alteration
3.5
1,5
None 1.o
DISSOCIATION. Vol. VI, No, 1, March 1993
CLINICAL ASSESSMENT: SCID-D
in support ofD.SM-IVcriteria. For further details on the scor-
ing and interpretation of the SCID-D, see the Interviewer's
Guide to the Structured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D) (Steinberg, 1993a).
Figure 1," The Disorder Profiles," illustrates the profiles
of dissociative symptoms for each of the five Dissociative
Disorders, as found in SCID-D research. These graphs use
numerical scaling (1-5) of the severity of dissociative symp-
toms. With the use of this guide, the interviewer can now
evaluate whether the patient meets the criteria for a specif-
ic dissociative disorder.
SYMPTOM PROFILES IN OTHER DISORDERS AND
IN CONTROL SUBJECTS
Figure 2 plots the symptom profiles of subjects with dis-
sociative disorders, mixed psychiatric patients, and normal
controls. As demonstrated, control subjects (without psy-
chiatric disorders) tend to score between none and mild (1-
2) for all five symptoms. Subjects with a variety of non-dis-
sociative disorders score between none and moderate (1-3).
Subjects with dissociative disorders experience recurrent to
persistent (moderate to severe [3-4]) dissociative symptoms.
ADMINISTRATION OF THE SCID-D
The SCID-D should be administered by experienced clin-
icians familiar with the tool and with theInterviewer's Guide
to the SCID-D.The interview can be administered to psychi-
atric outpatients and inpatients, as well as subjects without
psychiatric illness. A follow-up session should be scheduled
to review the results with the subject and to discuss issues
the subject may have considered since the interview.
CLINICAL APPLICATIONS OF THE SCID-D
The SCID-D is a time- and cost-effective instrument with
a variety of clinical applications. In addition to its diagnos-
tic utility, it is a tool that can be used for patient education
regarding the nature and significance of dissociative symp-
toms during the follow-up session with the subject. Moreover,
the SCID-D format facilitates long-term follow-up of patients
symptoms; a clinician can administer the instrument at 6-
month or yearly intervals in order to monitor changes in
symptomatology and reassess treatment strategy according-
ly.Lastly, since the SCID-D is designed to be filed with patients
charts, it provides easily accessible documentation of symp-
toms, for record-keeping and psychological reports.
Practitioners of hypnosis will find the SCID-D particu-
larly relevant to their work because the instrument allows
accurate assessment of the patient baseline dissociative symp-
tomatology. By nature, hypnosis involves inducing controlled
dissociation.Without the information obtained by pre-hyp-
notic assessment of dissociative symptoms, as performed by
the SCID-D, the clinician may not know if the symptoms elicit-
ed under hypnosis are secondary to hypnosis or primary to
a dissociative disorder. Since the SCID-D is intended to be
filed with patientscharts, therapists who practice hypnosis
will have documentation of patients  baseline dissociative
symptoms.
INTERVIEWER TRAINING WORKSHOPS
Additional training can be obtained by attending SCID-
D interviewer training workshops which are conducted sev-
eral times a year by two of the authors (M.S. and P.H.) . These
workshops illustrate the diagnostically discriminating fea-
tures of the dissociative symptoms and disorders evaluated
by the SCID-D and provide relevant training in the SCID-D
administration, interpretation, and scoring.
CASE STUDY AND SAMPLE PROTOCOL
The following case study is included in order to demon-
strate the incorporation of SCID-D findings into a diagnos-
tic evaluation summary suitable for patient records and psy-
chological reports.
[For the sake of conciseness, the past psychiatric history
of this patient is abbreviated and this sample protocol will
focus primarily on the SCID-D evaluation.]
Sample SCID-D Evaluation Report
Jane Smith is a 35-year-old single woman and is
employed as a receptionist. She has experienced intermit-
tent panic attacks, depression, auditory hallucinations,
"trances," "blackouts," and self- mutilating behaviors, since
she was twelve years-old. Jane reports a family history of
emotional and physical abuse at the hands of both par-
ents, including long periods of being locked in a closet and
recurrent whippings with a belt by her father. She has been
treated in outpatient psychotherapyfour times since age
fourteen, for periods of up to two years; past diagnoses
includebi-polardisorder, schizophrenia, atypicalpsychosis,
and depression. She was referred to me for a diagnostic
consultation by her present therapist, due to the presence
of suspected dissociative symptoms.
Dates of Evaluation
I evaluated Jane Smith on 5/17/93, 5/24/93, and
5/31/93. A complete psychiatric history was taken and a
mental status examination performed on 5/17/93. On
5/24/93, I administered the Structured ClinicalInterview
forDSM-IVDissociativeDisorders (SteinbergM, American
Psychiatric Press, I 993b). Scoring and interpretation of
the SCID-D were performed according to the guidelines
described in thelnter viewer's Guide to theSCID D (Steinberg
M, Amen can Psychiatric Press, 1993a). On 5/31/93, I
met with Jane Smith to review the findings of the SCID-D
interview and discussed recommendations for treatment.
SCID-D Assessment Summary
A review of the significant findings from the SCID-D
interview is as follows:Jane suffers from bimonthly episodes
of severe amnesia since age 9, which are the "blackouts "
she describes. She also experiences recurrent episodes of
depersonalization which include her "trances", during which
she feels she leaves her body and is sitting on her own shoul-
der. She reports that she occasionally cuts herself with a
razor in order to alleviate the feelings of depersonaliza-
tion. She endorses symptoms of recurrent derealization and
12
DISSOCIATION, Vol. CI. No. I, March 1993
STEINBERG/CICCHETTI/BUCHANAN/HALL/ROUNSAVILLE
identity confusion. In addition, Jane reports evidence of
identity alteration: she receives mail addressed to "Samantha"
and `Freddie, "from two other students at different under-
graduate institutions; she has also had people greet her
on the street as "Samantha." During administration of
the follow-up sections, Jane endorsed havingrecurrent feel-
ings that different people existed inside her, including a
child of toddler age, a "Biker" in her late teens, a rageful
person called "Son-of-a-Bitch" of uncertain age, and a
person named "Idiot. " She reported ongoing internal dia-
logues between "Son-of-a-Bitch " and "Biker." She report-
ed that she experiences these people as separate from her
"normal self' and that they assume control of her behav-
ior. As examples, she mentioned that "Idiot" was talking
to me during part of the interview; and that her boyfriend
broke up with her because the "Biker" came out several
times during theirdates and displayed inappropriate behav-
ior. During the SCID-D interview, I observed changes in
Jan 's affect, speech and physical posture consistent with
her child alter, such as curling up in the chair and suck-
ing her thumb.
Assessment
Jane's SCID-D symptom profile and past history of
traumatic experiences are consistent with a primary diag-
nosis of a dissociative disorder. Based on my evaluation,
Jane 's symptoms of amnesia, depersonalization, dereal-
ization, identity confusion, and identity alteration are all
present at a severe level. She has suffered from chronic dis-
sociative symptoms that interfere with her schoolwork and
relationships, and appear to be related to her self-cutting.
She has also described the presence of other personalities
within her which take control of her behavior to the extent
of forming alternate sets of relationships and behaviors.
The constellation of fan ' DSM-IVcrite-
ria for a diagnosis of multiple personality disorder. Her
depression appears to be secondary to the disruptions in
her life caused by the alter personalities.
Recommendation
I recommend weekly individual therapy focused on
the reduction ofJane's dissociative symptoms. Patient edu-
cation regarding these symptoms and their triggers is rec-
ommended during the initial treatment phase. A subse-
quent goal should be increased cooperation among the
alternate personalities in order to reduce the severity of
Jane's amnesia, identity confusion and identity alteration.
Finally, the use of an anti-depressant may relieve some of
the immediate symptoms of depression.
SUMMARY
Systematic assessment of the five dissociative symptom
areas is essential for early detection and appropriate treat-
ment of the dissociative disorders. The SCID-D assesses the
severity of five dissociative symptoms (amnesia, deperson-
alization, derealization, identity confusion, and identity
alteration) as well as the dissociative disorders based on -
IVcriteria. The SCID-D has reported good-to-excellent reli-
ability and validity and has been field-tested on over 500
patients (Boon Draijer, 1991; Goff, et al., 1992; Steinberg,
et al., 1989-1992; Steinberg, et al., 1989-1993; Steinberg, et
al., 1990). It can be used in clinical and research settings
with outpatients and inpatients, as well as in training pro-
grams. It is recommended that screening for the five disso-
ciative symptoms, as described in the SCID-D andInterviewer's
Guide to the SCID-D,be incorporated in diagnostic evaluations
of all patients with recurrent dissociative symptoms or sus-
pected/documented histories of trauma. 
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