THE DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE: A STRUCTURED INTERVIEW Colin A .S., FRCPC Sharon Heber, M.D. G. Ron Norton, Ph .D. Donna Anderson, M .D., FRCPC Geri Anderson, R .N. Paul Barchet, M.D. Colin A . Ross, M .D., FRCPC, is Associate Professor in the De- partment of Psychiatry at the University of Manitoba . Sharon Heber, M .D., is a Psychiatric Intern at McGill University . G .. Ron Norton, Ph .D., is Professor and Chairman of the De- partment of Psychology at the University of Winnipeg . Donna Anderson, M .D., FRCPC, is Assistant Professor in the Depart- ment of Psychiatry at the University of Manitoba . Geri Anderson, R .P.N ., is Dissociative Disorders Research Assis- tant in the Department of Psychiatry at St . Boniface Hospital. Paul Barchet, M .D., is a Psychiatry Resident at the University of Manitoba in Winnipeg, Manitoba. For reprints write Colin A . Ross, M .D ., FRCPC, Department of Psychiatry at St . Boniface General Hospital located at 409 Tache Avenue in Winnipeg, Manitoba, Canada, R2H 2A6. Acknowledgements : This project was supported by the B .Sc. Med . Program of the Faculty of Medicine, University of Manitoba and the Fee Pool of the Department of Psychiatry, St . Boniface Hospital. Prior copyright on the DDIS is held by Colin A . Ross, M .D. and Sharon Heber, M .D. The authors would like to than John Wiley & Sons (Ross, 1989) for permission to reprint the DDIS. ABSTRACT TheDissociative Disorders Interview Schedule (DDIS), a structured interview, has been developed to make DSM-III diagnoses of the dissociative disorders, somatization disorder, major depressive epi- sode, and borderline personality disorder information about substance abuse, childhood physical and sexual abuse, and secondary features of multiple personality disorder items provide information useful in the differential diagnosis of dissociative disorders. The DDIS has an overall inter-rater reliability of 0.68. For the diagnosis of multiple personality disorder it has a specifity of 100% and a sensitivity of 90%. The dissociative disorders, as classified in DSM-III-R (American Psychiatric Association, 1987), include psycho- genic amnesia, psychogenic fugue, multiple personality disorder (MPD), depersonalization disorder and dissocia- tive disorder not otherwise specified . These disorders are conceptualized by a number of authors as occurring on a spectrum of increasing severity, with MPD as the most complex (Beahrs, 1982 ; Braun, 1986 ; O'Brien, 1985 ; Orne, 1984 ; Ross, 1985) . MPD is the most controversial of the dissociative disorders and was thought to be rare up until 1980, at which time about 200 cases had been reported in the world literature (Greaves, 1980) . More recently one esti- mate indicates that a total of 6,000 cases of MPD have now been diagnosed in North America (Coons, 1986) . The rapidly expanding literature on MPD is well reviewed by Kluft (1985a ; 1985b ; 1987a). To date, there has been no valid and reliable method for diagnosing dissociative disorders . The currently available structured interviews, including the Diagnostic Interview Schedule (DIS) (Robins, Helzer, Croughan, & Ratcliff,1981), Research Diagnostic Criteria (RDC) (Spitzer, Endicott & Robins, 1978), Schedule for Affective Disorders and Schizo- phrenia (SADS) (Endicott & Spitzer, 1978) and Renard Diagnostic Interview (RDI) (Helzer, Robins, Croughan & Weiner, 1981), do not contain sections for the diagnosis of dissociative disorders . During the DSM-III field trials, which represent the only attempt to make reliable dissociative diagnoses, the dissociative disorders had a test-retest reliabil- ity which was the poorest of any disorders tested (Spitzer & Forman, 1979). Because of the rapid increase in the rate of diagnosis of MPD in the 1980s and because, in the two large series reported to date (Putnam, Guroff, Silberman, Barban, & Post, 1986 ; Ross, Norton, and Wozney, 1989) totalling 336 cases, MPD patients spent an average of 6 .8 years in the mental health system prior to correct diagnosis, a valid and reliable method of diagnosing MPD and other dissociative disorders is required . Consequently, we have developed a structured interview called the Dissociative Disorders Inter- view Schedule (DDIS), which attempts to provide accurate dissociative diagnoses and, additionally, to provide informa- tion about related symptoms, history and diagnoses. METHOD Development of the DDIS The DDIS was based on our clinical experience with 23 cases of MPD and a review of the literature . Sixteen sections were created with a total of 131 questions . The DSM-III criteria (American Psychiatric Association, 1980) for soma- tization disorder, major depressive episode and borderline personality disorder were included because of previous reports that these are common concurrent diagnoses of MPD (Kluft, 1985a ; 1985b ; 1987 ; Horevitz & Braun, 1984; Ross, Norton, & Wozney, 1989) . Other sections deal with historical and mental status factors associated with MPD such as drug abuse, history of childhood sexual and physical 169 DISSOCIATION, Vol . II, No . 3 : Sepcnihcr 1989 abuse, Schneiderian first rank symptoms of schizophrenia (Kluft, 1987b) , supernatural and extrasensory experiences (Taylor & Martin, 1944) , history of numerous previous diag- noses and treatments (Putnam et al ., 1986 ; Ross, Norton, & Wozney, 1989) and secondary features of MPD not included in the diagnostic criteria . The DSM-III criteria for all the dissociative disorders were also included. Because of controversy about the iatrogenic aspects of MPD (Harriman 1942a ; 1942b ; 1943 ; Kampman, 1976; Leavitt, 1947 ; Spanos, Weekes, Menary, & Bertrand, 1986), the DDIS is highly structured to minimize and control for demand characteristics of the interviewer . Questions are read verbatim by the interviewer and instructions as to how questions should be sequenced, and when to skip questions are imbedded in the schedule . Also, questions are sequenced to avoid cueing the subjects to the diagnosis of MPD before the formal criteria are asked about : this is done by placing indirect questions about secondary features of MPD first, followed by increasingly specific questions focused directly on MPD. The wording ofDSM-III diagnostic questions was kept as close to the text of DSM-III as possible but was simplified when necessary, usually by replacing psychiatric jargon with more widely used synonyms and simplifying phraseology. The initial draft of the DDIS was administered to five nondis- sociative inpatients to determine whether it was too fatigu- ing and to aid in clarifying wording where necessary . Instruc- tions to the interviewer, including instructions for skipping questions and occasional statements to be read verbatim to the reader were included. Subjects The DDIS was administered to 80 psychiatric patients who had received specific clinical diagnoses including 20 patients with MPD, 20 with schizophrenia, 20 with panic disorder and 20 with eating disorders . The three non-MPD groups were chosen for the following reasons : there is some question in the literature about the overlap or relationship between these disorders and MPD (Kluft 1987b ; Putnam et al ., 1986 ; Ross, Norton, & Wozney, 1989) ; a sufficient num- ber of subjects in each group were available to us ; the patients were drawn from specialized research clinics in which the DSM-III diagnoses were likely to be accurate ; and to provide both psychotic and nonpsychotic comparison groups . The panic disorder patients were drawn from an Anxiety Disorders Clinic ofwhich the senior author is medical director . The eating disorders patients were drawn from an Eating Disorders Clinic with an active research program. The schizophrenics were drawn from an outpatient intra- muscular neuroleptic clinic and all had had stable diagnoses of schizophrenia for periods of years . Prior to the structured interview, the schizophrenics' charts were reviewed by the second author, a psychiatric nurse with eight years of expe- rience working with schizophrenics, to ensure that they met DSM-III criteria for schizophrenia. Ethical approval had been obtained from the Faculty Committee on the Use of Human Subjects in Research, Faculty of Medicine at our university and all subjects signed a consent form . The consent form explained that the pur- pose of the interview was to study problems with memory . To avoid selection bias, the first 20 patients available in each group who consented to interview were administered the DDIS, with no refusals in the MPD group and only two to three refusals in the other groups. Reliability and validity procedures Inter-rater reliability and test-retest reliability were evalu- ated by having two independent interviewers administer the DDIS to 9 of the MPD patients, with a six-month interval between administrations . The long interval between admini- strations provided a stringent test of the instrument's relia- bility and reduced any effects due to subjects ' learning or remembering their previous responses . For the 9 subjects interviewed twice, one of their interviews was chosen at random for inclusion in the 20 MPD cases. Inter-rater reliability was calculated using the kappa sta- tistic (Cohen, 1960) . Kappa was calculated for each of the major sections of the DDIS and for the DDIS overall . No attempt was made to calculate inter-rater reliability for sections of a historical or descriptive nature . Although there are 131 separate questions in the DDIS, many with subques- tions, kappa was calculated only for the major categories. Therefore the number of calculations was much less than the total number of questions . For instance questions 3 - 39 yield only a single inter-rater reliability for the diagnosis of somatization disorder. Clinical validity of the MPD diagnoses was established in two steps . First, all MPD subjects received a clinical DSM-III diagnosis from the senior author prior to structured inter- view . These diagnoses were based on longitudinal assess- ments of the subjects . Second the fourth author, a psychia- trist with no previous experience treating MPD, clinically assessed the 9 MPD patients who had been given the DDIS twice . She was aware of the nature of the research, but had never met any of the 9 patients before and was told that anywhere from 0 - 9 of them could have MPD . She was otherwise blind to their diagnoses. Because no other reliable instrument for diagnosing dis- sociative disorders exists, we could not compare the DDIS to another instrument . However, the Dissociative Experiences Scale (DES) (Bernstein & Putnam, 1986} a valid and reliable self-report instrument for measuring dissociative experi- ences, was filled out by 17 of the 20 MPD patients and five of the schizophrenic patients. Scoring the DDIS Scoring rules for the instrument are based on DSM-III and/or DSM-III-R scoring rules for each of the diagnostic categories . Other sections such as Schneiderian symptoms are scored by adding up the total number of positive re- sponses . There is no overall score for the instrument . Norms for the instrument on 102 cases of MPD interviewed at four different centers are now available (Ross, Miller, Reagor, Bjornson, Fraser, & Anderson, unpublished data, 1989). 170 DISSOCIATION, Vol . IL Nu, :I : September 1989 1 i , ` , ` 1 , 9 ` II ! ` . 'I ` 1 III ` i 'I RESULTS Clinical validity and reliability The diagnostically blind psychiatrist diagnosed MPD in 8 out of the 9 women she interviewed . In the other case she diagnosed "atypical dissociative disorder - rule out MPD ." This woman had had the full syndrome of MPD in the past including amnesia between alters but was in remission at the time of assessment by the validating psychiatrist . That is, she was outside the "window of diagnosability" for MPD (Kluft, 1985a) and qualified for the diagnosis of MPD on a longitu- dinal but not a cross-sectional basis . These results indicate that the DDIS has excellent validity. The overall interrater reliability of the DDIS is 0 .68, which is above the standard of agreement for a new protocol to be considered reliable (Herson & Barlow, 1976) . Kappa values of the different sections of the DDIS are shown in Table 1. Using the clinical diagnoses of the senior author as the standard of comparison, there were two false negative diag- noses of MPD . One of these was the first interview done on an MPD patient a week after diagnosis : she scored positive for MPD six months later and scored negative the first time only because she answered `unsure' to the second DSM-JII diagnostic criterion . None of the subjects in the three comparison groups met the diagnostic criteria for MPD . The DDIS, therefore, has a specificity of 100% and a sensitivity of 90% for the diagnosis of MPD. Clinical findings and DES scores The clinical findings from the 80 subjects are reported elsewhere (Ross, Heber, Norton, & Anderson, 1989a ; Ross, Heber, Norton, & Anderson, 1989b) . The DDIS differenti- ated MPD from the other groups at the p = .05 level by the diagnosis of MPD, history of physical and sexual abuse, drug abuse, secondary features of MPD, extrasensory and super- natural experiences and a number of other items. The DES scores differentiated the MPD group from a group of 20 schizophrenics, of whom five are included in this study and 13 panic disorder patients drawn from the same clinic but not included in this study . These results are also reported elsewhere (Ross, Norton, & Anderson, 1988) . The DES scores provide partial external validation of the DDIS, however. DISCUSSION The DDIS has promising clinical validity and interrater reliability . Because it was tested on psychiatric groups ex- pected to show overlap with the dissociative disorders, the DDIS was subjected to a particularly severe test . If normal controls had been used the DDIS would probably have differentiated MPD from controls on many more items. The overall interrater agreement of the DDIS compares well with that of other structured interviews . The Anxiety Disorders Interview Schedule (Dinardo, O'Brien, Parlow, Wallell, & Plancherd, 1983) has an overall reliability of 0 .65; the RDC have a kappa of 0 .75 on 18 diagnoses with a range of 0 .40 - 1 .00 ; the SADS has a test-retest reliability of 0 .79 on 8 Axis I diagnoses ; the DIS has a kappa of 0 .69 on DSM-III diagnoses, a sensitivity of 75% and a specificity of 94% ; the RDI has an agreement of 0 .60 with a range of 0 .52 - 0.77 ; and in the DSM-TIT field trials the overall test-retest reliability was 0.66 for Axis I disorders and 0 .54 for Axis II disorders. The DDIS establishes, for the first time, that MPD, psychogenic amnesia, psychogenic fugue, and dissociative disorder not otherwise specified (atypical dissociative disor- der in DSM-III) can be reliably diagnosed . Depersonaliza- tion disorder, which we view as a symptom rather than a freestanding disorder, cannot be reliably diagnosed using the DDIS . The instrument also establishes the validity of the diagnosis of MPD. The DDIS can be administered in 30 - 45 minutes and could therefore be used in screening high risk populations, for research purposes, and for gathering data in the clinical treatment of dissociative disorders . It is designed to be administered by nurses, social workers, psychologists, physi- cians and other mental health professionals : persons with no knowledge of psychiatric disorders would be able to under- stand and administer the DDIS but the reliability of their findings has not been established. Further work on the reliability and validity of the DDIS is in progress . The authors emphasize that the present findings must be viewed as preliminary . The reliability and validity of the diagnoses of somatization disorder and de- pression are being studied by coadministering the DDIS and the Diagnostic Interview Schedule, which also makes those diagnoses, to a series of psychiatric inpatients . In addition, interrater reliability studies on 80 subjects, only a portion of whom will have MPD, are in progress . A number of such studies are being conducted which will contribute to estab- lishing the validity, reliability, and clinical utility of the instrument. Data from the DDIS have appeared in several different publications (Ross, 1989 ; Ross & Anderson, 1988 ; Ross et al ., 1989a ; Ross et al ., 1989b ; Ross, Anderson, Heber, Norton, Anderson, del Campo, & Pillay, 1989 ; Ross, Anderson, Heber, & Norton, in pres) . The DDIS is useful because there is no other published instrument for making dissociative diagno- ses, and because it enquires about much of the extensive comorbidity of MPD patients . For instance, no other pub- lished instrument enquires about secondary features of MPD and extrasensory experiences . The fact that data gath- ered with the DDIS have been published in a number of different journals suggests that the instrument provides useful information. The DDIS and the DES, used together, provide a rich source of information on clinical subjects . No other studies have yet been published which establish the validity and reliability of any of the dissociative disorders . a73 REFERENCES American Psychiatric Association (1980) . Diagnostic and statistical manual of mental disorders (third edition) . Washington, DC : Author. American Psychiatric Association (1987) . Diagnostic and statistical manual of mental disorders(third edition) . Washington, DC : Author. DISSOCIATION, vol . II. No :September1989 171 Beahrs, J .O . (1982) . Unity and multiplicity. New York : Brunner/ Mazel. Bernstein, E .M., & Putnam, F .W . (1986) . Development, reliability and validity of a dissociation scale .Journal of Nervous and Mental Disease,174, 727-735. Braun, B .G . (1986) . Issues in the psychotherapy of multiple person- ality disorder . In B .G .Braun (Ed .) Treatment of multiple personality disorder Washington, DC : American Psychiatric Press. 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Ross, C .A., Heber, S ., Norton, G .R., & Anderson, G . (1989a). Somatic symptoms in multiple personality disorder . Psychosomatics, 30 (2), 154-160. Ross, CA ., Heber, S ., Norton, G .R., & Anderson, G . (1989b). Differences between multiple personality disorder and other diag- nostic groups on structured interview .Journal of Nervous and Mental Disease,177 (8), 487-491. Ross, C .A., Anderson, G ., Heber, S ., Norton, G .R., Anderson, B ., del Campo, M ., & Pillay, N . (1989) . Differentiating multiple personality disorder and complex partial seizures . General Hospital Psychiatry, 11, 54-58. Ross, C .A., Anderson, G ., Heber, S ., & Norton, G .R. (in press). Dissociation and abuse in multiple personality patients, prostitutes, and exotic dancers . Hospital and Community Psychiatry. Spanos, N .P ., Weekes,J .R ., Menary, E ., & Bertrand, L .D. (1986). Hypnotic interview and age regression procedures in the elicitation of multiple personality symptoms : a simulation study . Psychiatry,49, 298-311. Spitzer, R .L., Endicott,J ., & Robins, E . (1978) . Research diagnostic criteria . Archives of General Psychiatry, 35,773-782. Spitzer, R .L., Forman, J .W., & Nee, J.(1979) . DSM-III field trials : I. Initial Inter-rater diagnostic reliability . American Journal of Psychia- try, 136, 815- 817. Taylor,'A' .S., & Martin, M .F . (1944) . Multiple personality .Journal of Abnormal and Social Psychologt, 39,281-300. DISSOCIATION, Vol . 3 APPENDIX I THE DISSOCIATIVE DISORDERS INTERVIERW SCHEDULE The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview which makes DSM-III diagnoses of somatization disorder, borderline personality disorder and major depressive episode, as well as all the dissociative disorders . It enquires about Schneiderian symptoms of schizophrenia, secondary features of MPD, ex- trasensory experiences, substance abuse and other items relevant to the dissociative disorders. The DDIS was initially administered to 80 subjects ; 20 with MPD, 20 with schizophrenia, 20 with panic disorder and 20 with eating disorders . Nine of the MPD subjects were interviewed by two different interviewers at six month intervals to determine inter-rater reliability . These nine MPD subjects were also given a clinical diagnostic assessment by a diagnostically blind psychiatrist. The DDIS has excellent clinical validity . The DDIS has an overall inter-rater reliability of 0 .68 . It has a specificity of 100% and a sensitivity of 90% for the diagnosis of MPD. The DDIS can be administered in 30-45 minutes . The DDIS discriminated the MPD subjects from the other groups at very high levels of significance on numerous items. If you administer the DDIS to an MPD patient, please send a copy to Colin A . Ross, M .D., FRCPC, Department of Psychiatry, St . Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba, Canada, R2H 2A6 . We would be interested in receiving copies of the DDIS administered to any other subjects, particularly those with schizophrenia and borderline personality disorder. CONSENT FORM FOR DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE I agree to be interviewed as part of a research project on dissociative disorders . Dissociative disorders involve problems with memory. I understand that the interview contains some personal questions about my sexual and psychological history, however, all information that I give will be kept confidential . My name will not appear on the research ques- tionnaire. I understand that the information I give to the interviewer will not be available to any doctor, authority, therapist, case worker or other person involved with me . My answers will have no direct effect on how I am treated in the future. I understand that the overall results of this research will be published and these results will be available to authorities or therapists involved with me. I understand that the interviewer and other researchers cannot offer me treatment and cannot intervene on my behalf with any authorities or therapists involved with me. I understand that the purpose of this interview is for research and that I cannot expect any direct benefit to myself other than knowing that I have helped the researchers understand dissociative disorders better. I agree to answer the interviewer's questions as well as I can but I know that I am free not to answer any particular questions I do not want to answer. Although I have signed my name to this form, I know that it will be kept separate from my answers and that my answers cannot be connected to my name, except by the interviewer and his/her research colleagues. I also understand that I may be asked to participate in further dissociative disorders interviews in the future, but that I will be free to say no . If I do say no this will have no consequences for me and any authorities or therapists involved with me will not be told of my decision not to be interviewed again. Signed : Witness : Date : 173 DISSOCIATION . Vol . 11. No .3:September 199 DEMOGRAPHIC DATA FOR DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE Age : [ ] [ ] Sex : Male = 1 Female = 2 [ ] Marital status : Single = 1 Married(including common-law) = 2 Separated/Divorced = 3 Widowed = 4 [ ] Number of children : (If no children, score 0) [ I Occupational status : Employed = 1 Unemployed = 2 [ ] Have you been in jail in the past? Yes = 1 No = 2 Unsure = 3 [ ] Physical diagnoses currently active [ [ I Current and past diagnoses must consist of written diagnoses provided by the referring physician or available in the patient's chart (give DSM-III codes if possible, if not write DSM-Ill diagnoses to the right of the brackets). Psychiatric diagnoses currently active [ 1 [ I [ ] Psychiatric diagnoses currently in remission [ l [ ] 174 DISSOCIATION, . 3 1 ' '1 ' 11 V ' '1 DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE Questions in the Dissociative Disorders Interview Schedule must be asked in the order they occur in the Schedule. All the items in the Schedule, including all the items in the DSM-III diagnostic criteria for dissociative disorders and borderline personality disorder must be enquired about . The wording of the questions should be used exactly as written in order to standardize the information gathered by different interviewers . The interviewer should not read the section headings aloud . The interviewer should open the interview by thanking the subject for his/her participation and then should say: "Most of the questions I will ask can be answered Yes, No or Unsure . A few of the questions have different answers and I will explain those as we go along ." 1. Somatic Complaints I . Do you suffer from headaches? Yes = 1 No=2 Unsure = 3 If subject answered No to question 1, go to question 3: 2. Have you been told by a doctor that you have migraine headaches? Yes = I No = 2 Unsure = 3 Interviewer should read the following to the subject: "I am going to ask you about a series of physical symptoms now . To count a symptom as present and to answer yes in these questions, the following must be met: a) no physical disorder has been found to account for the symptom. b) the symptom does not occur only during a panic attack. c) it caused you to take medicine (other than aspirin), see a doctor, or alter your life style .' Interviewer should now ask the subject, "Have you ever had the following physical symptoms for which doctors could find no physical explanation?" The interviewer should review criteria a-c for the subject immediately following the first positive response to ensure that the subject has understood. 3. Abdominal pain (other than when menstruating) Yes = 1 No=2 Unsure = 3 4. Nausea (other than motion sickness) Yes = 1 No=2 Unsure = 3 5. Vomiting (other than motion sickness) Yes = 1 No=2 Unsure = 3 6 . Bloating (gassy) Yes=1 No=2 Unsure=3 7. Diarrhea Yes=1 No=2 Unsure =3 8 . Intolerance of (gets sick on) several different foods Yes = 1 No=2 Unsure = 3 9 . Back pain Yes=1 No=2 Unsure =3 Dissociative Disorders Interview Schedule continued on next page. 175 DISSOCIATION, Vol . II . No. 3 : September 1989 tJ IIA1~l~f Dissociative Disorders Interview Schedule continued from previous page. 10. Joint pain Yes = 1 No=2 Unsure = 3 11. Pain in extremities (the hands and feet) Yes=1 No = 2 Unsure = 3 12. Pain in genitals other than during intercourse Yes = 1 No = 2 Unsure = 3 13. Pain during urination Yes = 1 No=2 Unsure = 3 14. Other pain (other than headaches) Yes = 1 No=2 Unsure = 3 15. Shortness of breath when not exerting oneself Yes = 1 No = 2 Unsure = 3 16. Palpitations (a feeling that your heart is beating very strongly) Yes = 1 No = 2 Unsure = 3 [ ] 17 . Chest pain Yes = 1 No=2 Unsure = 3 [ ] 18. Dizziness Yes = 1 No = 2 Unsure = 3 [ ] 19 . Difficulty swallowing Unsure =3 [ ] 20 . Loss of voice Yes = 1 No=2 Unsure = 3 [ ] 21. Deafness Yes = 1 No=2 Unsure = 3 [ ] 22 . Double vision Yes = 1 No = 2 Unsure = 3 [ ] 23 . Blurred vision Yes = 1 No=2 Unsure = 3 [ ] 24 . Blindness Yes = 1 No = 2 Unsure = 3 [ ] 25 . Fainting or loss of consciousness Unsure = 3 [ I Unsure = 3 [ ] Yes=1 26 . Amnesia Yes = I No = 2 No = 2 27 . Seizure or convulsion Unsure = 3 [ ] 28 . Trouble walking Yes = 1 No = 2 Unsure = 3 [ ] Dissociative Disorders Interview Schedule continued on next page. 176 DISSOCIATION, Vol, II, No . 3: September 1989 Dissociative Disorders Interview Schedule continued from previous page. 29. Paralysis or muscle weakness Yes = 1 No = 2 Unsure = 3 30. Urinary retention or difficulty urinating Yes = 1 No = 2 Unsure = 3 31. Long periods with no sexual desire Yes = 1 No = 2 Unsure = 3 32. Pain during intercourse Yes = 1 No = 2 Unsure = 3 Note : If subject is male ask question 33 and then go to question 38 . If female, go to question 34. 33. Impotence Yes = 1 No=2 Unsure = 3 34. Irregular menstrual periods Yes = 1 No=2 Unsure = 3 35. Painful menstruation Yes = 1 No = 2 Unsure = 3 36. Excessive menstrual bleeding Yes = 1 No = 2 Unsure = 3 37. Vomiting throughout pregnancy Yes = 1 No=2 Unsure - 3 38. Have you had many physical problems or a belief that you have been sick, for several years beginning before the age of 30? Yes = 1 No=2 Unsure =3 39. Have you ever had any other serious physical symptoms for which doctors could find no explanation? Yes = 1 No = 2 Unsure = 3 H. Substance Abuse 40. Have you ever had a drinking problem? Yes = 1 No=2 Unsure = 3 41. Have you ever used street drugs extensively? Yes = I No = 2 Unsure = 3 42. Have you ever injected drugs intravenously? Yes = 1 No = 2 Unsure = 3 43. Have you ever had treatment for a drug or alcohol problem? Yes = 1 No = 2 Unsure = 3 III . Psychiatric History 44. Have you ever had treatment for an emotional problem or mental disorder? Yes = 1 No = 2 Unsure = 3 Dissociative Disorders Interview Schedule continued on next page. ', , 1 '1 177 DISSOCIATION, Vol. Ii, No . 3: September 1989 Iw1w.&WA r~ 1_~ ~j 1~h/ \~ ~I rl \n1 I% i y \1~D l ni111~J vi!LV Dissociative Disorders Interview Schedule continued on next page. Dissociative Disorders Interview Schedule continued from previous page. 45 . Do you know what psychiatric diagnoses, if any, you have been given in the past? Yes=1 No=2 Unsure =3 [ ] 46 . Have you ever been diagnosed as having: a) depression [ 1b) mania [ ] c) schizophrenia [ 1d) anxiety disorder [ ]e) other psychiatric disorder (specify) [ lYes - 1 No = 2 Unsure = 3 If subject did not volunteer a diagnosis for 46 (e) go to question 48. 47 . If the subject volunteered diagnoses for (e) did the subject volunteer any of the following: a) psychogenic amnesia [ ] b) psychogenic fugue [ ] c) multiple personality disorder [ ] d) depersonalization disorder [ ] e) atypical dissociative disorder [ ] Yes = 1 No = 2 Unsure = 3 48 . Have you ever been prescribed psychiatric medication? Yes = 1 No=2 Unsure = 3 49 . Have you ever been prescribed one of the following medications? a) antipsychotic b) antidepressant c) lithium d) anti-anxiety or sleeping medication e) other (specify) Yes=1 No=2 Unsure=3 50 . Have you ever received ECT, also known as electroshock treatment? Yes = 1 No=2 Unsure = 3 51 . Have you ever had therapy for emotional, family, or psychological problems, for more than 5 sessions in one course of treatment? Yes = 1 No = 2 Unsure = 3 52. How many therapists, if any, have you seen for emotional problems or mental illness in your life? Unsure = 89 if subject answered No to both questions 51 and 52, go to question 54. 53 . Have you ever had a treatment for an emotional problem or mental illness which was ineffective? Yes = 1 No = 2 Unsure = 3 [ 178 DISSOCIATION . Vol. II, No . 3 : September 1989 fa73 ; e JA I Dissociative Disorders Interview Schedule continued on next page. 179 DISSOCIATION, Vol. Il, No 3 : September989 Dissociative Disorders Interview Schedule continued from previous page. IV . Major Depressive Episodes The purpose of this section is to determine whether the subject has ever had or currently has a major depressive episode. 54. Have you ever had a period of depressed mood lasting at least two weeks in which you lost interest or pleasure in all or almost all usual activities and past times and felt depressed, blue, hopeless, low, down in the dumps or irritable? Yes = 1 No = 2 Unsure = 3 If subject answered No to question 54, go to question 62. If subject answered Yes or Unsure, interviewer should ask,"During this period did you experience the following symptoms nearly every day for at least two weeks?" 55 . Poor appetite or significant weight loss (when not dieting) or increased appetite or significant weight gain. Yes = 1 No = 2 Unsure = 3 [ ] 56 . Sleeping too little or too much. Yes = 1 No-2 Unsure = 3 57 . Being physically and mentally slowed down, or agitated to the point where it was noticeable to other people. Yes = 1 No = 2 Unsure = 3 58 . Loss of interest or pleasure in usual activities, or decrease in sexual drive. Yes = 1 No = 2 Unsure = 3 59 . Loss of energy ; fatigue. Yes = 1 No = 2 Unsure = 3 60 . Feelings of worthlessness, self-reproach, or excessive or inappropriate guilt. Yes = 1 No = 2 Unsure = 3 61 . Difficulty concentrating or difficulty making decisions. Yes = 1 No = 2 Unsure = 3 62 . Have you ever had recurrent thoughts of death, suicidal thoughts, wishes to be dead, or attempted suicide? Yes = 1 No = 2 Unsure = 3 If you have made a suicide attempt, did you: a) take an overdose b) slash your wrists or other body areas c) inflict cigarette burns or other self injuries d) use a gun, knife, or other weapons e) attempt hanging 1) use another method Yes = 1 No = 2 Unsure = 3 63 . If you have had an episode of depression as described above, is it: currently active, first occurrence = 1 currently in remission = 2 currently active, recurrence = 3 uncertain = 4 due to a specific organic cause = 5 * a73- 1 a73 II 1 Dissociative Disorders Interview Schedule continued from previous page. V. Schneiderian First Rank Symptoms 64 . Have you ever experienced the following: Yes = 1 No = 2 Unsure = 3 [ ] a) voices arguing in your head [ ] b) voices commenting on your actions [ ] c) having your feelings made or controlled by someone or something outside you [ ] d) having your thoughts made or controlled by someone or something outside you [ ] e) having your actions made or controlled by someone or something outside you [ ] influences from outside you playing on or affecting your body such as some external force or power [ ] g) having thoughts taken out of your mind [ ] h) thinking thoughts which seemed to be someone else's [ ] i) hearing your thoughts out loud [ ] j) other people being able to hear your thoughts as if they're out loud [ ] k) thoughts of a delusional nature that were very out of touch with reality [ ] If subject answered No to all Schneiderian symptoms, go to question 67, otherwise, interviewer should ask: "If you have experienced any of the above symptoms are they clearly limited to one of the following :" 65 . Occurred only under the influence of drugs, or alcohol. Yes = 1 No = 2 Unsure = 3 [ ] 66 . Occurred only during a major depressive episode. Yes = 1 No = 2 Unsure = 3 [ ] VI. Trances, Sleepwalking, Childhood Companions 67 . Have you ever walked in your sleep? Yes = 1 No = 2 Unsure = 3 [ ] If subject answered No to question 67, go to question 69. 68. If you have walked in your sleep, how many times, roughly? 1-10 = 1 11-50 = 2 >50 = 3 Unsure = 4 [ ] 69. Have you ever had a trance-like episode where you stare off into space, lose awareness of what is going on around you and lose track of time? Yes = 1 No = 2 Unsure = 3 [ ] If subject answered No to question 69, go to question 71. 70 . If you have had this experience, how many times, roughly? 1-10 = 1 11-50 = 2 >50 = 3 Unsure = 4 [ ] 71 . Did you have imaginary playmates as a child? Yes = 1 No = 2 Unsure = 3 [ ] If subject answered No to question 71, go to question 73. 72. If you had imaginary playmates, how old were you when they stopped? Unsure=O [ ] { ] If subject still has imaginary companions score subject 's current age. Dissociative Disorders Interview Schedule continued on next page. 180 DISSOCIATION, Vol . II, No . 3 : September IYS9 f . ' / ' , i '1' Dissociative Disorders Interview Schedule continued from previous page. Dissociative Disorders Interview Schedule continued on next page. VII . Childhood Abuse 73 . Were you physically abused as a child or adolescent? Yes = 1 No = 2 Unsure = 3 If subject answered No to question 73, go to question 78. 74. Was the physical abuse independent of episodes of sexual abuse? Yes = 1 No-2 Unsure = 3 75. If you were physically abused, was it by: a) father b) mother c) stepmother d) stepfather e) sibling f) male relative g) female relative h) other male i) other female Yes = 1 No = 2 Unsure = 3 76. If you were physically abused, how old were you when it started? Unsure = 89 . If less than 1 year, score 0 . [ ] [ ] 77. If you were physically abused how old were you when it stopped? Unsure = 89 . If less than 1 year score 0 . If ongoing score subject's current age . [ ] [ ] 78. Were you sexually abused as a child or adolescent? Sexual abuse includes rape, or any type of unwanted sexual touching or fondling that you may have experienced. Yes = 1 No = 2 Unsure = 3 If the subject answered No to question 78, go to question 85 . If the subject answered Yes or Unsure to question 78, the interviewer should state the following before asking further questions on sexual abuse: The following questions concern detailed examples of the types of sexual abuse you may or may not have experienced . Because of the explicit nature of these questions, you have the option not to answer any or all of them . The reason I am asking these questions is to try to determine the severity of the abuse that you experienced . You may answer Yes, No, Unsure or not give an answer to each question ." 79. If you were sexually abused was it by: a) father [ ] b) mother [ ] c) stepfather [ ] d) stepmother e) sibling f) male relative [ ] g) female relative h) other male [ ] i) other female [ ] Yes = 1 No = 2 Unsure = 3 No Answer = 4 If subject is female skip question 80 . If male skip question 81. 80 . If you are male and were sexually abused, did the abuse involve: a) hand to genital touching b) other types of fondling [ 181 DISSOCIATION, W . II, No . 3 : Scptcmber 1989 Dissociative Disorders Interview Schedule continued from previous page. Dissociative Disorders Interview Schedule continued on next page. c) intercourse with a female d) anal intercourse with a male - you active e) you performing oral sex on a male f) you performing oral sex on a female g) oral sex done to you by a male h) oral sex done to you by a female i) anal intercourse - you passive j) enforced sex with animals k) pornographic photography 1) other (specify) Yes = 1 No=2 Unsure = 3 No Answer 4 81 . If you are female and were sexually abused, did the abuse involve: a) hand to genital touching b) other types of fondling c) intercourse with a male d) simulated intercourse with a female e) you performing oral sex on a male f) you performing oral sex on a female g) oral sex done to you by a male h) oral sex done to you by a female i) anal intercourse with a male j) enforced sex with animals k) pornographic photography 1) other (specify) Yes = 1 No=2 Unsure = 3 No Answer = 4 82 . If you were sexually abused, how old were you when it started? Unsure = 89 . If less than 1 year, score 0. 83 . If you were sexually abused, how old were you when it stopped? Unsure = 89 . If less than 1 year, score 0 . If ongoing score subject's current age . [ ] [ ] 84 . How many separate incidents of sexual abuse were you subjected to up until the age of 18? 1-5=1 6-10=2 11-50=3 >50=4 Unsure=5 [ ] 85 . How many separate incidents of sexual abuse were you subjected to after the age of 18? 0=1 1-5=2 6-10=3 11 -50=4 >50=5 Unsure=6 [ ] VIII . Features Associated with Multiple Personality Disorder For questions 86-95, if subject answers Yes, ask subject to specify whether it is occasionally, fairly often or frequently, excluding question 93. 86 . Have you ever noticed that things are missing from your personal possessions or where you live? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 87. Have you ever noticed that there are things present where you live, and you don't know where they came from or how they got there? e .g. clothes, jewelry, books, furniture. Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 182 UISSOCI3TION, Vol. IL No . 3 : September 1989 S ,t * . ` 1,`1 ` . ' I` V ` i Dissociative Disorders Interview Schedule continued from previous page . Dissociative Disorders Interview Schedule continued on next page. 88. Have you ever noticed that your handwriting changes drastically or that there are things around in handwriting you don't recognize? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 89. Do people ever come up and talk to you as if they know you but you don't know them, or only know them faintly? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 90. Do people ever tell you about things you 've done or said, that you can 't remember, not counting times you have been using drugs or alcohol? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 91. Do you ever have blank spells or periods of missing time that you can 't remember, not counting times you have been using drugs or alcohol? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 92. Do you ever find yourself coming to in an unfamiliar place, wide awake, not sure how you got there, and not sure what has been happening for the past while, not counting times when you have been using drugs or alcohol? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 93. Are there large parts of your childhood after age 5 which you can't remember? Yes = 1 No=2 Unsure = 3 94. Do you ever have memories come back to you all of a sudden, in a flood or like flashbacks? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 95. Do you ever have long periods when you feel unreal, as if in a dream, or as if you're not really there, not counting when you are using drugs or alcohol? Never = 1 Occasionally = 2 Fairly Often = 3 Frequently = 4 Unsure = 5 96. Do you hear voices talking to you sometimes or talking inside your head? Yes = 1 No = 2 Unsure = 3 If subject answered No to question 96, go to question 98. 97. If you hear voices, do they seem to come from inside you? Yes = 1 No = 2 Unsure = 3 98. Do you ever speak about yourself as "we" or "us"? Yes = I No=2 Unsure = 3 99. Do you ever feel that there is another person or persons inside you? Yes = 1 No = 2 Unsure = 3 If subject answered No to question 99, go to question 102. 100. Is there another person or persons inside you that has a name? Yes=1 No=2 Unsure=3 ] 183 DISSOCIATION . Vol. IL No, '3 ; September 1989 r I" 1 a73 ! Dissociative Disorders Interview Schedule continued from previous page. 101 . If there is another person inside you, does he or she ever come out and take control of your body? Yes=1 No=2 Unsure=3 [ ] IX . Supernatural/Possession/ESP Experiences/Cults 102 . Have you ever had any kind of supernatural experience? Yes = 1 No=2 Unsure = 3 [ ] 103 . Have you ever had any extrasensory perception experiences such as: a) mental telepathy [ ] b) seeing the future while awake [ ] c) moving objects with your mind [ ] d) seeing the future in dreams [ ] e) deja vu (the feeling that what is happening to you has happened before [ ] f) other (specify) [ ] Yes = l No = 2 Unsure = 3 104 . Have you ever felt you were possessed by a: a) demon [ ] b) dead person [ ] c) living person [ ] d) some other power or force [ ] Yes = 1 No=2 Unsure = 3 105 . Have you ever had any contact with: a) ghosts [ ] b) poltergeists (cause noises or objects to move around) [ ] c) spirits of any kind [ ] Yes = 1 No = 2 Unsure = 3 106 . Have you ever felt you know something about past lives or incarnations of yours? Yes = 1 No = 2 Unsure = 3 107 . Have you ever been involved in cult activities? Yes = 1' Unsure = 3 [ ] X . Borderline Personality Disorder Interviewer should state, "For the following eight questions, please answer Yes only if you have been this way much of the time for much of your life . Have you experienced :" 108 . Impulsive or unpredictable behavior in at least two areas that are potentially self-damaging, e .g., spending, sex, gambling, substance use, shoplifting, overeating, physically self-damaging acts. Yes = 1 No=2 Unsure = 3 [ ] 109 . A pattern in which many of your personal relationships tend to be intense, but unstable and short-lived. Yes = 1 No = 2 Unsure =3 [ ] 110 . Intense anger or lack of control of anger, e .g., frequent displays of temper, constant anger. Yes=l No=2 Unsure =3 [ ] Dissociative Disorders Interview Schedule continued on next page. 184 DISSOCIATION . Vol. II .1No, 3:September 1989 . 9 a73 I te . "1' # ' ! ' i `I Dissociative Disorders Interview Schedule continued on next page. 185 Dissociative Disorders Interview Schedule . continued from previous page. 111. Feeling uncertain about your identity, which may include problems with self-image, self-awareness, sexual identity or career choice . e .g. because you feel uncertain about who you are, you may try to imitate different people in an attempt to discover which identity fits best for you. Yes = I No = 2 Unsure = 3 112. Frequent mood swings : noticeable shifts from normal mood to depression, irritability or anxiety. Yes = 1 No = 2 Unsure = 3 113. Feeling uncomfortable being alone, e .g. frantic efforts to avoid being alone, depressed when alone. Yes = 1 No = 2 Unsure = 3 114. Physically self-damaging acts, e .g., suicidal gestures, self-mutilation, recurrent accidents or physical fights. Yes = 1 No = 2 Unsure = 3 115. Chronic feelings of emptiness or boredom. Yes = 1 No = 2 Unsure = 3 XL Psychogenic Amnesia 116. Have you ever experienced sudden inability to recall important personal information or events that is to extensive to be explained by ordinary forgetfulness? Yes=1 No=2 Unsure=3 If subject answered No or Unsure to question 116, go to 118. 117. If you answered Yes to the previous question was the disturbance due to a known physical disorder (e .g., blackouts during alcohol intoxication, or stroke)? Yes = 1 No = 2 Unsure = 3 XII .Psychogenic Fugue 118. Have you ever experienced sudden unexpected travel away from your home or customary place of work, with inability to recall your past? Yes = 1 No = 2 Unsure = 3 119. Have you ever assumed a new identity (partial or complete)? Yes=1 No=2 Unsure=3 If subject answered No to one or both of questions 118 and 119, go to 121. 120. If you answered Yes to both the previous two questions was the disturbance due to a known physical disorder? (e .g., blackouts during alcohol intoxication, or stroke)? Yes = 1 No = 2 Unsure = 3 [ XIII . Depersonalization Disorder 121. Interviewer should say, "I am now going to ask you a series of questions about depersonalization . Depersonalization means feeling unreal, feeling as if you're in a dream, seeing yourself from outside your body or similar experiences ." a) Have you had one or more episodes of depersonalization sufficient to cause problems in your work or social life? Yes = 1 No = 2 Unsure = 3 [ ] DISSOCIATION . Vol . II . 3September 1989 1 ~! f Dissociative Disorders Interview Schedule continued from previous page. b) Have you ever had the feeling that your feet and hands or other parts of your body have changed in size? Yes = 1 No = 2 Unsure = 3 [ ] c) Have you ever experienced seeing yourself from outside your body? Yes = 1 No=2 Unsure =3 [ ] d) Have you ever had a strong feeling of unreality that lasted for a period of time, not counting when you are using drugs or alcohol? Yes=1 No=2 Unsure=3 [ ] If subject did not answer Yes to any of 121 a-d, go to question 123. 122 . If you answered Yes to any of the previous questions about depersonalization, was the disturbance due to another disorder, such as Schizophrenia, Affective Disorder, Organic Mental Disorder (mental disorder with a physical cause), Anxiety Disorder, or epilepsy? Yes = 1 No = 2 Unsure = 3 [ ] X1V. Multiple Personality Disorder - NIMH Research Criteria, consisting of DSM-III (123-125) criteria plus two further criteria (126-127) 123 . Have you ever felt like there are two or more very different personalities within yourself, each of which is dominant at a particular time? Yes=1 No = 2 Unsure =3 [ ] If subject answered No to question 123, go to question 128. Do any of the following apply to you? 124. 125. 126. 127. XV . The personality or part of you that is dominant at any particular time controls your behavior. Yes = I No = 2 Unsure = 3 [ ] Each individual personality is complex and has behaviors and social relationships that are not shared by the other personalities. Yes = 1 No = 2 Unsure = 3 Two or more different personalities, have been in control of your body on at least three separate occasions. Yes = 1 No = 2 Unsure = 3 [ ] Some type of amnesia or combination of types of amnesia exists among the different personalities. Yes = 1 No = 2 Unsure = 3 [ ] Atypical Dissociative Disorder (Dissociative Disorder NotOtherwise Specified) Subject appears to have a dissociative disorder but does not satisfy the criteria for a specific dissociative disorder . Examples include trance-like states, derealization unaccompanied by depersonalization, and those more prolonged dissociated states that may occur in persons who have been subjected to periods of prolonged and intense coercive persuasion (brainwashing, thought reform, and indoctrination while the captive of terrorists or cultists). Yes =1 No = 2 Unsure = 3 [ ] 128. 186 Dissociative Disorders Interview Schedule continued on next page. DISSOCIATION, Vol. II,No. 3:Septemhrr1989 f I ` . `I ` 1 f ` i '1" APPENDIX II SCORING THE DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE Dissociative Disorders Interview Schedule continued from previous page. XVI . Concluding Items 129. During the interview, did the subject display unusual, illogical, or idiosyncratic though processes? Yes = 1 No = 2 Unsure = 3 130. If the subject is assessed as having a multiple personality disorder, and answered Yes to question 1, the interviewer should ask, "In your opinion are the headaches I asked about earlier part of your problem with different personalities controlling you?" Yes = 1 No = 2 Unsure = 3 131. If the subject is assessed as having MPD, and has also received the diagnosis of depression (question 63), the interviewer should ask : "In your opinion is the depression I asked about earlier :" Confined to one personality = 1 [ ] Affects most or all personalities = 2 [ ] Unsure = 3 [ ] Interviewer should make a brief concluding statement telling subject that there are no more questions, and thanking the subject for his/her participation. The Dissociative Disorders Interview Schedule is di- vided into 16 sections . Each section is scored independently. All DSM-III diagnoses are made according to the rules in DSM-III. There is no total score for the entire interview . However, average scores for 20 multiple personality disorder (MPD) subjects on selected subsections are given below. Following presentation of scoring rules for each section, you will find a description of a typical profile for an MPD patient . The DDIS has been administered to over 400 adult subjects without a confirmed false positive diagnosis of MPD. Structured interview data on 102 MPD subjects from across North America have been collected . These provide average scores for MPD which differ somewhat from those presented in the DDIS subsections . Structured interview data on 102 MPD subjects from across North America have been collected . These provide average scores for MPD which differ somewhat from those presented in the DDIS subsec- tions. I. Somatic Complaints This is scored according to DSM-III rules . To be positive for somatization disorder the subject must answer `yes' to question 38 ; in addition, the subject must answer `yes' to at least 14 questions if female and 12 questions if male, from questions 3-37 . We prefer to use the DSM-III-R criteria, which require 13 `yes' answers for either sex, from questions 3-37 . A history of somatization disorder distinguishes MPD from schizophrenia, eating disorders, and controls, but not from panic disorder . The average number of symptoms positive from questions 3-37 for MPD is 13 .5. IL Substance Abuse We score the subject as positive for substance abuse if he or she answers 'yes' to any question in this section . A history of substance abuse differentiates MPD from schizophrenia, eating disorders, panic disorder, and controls : 11 out of 20 MPD subjects were positive. III. Psychiatric History This is a descriptive section which does not yield a score as such . In a questionnaire study we found that in 236 cases of MPD, the average patient had received 2 .74 other psychi- atric diagnoses besides MPD. IV. Major Depressive Episodes This is scored according to DSM-III rules . To be positive the subject must answer `yes' to question 54 . He or she must answer `yes' to 4 questions from 55-62. A history of depression does not discriminate MPD from other diagnostic groups : 17 out of 20 MPD subjects were positive for major depressive episode at some time in their life . 187 DISSOCIATION, Vol . II, No :September 1989 Ul /i\I_C/Y~UI~LVJ ~ a73!Y!~\%IH'11 ~AI UI VI IL ~ V. Schneiderian First Rank Symptoms In this section we score the total number of 'yes' re- sponses . The total number of Schneiderian symptoms posi- tive discriminates MPD from all groups tested except schizo- phrenia . The average number of positive symptoms in MPD is 6 .6. VI. Trances, Sleepwalking, Childhood Companions Each of these items is scored independently . The subject is positive for sleepwalking if he or she answers 'yes' to ques- tion 67, positive for trances if 'yes' to 69, positive for imagi- nary playmates if 'yes' to 71 . Each of these items discrimi- nates MPD from schizophrenia, eating disorders, panic disorder and controls. VII. Childhood Abuse The subject is scored positive for physical abuse if he or she answers 'yes' to question 73 . Other data are descriptive. History of physical abuse discriminates MPD from schizo- phrenia, eating disorders, and panic disorder : 15 of 20 MPD subjects were positive. The subject is positive for sexual abuse if he or she answers 'yes' to question 78 . Sexual abuse also discriminates MPD from the other three groups : 16 out of 20 MPD subjects were positive. VIII. Features Associated With MPD The responses in this section are added up to give a total score . A positive response in this section is either 'yes,' or else 'fairly often' or 'frequently,' depending on the structure of the question . 'Never' and `occasionally' are scored as nega- tive . Secondary features discriminate MPD from the other three groups : average number of features positive in MPD is 8 .3. IX. Supernatural, Possession, ESP Experiences, Cults In this section the positive answers are added up to give a total score . These experiences discriminate MPD from the other groups : average number of positive responses for MPD is 5 .5. X. Borderline Personality Disorder This is scored by DSM-Ill rules . The subject must be positive for 5 items to meet the criteria for borderline personality . Borderline personality does not discriminate MPD from other groups tested to date, except for panic disorder and controls . However, the average number of borderline criteria positive does discriminate MPD from schizophrenia, eating disorders, and panic disorder : the average for 20 MPD subjects is 5 .3. XI. Psychogenic Amnesia This is scored by DSM-III rules . The subject must be positive for question 116 and negative for question 117. Psychogenic amnesia discriminates MPD from the other three groups : 13 out of 20 MPD subjects were positive. According to DSM-III-R rules, a positive diagnosis of MPD means that one cannot have a diagnosis of psychogenic amnesia . That makes sense to us . However, using DSM-III 188 rules, psychogenic amnesia provides an additional discrimi- nating section. XII. Psychogenic Fugue This is scored by DSM-III rules . The subject must be positive for questions 118 and 119, and negative for 120 . This diagnosis also discriminates MPD from the other three groups : 7 out of 20 MPD subjects were positive . As for psychogenic amnesia, DSM-III-R rules state that a diagnosis of MPD prevents a concurrent diagnosis of psychogenic fugue . XIII. Depersonalization Disorder This is scored by DSM-II1 rules . The subject must be positive for question 121a, and negative for 122 . Questions 121 b-d are further items which are not required for the DSM- III diagnosis . This diagnosis discriminates MPD from other groups very poorly . It is also the only DSM-III diagnosis in the interview schedule with a low inter-rater reliability (r= .56). We consider depersonalization to be a symptom, not a diagnosis, and recommend that it be ignored in interpreting the results of structured interview. XIV. Multiple Personality Disorder The criteria given are the NIMH criteria, of which the first 3 are the D5M-III criteria . The subject must be positive for all 3 items to meet the D5M-III criteria for MPD . The diagnosis of MPD discriminates MPD from all other groups tested to date with no false positives, and two false negatives out of 20 . The inter-rater reliability for MPD is (r= .78), the sensitivity is 90%, the specificity is 100%, and the clinical validity is excellent, in our initial study. Translation of DSM-III criteria into DSM-III-R criteria is problematic because of the wording in the two manuals. Subjects who meet the first two DSM-III criteria only are probably true multiples, however. XV. Atypical Dissociative Disorder This is scored positive based on the interviewer's judge- ment . A patient can be positive for atypical dissociative disorder only if he or she does not have any other dissociative disorder. XVI. Concluding Items This is a descriptive section and is not scored . Most MPD patients will meet the DSM-III criteria for MPD and all should meet the first two . Anyone who does not meet the first two criteria is unlikely to have full MPD unless he or she has a high score on secondary features . This may be the case in the first few assessment sessions, before the diagnostician has contacted alter personalities directly . We usually don't make a diagnosis of MPD until we have contacted alter personalities directly . If alters have not been contacted directly, or reported by a reliable observer, one can say that the subject almost certainly has MPD based on interview results, but a conclusive diagnosis is not possible. Most MPD patients will have : numerous somatic symp- toms ; a history of substance abuse and major depressive episode ; a number of Schneiderian symptoms ; sleepwalk- DISSOCIATION, Vol. II, No, 3 : September 1989 . 1 I I .'1`f . . 1 ing, trance states and/or imaginary playmates in childhood; a history of physical and/or sexual abuse ; borderline person- ality disorder, or at least 3 borderline symptoms ; numerous extrasensory experiences ; other dissociative diagnoses ; and a history of numerous past diagnoses and treatments. Not all MPD patients will have all of these features, but most will have a substantial proportion of them . MPD sub- jects with particularly severe abuse histories appear to have higher scores and more items positive, but we do not have sufficient data yet to say that for sure. DISSOCIATIVE DISORDERS INTERVIEW SCHEDULE NORMS FOR 102 CASES The following are average values for 102 cases of MPD diagnosed at four different centers . Two centers differed on two items, otherwise there were no significant differences between the centers on any of the items in the DD1S. Only 82 subjects completed the Dissociative Experi- ences Scale . The average score was 41 .4 (S .D. 20 .0), and the median score was 43 .8, with a range of 1 .2 - 83 .6. Average Number of Item Symptoms Per Subject (S .D .) Somatic symptoms 15 .2 (7 .3) Schneiderian symptoms 6.4 (2 .8) Secondary features of MPD 10 .2 (3 .5) Borderline criteria 5.2 (2 .3) Extrasensory experiences 5.6 (3 .3) Diagnosis % of Subjects Positive for Diagnosis MPD 94 .1 Major depressive episode 91 .2 Borderline personality disorder 63 .7 Somatization disorder 60 .8 a73 189 DISSOCIATION . Vol . II, No . 3: September 1989