Dissociation scale pdf

Similar to the concept of shutdown dissociation, the DSM-5 committee links the dissociation to an overwhelming experience that may arise when the individual is confronted with an overwhelming threat with perceived inescapability, such as childhood sexual abuse, torture, or war trauma American Psychiatric Association, Being confronted with an imminent life-threat, for which flight-or-fight is no longer a viable option to counter danger, the organism may shift to immobility and dissociative responding.

To escape the threatening situation as well as the internal distress and arousal, dissociative responding may be adaptive. Assumed survival advantage of the shutdown continuum according to Schauer and Elbert in order to inhibit non-adaptive action disposition and enable survival.

If the stimulus is threatening, then the sympathetic branch of the autonomous nervous system becomes dominant and the release of sympathetic mediated adrenalin is initiated.

This bodily adaption supplies the heart and muscles with the required energy for flight-or-fight. At the same time, amongst a concert of other actions, the peripheral vessels constrict in order to reduce potential blood loss in the case of injury. Reports about tonic immobility from rape survivors describe similar states in humans e.

It consists of functional sensory deafferentation, motor paralysis, alterations of the consciousness, and loss of speech perception and production. To shut down the bodily system, the parasympathetic system takes over dominance, resulting in bradycardia, a decrease in blood pressure, and vasodilatation Scaer, It is likely that this ongoing disruption of integrative processes would play a key role in the development and maintenance of PTSD.

Dissociative responding could then be understood, on the one hand, as an adaption in order to survive during life-threat and, on the other hand, as a problem as resulting in more fragmentation of the past and future memories. This is a self-rating scale that contains normal and pathological dissociative states and was developed as a tool to assess dissociation in the general population.

The authors of the scale referred to the concept of a dissociative continuum that ranges from minor dissociative experiences to major pathological dissociation, such as the multiple personality disorder.

The Clinician-Administrated Dissociative State Scale consists of both a self-rating and ratings scored by a professional observer Bremner et al. The Multidimensional Inventory of Dissociation is a item self-administered instrument, especially for clinical research and diagnostic assessment Dell, The SDQ measures somatoform dissociation that is closely related to Janet's concept of dissociation and includes positive e.

The fifth version of the Diagnostic and Statistical Manual of Mental Disorders DSM-5 describes the PTSD Dissociative Subtype with prominent symptoms of alternated usually integrated functions of consciousness, memory, sense of time, body awareness, and perceptions of the environment and the self American Psychiatric Association, The development of instruments has been based on clinical observations rather than on a biological model of dissociative responding.

Shutdown dissociation includes partial or complete functional sensory deafferentiation, classified as negative dissociative symptoms see Nijenhuis, ; Van Der Hart et al. The Shut-D focuses exclusively on symptoms according to the evolutionary-based concept of shutdown dissociative responding. The items are scored in an interview to be applicable also in resource-poor settings because self-ratings require well-educated, literate respondents. The newly developed scale should help to systematically record the impact of traumatic experiences with high proximity to danger and serve as a research tool for shutdown dissociative responding.

The goal of the present investigation was to obtain psychometric characteristics factor structure; internal consistency; retest reliability; and predictive-, convergent-, and criterion-referred concurrent validity of the Shut-D.

Different patient samples were selected that have been prone to symptoms of dissociation in previous reports such as patients with psychotic spectrum disorders, major depression, borderline personality disorder, PTSD, and dissociative identity disorder e. The Shut-D is a structured interview consisting of 13 items. Responses to all items were given on a scale including 0 not at all , 1 once a week or less , 2 2—4 times a week , to 3 5 or more times a week.

Summed scores can range from 0 to When completing this interview, interviewers should establish the time frame for which these shutdown dissociation symptoms have been reported. The interviewer should select a time frame within the past 6 months in order to acquire an overview of the patient's suffering in their everyday life. If the trauma occurred less than 6 months ago, symptoms are to be explored since the traumatic event. Use the prompt questions as written on the questionnaire; use additional questions as needed to accurately determine the frequency of the symptom.

Use open-ended questions to carefully inquire about the frequency. When was the last time you suffered from this symptom? When you think back over the last month, was [the symptom] a rare occurrence? Have you only sometimes experienced this symptom or does it occur often?

It is appropriate to use information that arises later in the interview to modify an earlier rating. If a person reports that he or she experiences spells of fainting, the interviewer should rate all corresponding symptoms measured by the scale e. Shutdown dissociation simulates central nervous system neuropathy. Peripheral neuropathy describes the damage to the peripheral nervous system. Peripheral damage affects one or more dermatomes and thus produces symptoms for specific areas of the body.

In contrast, shutdown dissociation affects a part of the body e. Please consider side effects of medication, and exclude if it was due to effects of alcohol or drugs. Please consider similar effects that may appear during adolescence or at the beginning of menopause. We recruited female refugees with multiple traumatic experiences at the University of Konstanz outpatient clinic for refugees.

They were referred to the clinic by a human rights organization, medical doctors, or lawyers for diagnostic clarification or potential treatment.

All patients participated in the assessment of shutdown dissociation. Complete data were obtained from 54 patients and 17 healthy controls with similar ethnic backgrounds, who were recruited from the general community.

Following this, the number of traumatic experiences was assessed using the sum of the event checklist of the Clinician Administered PTSD Scale Blake et al. For traumatic events, we made a distinction between the number of traumatic event types that were self-experienced and the number of traumatic event types that were witnessed.

A traumatic event type was judged as self-experienced if the participant was the victim high proximity of danger , or a witness low proximity of danger if the participant had observed the traumatic event while someone else was threatened. The score on the Hamilton Rating Scale for Depression Williams, estimated the degree of depression.

Data of the same sample are presented in Schalinski et al. The study sample 2 consisted of German psychiatric patients and healthy controls Table 2. Sample description, mean, and standard deviation of age, frequency of gender, and mean and standard deviation of shutdown dissociation. In this sample, we screened for adverse childhood experiences and applied the Shut-D. The responsible psychologist or the psychiatrists in charge made the current diagnoses based on the ICD World Health Organization, , and verified that the patient had sufficiently improved to provide informed consent and could participate in the assessment of adverse childhood experiences.

The inclusion criteria were at least age 18, and receiving treatment at the local psychiatry in the post-acute treatment section. Thus, the patient sample consisted of patients that were motivated for further treatment.

Two patients refused to participate for the following reasons: one because the participant felt bothered by his childhood experiences and one participant because of distrust. This sample consisted of 15 female patients with dissociative identity disorder Schlumpf et al. According to Schlumpf and colleagues, patients were recruited from private practitioners and psychiatric outpatient departments in Switzerland and Germany for an fMRI study for biosocial reaction.

Exclusion criteria were comorbid psychotic disorder, drug abuse or addiction, antisocial or histrionic personality disorder, and a neurological or organic brain disease.

During data collection, the patients were requested to answer the items for their main host personality. Analyses were performed using R version 2. The alpha level was set at 0. The factor structure as well as the internal consistency and item-total correlation were assessed in all study samples.

The test—retest was used to assess the reliability of the scale in the whole study sample 1. Furthermore, predictive validity was investigated in a symptom provocation paradigm study sample 1; see Predictive validity section , convergent validity was examined between the Shut-D and the DES study samples 2 and 4 , criterion-referenced concurrent validity was obtained by comparisons of different diagnostic groups study samples 1—4 and point-biserial correlates with the symptom spectrums depression and PTSD symptom severity study sample 1.

To avoid global correlations, the associations were assessed in the patient sample. Following exposure, a psychologist interviewed the participants about their shutdown dissociative responding.

The tendency towards shutdown dissociation was rated on a Likert scale with possible scores of 0 not at all , 1 a little bit , 2 moderately , 3 strongly , and 4 very strongly during picture presentation using the item Shut-D Intensity Scale.

The first factor eigenvalue 5. All other eigenvalues were below 1. Table 3 presents the factor loadings of the items as well as the rotated factor solution Varimax procedure.

The internal consistency could not be improved through item deletion. Item difficulties and factor loadings in an one-factor solution as well as in a rotated Varimax two-factor solution. The item-total correlation was performed in the whole sample. These consistently moderated to strong associations, indicating that every item was correlated with the sum score Table 4. The test—retest reliability was 0. Figure 1 shows the correlation between the first and second assessments.

The relationship between the sum score of the first and second assessments of the shutdown dissociation score. The line indicates the regression line model estimation from the patient sample. The shutdown dissociation strength in response to rapidly presented pictures was assessed in a study designed to trigger trauma-specific processing Schalinski et al.

The scatterplot is presented in Fig. The relationship between the shutdown dissociation score and the shutdown dissociative strength in response to emotional evocative pictures.

The line shows the regression line model estimation from the patient sample. In a study of 10 female patients with borderline personality disorder, 12 patients with a diagnosis of depression, 15 patients with dissociative identity disorder, and 48 healthy controls, the convergent validity of the DES and the Shut-D was assessed Fig. The scatterplot of the shutdown dissociation sum score and the sum score of the Dissociative Experience Scale DES across different diagnostic groups and healthy controls.

The patients in the dissociative identity disorder group were instructed to rate the symptoms for the host personality.

The dashed horizontal line presents the cut-off score of the DES sum score, and those values above 30 are indicative of a dissociative disorder or of posttraumatic stress disorder PTSD. Figure 4 shows the sum score for different diagnostic groups.

There was no significant difference between the Shut-D scores comparing groups of patients with PTSD and dissociative identity disorder Fig. Boxplot of the shutdown dissociation sum score across different diagnostic groups and healthy controls. The patients in the dissociative identity disorder group were instructed to rate their symptoms for the host personality. Scatterplots illustrating correlations between shutdown dissociation and A the number of different traumatic event types, B the number of different witnessed traumatic event types, C the severity of PTSD symptoms, and D the severity of depression symptoms.

The slope of the regression is presented for significant associations. Partial correlations were calculated to examine the common variances of these symptom clusters. The assessment is suitable for different levels of education and has been successfully applied in different samples, including low-income countries, migrant samples, and various psychiatric disorders Fiess et al. This report shows high-quality psychometric characteristics for data collected from healthy controls, samples with PTSD, major depression, psychosis, borderline personality disorder, and dissociative identity disorder.

Results demonstrated sufficient internal reliability and excellent test—retest reliability of the Shut-D. Furthermore, the scale shows high convergent validity with the sum score of the DES, a scale that has dominated in the research of dissociation in patients with PTSD. Complete Directory. If you are in crisis or having thoughts of suicide, visit VeteransCrisisLine.

Quick Links. Share this page. Are you using this measure with U. Does your sense of your own body feel changed: for. Do people seem motionless, dead, or mechanical? Do objects look different than you would expect? Do colors seem to be diminished in intensity? Do you see things as if you were in a tunnel, or looking.

Does this experience seem to take much longer than you. Do things seem to be happening very quickly, as if there. Do things happen that you later cannot account for? Do you space out, or in some other way lose track of. Do sounds almost disappear or become much stronger. Do things seem to be very real, as if there is a special. Does it seem as if you are looking at the world through a.

Do colors seem much brighter than you would have. Observer Items Did the subject seem eery or strange, or in some other. Did the subject blank out or space out, or in some other. Did the subject appear to be separated or detached from.

Did the subject say something bizarre or out of context,. Did the subject behave in a bizarre, unexpected manner,. Did the subject have to be put back on track, or. Did the subject show any unusual twitching or grimacing. Did the subject show any unusual rolling of the eyes. Discussion Our findings suggest that the CADSS is a reliable and valid instrument for the measurement of present-state dissociative symptomatology.

In the current study, the CADSS was shown to have a high level of agreement between different raters, as well as a high degree of internal consistency, which suggests that the individual items have a high level of agreement with one another. This suggests that the CADSS can be used as a repeated measure which assesses symptomatology at specific time points. Our findings do not support the current nosology of individual symp- tom areas of dissociation.

Internal consistency of the scale was higher for the total scale score than for the individual subscales of amnesia, deper- sonalization, and derealization. This sug- gests that the subscales are not particularly useful in the differentiation of subtypes of patients with dissociative symptoms.

We are not aware of other studies, however, which have established the construct validity of these symptom areas.

In the current sample of patients, dissociative symptoms tended to aggregate together. For instance, patients reported epi- sodes of losing periods of time amnesia. Immediately before or after these episodes they remembered the feeling that things around them were unreal, or that they felt like they were in a dream derealization.

Again, many of the patients who reported out-of-body experiences depersonalization said that during the experience they felt as if they were in a dream or as if colors had changed derealization. Future studies should address the ques- tion of whether the individual symptom areas of dissociation have construct validity as separate entities apart from general dissociative symptomatology.

Also, there are some differences in the content of the items in the two instruments. Some of the individual items which are part of the observer subscale did not correlate with total CADSS scale score. These items were included in the scale based on a review of the clinical literature, which suggested that they represent be- haviors commonly seen in dissociative states. Future studies may be useful in determining whether the variables contained in these items are related to the construct of dissociation.

More extensive train- ing of raters, or the use of specific anchors, may be needed in order to improve the reliability of this aspect of the scale. These items were included in the scale largely on the basis of a review of the literature related to multiple personality disorder currently termed dissociative identity disor- der DID. It may be that observable dissociative behaviors are primarily seen in patients with DID.

Reliability studies in a concentrated population of patients with DID would be useful to determine if this is the case. It also may be possible that observable dissociative behaviors do not represent a viable construct, and that dissociation is essentially a subjective phenome- non. It is premature, however, to draw conclusions about the viability of dissociative behavior as a construct merely on the basis of these preliminary findings.

Future studies are needed to investigate this important question. Our findings should be considered preliminary for several reasons. More extensive testing of reliability and validity in a larger number of sub- jects would be beneficial. Testing in different populations, such as dissocia- tive populations with larger numbers of DID patients, and in other settings, such as a repeated measure in a treatment trial for dissociative symptoma- tology.

There were also methodological limitations of the study, such as the fact the healthy controls were younger as a group than the patients. This should not represent a confound to our finding of increased dissocia- tive symptomatology in the patient group, however, since dissociative symp- tomatology measured with the DES has previously been shown to decrease with age Ross et al.

We thank Andreas Nicholau for reviewing the manuscript and for providing statistical exper- tise. We also thank Viola Vaccarino for providing statistical consultation and expertise. Diagnostic and statistical manual of mental disorders 3 rd ed. Washington, D. Bartko, J. The intraclass correlation coefficient as a measure of reliability. Psychological Reports, 19, Bernstein, E. Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease, , Bliss, E.

Multiple personalities, allied disorders, and hypnotizability. London: Oxford Press. Branscotnbe, L. Dissociation in combat-related posttraumatic stress disorder. Dissociation, 4,