SCID-D

TRAINING HANDOUT
COLLECTION OF REFERENCE ARTICLES

( This Handout with active links can be downloaded at http://ge.tt/8BWdn2s1 )

PRIMARY SCID-D REFERENCES:

Interviewers Guide:
Steinberg M: The Interviewers Guide to the Structured Clinical Interview for
DSM-IV Dissociative Disorders- Revised. Washington, D.C., American Psychiatric
Press, Second Printing, 1994, 1993
http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=62349

The SCID-D Interview:
Steinberg M: The Structured Clinical Interview for DSM-IV Dissociative
Disorders-Revised (SCID-D). Washington, D.C., American Psychiatric Press, Second
Printing, 1994, 1993
http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=8860

Clinical Handbook:
Steinberg M: Handbook for the Assessment of Dissociation: A Clinical Guide.
Washington, D.C., American Psychiatric Press, 1995
http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=8682

Popular Press for Therapists and Patients:
Steinberg M, Schnall M: The Stranger in the Mirror: Dissociation ,The
Hidden Epidemic, Harper Collins, 2001, 2000.
Amazon Paperback or Kindle Edition: http://tinyurl.com/k4se7hs





I.
Why Assess for Dissociation

a. Dissociation and Global Functioning
Complex dissociative disorders, i.e., dissociative identity disorder
and dissociative disorder-not- otherwise-specified, contribute to
functional impairment above and beyond the impact of co-existing
non-dissociative axis I disorders
http://ge.tt/66kPO0s1/v/0

b. Dissociations role in treatment resistance

i. Generally, among severely impaired

The high comorbidity of DD yielded in our patients, who all
received disability payments, compared to other outpatient studies
raises the question of the relationship between impaired
functioning and pathological dissociation. Axis 1 diagnoses
included primarily depressive disorders (n = 6, 21%), psychotic
disorders (n = 5, 18%), personality disorders (n = 4, 14%), eating
disorders (n = 4, 14%) and somatoform disorders (n = 3, 11%).
Seven (25%) of the 28 interviewed patients were diagnosed as
having a DD, only one of which had a mention of dissociation in
their medical chart
http://ge.tt/8gj7Q0s1

ii. Treatment resistance within standard PTSD treatment
regiments
The highly dissociative group was characterized by higher levels
of posttraumatic and general distress, more frequent reports of
suicidality, self-mutilation, eating problems and less favorable
treatment response. High in dissociation patients needed more
time to show improvement and were still clinically worse at the
end of treatment and at follow-up. The results highlight the
clinical relevance of using dissociation measures for identifying
subgroups of [trauma] patients with severe psychopathology who
may be more treatment resistant The high distress level in
complex dissociative disorder patients indicates that patients with
complex dissociative disorders need treatment that is in part
different from the more general treatment of polysymptomatic
CSA survivors, addressing the pathological aspects of dissociation
more vigorously.
http://ge.tt/4PglT0s1
iii. Treatment resistance within Substance Abuse Treatments

64.9% of substance inpatients that had a dissociative disorder
began to experience dissociation an average of 3.6 years prior
to substance use. Patients with comorbid dissociative
disorders were overrepresented among dropouts from the
treatment program. Moreover, five of the patients with high
scores on the DES dropped out of treatment before further
evaluation with the SCID-D. Overlooking the dissociative
disorder in these patients can be a handicap for their
treatment.

See the Substance Abuse link to research results provided

further below.

c. A Dissociative Disorder is a Superordinate disorder that can be
successfully addressed through Phasic treatment
[With Phasic Treatment for Dissociative Disorders], patients
showed decreased dissociation, PTSD, general distress, depression,
suicide attempts, self-harm, dangerous behaviors, drug use,
physical pain, and hospitalizations
http://ge.tt/7OPoX0s1
II.

Epidemiology of Dissociative Disorders as seen through patient

assessment for a dissociative disorder

a. Generally
Overall, independent studies from various countries clearly
demonstrate that dissociative disorders constitute a common
mental health problem not only in clinical practice but also in the
community as well. Using diagnostic tools designed to assess
dissociative disorders yielded lifetime prevalence rates around
10% in clinical populations and in the community. Special
populations such as psychiatric emergency ward applicants, drug
addicts, and women in prostitution demonstrated the highest rates.
http://ge.tt/9njsk0s1/v/0
b. Within specific patient populations

i. Bi-polar
In a group of 51 people attending to Sisli Etfal Training and
Research Hospital outpatients department who had been diagnosed
as bipolar disorder according to DSM-IV-TR and not in an episode
of mania, depression or mixed state on the assessment, the
frequency of any dissociative disorder, when assessed with the
SCID-D, was 35.4%
http://ge.tt/89BBe0s1
ii. Schizophrenia
62% assessed as having a past or present Dissociative Disorder.
Results of this study support the hypothesis that there are
unrecognized dissociative symptoms and disorders in a population
of patients with prior clinical diagnoses of psychotic disorders.
http://ge.tt/5iG7Z0s1/v/0

iii. Sex Addiction

66% of the survey sample qualified for a dissociative disorder
diagnosis.
http://ge.tt/3NlIg0s1/v/0
iv. Substance Abuse

The aim of the present study was to determine the prevalence

and correlates of dissociative disorders among inpatients with
drug dependency. Twenty-seven patients (26.0%) had a
dissociative disorder according to the SCID-D.
http://ge.tt/6sj3W3s1

v. Eating Disorders
Of the 21 bulimics scoring above 20 on the DES, 5 of them
(23.8%) met the criteria for a dissociative disorder when
assessed with the SCID-D
http://ge.tt/8X9463s1/v/0
vi. OCD

14% of the patients with OCD had comorbid dissociative
disorder. There was a statistically significant positive correlation
between Yale-Brown points and Dissociation Questionnaire points.
We conclude that dissociative symptoms among patients with
OCD should alert clinicians for the presence of a chronic and
complex dissociative disorder.
http://ge.tt/1bGQp0s1
vii. Prison/Juvenile delinquent
Forensic Inpatients: Almost 25% suffered from any kind of DD as
diagnosed with the SCID-D. The rates are more than twofold
higher than prevalence rates from the general population. These
results suggest that forensic patients resemble a very high-risk
population for both dissociative symptoms and disorders
Juveniles in Detention Center: A total of 28.3% met the criteria
for a dissociative disorder. Early detection may help identify a
group of children who could benefit from early intervention.
http://ge.tt/2CKDw0s1
c. Dissociation and Dissociative Disorders as a Commonality of
Conversion /Somatization /PTSD

i. Dissociative disorders within PTSD population

We studied 30 victims of intrafamily rape who were over the
age of 12. These victims were consecutive admissions to a
forensic center for sexual violence. The rapes were
perpetrated by the Father (30%) , the stepfather (27%), an
uncle (27%), a brother (10%), or a grandfather (7%). The
victims were interviewed by a psychiatrist using the SCID-D.
87% of the victims had a dissociative disorder.
http://ge.tt/8eYEqup1

ii. Evidence: PTSD as a Dissociative Disorder

Imaging studies in posttraumatic stress disorder (PTSD) have

shown differing neural network patterns between hypoaroused/dissociative and hyper-aroused subtypes. Since
dissociative identity disorder (DID) involves different emotional
states, this study tests whether DID fits aspects of the differing
brain-activation patterns in PTSD. Results confirm the notion that
DID is related to PTSD as hypo-aroused and hyper-arousal states
in DID and PTSD are similar.
http://ge.tt/9jbB8lp1

iii. Conversion (generally)
Thirty-eight consecutive patients previously diagnosed with
conversion disorder were evaluated [for a possible dissociative
disorder] using the SCID-D. A dissociative disorder was seen in
47.4% of the patients.
http://ge.tt/5b0zP3s1

iv. Pseudo-seizures as a Dissociative Disorder
Dissociation is nearly ubiquitous in pseudo-seizure patients but
often is overlooked and not formally diagnosed. When the SCIDD was used systematically, 90% of pseudo-seizure patients were
found to have a dissociative disorder.
http://ge.tt/9PClcYq1
v. Somatization as a Dissociative Disorder

In this study, 50% of the somatization disorder patients, when

assessed with the SCID-D, were diagnosed with dissociative
amnesia.
http://ge.tt/3XkUYjh1



d. Psychophysiological Changes as an observed part of dissociative
phenomenology

We present a patient with dissociative identity disorder (DID) who
after 15 years of diagnosed cortical blindness gradually regained
sight during psychotherapeutic treatment. At first only a few
personality states regained vision, whereas others remained blind.
http://ge.tt/9quySAU1

e. Traumatic Response and Culture

Within-Culture-Differences-Over-Time: can provide clues as
to inter-cultural differences. For instance, from war to war,
somatic expressions of exposure to trauma altered in
recognized predominance, from cardiac symptoms (mid-
1800's) to tremor and movement disorders (WWI) to
gastrointestinal symptoms (WWII: "In May 1942, digestive
disorders accounted for 17% of all discharges for diseases
from the army and RAF") to the somatic expressions of "Gulf
war syndrome". These differences can be explained, in part, by
changes in culturally acceptable ways to express traumatic
exposure, coupled with the observer's (eg, doctors') cultural
bias for explanations during that particular epoch.

Comparative Cultural Differences: In this case report of MPD
in a Hispanic woman, the author compares and contrasts her
presentation of symptoms with those of the culturally accepted
Ataque de Nervios, or ''Puerto Rican syndrome. " It is theorized
that the similarities may increase the incidence of misdiagnosis
of MPD in Hispanics and it is recommended that the diagnosis
of MPD be considered in Hispanics with histories of ataque.
http://ge.tt/1fQsydq1

III.

Use of the SCID-D in Assessing Dissociation

a. Overview

Introductory article: A comprehensive assessment of
dissociative symptoms is recommended for effective treatment
of trauma survivors. The author reviews the systematic
detection of dissociative symptoms and disorders using the
SCID-D

Review in Canadian Journal of Psychiatry: Like a rich

symphony, I never tire of the SCID-D and seem to be constantly
surprised and educated by it. This is in large part because of
the open-ended format, whereby most questions are followed
with can you describe what that experience is like? It allows
me to learn how the patient, having just answered yes,
actually many not have what is being asked for. More often,
though, it is amazing what the patient volunteers about
dissociation, long before the more direct questions are asked.
http://ge.tt/40rP13s1
b. Screeners and their limitations for diagnosis
Screener Study 1: We found no significant differences between
the diagnostic accuracy of the DES [cutoff=12], SDQ-20
[cutoff=30], and MID [cutoff=28] Looking at positive
predictive values and correct classification rates, the cut-off scores
we selected for a sensitivity greater than .80 only predicted an
accurate diagnosis (positive predictive value) of between 38 % and
51 % for DDs and between 39 % and 40 % for DDNOS-I/DID in
our sample. In other words, the use of these instruments with
optimal screening scores lacks sufficient diagnostic accuracy
because of high false positive rates, which often is the case for
screening instruments. This is not necessary an undesirable feature
of instruments used for screening purposes, where the
consequences of missing a true positive are more serious than
diagnosing a false positive. However, as is often the case with
screening instruments, follow-up testing with a more definitive
diagnostic evaluation that has better specificity is required, e.g., by
the SCID-D-R in patients with a positive result according to one of
these three psychometric instruments.
Screener Study 2: In a sample of 1,051 clinical subjects,
however, only 17% of those scoring above 30 on the DES actually
had DID (Carlson et al., 1993). The DES is not a diagnostic
instrument. It is a screening instrument. High scores on the DES do
not prove that a person has a dissociative disorder, they only
suggest that clinical assessment for dissociation is warranted.
DID subjects sometimes have low scores, so a low score does not
rule out DID. In fact, given that in most studies the average DES
score for a DID patient is in the 40s, and the standard deviation
about 20, roughly about 15% of clinically diagnosed DID patients
score below 20 on the DES.
http://ge.tt/8kR8T2s1

c. Forensic methods for assessing and providing expert opinions on

Dissociative Disorders
i. Standardized methods of Forensic Assessment, and Detection
of Feigners

Forensic Methods Article: The authors review specific SCID-
D-R interview criteria that support the accuracy of dissociative
diagnosis based on extensive scientific investigations by
providing standardized methods, methods that can also assist
in distinguishing valid versus simulated dissociation. The
application of the SCID-D-R in a forensic case is presented to
illustrate the utility of this diagnostic tool in the courtroom.

Study Assessing SCID-Ds Ability to detect Feigners: The SCID-
D was clearly the most efficacious measure of dissociation in
discriminating DID from schizophrenia and from feigned
dissociation. It appears to be difficult to feign convincing
> responses to a comprehensive interview that inquires about
numerous dissociative symptoms and requires the respondent
to generate plausible examples of a spectrum of dissociative
experiences. Not only did the SCID-D correctly assign all of the
DID and feigners in diagnostic classification, but the DID group
also scored significantly higher than the other groups in the
severity ratings of dissociative symptoms.
http://ge.tt/9thoi2s1

ii. Affidavit detailing expert opinion regarding dissociative
amnesia and recovered memory, including a sample patient
study proffering a dissociative condition.
http://ge.tt/2oGajck1

d. Differential Diagnosis: Psychosis vs. Dissociative Disorders
i. The meaningful purpose of differential diagnosis between
dissociation and psychosis is to determine if dissociation
treatment principles are an applicable treatment regiment for
this patient at this time. Use of the SCID-D is not to diagnose
Schizophrenia, but rather to identify those patients that, at the
time of assessment, evidence enough dissociative processes
such that a dissociative disorder can be diagnosed and, using
the information gleaned in the interview, dissociative
treatment principles can be optimally employed.
http://ge.tt/3r9UY2s1

e. Adolescents


Consecutive outpatients between 11 and 17 years of age who
were admitted to the child and adolescent psychiatry clinic of a
university hospital for the first time were evaluated using the
Structured Clinical Interview for DSM-IV Dissociative
Disorders (SCID-D) administered by two senior psychiatrists in
a blind fashion. There was excellent inter-rater reliability
between two clinicians on SCID-D diagnoses and scores.
Among 73 participants, thirty-three (45.2 %) had a dissociative
disorder, twelve (16.4%) having DID and 21 (28.8%)
dissociative disorder not otherwise specified. There was no
difference on gender distribution, childhood trauma, and
family dysfunction scores between dissociative and non-
dissociative groups. Of dissociative adolescents, 93.9% had an
additional psychiatric disorder.
http://ge.tt/9Cc2vEh1

f. SCID-D Psychometrics
i. Inter-rater Reliability
Interrater reliability was established on the basis of 43 SCID-D
interviews. A very high agreement (weighted kappa) was
reached between interviewer and rater on the five severity
ratings: amnesia (kappa=0.96), depersonal- ization
(kappa=0.92), derealization (kappa=0.96), identity confusion
(kappa=0.98), and identity alteration (kappa= 0.85) (all
significant at p0.001). Total agreement was reached between
interviewer and rater on the absence or presence of
dissociative disorders (kappa=1.0, z=6.56). Total agreement
was reached as well on the type of dissociative disorder.
http://ge.tt/8hZpF3s1
ii. Discriminant Validity

1. Discriminant validity as determined by significant
differences in SCID-D scores between dissociatives and
non-dissociatives as judged by raters blind to patient
diagnosis. Each of the three group comparisons
(patients with DD according to the SCID-D, patients with
non-dissociative psychiatric disorders, and normal
controls) had SCID-D scores significantly different from
each other on both the SCID-D total score and on each of
the 5 component SCID-D symptoms
http://ge.tt/5SaD83s1

2. Discriminant validity as determined by Neuroimaging

differences between SCID-D triaged subjects.
Differences in psychophysiological and neural
activation patterns were found between the [SCID-D-
identified] DID patients and both high and low fantasy
prone controls. That is, the identity states in DID were
not convincingly enacted by DID simulating controls.
Thus, important differences regarding regional cerebral
bloodflow and psychophysiological responses for
different types of identity states in patients with [SCID-
D-identified] DID were upheld after controlling for DID
simulation.
http://ge.tt/70IDt2s1