IJLP-01236; No of Pages 8

International Journal of Law and Psychiatry xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

International Journal of Law and Psychiatry

Assessment of complex dissociative disorder patients and simulated dissociation in

forensic contexts
Bethany L. Brand a,⁎, Aliya R. Webermann a, A. Steven Frankel b
a
Psychology Department, Towson University, Towson, MD, United States
b
Psychology Department, University of Southern California, Lafayette, CA, United States

a r t i c l e i n f o a b s t r a c t

Available online xxxx Few assessors receive training in assessing dissociation and complex dissociative disorders (DDs). Potential
differential diagnoses include anxiety, mood, psychotic, substance use, and personality disorders, as well as
Keywords: exaggeration and malingering. Individuals with DDs typically elevate on many clinical and validity scales on psy-
Dissociation chological tests, yet research indicates that they can be distinguished from DD simulators. Becoming informed
Dissociative identity disorder about the testing profiles of DD individuals and DD simulators can improve the accuracy of differential diagnoses
Trauma
in forensic settings. In this paper, we first review the testing profiles of individuals with complex DDs and contrast
Minnesota Multiphasic Personality Inventory-2
(MMPI-2)
them with DD simulators on assessment measures used in forensic contexts, including the Minnesota Multi-
Dissociative Experiences Scale (DES) phasic Personality Inventory-2 (MMPI-2), Personality Assessment Inventory (PAI), and the Structured Inventory
Structured Clinical Interview for DSM-IV of Reported Symptoms (SIRS), as well as dissociation-specific measures such as the Dissociative Experiences
Dissociative Disorders (SCID-D-R) Scale (DES) and Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). We then provide
recommendations for assessing complex trauma and dissociation through the aforementioned assessments.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction integration between memories of the past, awareness of identity and

Within the most recent edition of the Diagnostic and Statistical
Manual of Mental Disorders 5 (DSM-5; American Psychiatric
Association, 2013), dissociation is described as a “discontinuity in the
normal integration of consciousness, memory, identity, emotions,
perception, body representation, motor control, and behavior” (p. 291).
The primary dissociative disorder (DD) diagnoses in the DSM-5 are
dissociative amnesia, depersonalization/derealization disorder, and
dissociative identity disorder (DID). An individual with clinically signif-
icant dissociative symptoms who does not meet the diagnostic criteria
for these disorders would typically be diagnosed with other-specified
dissociative disorder (OSDD) according to DSM-5 criteria (American
Psychiatric Association, 2013), or dissociative disorder not otherwise
specified (DDNOS) according to DSM-IV-TR criteria (American
Psychiatric Association, 2000).
The International Statistical Classification of Diseases and Related
Health Problems—10th Revision (ICD-10; World Health Organization,
1992) states that “the common themes that are shared by dissociative
or conversion disorders are a partial or complete loss of the normal
immediate sensations, and control of bodily movements” (pp. 122–
123). Within the ICD-10, DID is listed as multiple personality disorder,
under the superordinate other dissociative [conversion] disorder, and
dissociative amnesia also appears in ICD-10, but the DD category in
ICD-10 (ICD-10; World Health Organization, 1992) more broadly
includes what DSM-5 defines as somatoform disorders (American
Psychiatric Association, 2013). According to the ICD-10, those with clin-
ically significant dissociative symptoms who do not meet full diagnostic
criteria for a particular DD can be diagnosed with a mixed or unspecified
DD.
A myriad dissociative experiences occur within the confines of DDs
as well as other disorders encompassing trauma-based dissociation
(e.g., dissociative posttraumatic stress disorder [PTSD]), including
absorption, derealization, depersonalization, amnesia, and identity
confusion and alteration. Dissociative experiences such as depersonali-
zation (e.g., a sense of being unreal) are common transient symptoms
in other disorders including borderline personality disorder (BPD),
psychotic disorders, in periods of acute stress such as during panic
attacks, and as a result of consuming particular substances such as
hallucinogens.

2. The etiology, prevalence, and treatment of dissociative disorders

⁎ Corresponding author.
E-mail addresses: bbrand@towson.edu (B.L. Brand), awebermann@towson.edu The empirically-supported trauma model of dissociation (Dalenberg
(A.R. Webermann), drpsylex@gmail.com (A.S. Frankel). et al., 2012) explains the etiology of dissociation as stemming from

http://dx.doi.org/10.1016/j.ijlp.2016.10.006
0160-2527/© 2016 Elsevier Ltd. All rights reserved.

Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006
2 B.L. Brand et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
chronic and severe childhood maltreatment. A common outcome of
trauma is dissociation, which enables individuals to adapt and cope
with unbearable and unescapable trauma, especially trauma perpetrated
by a trusted caregiver during childhood (Dalenberg et al., 2012; Freyd,
1996; Loewenstein & Putnam, 1990; Putnam, 1991; Spiegel, 1984). In
contrast to childhood maltreatment rates of 20–40% in the general
public (e.g., Felitti et al., 1998), individuals with severe DDs typically
evidence childhood maltreatment rates of 80–95% (Brand et al., 2009;
Dalenberg et al., 2012; Putnam, Guroff, Silberman, Barban, & Post,
1986).
Community epidemiology studies estimate that 1–10% of individuals
from the general population are diagnosed with a DD in their lifetime
(Şar, 2011). For individuals with DDs, their dissociative symptoms
often lead to marked impairment and functional limitations in a variety
of domains, including personal (e.g., self-care and emotion regulation),
psychosocial and interpersonal, and vocational domains, among others
(Brand et al., 2009, 2013; Johnson, Cohen, Kasen, & Brook, 2006;
Mueller-Pfeiffer et al., 2012). Due to their poor functioning, severe
dissociative symptoms (Brand et al., 2009; Putnam, 1991; Putnam
et al., 1986), trauma-based distorted cognitions (i.e., “I am dirty, I am a
bad person”; Brand, 2002; Kluft, 1995), and complex post-trauma
symptoms (Herman, 1992), those with DDs have higher rates of self-
harm and suicidality than many other psychiatric patients (Foote,
Smolin, Neft, & Lipschitz, 2008; Webermann, Myrick, Taylor, Chasson,
& Brand, 2016).
Because of their high rates of self-harm and severe psychiatric
symptoms, DD patients require high levels of intensive mental health
and medical services, including psychiatric hospitalizations (Brand
et al., 2009; Fraser & Raine, 1992; Lloyd, 2011; Loewenstein, 1994;
Ross & Dua, 1993). Many individuals with DID receive psychiatric dis-
ability benefits, making them among the most costly and frequently
misdiagnosed psychiatric patients (Mueller-Pfeiffer et al., 2012). DDs,
especially DID, require lengthy and intensive treatment, and are often
misdiagnosed and underdiagnosed by clinicians (International Society
for the Study of Trauma and Dissociation, 2011; Loewenstein, 1994).
DID patients spend an average of 7–12 years in the mental health care
system and often receive multiple inaccurate diagnoses before receiving
an accurate DID diagnosis and appropriate treatment (Boon & Draijer,
1993; Hornstein & Putnam, 1992; Putnam et al., 1986; Rivera, 1991;
Ross, Joshi, & Currie, 1990).
For these reasons and more, accurate assessment and diagnosis of
DDs are crucial. However, training and education on assessing DDs
and complex trauma are limited (Brand, Armstrong, & Loewenstein,
2006; Courtois & Gold, 2009). Inaccurate diagnoses may occur when
clinicians cannot accurately differentiate genuine posttraumatic and
dissociative symptoms from malingering, or cannot differentially
diagnose trauma disorders (e.g., PTSD and DID) from other disorders
with overlapping symptoms (e.g., BPD and schizophrenia; Welburn
et al., 2003). Individuals may malinger within forensic settings to obtain
financial gain or beneficial legal outcomes, or within clinical settings to
obtain disability payments or attention (Guriel & Fremouw, 2003). It
is estimated that about 15% of litigation cases involve psychological
malingering (Rogers, 1997; Young, 2015).
This paper will explore issues related to the assessment of DDs via
personality and psychological measures, including: common clinical
dilemmas when assessing complex trauma and DDs; challenges to
accurate diagnosis of DDs (e.g., misdiagnoses, comorbid diagnoses,
differential diagnoses); signs of DDs obtained through assessment
(e.g., symptomatic markers); and the psychological profiles of individ-
uals with genuine DDs as well as DD-simulating individuals on well-
validated measures including the Minnesota Multiphasic Personality
Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, &
Kaemmer, 1989), the Personality Assessment Inventory (PAI; Morey,
1991), and the Structured Inventory of Reported Symptoms (SIRS/
SIRS-2; Brand et al., 2014; Rogers, Bagby, & Dickens, 1992; Rogers,
Sewell, & Gillard, 2010).
Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006
3. Challenges to accurately assessing dissociative disorders
3.1. Clinical dilemmas when assessing dissociative disorders
A typical response of clinicians to the question of how many cases of
DID they have encountered is as follows: “I've never seen it, and I've
been in practice for so many years that it either has to be very rare, or
non-existent.” DID is characterized by a need to “not be seen or
known” (e.g., Chefetz, 2015; Frankel, 2015). Furthermore, few graduate
programs offer training with childhood trauma survivors, and psychol-
ogy textbooks often focus more on controversies surrounding DID
and “recovered memories of abuse” rather than providing important
information on the etiology, impairment, and treatment of dissociation
(Wilgus, Packer, Lile-King, Miller-Perrin, & Brand, 2015). For these
reasons, it is not surprising to encounter comments from clinicians
indicating skepticism about DID. The lack of training and familiarity
with DID is associated with denying the existence of the disorder and
misdiagnosis (Dorahy, Lewis, & Mulholland, 2005; Perniciaro, 2015).
Only 60.4% of clinicians who reviewed a vignette of a patient
presenting with all the symptoms of DID accurately diagnosed DID
(Perniciaro, 2015). Perniciaro (2015) found that neither clinicians' age,
professional degree, years of experience, nor certainty about their diag-
nostic accuracy were associated with an accurate diagnosis, suggesting
that even experienced clinicians who are quite certain that a patient
does not have DID may be incorrect. In fact, extensive literature
concludes that DID is not rare, iatrogenic, a fad, or overdiagnosed
(Brand, Loewenstein, & Spiegel, 2014; Brand et al., 2016; Şar, 2011).
The estimated lifetime prevalence of DDs in both clinical and community
populations is 10%, and DID is estimated at 1–3%, making DID as preva-
lent as schizophrenia and bipolar disorder (Şar, 2011). Additionally, a
meta-analysis by Dalenberg et al. (2012) found a strong relationship
between trauma and dissociation, even when trauma was objectively
verified via court and medical records.
3.2. Comorbid and differential diagnoses
One of the most significant difficulties in accurately diagnosing DID,
especially by professionals with little training or experience in assessing
dissociation and DDs, is that DID patients typically manifest cross-
cutting symptoms found in other disorders, most notably BPD,
schizophrenia, bipolar disorder, PTSD, and substance use disorders
(Brand et al., 2009; Ellason, Ross, & Fuchs, 1999; Foote et al., 2008;
Rodewald, Wilhem-Gößling, Emrich, Reddemann, & Gast, 2011; Ross,
Heber, Norton, & Anderson, 1989a; Şar, Alioğlu, Akyuz, & Karabulut,
2014; Saxe, van der Kolk, Berkowitz, & Chinman, 1993; Yargiç, Şar,
Tutkun, & Alyanak, 1998). However, DID can be reliably distinguished
from other disorders in clinical and forensic settings when clinicians
use empirically-supported assessment approaches (Brand et al., 2014;
Frankel & Dalenberg, 2006; Welburn et al., 2003). Additionally, research
supports the view that such “competing” diagnoses may appear
comorbidly with DID (Armour, Elklit, Lauterbach, & Elhai, 2014;
Armour, Karstoft, & Richardson, 2014; Brand & Lanius, 2014; Ross,
Ferrell, & Schroeder, 2014; Şar et al., 2014). Personality disorders should
only be diagnosed in DID patients when the personality disorder
symptoms have an early developmental onset, are typical of the
individual's functioning (American Psychiatric Association, 2013), and
are present among the majority of internal dissociated self-states,1
rather than only one or two self-states, as pathological personality traits
are common among DID patients who experience internal conflict
between dissociative self-states and/or therapeutic discord (Frankel,
2009). In addition, while about a fifth of individuals with DDs have a
comorbid substance use disorder (Brand et al., 2009), trauma-based
1
We will use the term “dissociated self-state” to denote the parts of a DID person's per-
sonality. These states have also been referred to as personalities, identities, and alters,
among others.
 B.L. Brand et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
dissociation should be differentially diagnosed from substance-based
dissociation by clarifying what dissociative symptoms occur while the
patient is not under the influence of drugs or alcohol.
4. Assessing dissociation, complex trauma and dissociative disorders
The past decade has seen increases in empirically-supported
assessment instruments and structured interviews for use with DID
and the DDs in both clinical and forensic contexts. These developments
fall into two categories: screening and diagnosis. Screening approaches
focus on alerting evaluators as to the possible presence of DDs, while
diagnostic approaches provide pathways toward making definitive
diagnoses. In addition, while less widely used within clinical and foren-
sic settings, neurobiological assessments provide additional evidence of
DDs through marked differences in the brains of survivors of complex
trauma.
4.1. Instruments to screen for dissociation
Two self-report screening instruments have appeared frequently in
the clinical and research literature: the Dissociative Experiences Scale
(DES; Carlson & Putnam, 1993; Carlson, Putnam, & Ross, 1993; Carlson,
1997) and the Somatoform Dissociation Questionnaire (SDQ; Nijenhuis,
Spinhoven, van Dyck, van der Hart, & Vanderlinden, 1996, 1998). Both
of these instruments have “cut-off” scores that are useful in establishing
confidence in positive screening results (e.g., the likelihood the client
being assessed has a DD). The DES tends to focus on “psychoform disso-
ciation” (i.e., dissociative symptoms that phenomenologically involve the
mind, such as absorption, dissociative amnesia, depersonalization, dere-
alization, identity confusion, and identity fragmentation; Carlson &
Putnam, 1993), whereas the SDQ addresses “somatoform dissociation”
(i.e., dissociative symptoms that phenomenologically involve the body,
such as analgesia, anesthesia, and loss of control of sensory or motor
functioning that is not due to a medical condition or substance;
Nijenhuis, 2000). The DES, in particular, has appeared in more than
1100 research studies and is a staple in the armamentarium of clinical
and forensic evaluators, while the SDQ has been used hundreds of
times and serves as a useful alternative method of conceptualizing disso-
ciation and DDs. Neurobiological research has shown a dose response
relationship between emotional abuse and trauma and DES scores, in
that higher doses of trauma lead to higher DES scores (Teicher,
Samson, Sheu, Polcari, & McGreenery, 2010).
Two self-report measures have recently been developed that may
provide additional information useful to clinicians to make differential
diagnoses of DDs: the Multiscale Dissociation Inventory (MDI; Briere,
2002) and the Multidimensional Inventory of Dissociation (MID; Dell,
2002, 2006). The MDI is a 30-item measure which explores six domains
of dissociation and offers a profile of dissociative symptoms that can
be compared to both clinical and non-clinical samples. The MID is a
218-item multiscale instrument that measures 14 major facets of disso-
ciation. It operationalizes both the subjective and phenomenological
domains of dissociation as well as 23 dissociative symptoms potentially
indicative of DID. Comparing the MID to the MDI, the MID gives a more
comprehensive profile of DID clients who report dissociative self-states,
whereas the MDI is the better choice for more general dissociative
phenomena and in cases in which t scores based on nationally represen-
tative (and by extension, non-clinical) samples are desired. At present,
the MDI is the only measure of complex dissociative symptoms that
was validated on a large, nationally representative standardization
sample of Americans; an administration and interpretation manual
is also available (Briere, 2002). The MDI, therefore, may be more defen-
sible forensically, although the MID provides rich supplemental data for
DD cases. Individuals who score high on the DES, SDQ, MID, and/or MDI
should subsequently be assessed with one of the diagnostic DD
interviews.
Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006
3
4.2. Diagnostic interviews for dissociative disorders
The Structured Clinical Interview for Dissociative Disorders (SCID-D-
R; Steinberg, 1994, 2000; Steinberg, Hall, Lareau, & Cicchetti, 2001) is
regarded as the most valid and reliable approach to the diagnosis of
DDs. The SCID-D-R yields scores along five dimensions that may indi-
cate the presence of a DD: amnesia, depersonalization, derealization,
identity confusion, and identity alteration. The SCID-D-R requires the
examiner to thoroughly assess common dissociative symptoms and
provides the option of a follow-up probe for each question, through
which the assessor may obtain clinically useful historical information
about the onset, frequency, severity, and recency of dissociative
symptoms. In some cases, the detailed questions lead to information
that suggests the individual does not experience dissociation, or experi-
ences it only in the context of other disorders (e.g., BPD and traumatic
brain injury [TBI], among others) or while under the influence of
drugs or alcohol.
Additional interviews that are helpful in diagnosing DDs include
the Office Mental Status Examination (OMSE; Loewenstein, 1991) and
the Dissociative Disorders Interview Schedule (DDIS; Ross, Heber, &
Anderson, 1990; Ross, Heber, Norton, & Anderson, 1989b). The OMSE
is used in clinical, rather than forensic contexts. The OMSE does not
yield quantitative scores or cut-off scores. Rather, it requires clinicians
to use clinical judgment based on the signs and symptoms reported
and observed during the interview. The DDIS inquires about signs and
symptoms of DDs and related disorders, as well as childhood trauma.
The DDIS yields diagnoses that are linked to the DSM-IV's diagnostic
criteria. However, the DDIS does not require patients to describe their
symptoms, nor is information about the severity, onset and most recent
experience with symptoms ascertained. A DSM-5 version of the DDIS is
available online, but published research on the updated DDIS was not
yet available at the time of writing this review.
4.3. Neurobiological assessments of dissociation
Neurobiology research utilizing positron emission tomography
(PET) and functional magnetic resonance imaging (FMRI) shows
marked differences in the brains of survivors of childhood maltreatment
with DDs and PTSD, as compared to healthy and non-abused controls,
including but not limited to reduced resting-state connectivity in
the default mode network, reduced anterior–posterior integration,
abnormalities in white matter, and overconnected amygdala regions
(e.g., Choi, Jeong, Rohan, Polcari, & Teicher, 2009; Frewen & Lanius,
2006; Navalta, Tomoda, & Teicher, 2008; Nicholson et al., 2015).
Research on the neurobiology of trauma (such as the 4-D model;
Frewen et al., 2015; Lanius, 2015) differentiates between dissociative
experiences stemming from trauma exposure as compared to those
occurring normally during waking consciousness, such as when under
the influence of substances, and in times of acute stress. These authors
(see Frewen and colleagues, 2015; Navalta et al., 2008) posit that
brain changes caused by early exposure to childhood trauma lead to
various symptom and behavioral outcomes, of which are likely to influ-
ence how these individuals are represented by standard personality and
psychological assessments.
4.4. Detecting feigned dissociation
Rates of malingering among those with DDs are likely higher (2%–
14%; Coons & Milstein, 1994; Friedl & Draijer, 2000; Thomas, 2001)
than those found in the general psychiatric patient population (5%–
6%; Eisendrath, 1995; Pope, Jonas, & Jones, 1982). Given that DID is
prominently featured in popular culture and media (albeit often
misportrayed), individuals feigning DID may be knowledgeable about
its more well-known symptoms, such as amnesia and “switching”
between dissociative self-states (Coons & Milstein, 1994; Draijer &
Boon, 1999). Methods to detect factitious and malingered DID that do
4 B.L. Brand et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
not overclassify or misclassify genuine traumatized patients are impor-
tant, but also challenging given genuine DD patients' elevated clinical
and validity scale profiles on some, but not all, psychological measures.
Accurate DID diagnosis is further complicated in that an individual
might have both a genuine severe DD as well as factitious exaggeration
of some aspects of dissociation or trauma (Brown & Scheflin, 1999;
Kluft, 1987b); the assumption that feigning is an either-or differential
classification is inaccurate. The combination of genuine and simulated
dissociative symptoms, coupled with more refined and informed
feigned presentations, introduces challenges to mental health and
legal experts (Brown & Scheflin, 1999; Chu, 1991; Kluft, 1987b).
Until quite recently, there was minimal empirical guidance for
detecting feigned DID, other than clinical papers (Brick & Chu, 1991;
Brown, 2009; Coons, 1991; Kluft, 1987b) and descriptive case series
(Draijer & Boon, 1999; Thomas, 2001). These papers typically employ
dissociation-specific assessments, including the SCID-D-R (Steinberg,
1994) and the DES (Carlson & Putnam, 1993). This literature suggests
that clinicians experienced in diagnosing and treating DID can identify
feigning through observing classic malingering signs while they obtain
a detailed psychosocial history from the patient (typically via the
SCID-D-R). For instance, Draijer and Boon (1999) used the SCID-D (the
earlier version of the SCID-D-R) to differentiate genuine and simulated
DID, and found lower scores on amnesia, identity confusion, and
identity alteration among DID simulators as compared to genuine DID
patients, although no group differences were found on depersonaliza-
tion and derealization. While this study provides rich clinical informa-
tion, it includes little systematic data for forensic assessors who
require rigorous methods for detecting feigned DID.
There are several recent empirical studies examining whether
psychological tests and interviews can reliably distinguish factitious
and/or malingered DID from genuine DID (Brand & Chasson, 2015;
Brand, McNary, Loewenstein, Kolos, & Barr, 2006; Brand et al., 2014;
Coons & Milstein, 1994; Welburn et al., 2003). First, we will review
the two studies that compared genuine DID to feigned and simulated
DID using multiple tests, which demonstrated no veritable gain in
utilizing multiple tests. In the subsequent sections, we will review
studies that compared genuine and feigned DID groups on a single
test, which demonstrated mixed results in their efficacy to differentially
detect genuine and feigned DID.
Welburn et al. (2003) compared genuine DID profiles on a battery of
tests including the MMPI-2, DES, SCID-D, and the Millon Clinical
Multiaxial Inventory-III (MCMI-III; Millon, 1997) to the testing profiles
of clinical staff who were simulating DID, genuine schizophrenic
patients, and nine staff responding honestly (i.e., not feigning any disor-
der). These authors found that while DID simulators had more elevated
DES and MMPI-2 scores than staff who were responding honestly,
MMPI-2, DES, and MCMI-III scores were not useful in distinguishing
the genuine DID group from the simulated DID group. SCID-D profiles
were the most effective in distinguishing DID simulators from genuine
DID patients, while the DES was able to differentiate DID and schizo-
phrenia but not identify malingered DID, and the personality assess-
ments were not diagnostically useful in this population. Coons and
Milstein (1994) compared testing profiles of patients with genuine
DID and simulated DID using a test battery that included the MMPI, a
mental status examination, intelligence testing (either the Wechsler
Adult Intelligence Scale [WAIS] or Shipley Hartford Vocabulary Test),
and collateral interviews. These authors found that while MMPI scores
did not differentiate the groups, the presence of well-known character-
istics of malingering did differentiate the groups, such as refusing to
participate in collateral interviews and displaying extreme exaggeration
during the mental status examination.
4.5. Assessing complex trauma and dissociation on the MMPI-2
Pioneering research on the Minnesota Multiphasic Personality
Inventory-2 (MMPI-2; Butcher et al., 1989) indicated that the F scale
Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006
(Infrequency) was effective in distinguishing honest from “faking-
bad” profiles among psychiatric patients (Bagby, Buis, & Nicholson,
1995; Berry et al., 1996; Rogers, Sewell, & Ustad, 1995). However,
when this work was extended to PTSD patients, the F scale and other
validity scales did not prove particularly effective in detecting feigned
PTSD, given the high rates of false-positive feigning classifications
among traumatized groups. An MMPI-2 meta-analysis found extreme
elevations on validity scales for PTSD patients as compared to non-
traumatized patients, including the Fb (Infrequency-Back), F, and Fp
(Infrequency-Psychopathology) scales (Rogers, Sewell, Martin, &
Vitacco, 2003).
Rogers et al. (2003) noted that Fp was the most accurate validity
scale for assessing feigned PTSD, and recommended a cut-off score of
9. Similarly, others have recommended using the Fp scale, as compared
to F or FPTSD (Infrequency-Posttraumatic Stress Disorder scale), or F-K/
O-S scales, when examining an MMPI profile's validity among patients
with a history of childhood maltreatment, as F or FPTSD may inaccurately
identify trauma survivors' profiles as invalid (Elhai, Gold, Sellers, &
Dorfman, 2001; Elhai et al., 2004; Flitter, Elhai, & Gold, 2003). Trauma-
tized patients, especially those with severe dissociation, elevate on
clinical scales as well as validity scales, and thus their MMPI-2 profiles
are often misinterpreted as invalid, or interpreted as indicative of
schizophrenia or antisocial personality disorder (Engels, Moisan, &
Harris, 1994; Flitter et al., 2003; Korbanka, 1997; Korbanka & McKay,
2000; McGrath et al., 2000; Wolf, Reinhard, Cozolino, Caldwell, &
Asamen, 2009).
Caldwell (2001) proposed that MMPI interpretive guidelines over-
look crucial diagnostic information related to childhood maltreatment.
In response to this view, Wolf et al. (2009) found that 11 items from
Scale 8 correctly distinguished 81% of adults abused in childhood from
non-abused control group participants2. The authors described these
11 items on Scale 8 as reflecting various traits found among adults
traumatized as children, including emotion dysregulation, impulsivity,
poor concentration, dissociation, somatic complaints, and inhibited
executive functioning. In fact, two of the 11 items explicitly assess
dissociative processes (i.e., daydreaming and “blank spells”).
4.5.1. The profiles of individuals with dissociative disorders on the MMPI-2
Survivors of chronic childhood maltreatment, such as patients with
complex DDs, typically elevate MMPI-2 Scales 6, 7, 2, 4, and 8 and
often present with the code types of 8–4, 8–2, 4–2, and 7–2 (Bliss,
1984; Brand & Chasson, 2015; Coons, 1984; Coons & Milstein, 1994;
Coons & Sterne, 1986; Elhai, Gold, Mateus, & Astaphan, 2001; Engels
et al., 1994; Flitter et al., 2003; Korbanka, 1997; Korbanka & McKay,
2000).3 Those with invalid profiles often present with 8–6 code types
(Coons & Sterne, 1986; Solomon, 1983).
Dissociation is associated with validity scale elevations. Flitter et al.
(2003) found that among 88 treatment-seeking women who had
experienced childhood sexual abuse, dissociation, PTSD, depression,
and family backgrounds correlated significantly with F scale scores. All
together, these four trauma-based phenomena accounted for 40% of
the variance in F scale scores, with dissociation most strongly predicting
F scale scores (r = .51). One-fifth of the sample had F scores N100T
and 13% had F scores higher than 120T, which the authors interpreted
as reflecting genuine, albeit severe, clinical problems including dissoci-
ation, depression, PTSD, and exposure to poor family-of-origin environ-
ments. In addition, substance abusers have shown a strong relationship
between dissociation and F scale elevations (Dunn, Paolo, Ryan, & van
Fleet, 1993).
2
Scale 8 (Sc) = measures schizophrenic and schizotypal symptoms.
3
Scale 2 (D) = measures depressive symptoms; Scale 4 (Pd) = measures social devia-
tion and rebellion; Scale 6 (Pa) = measures symptoms of paranoia; Scale 7 (Pt) =
measures obsessive–compulsive symptoms; Scale 8 (Sc) = measures schizophrenic and
schizotypal symptoms.
 B.L. Brand et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
Few studies have specifically examined the MMPI-2 profiles and
elevated scales of DID patients. Coons and Sterne (1986) deemed one-
third of DID patients' MMPI profiles invalid due to high F scores, with
extremely high elevations on Scale 8 (M N 90.50T), and somewhat
lower elevations on Scales 2, 4, 6, and 7. Similarly, Welburn et al.
(2003) found high elevations (M N 80T) on Scales 2, 4, 6, 7 and 8, a
typical 8–6–2 code type, and extreme F score elevations (M N 100T)
among DID patients. Brand and Chasson (2015) reported that Scale 8
was the most elevated clinical scale among DID patients, and that signif-
icant elevations (N 70T) were present for clinical Scales 2, 4, 6, and 7.
These authors also found that Scale 8 was associated (r = .47) with
dissociation among DID patients, although non-significantly. These
findings suggest that the MMPI validity scales should be interpreted
with caution on the test profiles of trauma survivors, especially those
with PTSD and DDs, as the MMPI is not adequately normed in this
population and some of the validity scales are of questionable use
with this population.
4.6. The profiles of individuals with dissociative disorders on the PAI
Consistent with MMPI-2 research, adults with childhood trauma
histories elevate on validity and clinical scales on the Personality
Assessment Inventory (PAI; Morey, 1991). The most notable elevation
occurs on the Negative Impression Management (NIM) scale, which
assesses symptom exaggeration (rather than malingering) and includes
items infrequently endorsed by honest responders, although often
endorsed by traumatized and dissociative patients. Thus, this scale is
similar to the MMPI-2's F scale (Calhoun, Collie, Clancy, Braxton, &
Beckham, 2010). A study by Rogers, Gillard, Wooley, and Ross (2012)
found an average score of 71.97T (SD = 15.38) on the NIM Scale
among inpatients with severe trauma exposure, and an average score
of 85.85T (SD = 22.02) among complex DD patients. Similarly,
Stadnik, Brand, and Savoca (2012) found an elevated NIM scale (M =
77.59T, SD = 18.72) among patients with DDs, and to a lesser extent,
elevations on malingering-related scales including Malingering Index
(MAL). These authors suggested that the NIM Scale on the PAI is not
well-suited to accurately assess DD patients, because it often misclas-
sifies genuine, albeit severe, symptoms as exaggerated.
4.7. The profiles of individuals with dissociative disorders on the SIRS/SIRS-2
Similar elevations among trauma survivors on scales meant to assess
over-endorsement of psychiatric symptoms have been found using both
versions of the Structured Interview of Reported Symptoms (SIRS and
SIRS-2; Brand et al., 2014; Rogers et al., 1992, Rogers et al., 2010).
While the SIRS has excellent discriminant validity in accurately
distinguishing feigned disorders in most psychiatric groups (Rogers
et al., 1992), three studies suggest that it overclassifies severely trauma-
tized patients, including those with DID, as feigners (Brand et al., 2006,
2014; Rogers, Payne, Correa, Gillard, & Ross, 2009).
Brand et al. (2006) found that the SIRS misclassified approximately
35% of patients diagnosed with DID, due largely to the patients' high
level of endorsement of psychiatric symptoms on the Subtle and
Selectivity scales. A study by Rogers et al. (2009) found that the SIRS
misclassified 31% of patients with genuine severe trauma histories as
feigners. These authors theorized that the elevated profiles were due
to trauma-based distress and dissociation as opposed to feigned
symptoms because the high elevations were on scales measuring
amplified symptoms (e.g., Subtle and Selectivity) and not on scales
which typically do not elevate in clinical populations. The finding that
DD patients only elevate on scales capturing severe symptoms counters
the notion that severe trauma survivors are indiscriminately endorsing
items or simply “crying for help.” These findings led to Rogers et al.
(2009) to develop a Trauma Index for the SIRS that did not over-
classify complex trauma survivors as feigners, as it included three
primary SIRS scales (SC = symptom combination; IA = improbable or
Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006
5
absurd symptoms; and RO = reported versus observed symptoms)
that were unaffected among individuals with complex trauma. Brand
et al. (2014) found that the SIRS Trauma Index was able to accurately
distinguish genuine versus feigned DID. The authors found the best
balance of test sensitivity (probability of the test detecting feigning,
given that the person is feigning) and specificity (probability of the
test classifying the person as not feigning, given that they are not
feigning) by using the SIRS Trauma Index in combination with the
original SIRS, as the SIRS-2 had lower sensitivity and was thus less
able to detect feigned DID.
Altogether in studies of test batteries and studies of single tests,
results indicate that traumatized and severely dissociative individuals
often elevate on many validity and clinical scales. This consistent finding
has led to a general consensus among trauma, forensic, and assessment
experts that the high elevations on validity and clinical scales often
reflect the functional impairment, severe symptomatology, and
emotional distress common among individuals who experience com-
plex trauma in childhood (Brand et al., 2006; Carlson & Armstrong,
1994; Rogers et al., 2009; Wolf et al., 2009).
5. Discussion
The accurate assessment and diagnosis of severe, complex DDs are
complicated but quite possible. First and foremost, it requires clinicians
to accept the overwhelming evidence that DDs are common, typically
originate from interpersonal trauma occurring in childhood, and that
DDs include a broad set of symptoms that are severe and impairing.
Second, clinicians must be able to both differentially diagnose DDs
from disorders with similar and overlapping symptoms (e.g., PTSD
and BPD), and also identify comorbid presentations of DDs with other
trauma-based disorders and mood disorders, among others. Third,
clinicians must be familiar with the unique testing profiles of childhood
trauma survivors, patients with PTSD, and patients with DDs, including
on the MMPI-2, PAI, and SIRS, among others. Assessors should under-
stand that elevated clinical and validity scales among these populations
do not necessarily indicate an invalid profile or feigned symptoms.
5.1. Recommendations for assessing complex trauma and dissociation
5.1.1. MMPI-2
Clinicians should expect elevations on clinical and some, but not all,
validity scales among patients with complex trauma histories, DDs, and
PTSD. In terms of clinical scales, this population most frequently
elevates on Scale 8, which is not necessarily indicative of psychosis (as
Scale 8 is typically conceptualized), but rather trauma-based difficulties
with emotion regulation, impulse control, and cognitive impairment,
which may also overlap conceptually with psychotic experiences such
as auditory hallucinations, further complicating the diagnostic picture
(Brand & Chasson, 2015; Kluft, 1987a; Welburn et al., 2003; Wolf
et al., 2009). Validity scale scores, especially F and Fb, should be very
cautiously interpreted among trauma survivors with dissociative and
PTSD symptoms, and not necessarily used to invalidate their profiles
(Coons & Sterne, 1986; Elhai et al., 2004; Flitter et al., 2003; Rogers
et al., 2003; Welburn et al., 2003). Fp appears to be the most useful
validity scale to interpret for individuals with complex trauma exposure
and dissociation, in that it is the least susceptible to trauma-based
elevations.
5.1.2. PAI
The PAI may not have sufficient empirical evidence to support its use
among those with DDs and complex trauma histories (Stadnik et al.,
2012). Preliminary research on the PAI profiles of DD patients suggests
that they elevate on some but not all scales measuring exaggerated
symptoms, including the NIM scale, and the PAI has poor validity
among those with severe dissociation (Calhoun et al., 2010; Rogers
et al., 2012; Stadnik et al., 2012). Until further research is conducted
6 B.L. Brand et al. / International Journal of Law and Psychiatry xxx (2016) xxx–xxx
on using the PAI with DD patients and those with childhood trauma, it
may be most prudent to avoid using the PAI with individuals suspected
of having significant dissociation.
5.1.3. SIRS/SIRS-2
The SIRS should be used cautiously with DD patients, PTSD patients,
and complex trauma survivors, in that it has been shown to misclassify
many of these individuals as feigners (Brand et al., 2006; Rogers et al.,
2009). However, similar to the PAI, DD patients typically elevate
only on SIRS scales measuring amplified symptoms (e.g., Subtle and
Selectivity scales) rather than scales measuring malingered symptoms;
this pattern suggests that severe symptomatology may be driving the
elevations rather than malingering. Clinicians are encouraged to use
the SIRS' Trauma Index, and consider using the original SIRS, rather
than the SIRS-2, given that the SIRS combined with the Trauma Index
has higher sensitivity than the SIRS-2 with the Trauma Index (Brand
et al., 2014).
6. Conclusion
In summary, clinicians assessing DDs in clinical and forensic settings
face multiple challenges, including a general lack of experience
and training in dissociation and complex trauma; reliance on gold-
standard and well-validated measures that were not designed to assess
complex trauma and dissociation and have typically received little
empirical validation with these samples; and difficult differential and
comorbid diagnostic questions for individuals with complex clinical
presentations. Among psychometric assessment instruments commonly
used in forensic settings, at this point, the MMPI-2 and SIRS combined
with the Trauma Index hold the most promise for distinguishing those
with genuine DD from those with feigned DD, although more research
is needed.
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Please cite this article as: Brand, B.L., et al., Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts,
International Journal of Law and Psychiatry (2016), http://dx.doi.org/10.1016/j.ijlp.2016.10.006