Screening for Dissociative Disorders in Psychiatric Out- and Day Care-Patients

  • Christoph Mueller-Pfeiffer
  • Kaspar Rufibach
  • Daniela Wyss
  • Noelle Perron
  • Roger K. Pitman
  • Michael Rufer
Article

Abstract

Dissociative disorders are frequent and clinically relevant conditions in psychiatric populations. Yet, their recognition in clinical practice is often poor. This study evaluated the performance of three well known and internationally used dissociation scales in screening for dissociative disorders. Consecutively treated out- and day care-patients (n = 160) from several psychiatric units in Switzerland completed the Dissociative Experiences Scale (DES), Somatoform Dissociation Questionnaire (SDQ-20), and Multidimensional Inventory for Dissociation (MID). The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R) was then administered. Test performance of the scales was analyzed by receiver operating characteristic curves. The diagnostic accuracy, represented by the area under the curve, did not differ significantly between the three summary scales. Cut-off scores for detecting at least 80 % of any dissociative disorder and dissociative disorder-not-otherwise-specified/dissociative identity disorder, respectively, were 12 and 20 for the DES, 30 and 33 for the SDQ-20, and 28 and 28 for the MID summary scale. The diagnostic accuracy of the DES subscale ‘absorption’ and the MID subscale ‘somatic symptoms’ was equal or slightly lower than the corresponding summary scale. The DES, SDQ-20, and MID summary scales are suitable in screening for dissociative disorders in general psychiatric out- and day care-patients. Adequate cut-off scores in the German-adapted DES are lower than in non-German versions. Screening with the DES subscale ‘absorption’ and the MID subscale ‘somatic symptoms’ could be more efficient without the loss of diagnostic accuracy.

Keywords

Dissociative disorders Dissociation Sensitivity and specificity Predictive value of tests Correct classification rate Rating scales 

Supplementary material

10862_2013_9367_MOESM1_ESM.doc (331 kb)
ESM 1(DOC 331 kb)

References

  1. Amaral do Espirito Santo, H. M., & Pio-Abreu, J. L. (2007). Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20). Revista Brasileira de Psiquiatria, 29(4), 354–358.PubMedCrossRefGoogle Scholar
  2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press.Google Scholar
  3. Backers, E., Sachsse, U., Jacobs, S., & Strack, M. (2008). Dissoziativität – zur Sensitivität und Spezifität des FDS [Dissociation – sensitivity and specificity of the FDS]. Persönlichkeitsstörungen: Theorie und Therapie, 12(3), 186–188.Google Scholar
  4. Bernstein, E. M., & Putnam, F. W. (1986). Development, reliability, and validity of a dissociation scale. The Journal of Nervous and Mental Disease, 174(12), 727–735.PubMedCrossRefGoogle Scholar
  5. Brown, R. J. (2006). Different types of “dissociation” have different psychological mechanisms. Journal of Trauma & Dissociation, 7(4), 7–28. doi:10.1300/J229v07n04_02.CrossRefGoogle Scholar
  6. Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale. Dissociation, 6(1), 16–27.Google Scholar
  7. Carlson, E. B., Putnam, F. W., Ross, C. A., Torem, M., Coons, P., Dill, D. L., et al. (1993). Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: a multicenter study. The American Journal of Psychiatry, 150(7), 1030–1036.PubMedGoogle Scholar
  8. Dell, P. F. (1998). Axis II pathology in outpatients with dissociative identity disorder. The Journal of Nervous and Mental Disease, 186(6), 352–356.PubMedCrossRefGoogle Scholar
  9. Dell, P. F. (2004). An interpretive mini-manual for the Multidimensional Inventory of Dissociation. [Unpublished manuscript].Google Scholar
  10. Dell, P. F. (2006a). The Multidimensional Inventory of Dissociation (MID): a comprehensive self-report instrument for pathological dissociation. Journal of Trauma & Dissociation, 7(2), 77–106. doi:10.1300/J229v07n02_06.CrossRefGoogle Scholar
  11. Dell, P. F. (2006b). A new model of dissociative identity disorder. Psychiatric Clinics of North America, 29(1), 1–26. doi:10.1016/j.psc.2005.10.013.PubMedCrossRefGoogle Scholar
  12. Dell, P. F. (2009). The long struggle to diagnose multiple personality disorder (MPD): Partial MPD. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the Dissociative Disorders: DSM-IV and beyond (pp. 403–428). New York: Taylor & Francis.Google Scholar
  13. Dell, P. F. (2011). Appendix 3: The Multidimensional Inventory of Dissociation (MID). In J. A. Chu (Ed.), Rebuilding Shattered Lives: Treating Complex PTSD and Dissociative Disorders (2nd ed., pp. 287–298). New York: Wiley.Google Scholar
  14. Dell, P. F., & Lawson, D. (2009). An empirical delineation of the domain of pathological dissociation. In P. F. Dell & J. A. O’Neil (Eds.), Dissociation and the Dissociative Disorders: DSM-IV and beyond (pp. 667–692). New York: Taylor & Francis.Google Scholar
  15. Draijer, N., & Boon, S. (1993). The validation of the Dissociative Experiences Scale against the criterion of the SCID-D, using receiver operating characteristics (ROC) analysis. Dissociation, 6(1), 28–37.Google Scholar
  16. First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. M., & Benjamin, L. S. (1997a). User’s Guide for the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric Press.Google Scholar
  17. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. M. (1997b). User’s Guide for the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Washington, DC: American Psychiatric Press.Google Scholar
  18. Fischer, D. G., & Elnitsky, S. (1990). A factor analytic study of two scales measuring dissociation. American Journal of Clinical Hypnosis, 32(3), 201–207.PubMedCrossRefGoogle Scholar
  19. Foote, B., Smolin, Y., Kaplan, M., Legatt, M. E., & Lipschitz, D. (2006). Prevalence of dissociative disorders in psychiatric outpatients. The American Journal of Psychiatry, 163(4), 623–629. doi:10.1176/appi.ajp.163.4.623.PubMedCrossRefGoogle Scholar
  20. Freyberger, H. J., Spitzer, C., Stieglitz, R. D., Kuhn, G., Magdeburg, N., & Bernstein-Carlson, E. (1998). Fragebogen zu dissoziativen Symptomen (FDS). Deutsche Adaptation, Reliabilität und Validität der amerikanischen Dissociative Experience Scale (DES) [Questionnaire on dissociative symptoms. German adaptation, reliability and validity of the American Dissociative Experience Scale (DES)]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 48(6), 223–229.PubMedGoogle Scholar
  21. Gast, U. (2003). Das Konzept der Komplexen Dissoziativen Störungen [The concept of major dissociative disorder]. Psychodynamische Psychotherapie, 2, 79–90.Google Scholar
  22. Gast, U., Oswald, T., & Zundorf, F. (2000). Strukturiertes Klinisches Interview für DSM-IV Dissoziative Störungen (SKID-D) [Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D)]. Gottingen: Hogrefe.Google Scholar
  23. Ginzburg, K., Somer, E., Tamarkin, G., & Kramer, L. (2010). Clandestine psychopathology: unrecognized dissociative disorders in inpatient psychiatry. The Journal of Nervous and Mental Disease, 198(5), 378–381. doi:10.1097/NMD.0b013e3181da4d65.PubMedCrossRefGoogle Scholar
  24. Hanley, J. A., & McNeil, B. J. (1982). The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology, 143(1), 29–36.PubMedGoogle Scholar
  25. International Society for the Study of Trauma and Dissociation. (2011). Guidelines for treating dissociative identity disorder in adults, third revision. Journal of Trauma & Dissociation, 12(2), 115–187.CrossRefGoogle Scholar
  26. Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2006). Dissociative disorders among adults in the community, impaired functioning, and axis I and II comorbidity. Journal of Psychiatric Research, 40(2), 131–140. doi:10.1016/j.jpsychires.2005.03.003.PubMedCrossRefGoogle Scholar
  27. Lima, A. A., Fiszman, A., Marques-Portella, C., Mendlowicz, M. V., Coutinho, E. S. F., Maia, D. C. B., et al. (2010). The impact of tonic immobility reaction on the prognosis of posttraumatic stress disorder. Journal of Psychiatric Research, 44(4), 224–228. doi:10.1016/j.jpsychires.2009.08.005.PubMedCrossRefGoogle Scholar
  28. Marmar, C. R., Weiss, D. S., Schlenger, W. E., Fairbank, J. A., Jordan, B. K., Kulka, R. A., et al. (1994). Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. The American Journal of Psychiatry, 151(6), 902–907.PubMedGoogle Scholar
  29. Michal, V. M., Sann, U., Niebecker, M., Lazanowski, C., Aurich, S., Kernhof, K., et al. (2004). Die Erfassung des Depersonalisations-Derealisationssyndroms mit dem Fragebogen zu Dissoziativen Symptomen [Assessment of the depersonalization-derealization syndrome using the German version of the Dissociative Experiences Scale]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 50(3), 271–287.PubMedGoogle Scholar
  30. Michelson, L., June, K., Vives, A., Testa, S., & Marchione, N. (1998). The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia. Behaviour Research and Therapy, 36(11), 1011–1050.PubMedCrossRefGoogle Scholar
  31. Mueller-Pfeiffer, C., Rufibach, K., Perron, N., Wyss, D., Kuenzler, C., Prezewowsky, C., et al. (2012). Global functioning and disability in dissociative disorders. Psychiatry Research, 200(2–3), 475–481. doi:10.1016/j.psychres.2012.04.028.PubMedCrossRefGoogle Scholar
  32. Mueller-Pfeiffer, C., Schumacher, S., Martin-Soelch, C., Pazhenkottil, A., Wirtz, G., Fuhrhans, C., et al. (2010). The validity and reliability of the German version of the Somatoform Dissociation Questionnaire (SDQ-20). Journal of Trauma & Dissociation, 11(3), 337–357. doi:10.1080/15299731003793450.CrossRefGoogle Scholar
  33. Mueller, C., Moergeli, H., Assaloni, H., Schneider, R., & Rufer, M. (2007). Dissociative disorders among chronic and severely impaired psychiatric outpatients. Psychopathology, 40(6), 470–471. doi:10.1159/000108129.PubMedCrossRefGoogle Scholar
  34. Nijenhuis, E. R., Spinhoven, P., Van Dyck, R., Van der Hart, O., & Vanderlinden, J. (1996). The development and psychometric characteristics of the Somatoform Dissociation Questionnaire (SDQ-20). The Journal of Nervous and Mental Disease, 184(11), 688–694.PubMedCrossRefGoogle Scholar
  35. Nijenhuis, E. R., Spinhoven, P., van Dyck, R., Van der Hart, O., & Vanderlinden, J. (1998). Psychometric characteristics of the somatoform dissociation questionnaire: a replication study. Psychotherapy and Psychosomatics, 67(1), 17–23.PubMedCrossRefGoogle Scholar
  36. Pepe, M. S. (2003). The statistical evaluation of medical tests for classification and prediction. New York: Oxford University Press.Google Scholar
  37. Development Core Team, R. (2011). R: A language and environment for statistical computing. (2.14.1 ed.). Vienna: R Foundation for Statistical Computing.Google Scholar
  38. Rodewald, F. (2005). Diagnostik dissoziativer Störungen [Diagnosis of dissociative disorders]. Doctoral thesis, Hannover Medical School, Hannover, Germany.Google Scholar
  39. Rodewald, F., Gast, U., & Emrich, H. M. (2006). Screening auf Komplexe Dissoziative Störungen mit dem Fragebogen für dissoziative Symptome (FDS) [Screening for major dissociative disorders with the FDS, the German version of the Dissociative Experience Scale]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 56(6), 249–258. doi:10.1055/s−2006−932590.PubMedCrossRefGoogle Scholar
  40. Rodewald, F., Wilhelm-Goling, C., Emrich, H. M., Reddemann, L., & Gast, U. (2011). Axis-I comorbidity in female patients with dissociative identity disorder and dissociative identity disorder not otherwise specified. The Journal of Nervous and Mental Disease, 199(2), 122–131. doi:10.1097/NMD.0b013e318208314e.PubMedCrossRefGoogle Scholar
  41. Rufer, M., Held, D., Cremer, J., Fricke, S., Moritz, S., Peter, H., et al. (2006). Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 75(1), 40–46. doi:10.1159/000089225.PubMedCrossRefGoogle Scholar
  42. Ruiz, M. A., Poythress, N. G., Lilienfeld, S. O., & Douglas, K. S. (2008). Factor structure and correlates of the Dissociative Experiences Scale in a large offender sample. Assessment, 15(4), 511–521. doi:10.1177/1073191108315548.PubMedCrossRefGoogle Scholar
  43. Sar, V., Kundakci, T., Emre, K., Bahadir, B., & Oya, B. (2000). Differentiating dissociative disorders from other diagnostic groups through somatoform dissociation in Turkey. Journal of Trauma & Dissociation, 1(4), 67–80.CrossRefGoogle Scholar
  44. Silverman, B. W. (1986). Densitiy estimations for statistics and data analysis. London: Chapman and Hall.Google Scholar
  45. Simeon, D., Guralnik, O., Gross, S., Stein, D. J., Schmeidler, J., & Hollander, E. (1998). The detection and measurement of depersonalization disorder. The Journal of Nervous and Mental Disease, 186(9), 536–542.PubMedCrossRefGoogle Scholar
  46. Spiegel, D., Loewenstein, R. J., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., et al. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28(9), 824–852. doi:10.1002/da.20874.PubMedCrossRefGoogle Scholar
  47. Spitzer, C., Barnow, S., Freyberger, H. J., & Grabe, H. J. (2007). Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. The Australian and New Zealand Journal of Psychiatry, 41(8), 682–687.PubMedCrossRefGoogle Scholar
  48. Spitzer, C., Freyberger, H. J., Stieglitz, R. D., Carlson, E. B., Kuhn, G., Magdeburg, N., et al. (1998). Adaptation and psychometric properties of the German version of the Dissociative Experience Scale. Journal of Traumatic Stress, 11(4), 799–809.PubMedCrossRefGoogle Scholar
  49. Steinberg, M. (1989–1992). Field Trials of the Structured Clinical Interview for DSM-III-R Dissociative Disorders. New Haven: Yale University School of Medicine.Google Scholar
  50. Steinberg, M. (1994). Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised (SCID-D-R). Washington, DC: American Psychiatric Press.Google Scholar
  51. Steinberg, M., Rounsaville, B., & Cicchetti, D. (1991). Detection of dissociative disorders in psychiatric patients by a screening instrument and a structured diagnostic interview. The American Journal of Psychiatry, 148(8), 1050–1054.PubMedGoogle Scholar
  52. Van der Hart, O., Nijenhuis, E. R., Steele, K., & Brown, D. (2004). Trauma-related dissociation: conceptual clarity lost and found. The Australian and New Zealand Journal of Psychiatry, 38(11–12), 906–914.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Christoph Mueller-Pfeiffer
    • 1
    • 2
    • 3
  • Kaspar Rufibach
    • 4
  • Daniela Wyss
    • 2
  • Noelle Perron
    • 2
    • 5
  • Roger K. Pitman
    • 3
  • Michael Rufer
    • 1
  1. 1.Department of Psychiatry and PsychotherapyUniversity Hospital ZurichZurichSwitzerland
  2. 2.Center of Education and Research (COEUR)Psychiatric Services of the County of St. Gallen-NorthWilSwitzerland
  3. 3.Department of PsychiatryMassachusetts General Hospital and Harvard Medical SchoolBostonUSA
  4. 4.Division of Biostatistics, Institute of Social and Preventive MedicineUniversity of ZurichZurichSwitzerland
  5. 5.Clinical Psychology and PsychotherapyUniversity of BernBernSwitzerland

Personalised recommendations