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Assessment of the five SCID-D-R dissociative symptoms
Assessing amnesia. Amnesia, which is the first symptom assessed by the SCID-D-R (Structured Clinical Interview for DSM Dissociative Disorders-Revised), may be defined as the inability to recall a significant block of time that has passed, and/or the inability to recall important personal information (Steinberg, 1994a, 1995). It is described by patients as "gaps" in their memory or "lost time," ranging from seconds to years. Many patients with dissociative disorders understand and describe their amnesia as "blank spells" or as "spaciness." Patients may report failure to recall their name, age, or address. Patients with severe amnesia are often unable to remember the frequency or duration of their amnestic episodes (Steinberg, 1994a). Individuals with chronic amnesia often confabulate or use reports from relatives or friends in attempts to fill the gaps in their memory (Kluft, 1991). Amnesia of psychogenic etiology must be distinguished from that found in organic brain dysfunction or secondary to substance abuse. Questions in this section of the SCID-D-R explore the different manifestations of amnesia. The first question of the amnesia section asks: "Have you ever felt as if there were large gaps in your memory?" One patient with DID responded: "Yeah. Like, say, a friend of mine will talk about something we did a month ago, or some place we went, or whatever, and I have no memory of it. It's scary" (SCID-D-R interview, unpublished transcript). It is very common for patients suffering from severe amnesia to report difficulty remembering basic items of personal information. One patient with DID first became aware of her symptom when she had problems filling out job applications and similar forms: "It's embarrassing. There are things I need to know sometimes that I can't remember. It could be like a phone number, it could be my street address, it could be things like that. Or my salary. If I have to fill out a form or something, and it asks for that kind of stuff, it's like I suddenly don't remember it" (SCID-D-R interview, unpublished transcript).
Assessing depersonalization. Depersonalization involves the experience of detachment from one's body or self, for example, feeling that the self is strange or unreal, or feeling that one is "going through the motions of life" like a robot. Transient depersonalization may be found in the general population as a common response to alcohol and drug use, sleep and sensory deprivation, or severe emotional stressors, and it also has been seen as a side effect of medications (Roberts, 1960; Trueman, 1984b). SCID-D-R research has found that patients with dissociative disorders often experience depersonalization within the context of ongoing, coherent dialogues with the self (Steinberg, 1994a, 1995). Depersonalization is difficult for patients to describe, and can sometimes go unnoticed or can be experienced as "normal" by patients who have become habituated to it. The depersonalization section of the SCID-D-R includes questions intended to evaluate the different manifestations of depersonalization that patients may experience. In addition, the presence of some nonverbal cues, such as a trancelike state, may suggest depersonalization during an interview. Question 38 asks: "Have you ever felt that you were watching yourself from a point outside of your body, as if you were seeing yourself from a distance (or watching a movie of yourself)?" One patient with DID responded: "I can remember when I was delivering my daughter, of being up on the ceiling and watching the whole process of labor and delivery while she was born ... and I've had the same experience when I've finally remembered my husband raping me, and I had the same experience when my father sexually assaulted me when I went down to visit my mother after she had a hysterectomy, and I remember being in the corner of the bedroom ceiling when that happened" (SCID-D-R interview, unpublished transcript). In addition to providing information about depersonalization, this patient provided information spontaneously about her history of abuse. This feature of the SCID-D-R allows clinicians to document that they obtained information regarding traumatic histories without the use of leading or intrusive questions. Another patient responded to the same depersonalization question by saying, "Yeah, I have felt like that. I always described it as being like a zombie" (SCID-D-R interview, unpublished transcript). In terms of another aspect of depersonalization, Question 41 asks: "Have you ever felt as if a part of your body or your whole being was foreign to you?" One patient responded: (pauses) "Yeah. Sometimes my hands don't seem like my hands. I've always hated my legs and they don't ... sometimes they're not mine. This is very weird" (sighs). A very common variant of depersonalization involves experiences of splitting into a participator and an observer. This experience often contains elements of identity alteration. Question 47 asks: "Have you ever felt as if you were two different people, one person going through the motions of life, and the other part observing quietly?" One patient responded: (takes deep breath) "Again, it's an unreal feeling, of not really being connected to other humans in some way. Because it's as though there's a fake self out there living my life" (SCID-D-R interview, unpublished transcript). The experience of ongoing internal dialogues in the context of depersonalization occurs in patients with dissociative disorders (Steinberg, 1995). One patient with DDNOS had the following description: "I start to argue with somebody that's in that chair, but I see that person in that chair and I see it's me ... he's looking at me and he's laughing at me, and he's calling on me to fight him ... and I don't want to fight him.... I see me outside myself, in other words, and he's laughing at me, calling out saying, "Come on, punk, fight me, come on, punk, fight me" (SCID-D-R interview, unpublished transcript). Thus this patient experiences severe depersonalization in conjunction with identity confusion.
Assessing derealization. Derealization involves the sense that one's physical and/or interpersonal environment has lost its sense of familiarity or reality. Isolated episodes of derealization may occur in subjects without psychiatric disorders, in response to substance use, sensory and sleep deprivation, and mild social stressors such as examinations or minor car accidents. In dissociative disorders, patients with derealization report that friends and relatives seem strange and unfamiliar, as may their home, workplace, or immediate physical environment (Steinberg, 1994a, 1995). Derealization often occurs in the context of flashbacks in which a person reexperiences a past trauma. As a result, the present feels unreal to the person. The SCID-D-R allows the interviewer to explore different aspects of the symptom of derealization. Question 79 asks: "Have you ever felt as if familiar surroundings or people you knew seemed unfamiliar or unreal?" One patient with DID responded: "Yes, I have felt that. That's like every place that I've ever lived has never felt familiar to me, even if I lived there for years. It never feels like I live there. It's kind of like a Twilight Zone experience" (SCID-D-R interview, unpublished transcript). Derealization commonly occurs in the context of a flashback in which a friend or parent reminds the patient of an abuser, and the patient feels that the person he or she is with becomes unreal. Question 84 often elicits descriptions of flashbacks: "Have you ever felt puzzled as to what is real and what's unreal in your surroundings?" A patient's response follows: "Yes. When I have flashbacks. That's what I call them. It's like I'd be out on a date with a boyfriend and see a totally different guy. It's like really weird. That's happened where it's a flashback of one of the guys that raped me. You know, I'd be with him, and then, oh my god, I'd run out of the theater or something" (SCID-D-R interview, unpublished transcript). The next question, 81, asks: "Have you ever felt as if your surroundings or other people were fading away? One patient responded: "I have had that experience when I visit my family. They become blurry, they become almost invisible. Their voices all meld together. I have a wonderful time by myself.... I had no idea what the conversations were about, what was said, who was there, or anything" (SCID-D-R interview, unpublished transcript). As seen in the previous example, derealization can involve auditory and visual distortions.
Assessing identity confusion. Identity confusion, as assessed in the SCID-D-R, is defined as a sense of uncertainty, puzzlement, or conflict regarding personal identity (Steinberg, 1994a, 1995). Patients who experience dissociative symptoms often express confusion as to who they really are. In dissociative disorders, identity confusion often manifests as a fierce battle for inner survival, where the subject experiences conflicting and opposing attitudes regarding issues and events in his or her life (Steinberg, 1994a, 1995). Although identity confusion may occur transiently during adolescence or life crises, identity confusion in patients with dissociative disorders tends to be more chronic and distressing.
Assessing identity alteration. Identity alteration, as defined in the SCID-D-R, involves objective behavior indicating the assumption of different identities (Steinberg, 1994a, 1995). Examples of identity alteration include the use of different names, finding possessions that one cannot remember acquiring, and possessing a skill that one cannot remember having learned. Patients with DID sometimes refer to themselves as "we" or "us" (Kluft, 1991). Severe identity alteration that occurs in dissociative disorders is accompanied by amnesia for events experienced under alternate personality states. Identity alteration in DID is characterized by its complexity, distinctness, the ability of the states to take control of behavior, and the interconnection with other dissociative symptoms assessed in the SCID-D-R.
Because amnesia for identity alteration can mask its assessment, the SCID-D-R explores both direct and indirect evidence of this symptom. The evidence for identity alteration comes from three sources: reports of identity alteration from the subject; feedback from relatives or friends; and behavioral indications, such as finding objects in one's possession that one cannot account for. These occurrences are independent of a patient's amnesia for his or her identity alteration. For instance, the SCID-D-R asks if others have noted the patient acting like a child, acting like a different person, or calling himself or herself a different name. The patient may volunteer information obtained from other people concerning different behaviors or personalities, while not knowing that he or she has alternate personalities. Direct information includes the patient's awareness of referring to himself or herself by different names, acting like a child or like a different person, or feeling possessed. Nonverbal cues during the interview can also help assess the extent of identity alteration. Severe mood changes, particularly in conjunction with amnesia during the interview, may indicate the presence of identity alteration. Question 114 asks: "Have you ever acted as if you were a completely different person?" One man with DDNOS responded: "Yeah, I think so. Sometimes it could be nice, if I'm having a good time. Going out dancing--just being a totally different person from how I am now. And sometimes I'm really mean, nasty, and irritable. And that's not my usual personality" (SCID-D-R interview, unpublished transcript). In some instances, the patient is made aware of personality changes by others in his or her family or workplace. Question 116 asks: "Have you ever been told by others that you seem like a different person?" One patient with DID responded: "Yes. Guys that I've dated, my family, people that I work with ... some of them even said that, it's like, different ways, different opinions--my opinion might change right in the middle of a conversation. One way definitely over here, and then the next time, just within seconds, over here" (SCID-D-R interview, unpublished transcript). Other types of indirect evidence for identity alteration include finding objects that were taken home by an alternate personality. Question 122 asks: "Have you ever found things in your possession (for instance, shoes) which belong to you, but you could not remember how you got them?" One patient responded: "Yes ... Weekly. Like I'd go shopping. I'd buy things. I'd remember that I'd purchased it. I had the receipt. So I know I didn't steal it or something. But why I bought it, where I bought it--buy things that I don't even wear--wouldn't be caught dead wearing. Totally strange items--a thousand scarves, ponchos, and shawls. And I've never worn one of them. But I have a whole mess of them. My mom says I wear them a lot, but I don't know of ever wearing one of them. It's odd" (SCID-D-R interview, unpublished transcript).
Reflection Exercise #11
Online Continuing Education QUESTION 25
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