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Order Number 9421'138Screening instruments for dissociative disorders: Theirevaluation in a college populationAngiulo, Michael James, Ph.D.The University of Arizona, 1993V·M·I300 N. Zeeb Rd.Ann Arbor, MI 48106
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SCREENING INSTRUMENTS FOR DISSOCIATIVE DISORDERS:THEIR EVALUATION IN A COLLEGE POPULATIONbyMichael .James AngiuloA Dissertation Submitted to the Faculty of theDEPARTMENT OF EDUCATIONAL PSYCHOLOGYIn Partial Fulfillment of the RequirementsFor the Degree ofDOCTOR OF PHILOSOPHYIn the Graduate CollegeTHE UNIVERSITY OF ARIZONA1 993
2THE UNIVERSITY OF ARIZONAGRADUATE COLLEGEAs members of the Final Examination Committee, we certify that we haveread the dissertation prepared by-- ---------Nichv.el Jumef:'. ,i\nc;iuloentitledScreening Inutrnnents for Dissociative Disorc'ers:Their Evaluation in A CollegePo ulationand recommend that it be accepted as fulfilling the dissertationrequirement for the Degree of/ !/,.:?4 :?Alearnoni, :;J &-t."\. F/d:!J{ Date/1John F. Kihlstrom, Ph.D.DateL0c. c:Jri' .D.DateT .D.1'- yh)DateFinal approval and acceptance of this dissertation is contingent uponthe candidate's submission of the final copy of the dissertation to theGraduate College.I hereby certify that I have read this dissertation prepared under mydirection and recommend that it be accepted as fulfilling the dissertation
3STATEMENT BY AUTHORThis dissertation has been submitted in partial fulfillment of requirementsfor an advanced degree at The University of Arizona and is deposited in theUniversity Library to be made available to borrowers under rules of the Library . Brief quotations from this dissertation are allowable without special permission, provided that accurate acknowledgement of the source is made.Requests for permission for extended quotation from or reproduction of thismanuscript in whole or in part may be granted by the head of the majordepartment or the Dean of the Graduate College when in his or her judgmentthe proposed use of the material is in the interests of scholarship. In all otherinstances, however, permission must be obtained from the author.Signed: . . - c.
4TABLE OF CONTENTSPageTABLE OF CONTENTS. ,.4LIST OF TABLES6LIST OF FIGURES7ABSTRACT . . . . . .I CI-IAPTER 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I I , INTRODUCTION AND STATEMENT OF THE HYPOTHESIS . . . . . . . . .CHAPTER 2 . . . . . . . . .I I I I89916REVIEW OF THE LITERATURE . . . . . . . . . . . . . . . . . . . . . . . . . . . .Dissociative Experiences Scale . . . . . . . . . . . . . . . . . . . . . . .Tellegen Absorption Scale . . . . . . . . . . . . . . . . . . . . . . . . . .Perceptual Alteration Scale . . . . . . . . . . . . . . . . . . . . . . . . .Dissociative Disorders Interview Schedule . . . . . . . . . . . . . . .Questionnaire of Experiences of Dissociation . . . . . . . . . . . . .Structured Clinical Interview for DSM-IV Dissociative Disorders.16202122222324CHAPTER 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .METHODS AND PROCEDURES . . . . . . . . . . . . . . . . . . . . . . . . . . .Research Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Population and Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . .Measurement of Variables . . . . . . . . . . . . . . . . . . . . . . . . . .Dependent Variablo . . . . . . . . . . . . . . . . . . . . . . . . . . .Independent Variables . . . . . . . . . . . . . . . . . . . . . . . . .Sampling Methods and Procedures . . . . . . . . . . . . . . . . . . . .Analytical Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Factor Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Analysis of Variance of DES Scores by DES Category . . .Analysis of Variance of Age and Sex By DES Category .Analysis of Variance of Mini-SCID-D Score by DESCategory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Multiple Regression Analysis . . . . . . . . . . . . . . . . . . . . .Method for the Sensitivity, Specificity, and PredictiveValue Analyses . . . . . . . . . . . . . . . . . . . . . . . . . .262627282828293032323232333333
5TABLE OF CONTENTS (Continued)PageCHAPTER 4 . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . .ANALYSIS OF THE PILOT STUDY . . . . . . . . . . . . . . . . . . . . . . . .CHAPTER 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ANALYSIS OF THE MAIN STUDY . . . . . . . . . . . . . . . . . . . . . . . . . .Factor Analysis . , . . . . . . . . . . . .Analysis of Variance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Regression Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sensitivity, Specificity and Predictive Value Analysis . .Dissociative Psychopathology In A College Population . .II I I ,I 353537373743505153CHAPTER 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .FINAL DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Discussion of Pilot Study Findings . . . . . . . . . . . . . . . . . . . . .555555REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
6LIST OF TABLESPageTable 5-1 Exploratory factor analysis with varimax rotation extractingfive factors . . . . . . " . . , . . . . . . . . . . . . . . . . . . . . . . . 38-39Table 5-2 Factor analysis with varimax rotation extracting threefactors . . . . . .I 41-42Table 5-3 Mean Scores for Age and Mini-SCID-D Score by DESCategory and F Test for Levels of DES Category . . . . . . . . . . . . 44Table 5-4 Comparison of Means and Standard Deviations of Items inthe DES for the Main Study (N 2480) with Ross, Joshi &Curri (1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46-47Table 5-5 Comparison of correlations of items in the DES with overallDES Score for the Main Study (n 2480) and Ross, Joshi &Curri (1991) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48-49Table 5-6 Screening indexes for DES (N 79). . . . . . . . . . . . . . . . . . 52Table 5-7 Frequency Distribution of Diagnostic Categories on the MiniSCID-D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7LIST OF FIGURESPageFigure 1 Graphic Illustration of the Distribution of the DES ScoresAmong the Three Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
8ABSTRACTIn the interest of early identification and prevention of dissociativedisorders, this author has contributed to the research history of variousscreening instruments and has commented on the degree to which suchinstruments are appropriate for screening subjects in a college population. TheDissociative Experiences Scale (DES; Bernstein & Putnam, 1986) wasadministered to approximately 2500 college freshmen. Subjects from variouslevels of the distribution of DES scores were recalled to the laboratory forfurther testing on the abbreviated version of the Structured Clinical Interviewfor Dissociative Disorders (Mini-SCID-D) (Steinberg, Rounsaville & Cicchetti,1987) to determine how many of these subjects might actually qualify for adiagnosis of dissociative disorder.The results of this study supported thefactor structure of the DES as reported by Ross, Joshi and Currie (1991). Inaddition, the DES evidenced a significant predictive relationship with the MiniSCID-D.The research was designed to screen a population at large fordissociative tendencies, the results of which will be useful to people who wishto identify ostensibly normal individuals who may be at risk for dissociativedisorders. This research was supported in part by Grant #MH35856 from theNational Institute of Mental Health to John F. Kihlstrom.
9CHAPTER 1INTRODUCTION AND STATEMENT OF THE HYPOTHESISDissociation has been of interest both for research purposes and in aclinical setting for over 100 years.Society's awareness of the long termeffects of war, child abuse, dysfunctional families and stress has prompted themental health system to address symptomatology related to the diagnosis ofdissociative disorders (Aalpoel & Lewis, 1984; Abse, 1974; Cattell & Cattell,1974; Kluft, 1988a; Nemiah, 1979,1989; Sutker & King, 1984).According to the American Psychiatric Association(1987),thedissociative disorders include a wide variety of syndromes whose common coreis an alteration in consciousness, memory and/or identity.The onset of thesymptoms may be sudden or gradual, and may be transient or chronic. Thediagnostic category is sub-divided into depersonalization disorder, psychogenicfugue, psychogenic amnesia, dissociative disorders not otherwise specified andmultiple personality disorder.While impairments of memory and consciousness are often observed inthe organiC brain syndromes, dissociative disorders can be differentiated inetiology since they are "functional", that is, not caused by physical injury ordisease of the brain.Dissociative disorders produce more impairment thanwould normally occur in the absence of trauma (Kihlstrom & Evans, 1979;Schacter & Kihlstrom, 1989).
10After a diagnosis of organic brain syndrome has been ruled out, theclinician can then differentiate a functional disorder and screen for dissociativedisorders. Although there may be a variety of causative factors resulting indissociative disorders, the most consistent event related with their emergenceappears to be psychological trauma which may include, but not be limited to,severe abuse, neglect and war.Any consideration of dissociative disorders, as a group of mental illnesses, properly begins with a discussion of the dissociation concept itself(Kihlstrom, 1992).Dissociation was formerly known as disaggregation (Janet, 1879). Overthe years, the meaning of dissociation changed, particularly as it wasintroduced into the United States by researchers in the early part of thiscentury. More recently, dissociation has become associated with a disturbancein one's consciousness, identity or memory (American Psychiatric Association'sDiagnostic and Statistical Manual Of Mental Disorders, 3rd Edition, Revised)(DSM-III-R).Various screening tools have been developed for the purpose of studyingthe role of dissociation and the natural history of dissociative disorders. Faganand McMahon (1984) listed 20 behavioral characteristics and six objectiveexperiences of dissociation based upon their extensive review of detailedretrospective reports of trauma experienced by adults. Putnam (1981) is citedby Kluft (1984) as proposing 13 childhood symptoms, including occurrences
11of sustained repeated abuse, amnesia for abuse and marked fluctuations andvariability in performance and abilities. Putnam identifies these as predictorsof one or more of the dissociative disorders appearing in adulthood.In light of other authors having devised predictor lists of thesymptomatology of various dissociative disorders (Kluft, 1984), Fagan andMcMahon (1984) address observations that teachers and parents may readilymake in both the classroom and home setting regarding children at risk fordissociative pathology. Fagan advises utilizing other authors' checklists as astarting point to explore, with a referral source and the family, whether or notthe child shows a sufficient number of behaviors to make a tentative diagnosisof a dissociative disorder. The authors of such checklists have identified somesymptoms to be more pathognomonic than others.They present cutpointscores that strongly suggest the child as being at risk for experiencingdissociative symptoms and a need for referral and evaluation. The authors notethat perplexing forgetfulness, uneven performance and inconsistent schoolwork regarding skills the child should have mastered, are significant indicatorsof a dissociative phenomena. Silberman, Putnam, Weingartner, Braun, and Post(1984), found no significant differences in learning and remembering abilitiesin patients diagnosed with dissociation when compared to a control group.These authors did note, however, there were "qualitative differences betweenthe cognitive performance of patients and that of controls attempting to roleplay alter personalities," for example multiple personality disorder.
12The above mentioned lists have been utilized as screening instruments.The authors suggest that further evaluation and testing be performed prior toa formal diagnosis. As such, these instruments are not diagnostic tools, nor areany of the individual factors in isolation considered to be diagnostic of multiplepersonality disorder. Rather, it is the cluster of these symptoms after othertypes of disorders have been ruled out that suggests dissociative disorder mightbe considered further.The above summaries have indicated various behavioral and cognitiveindicators which would lead teachers, parents and mental health professionalsto suspect dissociative pathology in children.These studies have stronglylinked the development of dissociative reaction to early traumatic occurrencesfrom which the child needed protection and used the defense of dissociation.Many victims of abuse and other forms of trauma protect and defendthemselves by dissociation. In doing so, they are able to emotionally detachfrom or forget the occurrence of the trauma. Dissociation is conceptualized ona continuum from mild dissociations in life, such as daydreaming, to moresevere pathological forms as seen in multiple personality disorder (Bernstein &Putnam, 1986).Very little data exist on the epidemiology of any of the dissociativedisorders. Dissociative disorders were not the subject of inquiry in any majorpsychiatric epidemiology studies.Everything that can be said about theprevalence of dissociative disorders in North America in the 1980s and early
131990s is therefore guess work (Ross, 1989). It would be useful to identifythose individuals with dissociative symptomatology within a normal populationand a mentally ill population. This information would be valuable for researchstudy and in clinical practice.It is believed that a majority of individuals with dissociative disordershave witnessed or experienced some type of psychological trauma, abuseand/or neglect.It became apparent during World War " that the traumaveterans witnessed and experienced were associated with what we now calldissociative symptoms (at that time called shell shock).The purpose of this research study is to examine screening instrumentsused to assess dissociative phenomena. Random selections from a collegepopulation were drawn to assess whether scores on the DissociativeExperiences Scale (DES; Bernstein & Putnam, 1986) correlate with scores onthe Mini-Structured Clinical Interview for Dissociative Disorders - ClinicianVersion (Mini-SCID-D) (Steinberg, Rounsaville & Cicchetti, 1990). With a betterunderstanding of which cutpoints should be used, the information would bevaluable to improve the correlation of scores on another instrument. In doingso, it will facilitate making a more accurate screening instrument of dissociativedisorders. Furthermore, treatment might become more rapid and cost effective.Until recently, there were no standardized instruments designed to yielduniform clinical diagnoses of dissociative disorders (Steinberg, et al. 1990).The DES has been the screening instrument most widely used. The DES will
14be compared to the Mini-SCID-D (Steinberg, et aI., 1987). The results fromthis research will aid in defining the cutpoints considered most valuable to beused in identifying those individuals at risk for pathological dissociativesymptoms.Both the DES and the Mini-SCID-D are considered screeningdevices for dissociative disorders, although they are not considered diagnosticinstruments.Kihlstrom, Tataryn and Hoyt (1990) discussed the influence of PierreJanet (1889, 1907) on the first dynamic Psychiatry (Haule 1986; Havens,1973; Mayo, 1952; Perry & Lawrence, 1984).He used psychologicalprinciples in his attempt to organize the neuroses as Kraepelin organized thepsychoses. Janet was significantly influenced by Jacksonian neurophysiologyand adopted the term "psychological automatisms" which was introducedearlier by Despine (Ellenberger, 1970; Janet, 1879). Janet believed that theseautomatisms,preceded by an idea and accompanied by an emotion,represented a complex act finely tuned to external and internal circumstances.As such, Janet believed this reflected cognition, emotion and motivation. Suchtypes of consciousness have been described by scientists and philosophers ofthe mind at least since the time of Kant (Hilgard, 1980b).Charcot's term for this situation was condition seconde; Janet preferredthe term disaggregation, translated into English as dissociation. Disaggregationreferred to the fragmentation that was once considered integrated mental life.Modern researchers believe that disaggregation may have served Janet and his
15theory, and perhaps the syndromes themselves, somewhat more descriptivelythan dissociation (Kihlstrom, et aI., 1990. p. 4).Patients with dissociative disorders were observed to have significantlyhigher hypnotizability scores on various measures than all other groups had(Frischholz, Lipman, Braun, & Sachs, 1992, pp. 1521 - 1525). These authorsbelieved that a diagnosis of Post Traumatic Stress Disorder was an inaccuratedescription given to the anxiety disorder patients in their study. They foundthat patients with Post Traumatic Stress Disorder had a higher meanhypnotizability score than normal subjects in prior studies (Frischholz, 1992,pp. 1521-1525). Other researchers have found measuring the hypnotizabilityin an individual assessment may be useful in differentiating dissociativedisorders (Frischholz, et aI., 1992, pp. 1521-1525)The null hypothesis for this experiment is as follows: Scores on the DEShave no significant correlation or prediction value with dissociative disorderdiagnoses as yielded by the Mini-SCIO-D. The alternative hypothesis is asfollows: Scores on the DES predict and highly correlate with scores on theMini-SCID-D.
16CHAPTER 2REVIEW OF THE LITERATUREOne of the most important aspects in all fields of medicine is the accurate diagnosis of each individual's disease.With the proper diagnosis, thephysician and other care providers are better able to identify, describe andunderstand the individual and develop an effective treatment plan. A wrongdiagnosis has potential hazards. It creates a disservice to the individual by aninaccurate classification and, consequently, can lead to inappropriate treatment.Such treatment, including therapy and medications, may even be dangerous tothe individual.Inaccurate diagnoses have likely been the result of a lag in thedevelopment of the science. For example, some people now diagnosed withmajor depressive disorder, with psychotic features, had been diagnosed withschizophrenia earlier this century because they had presented with auditoryhallucinations and social withdrawal.Such symptoms can now be betterunderstood as characteristics of an affective disorder, rather than a disturbancein one's thinking.The mental health profession has used diagnostic observation andinterviews to detect problem areas in individuals. At times, psychological testshave aided the professional in corroborating the findings. Psychological testsbecame particularly popular in the 1940s, when they were predominantly usedfor the screening of military personnel prior to entry into the armed forces.
17Subsequently, psychologists have devised tests for numerous variablesbeyond the initial objectives of screening and diagnosis.Nevertheless, thestandard battery usually includes a brief test to rule out organic illness such asthe Bender Gestalt test, an I.Q. test to further assess cognitive streng
Very little data exist on the epidemiology of any of the dissociative disorders. Dissociative disorders were not the subject of inquiry in any major psychiatric epidemiology studies. Everything that can be said about the prevalence of dissociative d
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