Preface to the 2023 Edition of the SCID-D
From The SCID-D Interview, Marlene Steinberg, M.D.
Note: this has been duplicated here in an effort to provide useful context and sources to further public knowledge of dissociative disorders and plurality. We believe it contains useful and important information that should be more widely available than as a preface to an expensive $92 diagnostic manual. A mirrored copy is also available here.
Dissociation is the mind's way of coping with overwhelming stress and trauma. Facing what it perceives as a life-threatening situation, the mind disconnects from its immediate surroundings, compartmentalizing authentic feelings—like despair or terror—that may hinder survival. At some point in their lives, to some degree, most people have experienced dissociation. For instance, following a car accident or the death of a loved one, you might feel emotionally numb or disconnected. This transient dissociation usually isn't problematic. But when due to trauma that's severe or ongoing, dissociation can cause considerable distress and/or difficulty functioning. Children, adolescents, and adults exposed to attachment traumas, neglect, or abuse, as well as combat veterans and survivors of sexual assault, are all at risk for developing recurrent dissociation-with the attendant and abiding feelings of inner fragmentation, self-alienation, shame, and fear. It is important to note that trauma encompasses more than might come to mind at first. For example, in addition to physical or sexual abuse, underrecognized traumas, such as chronic childhood invalidation, vicarious trauma, or intergenerational trauma, can also contribute to the development of dissociation.
Over the last few decades, societal consciousness has come to recognize the high prevalence of trauma in the public.[1] A study by the National Survey of Children's Health found that almost 50% of children under the age of 17 in the United States have experienced at least one significant trauma (The Child and Adolescent Health Measurement Initiative 2017-2018). What's more, a growing number of clinicians have endorsed therapy models predicated upon multiple aspects of self[2], suggesting the wide prevalence of inner fragmentation typical of persons who have suffered trauma. Still, very few survivors ever learn that what they're suffering from is called dissociation, despite the fact that it underlies all posttraumatic conditions. Simply put, "all trauma-related disorders (i.e., Acute Stress Disorder, PTSD, and Dissociative Disorders) share a common central psychobiological pathology that is dissociative" (Van der Hart, Nijenhuis, and Steele 2005).
[1]: Dr. Vedat Sar reviewed an extensive body of epidemiological research to investigate the prevalence of dissociative disorders. Typically correlated with childhood abuse and other traumas, dissociative disorders, Sar concludes, "constitute a hidden and neglected public health problem," with around 10% of clinical populations, and 0.4%-3% of the general population, suffering from Dissociative Identity Disorder (DID) (Sar 2011). (Prevalence is even higher when all dissociative conditions, not just DID, are considered. For more information, see Johnson, Cohen, Kasen, and Brook 2006, a major epidemiological study of dissociative disorders in the community.) [2]: Such models include Compassion-Focused Therapy, Ego State Therapy, Internal Family Systems Therapy, Phase Oriented Trauma and Dissociation Informed Treatment, Structural Dissociation, and other integrative models (Brown and Eliot 2016; Fine 1996; Fisher 2017; Gilbert 2010; Herman 2015; Howell 2020; International Society for the Study of Trauma and Dissociation 2005; Kluft 1993; Kluft, Bloom, and Kinzie 2000; Perry and Dobson 2013; Schwartz 2001; Siegel 2020; Sinason 2010; Steele, Van der Hart, and Nijenbuis 2005; Van der Hart, Nijenhuis, and Steele 2006; Watkins and Watkins 1997).
The connection between posttraumatic stress disorder (PTSD) and dissociation deserves emphasis, with empirical research illuminating a robust correlation.[3] In recognition of the prevalence of a limited subset of dissociative symptoms (specifically depersonalization and derealization) in people suffering from PTSD, DSM-5 added a dissociative subtype of PTSD, marking a watershed moment in the PTSD field's understanding of these afflictions (American Psychiatric Association 2013). Recent studies have noted a significant percentage of persons with PTSD with histories of childhood and/or adult trauma met criteria for the dissociative subtype, ranging from 54% to 83% (Hill, Wolff, Bigony et al. 2019; Swart, Wildschut, Draijer et al. 2020).
[3]: For studies relevant to dissociation in trauma survivors, see Carlson, Dalenberg, and McDade-Montez 2012; Lyssenko, Schmahl, and Bockhacker 2018; Spiegel and Cardena 1990; Wolf, Lunney, Miller et al. 2012).
There is a growing body of empirical evidence indicating that many PTSD sufferers experience a range of dissociative symptoms beyond depersonalization or derealization, and that the new dissociative subtype of PTSD may understate dissociation's role in PTSD. Studies that evaluated the full range of dissociative symptoms found that 34%-87% of people suffering from PTSD met the criteria for a dissociative disorder, many with dissociative conditions beyond what is detectable using diagnostic tools for the dissociative subtype of PTSD (Darves-Bomoz 1997; Darves-Bomoz, Degiovanni, and Gaillard 1995; Darves-Bomoz, Berger, Degiovanni et al. 1999; Roca, Hart, Kimbrell 2006). Vietnam veterans diagnosed with PTSD were found not only to suffer from the full range and severity of dissociative symptoms but also to have dissociative symptom severity scores that were virtually identical to those of persons suffering from complex dissociative disorders (Bremner, Steinberg, Southwick et al. 1993). In light of this research, some experts have asserted that "dissociation is characteristic of all PTSD" (Dorahy and Van der Hart 2015). Elizabeth Howell speaks for a growing number of experts in boldly defining trauma as "that which causes dissociation" (Howell 2020).
When someone suffers from dissociation, it is not usually their presenting complaint. Extensive research indicates that people suffering from dissociation seek treatment for depression, anxiety, mood swings, hearing voices, attention problems, obsessive-compulsive symptoms, addictions, self-destructive behavior, and somatic symptoms—essentially everything but dissociation (Bailey, Boyer, Brand 2019; Bakim, Baran, Diyaddin et al. 2016; Bowman 2006; Coons 1984; Coons, Bowman, Milstein 1988; Goff, Jenilee, Baer et al. 1992; Haugen and Castillo 1999; Karadag, Sar, Tamar-Gurol et al. 2005; Kluft 1985, 1987; Nijenhuis 2000; Putnam, Guroff, Silberman et al. 1986; Sar 2011; Sar, Kundakçi, Kiziltan et al. 2003; Somer, Altusa, and Ginzburg 2010; Steinberg 1995; Steinberg and Schnall 2010; Steinberg, Barry, Sholomskas et al. 2005; Tanner, Wyss, Perron et al. 2017). Yet optimal care depends on accurate diagnosis. For decades, lack of a reliable methodology for diagnosing dissociation led to misdiagnosis, ineffective treatment, and unnecessary suffering, sometimes lasting as many as fifty years. Before that diagnostic methodology could be developed, however, the symptoms of the underlying dissociative condition had to be understood. While eminent theorists such as Janet and Prince explored dissociation in case studies more than a century old (Janet 1907; Prince 1925), only over the last thirty-five years have the basic components of this ubiquitous defense mechanism been examined systematically and clarified on the basis of large-scale, replicable investigations. Until then, lack of empirical research led some psychiatrists to wonder whether dissociative identity disorder, the most complex of those disorders, was a genuine condition, or even iatrogenic (Brand, Sar, Stavropoulos et al. 2016; Loewenstein 2018). And when doctors did accept the disorder's reality, diagnostic methods varied in sensitivity, with missed cases of dissociative identity disorder risking decompensation due to the lack of trauma-informed treatment.
I still remember, when I was in training, witnessing a woman named Gloria in the psychiatric in-patient unit receive sodium amobarbital (Amytal), a sedative meant to allow her alternate personalities to emerge, which, if present, would facilitate diagnosis of what was then known as Multiple Personality Disorder. Before our eyes, Gloria switched to a tearful adolescent alter who complained in a high, girlish voice about the hopelessness of her life. Suddenly she switched to an even more childish alter who babbled about the "bad booboos that Mommy and Daddy did." There was no doubt that Gloria was suffering from a dissociative disorder and needed treatment. But later, when I asked about her, I learned that she'd fled the hospital the next day after the Amytal had made her alters surface before a group of wide-eyed residents—including me. Humiliated, Gloria had bolted. I could understand why. Regret for the insensitivity she had suffered under the rubric of "training" turned this into a defining moment for me.
When I made it my mission to study dissociation, however, I encountered resistance. After completing my residency, I went to see a well-respected expert in psychiatry to inquire about my research options. As I told him about my plan to study dissociation, he listened with an inscrutable expression. I finished, and e cocked an eyebrow at me quizzically. He paused for a long moment. Then he said, as tactfully as he could, "Marlene, I would advise you that if you're interested in a successful career in research, find another subject."
Nevertheless, I persisted. Four years later, in 1989, I was awarded the first of two substantial grants from the National Institute of Mental Health, the first ever given to a researcher in dissociation. These grants allowed me to further refine my Five Component Model for Dissociation Assessment and conduct field trials of the Structured Clinical Interview for DSM-III-R Dissociative Disorders—the SCID-D, for short—the specialized interview I'd developed to meet the need for reliable dissociative symptom and disorder diagnosis. Over the course of the field trials, over three hundred interviews were conducted by ten clinicians, producing over one thousand hours of videotaped interviews. Those tapes were then reviewed; the data were analyzed to identify and validate the salient features that distinguished those who were suffering from a dissociative disorder from those who weren't. When we studied the results, it became clear that the clinicians' independent assessments almost always agreed, establishing high inter-rater reliability for the SCID-D. Finally, in 1993, the SCID-D and Interviewer's Guide were published for widespread use (Steinberg 1993a, 19936). Since then, the interview has been administered with adolescents as young as eleven, and adults, in French, Gennan, Hebrew, Korean, Turkish, Dutch, Nmwegian, Spanish, Filipino, Danish, Persian, and more. Decades of intemational research and clinical experience have replicated our findings and established the SCID-D's reputation as the "gold standard" of dissociation assessment (Aquarone 2022; Boon and Draijer 1991, 1993; Carrion and Steiner 2000; Chang, Chang, Shiah, and Huang 2005; Friedl and Draijer 2000; Gast, Rodewald, and Nickel 200 I; Gingrich 2004; Jepsen, Langeland, Sexton et al. 2014; Kim, Kim, and Jung 2016; Knudsen, Draijer, Haselrud, et al. 1995; Kundakçi, Sar, Kiziltan et al. 2014; Mohajerin, Lynn, Bakhtiyari et al. 2020; Mueller-Pfeiffer, Rufibach, and Wyss 2013; Mychai.lyszyn,Brand, Webermann et al. 2020; Piedfort-Marin, Tarquinio, Steinberg et al. 2021; Rodewald 2005; Sar, Onder, Kilicaslan et al. 2014; Steinberg 1995, 2000; Steinberg and Steinberg 1995; Steinberg, Cicchetti, Buchanan et al. 1994; Steinberg, Rounsaville, and Cicchetti 1990, 1991; Welburn, Fraser, Jordan et al. 2003).
Although theoretical models of dissociation existed, a practical model for clinical assessment was lacking. The SCID-D implements the Five Component Model of Dissociation Assessment and fills this need. As I define it for the purpose of clinical assessment, dissociation can be characterized by five primary components: amnesia, depersonalization, derealization, identity confusion, and identity alteration.[4] While I created the following definitions for "amnesia," "identity confusion," and "identity alteration," the definitions for "depersonalization" and "derealization" were synthesized from the literature.
Amnesia refers to a subjective sense of gaps in one's memory for autobiographical information or experiences, or for blocks of time that have passed, where such lapses cannot be attributed to ordinary forgetfulness.
Depersonalization refers to a feeling of disconnection from oneself (e.g., from one's feelings, thoughts, behavior, or body), or a sense of being an outside observer of one's self.
Derealization refers to a feeling of disconnection from one's surroundings (e.g., people or surroundings feel as if they are unfamiliar, unreal, or distorted).
Identity confusion refers to subjective feelings of uncertainty, puzzlement, conflict, or struggle regarding one's own identity or sense of self.
Identity alteration refers to observable behavior associated with alterations or shifts in one's identity or personality states.
[4]: Though the terms "symptom" and "component" may appear to be used interchangeably throughout the text, there is a subtle distinction. Recently, I introduced the term "component" to depathologize each dissociative experience—amnesia, depersonalization, derealization, identity confusion, and identity alteration—associated with dissociation. Additionally, I use the term to emphasize that such behaviors occur along a spectrum of severity, defined by the SCID-D assessment model's severity rating definitions. Dissociative behaviors that cause distress or compromise functioning are labeled "symptomatic," since the term connotes illness or a condition. Behaviors that don't compromise functioning or cause distress are referred to more neutrally as "components."
Identifying the five primary components of dissociation, developing their standard definitions, and using a standardized method to rate their severity are three major innovations in the SCID-D's assessment of dissociation.
In what sense are these components primary? Just as all other colors can be obtained by mixing the primary colors—red, yellow, and blue—so all posttraumatic dissociative experiences can be understood as consisting of a mixture of these five components. As with a primary color, the intensity of each component varies along a spectrum. On the one end, each can be a normative, transient coping mechanism that does not cause dysfunction or distress. On the other end, each can be recurrent or ongoing, interfering with relationships, causing internal suffering, or otherwise impairing functioning.
Consider flashbacks, a common dissociative experience. What mixture of these components constitutes a flashback? People who experience traumatic flashbacks, including rape survivors and veterans with PTSD, at the time feel disconnected from their current surroundings (derealization), behave as they would have at the time of the trauma (identity alteration), and have memory lapses for events happening around them in the present (amnesia). Another common dissociative behavior is sleepwalking. An individual who sleepwalks has no recollection of their sleepwalking activities (amnesia) and may behave very differently from how they usually would (identity alteration). All other dissociative experiences can be composed in this way using the five primary components as building blocks. Similarly, specific dissociative disorders can also be characterized by their various combinations of the five components-for instance, a moderate-to-severe level of amnesia with none-to-mild levels of the other four symptoms characterizes a diagnosis of Dissociative Amnesia, whereas moderate-to-severe levels of four or five components characterize Dissociative Identity Disorder.
Too frequently, systematic assessment for dissociative processes is overlooked, and the external signs of dissociation (e.g., intrusive thoughts, mood swings, somatization) are not linked to underlying dissociative conditions. The failure to detect dissociation can lead to ineffective treatment, higher rates of hospitalization and suicide attempts, and generally prolonged suffering (Brand, Classen, McNary et al. 2009; Foote, Smolin, and Neft 2008; Kluft 1985, 1987; Mueller, Moergeli, Assaloni et al. 2007; Mueller-Pfeiffer, Rufibach, Perron et al. 2012; Sar, Koyuncu, Ozturk et al. 2007; Tanner, Wyss, Perron et al. 2017; Zoroglu, Tuzun, and Sar 2003). The SCID-D allows clinicians to uncover this connection. By inquiring about the core components of dissociation, the interview gathers the information necessary to look beyond the outermost signs-like depression, anxiety, mood swings, and flashbacks-to establish whether the underlying ailment is dissociative. Like the radiologist's X-ray, the SCID-D reveals the internal structure of dissociation, thereby suggesting a roadmap for effective dissociation-informed treatment.
ln the decades since the SCID-D was first published, research has established the interview's diagnostic accuracy across diverse cultures; the five components present universally in trauma survivors. Numerous investigators have also confirmed the SCID-D's good-to-excellent inter-rater reliability and discriminant validity (Boon and Draijer 1991, 1993; Chang, Chang, Shiah et al. 2005; Friedl and Draijer 2000; Gingrich 2004; Jepsen, Langeland, Sexton et al. 2014; Kim, Kim, and Jung 2016; Knudsen, Draijer, Haselrud, et al. 1995; Kundakçi, Sar, Kjziltan et al. 2014; Mobajerin, Lynn, Bakhtiyari et al. 2020; Piedfort-Marin, Tarquinio, Steinberg et al. 2021; Rodewald 2005; Sar, Onder, Kilicaslan et al. 2014; Steinberg 1995, 2000; Steinberg, Cicchetti, and Buchanan 1994; Steinberg, Rounsaville, and Cicchetti 1990, 1991; Welburn, Fraser, Jordan et al. 2003). A recent meta-analysis of fifteen studies overwhelmingly confirmed the interview's ability to identify individuals with dissociative disorders and distinguish them from other psychiatric disorders and controls (Mychailyszn, Brand, Webennan et al. 2020).
Furthermore, neuroimaging studies have confirmed that people diagnosed with Dissociative Identity Disorder (DID) using the SCID-D interview exhibit unique physiological reactions and cerebral blood flow patterns during identity shifts compared with control subjects, high fantasizers, or actors asked to simulate a shift (Reinders, Willemsen, Vos et al. 2012). These results demonstrate that DID is neither fantasy proneness nor role playing; the brain images simply cannot be simulated. Few diagnostic interviews in psychiatry have demonstrated such diagnostically discriminating findings confirmed by brain imaging studies.
Over the last twenty years, a growing number of studies have also investigated the neuroimaging biomarkers of dissociative disorders. Though findings have not always been consistent, studies of SCID-D-identified individuals with DID suggest that the indicators of dissociation include decreased volume in key brain regions related to memory and executive functioning, similar to the brain patterns displayed by those diagnosed with PTSD (Chalavi, Vissia, Giesen et al. 2015; Logue, van Rooij, Dennis et al. 2018; Roydeva and Reinders 2020). Furthermore, smaller hippocampal volumes were found to be significantly correlated with severe childhood trauma, as well as with increased dissociative symptoms in DID and PTSD (Chalavi, Vissia, Giesen et al. 2015; Dimitrova, Dean, Schlumpf et al. 2021). Research remains to be done to characterize the biomarkers associated with PTSD, its dissociative subtypes, and dissociative disorders generally—but all in all, over two hundred recent investigations have laid the groundwork for understanding the neuroscience of dissociation (Roydeva and Reinders 2020).
When I was developing the SCID-D, my intention was to make visible the hidden components of dissociation. By devising a practical framework and systematic method of inquiry, I hoped to enable detailed assessment of a person's inner world of dissociative experiences and provide clients and therapists with a language for symptoms previously unspoken. That was my original mission. Now, over three decades of use have revealed that, besides serving as a powerful assessment tool, the SCID-D also provides therapeutic benefits (Fisher 2017; Finn and Martin 2013; Finn, Fischer, and Handler 2012; Kluft 2015; Steinberg and Hall 1997). Unlike many psychological tests whose main goal is to gather diagnostic information, the SCID-D poses open-ended questions designed to elicit rich, clinically meaningful information about an individual's subjective sense of their experiences. The chance to discuss, in a nonjudgemental setting, previously hidden or misunderstood experiences can enhance the therapeutic alliance and promote valuable insights. Making space for the individual to develop a more coherent narrative about their dissociative experiences constitutes one of the interview's principal benefits. Lastly, it should be noted that the SCID-D offers therapeutic benefits precisely because it does not pathologize these normal human experiences. For this reason, the information elicited during the interview can be used during feedback and in therapy to validate, educate, and empower.
Since the SCID-D's first use in 1983, it's been gratifying to see increased interest and advances in the field of dissociation. Mental health professionals in specialty clinics, private practices, and forensic settings have used the interview for systematic assessment and client education and as a practical method of inquiry that can enhance treatment. And researchers worldwide have used it to study dissociation and its impact among all posttraumatic conditions, about which we still have so much to learn. This revised edition, informed by over thirty-five years of research and clinical experience, incorporates the following updates:
The title has been changed to The SCID-D Interview: Dissociation Assessment in Therapy, Forensics, and Research to highlight, in addition to its diagnostic value, the tool's therapeutic, forensic, and research applications.
Reference to the DSM has been removed from the title to underscore that the SCID-D's assessment model does not depend on DSM or ICD nosology. The results of the SCID-D form a superset of information which can be mapped into the diagnostic criteria of any edition of the DSM or ICD.
The acronym "SCID-D" has been updated and now stands for the "Semi-Structured Clinical Interview for Dissociative Symptoms and Disorders." This is intended to emphasize that in addition to the dissociative disorders, the interview can be used in identifying dissociative symptoms present in other psychiatric conditions.
The design has been streamlined for ease of use in clinical settings.
An expanded "Psychiatric and Medical History" section includes questions related to somatic symptoms for scoring based on ICD-11 (International Classification of Diseases, 11th Revision), the global standard for diagnosis. An optional follow-up section has also been added for exploring the new ICD classification of Partial DID. This new follow-up section may be useful for researchers investigating whether Partial DID is meaningfully distinct from DID.
For those new to the SCID-D, further instructions and optional questions have been included that guide the interviewer in exploring varied manifestations of dissociative symptoms. For those clinicians using the SCID-D as an adjunct to therapy, optional therapeutically relevant questions have been added to the Follow-Up sections of the interview.
The 2023 edition of the Interviewer's Guide to the SCID-D, which is under development and forthcoming from American Psychiatric Association Publishing, includes expanded information about feedback and psychoeducation based on interview results; applications of the SCID-D method in therapy; dissociation in varied psychiatric conditions (e.g., posttraumatic stress, psychotic, mood, and other anxiety conditions); use in adolescent, adult, and forensic populations; and SCID-D psychometrics. Cross-cultural manifestations of dissociation and updated scientific references have also been included.
The content and sequence of the original questions remain unchanged from previous editions. Assessment of the five components of dissociation along a spectrum forms the basis for identifying symptom severity. Open-ended questions still encourage personalized follow-up. And emphasis remains on the importance of bringing attuned interviewing skills to systematic inquiry. Since it was unnecessary to make major revisions to the interview itself, the good-to-excellent psychometric properties of the previous editions persist (Piedfort-Marin, Tarquinio, Steinberg et al. 2021).
If you're a clinician, I hope you will familiarize yourself with the interview, as well as the Interviewer's Guide. You might begin by weaving some of the questions into your assessments and therapy. If you find that a client suffers from dissociative experiences, consider setting aside time to administer the full interview. For specialized training, consider attending a workshop or scheduling supervision with an expert in dissociation.
In my own work, I've marveled at the effect the interview can have on people whose symptoms were once labelled treatment-resistant or "psychotic." When they hear their experience reflected back to them for the first time without judgment or misattribution, I watch hope return as fear dissolves. Gradually, they grant me their trust, and we begin to explore the hidden, internal world that holds, somewhere inside it, the key to healing. Often, the interview is the first step on the road to recovery for those suffering from posttraumatic dissociation-it's the beginning of a journey that, when all is said and done, may be the most meaningful journey a person takes in their lifetime. I hope you find this enhanced version of the SCID-D useful both as a diagnostic interview and as a therapeutic method for helping your clients lead more authentic, fulfilling lives.
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