Instructions for Administration

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1 The Clinician Administered Dissociative States Scale (CADSS) J. Douglas Bremner, M.D., Emory University, March 4, 2014 Instructions for Administration The Clinician Administered Dissociative States Scale (CADSS) is a 28-item scale for the assessment of dissociative states at discrete points in time. The instrument contains both subjective and objective items. This is intended to capture the fact that dissociation is both subjective experience as well as a set of behaviors which can be observed by an outside observer. The CADDS can be used as a change measure to assess, for example, dissociative states before and after a course of treatment. A basic knowledge of the phenomenology of dissociation is required for administration of the CADSS. We have included a recommended bibliography below. This represents only a part of the literature in this area, but it is a good starting point. Dissociative symptoms by their very nature have a strange or unreal feeling about them. Patients with dissociation will immediately recognize the questions on the instrument as being consonant with their own experiences. Patients with psychosis or other pathology may use the items as a starting place for a digression about what they are experiencing. We have found the ÒthatÕs it!ó response to be characteristic of the patient with dissociation. Dissociative symptoms from the different symptom areas tend to aggregate together. For instance, a patient may have an experience of amnesia, with the time after the loss of memory having the feeling of being unreal or detached from their body. This type of clumping together of symptoms is the rule, rather than the exception.

2 In preliminary psychometric studies, the CADSS was shown to be a reliable and valid instrument for the measurement of dissociative states. Tests of inter-rater reliability showed a high level of agreement, with an intraclass correlation coefficient (ICC) (Bartko, 1961) of.92 (F=16.3; df=15,16; p<0.01) for the total score, ICC of.99 (F=99.0; df=15,16; p<.001) for the subjective subscale, and ICC=.34 (F=1.36; df=15,16; p<.05) for the observer rated component. The CADSS also showed high internal consistency across all items (N=124; Cronbach coefficient alpha=.94; p<.05) (Cronbach, 1954), suggesting that individual items were generally measuring the same construct. Alpha coefficients were also performed for the: 1) subjective subscale; 2) observer subscale, and; 3) symptom subscales (amnesia, depersonalization and derealization). Cronbach coefficient alpha for the subjective ratings was.94 (p<.05), while for the objective ratings it was.90 (p<.05). Cronbach coefficient alpha values for the subjective subscales based on individual symptom areas of dissociation were.74 for amnesia (p<.05),.82 for depersonalization (p<.05), and.90 for derealization (p<.05). There was a strong relationship between subjective items 1-19 and the total scale score, with significant correlations between each of these items and the total scale score minus that item after adjustment for multiple comparisons (p<.00185). Objective items that were endorsed by less than 5% of the patients in the original study were dropped from the current version of the CADSS. When the frequency with which items were endorsed at a level of slightly or greater was investigated, the most frequently endorsed item by PTSD patients at baseline were items 15, 16, and 17. Items from the subjective scale were endorsed more frequently than items from the objective scale. The correlation between the total baseline score on the CADSS and the score on the DES was r=.48 (df=49; p=.0004). PTSD patients were compared to other patient groups and control subjects at baseline. The term ÒbaselineÓ is used to refer to a state during which the individual is not

3 undergoing a cognitive or pharmacological challenge. Baseline scores on the CADSS were significantly different for patients with PTSD (M=18.9, SD=118.3) versus patients with schizophrenia (M=3.7, SD=5.2), affective disorders (M=7.5, SD=9.6), as well as healthy controls (M=1.5, SD=2.5) and Vietnam combat veterans without PTSD (M=1.3, SD=3.9) (F=8.25; df=4,119; p<.0001), as determined with one-way analysis of variance and DuncanÕs multiple range test. A subgroup (N=39) of patients with PTSD showed a significant increase in dissociative symptomatology following exposure to a traumatic memories group in comparison to baseline (M=35.0, SD=21.9 vs. M=21.8, SD=18.8) (paired t-test:t=4.03; df=37; p=.0003). Items 1-23 are subjective items. The interviewer reads the item out loud to the subject, and the subject responds to the question with the help of anchors. The anchors are intended for use as a guide. They are not meant to make the process more cumbersome. For instance, if a patient is read an item, and he does not recognize it as being similar to his or her experience, there is no need to read through all of the anchors. The interviewer should circle the number that best corresponds to how an individual is feeling at the current time. The instrument can also be used retrospectively. For instance, immediately after viewing trauma-related slides, the interviewer can prompt the subject, During the slides, did things seem to be moving in slow motion?, etc. Item 7. Does your sense of your own body feel changed; for instance, does you body feel unusually large or unusually small? The rater may prompt the subject with bodily changes which are specific to the individual, for instance some individuals may say that they become large like a giant, or that their arms become like toothpicks, or their chests swell to enormous sizes, etc.

4 Item 12. Do things seem to take much longer than you would have expected? The interviewer can point out the true elapsed time since the initiation of the administration of the CADSS in order to assist the subject with this question. Items represent an addendum to the CADSS for which psychometric information has not been obtained. Items 21 & 23 are specifically identity confusion/alteration items which may be useful in some protocols or clinical situations where this aspect of dissociation is particularly pertinant. Item 22 is a supplementary amnesia item. Items are objective items. The interviewer fills them out based on their observations of the patient during the interview. The interviewer does not read the items out loud to the patient, or give it to the patient to fill out. Readings from the bibliography can be helpful in administration of this section. The objective items should be completed as an honest assessment of the patient s behavior during the interview, not as a second guessing of the interviewer s view about whether the patient has dissociative symptoms or not. The subjective experience of dissociation is typically more marked than objective behavioral reactions which are characteristic of dissociation, and this is reflected in responses to subjective and objective items of the CADSS. We have found that many patients will be having marked dissociative symptoms on almost a daily basis, but have little or no external manifestation of their experience. Patients often do not spontaneously discuss their experiences unless prompted with questions from the interview. However, we have found a correlation between the subjective and objective components of the CADSS. Subtle behaviors which are captured in the objective section are often associated with more marked subjective experiences of dissociation. Recommendations

5 We have developed the CADSS as a clinician administered questionnaire as in our experience people in a dissociated state have trouble filling out questionnaires accurately. We also recommend not using the objective items as they are not valid based on our investigations. However some objective items are included for those interested in using them in their research projects. We recommend using only the Subjective Items Score in most cases. CADSS can be scored by adding up the number associated with the frequency for each item. Cut offs for dissociated state can be used based on one standard deviation from mean scores for healthy subjects, making a score of greater than 4 consistent with a current dissociated state. The CADSS has been translated into foreign languages. The CADSS is free for use without payment or advance permissions as long as attribution is made to the original published papers listed below. The CADSS cannot be re-licensed for commercial distribution in any language. If you translate the CADSS into a foreign language, we ask that you send us a validated version which will be put on our web site after your first publication has come out, and that after that point you make it available for free to other investigators. Suggested Readings: Bernstein, E., Putnam, T. (1986). Development, reliability, and validity of a dissociation scale. J. Nerv. Ment. Dis. 174:

6 Braun, B. (1984). Towards a theory of multiple personality and other dissociative phenomena. Psychiatr. Clin. N.A. 7: Bremner, J.D., Southwick, S.M., Brett, E., Fontana, A., Rosenheck, R., Charney, D.S. (1992). Dissociation and posttraumatic stress disorder in Vietnam combat veterans. Am. J. Psychiatry. 1992;149: Bremner, J.D., Steinberg, M., Southwick, S.M., Johnson, D.R., Charney, D.S. (1993). Use of the Structured Clinical Interview for DSMIV-Dissociative Disorders for systematic assessment of dissociative symptoms in posttraumatic stress disorder. Am. J. Psychiatry. 150: Bremner JD, Krystal JH, Putnam F, Marmar C, Southwick SM, Lubin H, Charney DS, Mazure CM: Measurement of dissociative states with the Clinician Administered Dissociative States Scale (CADSS). J. Trauma. Stress 1998; 11: Cardena, E., and Spiegel, D. (1989). Dissociative reactions to the San Francisco Bay Area earthquake of Am. J. Psychiatry. 150: Carlson, E.B., and Rosser-Hogan, R. (1991). Trauma experiences, posttraumatic stress, dissociation, and depression in Cambodian refugees. Am. J. Psychiatry. 148:

7 Chu, J.A., Dill, D.L. (1990). Dissociative symptoms in relation to childhood physical and sexual abuse. Am. J. Psychiatry. 147:7, Kihlstrom, J. (1993). Dissociative disorders, in Comprehensive Handbook of Psychopathology, 2nd edition, Sutker P and Adams H (ed.). New York, Plenum. Kluft, R.P. (1984). Treatment of multiple personality disorder: a study of 33 cases. Psychiatr. Clin. North Am. 7:9-29. Kluft, R.P. (Ed.). Childhood Antecedents of Multiple Personality Disorder. Washington D.C., American Psychiatric Press, Koopman, C., Classen, C., and Spiegel, D. (1994). Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm. Am.J. Psychiatry. 151: Marmar, C.R., Weiss, D.S., Schlenger, D.S., Fairbank, J.A., Jordan, B.K., Kulka, R.A., and Hough, R.L. (1994). Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. Am. J. Psychiatry. 1994;151: Nemiah, J.C. (1989). Janet redivivus: the centenary of l'automatisme Psychologique. Am. J. Psychiatry. 146:

8 Putnam, F.W., Guroff, J.J., Silberman, E.K., Barban, L., and Post, R.M. (1986). The clinical phenomenology of multiple personality disorder: a review of 100 recent cases. J. Clin. Psychiatry. 47: Putnam, F.W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York, Guilford Press. Ross, C.A., Joshi, S., and Currie, R. (1990). Dissociative experiences in the general population. Am. J. Psychiatry. 147: : Spiegel, D. (1984). Multiple personality as a posttraumatic stress disorder. Psych Clin NA Spiegel D (ed.). Dissociation: Culture, Mind, and Body. Washington D.C., American Psychiatric Press, Washington. van der Kolk, B.A. (Ed.) (1987). Psychological Trauma. American Psychiatric Press,

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