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Measuring dissociative symptoms and experiences in an
Australian college sample using a short version of the
Multidimensional Inventory of Dissociation
Journal:
Journal of Trauma & Dissociation
Manuscript ID
WJTD-2020-0974.R1
Manuscript Type:
Original Research Articles
Keywords:
Dissociative disorders, Measure development, Epidemiology
URL: http://mc.manuscriptcentral.com/wjtd Email: editor.jtd@gmail.com
Journal of Trauma & Dissociation
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Measuring dissociative symptoms and experiences in an Australian college sample
using a short version of the Multidimensional Inventory of Dissociation
Abstract
This paper investigated a 60-item version of the Multidimensional Inventory of
Dissociation (MID) with the potential to capture the full range of dissociative
symptoms that characterize each of the dissociative disorders (DD). The 28-item
Dissociative Experiences Scale (DES) was designed to capture a wide range of
dissociative phenomena, but college population studies indicate it may not be
adept at identifying the full range of dissociative symptoms and disorders. The
218-item MID has the advantage of capturing the full range of dissociative
symptoms and has diagnostic capabilities for all DSM-5 DD, but the
disadvantage of taking considerably longer than the DES to complete. Using
university students and staff (N = 313), this paper investigated a 60-item version
of the MID with the potential to capture the full range of dissociative symptoms
that characterize each of the DD. Results indicate the MID-60 has a nearly
identical factor structure to the full MID, excellent internal reliability, and
content and convergent validity. Using the MID-60, at least 8% of participants at
an Australian university were positive for a DD and, on average, participants
self-reported having dissociative experiences 13% of the time. The present
study’s findings suggest the MID-60 is a promising alternative to the DES, with
results about the prevalence of DDs and dissociative experiences consistent with
those found using clinical interviews and the DES.
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Keywords: Dissociation, instruments, prevalence, Multidimensional Inventory
of Dissociation (MID), assessment
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The 28-item Dissociative Experience Scale (DES; Bernstein & Putnam, 1986) is
the most commonly used instrument measuring dissociation in both research and
clinical settings. Yet in non-clinical samples or people newly presenting for treatment
its clinical cut-off often misses dissociative disorders (DD) other than dissociative
identity disorder (DID). The 218-item Multidimensional Inventory of Dissociation
(MID; Dell, 2006) can be used as an alternative to the DES and is more accurate but
takes longer to complete. This paper introduces a 60-item version of the MID to provide
a middle ground between the comprehensiveness of the MID and the brevity and
specificity of the DES.
A recent meta-analysis by Kate, Hopwood, and Jamieson (2020) raised questions
about the effectiveness of the DES to capture the full range of symptoms experienced by
college students meeting criteria for DD. Over its 28 items, the DES assesses mild
dissociative experiences through to severe dissociative symptoms (Bernstein & Putnam,
1986). At the pathological end, the DES focuses heavily on the symptoms of
dissociative identity disorder (DID) but does not contain items that specifically assess
amnesia for traumatic events that are characteristic of dissociative amnesia, and only
contains one question about experiences of intrusions and internal dialogue
characteristic of the subclinical form of DID (Dell, 2009), which falls under other
specified dissociative disorder-type one (OSDD-1) in the DSM-5 (American Psychiatric
Association, 2013).
Whilst only ever developed as a screening tool for DD, the shortcomings of the
DES in capturing less severe dissociative symptoms and disorders are evident in college
population studies. Nilsen (2000) interviewed 415 females with the Structured Clinical
Interview for DSM-IV Dissociative Disorders (SCID-D; Steinberg, 1994) and found
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that if she applied the recommended DES cut-off of 30 for identifying pathological
dissociation (Carlson et al., 1993) only one of the 23 (4.3%) cases of dissociative
amnesia and one of the four (25%) cases of depersonalization would have been
identified, whereas this cut-off identified all cases of DID. A similar pattern was
apparent using the Dissociative Disorders Interview Schedule (DDIS; Ross et al., 1989)
alongside the DES. The DDIS subscale capturing multiple features of DID was strongly
correlated with DES scores (Murphy, 1994: r = .60, p <. 01; Ryan, 1988: r = .78, p
<.05). Yet the correlation between the DES and the DDIS subscale of depersonalization
was weaker or non-significant (Murphy, 1994: r = .49, p < .05; Ryan, 1988: ns).
Moreover, the DES was not related to the DDIS dissociative amnesia subscale (Ryan,
1988). Although these are college populations studies, the problem is likely to extend to
those conducted in clinical populations given many participants with a DD, including
DID, may not reach the DES cut-off of 30 that identifies those for further clinical
assessment (Coons & Millstein, 1992; Simeon, 2009; van Ijzendoorn & Schuengel,
1996). There is greater potential for individuals with DD to have a DES score below the
30 cut-off in non-clinical populations as it can be expected that those who are more
symptomatic are more likely to present to mental health services.
Multidimensional Inventory of Dissociation (MID)
The Multidimensional Inventory of Dissociation (MID; Dell, 2006) is a self-
report instrument that assesses the full range of dissociative symptoms for all DSM-5
DDs. Although the MID captures a wider range of dissociative symptoms than the DES,
the two instruments are strongly correlated (r = .94; Dell, 2006). Dell (2006) found the
MID strongly correlated with diagnostic clinical interviews (i.e. SCID-D; r = .78).
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While the MID assesses derealization, depersonalization, and amnesia
symptoms, its diagnostic capacities are limited to DID and OSDD-1, posttraumatic
stress disorder (PTSD), and conversion disorder. Hence, it does not generate a
diagnostic impression for derealization / depersonalization disorder or dissociative
amnesia. However, MID reports can be useful in discerning whether derealization /
depersonalization disorder or dissociative amnesia are present to the exclusion of DID
and OSDD-1 (Dell, Coy, & Madere, 2017).
The MID assesses 12 factors, including self-confusion (i.e., profound and
chronic self-puzzlement), angry and persecutory intrusions, dissociative disorientation,
amnesia (e.g. time loss, ‘coming to’, fugues and disremembered actions), distress about
severe memory problems, subjective awareness of alter personalities and self-states,
derealization/depersonalization, trance, flashbacks, body symptoms, and circumscribed
loss of remote autobiographical memory. The MID is often used in clinical settings, but
rarely used in research, perhaps due to it being seven times longer than the DES,
making it significantly more time consuming to complete. Consequently, a short-form
of the MID would be valuable in research, as the option of clinical interviews may not
be possible for researchers due to time and resource constraints.
This paper introduces a 60-item version of the MID as a potential screening tool
to capture the full range of dissociative symptoms characteristic of each DD, and
assesses the instrument’s internal reliability, and content and concurrent validity in a
non-clinical sample.
Method
Participants
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The sample consisted of 269 female and 44 male students and academic staff (N
= 313) from a regional Australian university. Although data on student status was not
collected, the majority of participants were likely to have been first-year psychology
students who were eligible to receive course credit for their participation.
Females were overrepresented in the sample. Although males comprise 22% of
psychology students at the university, only 14% of the sample were male indicating that
females were proportionally more likely to choose to participate in this particular study
than males. The average age of participants was 32.88 years (SD = 10.52), which was
higher than that found in a meta-analysis of college students (M = 21.0 SD = 3.7; Kate
et al., 2020), which can be explained by the university specializing in online and
distance education, that attracts mature-age students balancing work or family life.
MID-60
Following consultation with the MID’s creator Paul Dell, the decision was taken
to use a 60 item version based on the five questions with the highest pattern matrix
loading for each of the MID’s 12 factors (Dell & Lawson, 2009, pp. 685 – 689). Hence,
the MID-60 includes items that capture phenomena specific to each DD, broader
dissociative symptoms, and related experiences that are characteristic of people with
DDs, including PTSD symptoms and the self-confusion that arises from dissociative
symptoms and experiences. The MID-60 response format is a Likert scale where
respondents indicate how often they have dissociative symptoms and experiences from
0 (never) to 10 (always).
Procedure
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Participants were informed about the opportunity to take part in the study in a
number of ways. The study was listed as one of the research participation options for
first-year psychology students and the psychology department’s website, and
information about the study was e-mailed through, and posted on, various internal
university networks. Once consent was given, participants were directed to the
questionnaire that was hosted online by Qualtrics. The study, titled “Dissociative
Experiences in Adulthood”, was introduced by advising participants “you will be asked
about any dissociative experiences you have had in the past or are continuing to
experience in your life”. The timeframe for reportable experiences is not specified in the
MID, although Dell et al. (2017) recognize that experiences occurring years ago may
still be relevant. The instructions that followed were identical to those that accompany
the full MID. The order in which the 60 items appeared was randomized for each
participant. The contact details of university counselling and other support services were
given to participants should they consider this beneficial.
Student participants were not taught about DDs as part of their Introductory
Psychology classes during the three trimesters of data collection, and the required
textbook questioned the validity of dissociation and DD (Lilienfeld et al., 2014). Thus,
the sample were thought to have little or no scientific knowledge of the nature of DDs.
Main analysis
To establish the validity and reliability of the MID-60 in a non-clinical sample the
following criteria were tested:
(1) Structural validity – a Confirmatory Factor Analysis was conducted to evaluate
the instrument’s similarity to the full MID.
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(2) Reliability – Cronbach’s coefficient alpha was calculated to assess the internal
consistency of the 60 items and that of each subscale. The minimum criteria set
for acceptability was r = 0.70 (Cortina, 1993).
(3) Concurrent validity – The extent to which scores on the MID-60 have
concurrent validity was tested by assessing whether the prevalence of both
dissociative experiences and clinical levels of dissociation found using the MID-
60 was comparable to that found in studies with a similar cohort and in those
using the full MID, DES and structured clinical interviews.
To assess concurrent validity benchmarks needed to be established to determine
whether the prevalence of dissociative symptoms and experiences, and clinical levels of
dissociation as measured by the MID-60 were consistent with findings from studies in
normal and clinical populations using clinical interviews, the DES or the full MID. For
the MID-60 to be considered a valid measure, the prevalence of symptoms, experiences,
and clinical levels of dissociation must be consistent with other college populations,
broadly similar to normal populations, and markedly lower than those found in clinical
populations.
Establishing a benchmark for the prevalence of dissociative symptoms and
experiences
DES and MID scores are calculated by averaging the percentage of time a
person self-reports having each dissociative symptom and experience described in the
respective instruments. The DES measures both dissociative experiences common in the
general population, as well as dissociative symptoms, whereas the MID is limited to
more pathological manifestations of dissociation. For this reason, it can be expected that
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in a normal population the MID mean score will be slightly lower than the DES mean
score. Support for this premise is evident in Table 1. ‘Non-clinical adults’ (Dell et al.
2017) were experiencing the dissociative symptoms and experiences described in the
MID slightly less often than ‘normal adults’ were experiencing the dissociative
symptoms and experiences described in the DES (Van Ijzendoorn & Schuengel, 1996),
i.e. 8.0 vs. 11.1. Lauterbach et al. (2008), which is the only study to report MID scores
in a college population, found students reported having dissociative symptoms and
experiences described by the MID considerably less often than in college population
studies using the DES (Kate et al., 2020), i.e. 6.9 vs. 16.6. In contrast, the percentage of
time dissociative symptoms and experiences were being experienced by people
diagnosed with DID or OSDD-1 was slightly higher using the MID as compared to the
DES (see Table 1), which is consistent with the MID focussing more heavily on
dissociative symptoms rather than experiences.
<Insert Table 1 here>
Establishing a benchmark for prevalence of DDs
A meta-analysis by Kate et al. (2020) found a DD prevalence rate of 11.4% (N =
2,148) in college samples following diagnostic interview using the SCID-D, DDIS, or
mini SCID-D (Steinberg, Rounsaville, & Cicchetti, 1990) with 1) all participants or 2)
after pre-screening with the DES. The authors found that 16.6% (N = 4,061) of students
were experiencing clinical levels of dissociation on the DES (i.e., 30 or more). This rate
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is higher than the average of 9.9% found in general population samples from around the
world using a variety of methods and diagnostic tools (Kate et al., 2020).
Establishing a benchmark for normal and clinical levels of dissociation using the
MID-60
As the MID-60 is not a diagnostic tool, the threshold for clinical levels of
dissociation needs to be established. Dell et al. (2017) recommend clinicians examine
cases with a MID score of 20 or higher carefully due to the elevated risk of a DD,
noting that respondents scoring between 21 and 30 may have a DD or PTSD; those
scoring between 31 and 40 may have a DD and PTSD; and those with a score of over 41
likely have DID and PTSD. Dell and colleagues advise that respondents scoring
between 15 and 20 may also have PTSD or a mild dissociative disorder. In the present
study, the MID-60 cut-off score for identifying clinical levels of dissociation was 21.
While it is possible that this cut-off excludes a small number of individuals with a mild
DD scoring between 15 and 20, this was preferable to reducing the threshold to 15 and
thereby potentially including numerous individuals who would not meet DD diagnostic
criteria. With benchmarks for clinical levels of dissociation in place, the percentage of
respondents who met these criteria was calculated and compared to those found in
studies using the MID and the DES.
The analysis also employed thresholds for clinical significance for each MID
item established by Dell (2004). For example, if the respondent reports having DID-
type amnestic experiences 10% of the time, this is deemed to be clinically significant.
Dissimilarly, it is not uncommon for people to have the feeling that pieces of their past
are missing, so that particular item is only considered clinically significant if the person
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reports having this experience more than 50% of the time. To examine the prevalence of
clinically significant symptoms and experiences in the present sample, clinically
significant cut-off markers for all MID-60 factors were established by averaging the
scores for each item assigned by Dell (2004). With clinical cut-off scores for each MID-
60 subscale in place, the percentage of participants in the present study with clinically
significant symptoms was calculated for each of the subscales that correspond to Dell’s
specific DD, PTSD, and conversion disorder markers. In addition, the mean scores for
all MID-60 subscales were compared to the mean for the corresponding MID subscales
found in non-clinical adults, and those with PTSD, OSDD-1, and DID (Dell, 2004).
Results
Structural validity
To assess whether the MID-60 measures the same construct as the full MID-60 a
factor analysis with oblique rotation was conducted on all 60 items to establish whether
the short version retains a similar factor structure to the original instrument. The Kaiser-
Meyer Olkin (KMO) measure of sampling adequacy exceeded 0.5 (KMO = .943),
suggesting the sample was factor analysable, and Bartlett's test of sphericity was
significant, χ2 (1,770) = 16,576.57, p < .001.
In exploring the potential for multicollinearity the correlations between the 60
items were screened for any above 0.8, with four evident. These related to self-
confusion and memory issues, specifically: ‘feeling very confused about who you really
are’ and ‘feeling uncertain about who you really are’ (r = .85); as well as between the
items relating to memory, ‘poor memory causing serious difficulty for you’ and ‘being
bothered or upset by how much you forget’ (r = .81); ‘being able to remember very little
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of your past’ and ‘not remembering large parts of your childhood after age 5’ (r = .85);
and ‘being able to remember very little of your past’ and ‘feeling that there are large
gaps in your memory’ (r = .81).
Eleven items had initial Eigenvalues of one or more, and these cumulatively
accounted for 73% of the variance in MID-60 scores (full details can be viewed via
Open Science Foundation [OSF] link: https://osf.io/y96dc/). The item ‘feeling very
confused about who you really are’ accounted for 41% of the variance alone. Self-
puzzlement is not a dissociative symptom per-se, but results from the dissociative
individual’s inexplicable feelings, reactions, and behaviors (Dell et al., 2017). It is
therefore likely that the reason this single item accounts for such a large amount of
variance is that self-confusion is the cumulative effect of all of the different aspects of
the dissociative symptoms and experiences. No items were deleted on the basis of
multicollinearity and Eigenvalues To ensure the MID-60 was fully comparable with the
MID,.
Principal Axis Factoring was conducted by specifying that all 12 factors and 60
items be retained to enable a comparison between the MID-60 and the original
instrument. An oblique promax rotation was conducted as it was expected that many
items would be correlated with more than one factor. The pattern matrix can be viewed
via OSF link: https://osf.io/y96dc/
The factor structure of the MID-60 was similar to the original instrument
replicating 11 of the 12 identified in the full MID (Dell & Lawson, 2009). The 12th
factor, named here as psychogenic non-epileptic seizures (PNES), contained a single
item that fell into Dell and Lawson’s (2009) ‘body (somatoform / conversion)
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symptoms’ factor. The missing original factor was the broad category of ‘dissociative
disorientation’ that contains five items. The ‘dissociative disorientation’ factor had
contained the somatoform item ‘having difficulty swallowing’, which, not surprisingly,
had the strongest correlation in this study to the ‘body symptoms’ factor, although
curiously, another of the somatoform items (‘having difficulty walking’) from the ‘body
symptoms’ factor had a far stronger correlation with the current ‘trance’ factor. The
‘dissociative disorientation’ item ‘having trance-like episodes where you stare off into
space and lose awareness of what is going on around you’ could have been expected to
move to the ‘trance’ factor, but had the strongest correlation with ‘self-confusion’. Two
‘dissociative disorientation’ items about not remembering eating and forgetting what
was done earlier in the day had the strongest correlation with the ‘distress about severe
memory problems’ factor. The final ‘dissociative disorientation’ item, ‘being told of
things that you had recently done, but with absolutely no memory of having done those
things’ might have been expected to move to ‘amnesia’ or ‘distress about severe
memory problems’ but actually had the strongest correlation with ‘depersonalizaton /
derealization’. A similar item (“coming to” and finding that you have done something
you don’t remember doing), originally in the amnesia factor, also moved to
‘depersonalizaton / derealization’, as did ‘totally forgetting how to do something that
you know very well how to do’, which shared a slightly stronger correlation than it did
with its original factor (distress about severe memory problems). Although there were
minor differences, the factor structure was highly similar to the original instrument.
Furthermore, amnesia and depersonalization showing up in unexpected factors may be
attributed to these being interlinked, rather than wholly distinct, categories. For
example, if a person becomes so depersonalized and experiences a sense of ‘absence’,
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they may fail to encode salient aspects of their experience leading them to report
amnesia for some of the events during an episode of depersonalization (Krause-Utz,
Frost, Winter, & Elzinga, 2017).
Content validity
As the factor structure is highly similar to the original instrument, the MID-60
demonstrates content validity.
Reliability
Cronbach’s co-efficient alpha (60 items; α = .97) indicates the MID-60 has
excellent internal reliability, with the alpha being identical to that found with the full
MID (Dell, 2006). Excellent internal consistency was confirmed by comparing odd and
even-numbered items (Guttman Split-half = .98).
The internal reliability of each of the 11 subscales was acceptable. The alpha
exceeded .70 for: self-confusion (6 items; α = .92), angry intrusions (5 items; α = .85),
persecutory intrusions (5 items; α = .92), amnesia (4 items; α = .81), distress about
severe memory problems (6 items; α = .90), subjective awareness of alter personalities
and self-states (5 items; α = .90), derealization / depersonalization (8 items; α = .92),
trance (6 items; α = .88), flashbacks (5 items; α = .90), body symptoms (4 items; α =
.71), circumscribed loss of remote autobiographical memory (5 items; α = .94).
Assessing concurrent validity: The prevalence of dissociative experiences and clinical
levels of dissociation
The average MID-60 score in this study reveals that the sample (N = 313)
reported dissociative experiences 13.04% of the time (SD = 13.82, median = 8.67) with
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scores ranging from zero to 90. MID-60 scores were non-normally distributed, with
skewness of 2.23 (SE = .138) and kurtosis of 6.53 (SE = 0.10). The distribution and
skew of the full MID has not been reported (Dell, 2006; Dell et al., 2017), but the
findings of the present study are consistent with the right-skewed and leptokurtic
distribution of dissociative experiences as measured by the DES in normal and clinical
populations (Bernstein & Putnam, 1986). Of the total sample, 57 (18.2%) had a MID
score equal to or greater than 21, which includes 31 respondents (10.2%) who had
scores between 21 and 30 indicating a DD or PTSD was likely; 12 (3.8%) who had a
score between 31 and 40 indicating a DD with comorbid PTSD was likely; and 14
(4.5%) who had a score of over 41 indicating DID with comorbid PTSD was likely.
Forty-one individuals (13.1%) scored between 15 and 20 where a mild DD was
possible, but their score was considered to indicate sub-clinical levels of dissociation for
the purposes of the present study.
No significant differences in mean MID-60 scores were found between males
(M = 13.02) and females (M = 13.04) or any of the subscales, with similar proportions
having levels of dissociation consistent with DD or PTSD (i.e., 10 males [22.7%] and
47 females [17.5%] had MID-60 scores equal to or above 21). Due to the markedly
older age of the present sample compared to other college samples, the mean MID-60
for the 223 respondents that were aged 25 or older (M = 12.30) was compared to the 90
respondents aged 24 or under (M = 14.86), but these differences were not significant,
t(311) = -1.49, p = .1.39. The age of 25 was chosen as it marks the end of the
neurological changes observed in adolescence (Siegel, 2013). However, those aged 24
or under had significantly higher scores compared to their older peers on the subscales
of self-confusion (i.e., 19.32 vs. 14.58), t(311) = -2.75, p = .007, and angry intrusion,
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(i.e., 9.99 vs. 6.57), t(314) = -2.93, p = . 004. There was a weak negative correlation
between age and MID-60 scores, r = -.114, p = .044, however only three of the 12
subscales had a significant correlation, the two identified in t-tests, that is, self-
confusion (r = -228, p = .000) and angry intrusions (r = -.180, p = .001), and the third
was the mixed category of dissociative disorientation (r = -184, p = .001).
Presence of clinically significant symptoms
<Insert table 2 around here>
The percentage of participants meeting clinically significant cut-off for specific
disorder-related subscales is presented in Table 2. The findings show clinically
significant symptoms specific to DDs were generally uncommon (i.e., ranging from
zero to 4%) in the group scoring between zero and 14 on the MID-60, although 12%
reported experiencing clinically significant angry intrusions and autobiographical
memory problem. No member of this group met the clinical cut-off for subscales
specific to DID, OSDD-1, or dissociative amnesia. DD symptoms were not uncommon
in those with a MID-60 score of 15-20, with 14% and 17% respectively meeting the
clinical cut-offs for the subscales specific to depersonalization / derealization, and
dissociative amnesia. Clinically significant angry and persecutory intrusions were
reported by 12% and 4% respectively of this group (although no respondent met the cut-
off for all DID and OSDD-1 related subscales). In the DD or PTSD group (i.e. 21-30),
45% met the clinical cut-offs for the depersonalization / derealization subscale, 29%
met the clinical threshold for both subscales relevant to dissociative amnesia, and 12.9
met the cut-off for the three shared DID and OSDD-1 related subscales and 77%
reported clinically significant PTSD flashback-type symptoms. OSDD-1 was expected
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to be common in participants scoring between 31 to 40 on the MID-60, and although
angry intrusions were experienced by most (92%), and half met the clinical cut-off for
DID-type amnesia, only a third met all three relevant subscale cut-offs for OSDD-1.
However, all had depersonalization / derealization, and distress about memory problems
with most meeting the clinical cut-offs for both memory scales relevant to dissociative
amnesia. Dell et al. (2017) advise a score of 41 on the MID is consistent with DID, yet
just under two-thirds met the clinical cut-off for the DID-type amnesia scale, and only
57% met the cut-offs for all relevant subscales. However, there was high rates of all
other DD-related symptoms beyond amnesia (ranging from 71% to 100%) in addition to
PTSD (100%). This suggests that approximately one-third of those scoring over 41 may
have a DD, but not DID, in addition to PTSD (and for many, conversion disorder as
well).
Percentage of time the symptom clusters described in MID-60 and MID subscales are
being experienced
Table 3 compares the MID-60 subscales (revised based on the factor analysis
described above) to the 12 MID subscales data drawn directly from the calculations tab
of the MID V3.6 (Dell, 2004). The table also lists the clinical cut-off for each subscale,
with the groups’ mean score for each subscale underlined if it met or exceeded the cut-
off score.
<insert Table 3 around here>
Broad similarities should be apparent between the two non-dissociative groups (i.e.,
those scoring between zero and 14 on the MID-60 and non-clinical adults), and between
those scoring between 31-40 and OSDD-1, and those scoring over 41 and DID. An
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examination of the means and standard deviations demonstrates consistency across the
majority of items, yet there are some clear points of divergence. There were far higher
rates of self-confusion in the group scoring between zero to 14 (MID-60) than in non-
clinical adults (MID). DD-specific symptoms and experiences were more common in
non-clinical adults (i.e., memory problems, DID type amnesia, subjective awareness of
self-states, and persecutory intrusions), although depersonalization and derealization
was similar, and angry intrusions were slightly less common. Angry intrusions and self-
confusion were also higher in the group scoring between 31 and 40 than in the group
with OSDD-1 (as was distress about memory problems, DID-type amnesia and
depersonalization derealization), whereas the experience of subjective awareness of self
states, and persecutory intrusions were higher in the OSDD-1 group. A similar pattern
was apparent in the group scoring over 41 on the MID-60 when compared to the DID
group. As expected DID-type amnesia and subjective awareness were slightly higher in
the diagnosed DID group, yet self-confusion, distress about memory problems, and
derealization and depersonalization were higher in the MID-60 group scoring over 41.
The mean for all subscales was higher in the 15 to 20 group (recalling a mild
DD is possible in people scoring in this range on the MID) than the group scoring below
15, and substantially higher than the non-clinical group for all but two subscales
(amnesia and subjective awareness of self-states were fractionally higher). Furthermore,
15 to 20 group’s subscale means for self-confusion, distress about severe memory
problems, and flashbacks, were clinically significant. As those scoring between 21 and
30 may have PTSD or a DD, this group can be contrasted to Dell’s (2004) PTSD group
to assess whether the symptom profile is more consistent with PTSD or a DD.
Compared to the PTSD group, those scoring between 21 and 30 rates had higher mean
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scores on all scales, including flashbacks (with the exception of the trance subscale
which was identical). Based on the mean score subscales, the 21 to 30 group met the
clinical threshold for 8 of the 11 subscales, whereas the the PTSD group only met the
clinical threshold for flashbacks and trance.
Discussion
The factor structure of the MID-60 proved to be nearly identical to the full MID,
and the 60 items displayed a very high level of internal consistency indicating that the
MID-60 is a reliable measure of dissociation. The findings on mean and clinical levels
of dissociation suggest the MID-60 has concurrent validity as these are consistent with
those found using clinical interviews, the DES and the full MID.
The prevalence of dissociative symptoms and experiences
Comparisons with the DES
The prevalence of dissociative symptoms and experiences using the MID-60 is
consistent with studies using the DES. In the present study respondents reported
experiencing dissociative symptoms, on average, 13.04% of the time. This is somewhat
lower than the DES mean of 16.62 found in a recent meta-analysis of 26,821 students
from 16 different countries (Kate et al., 2020). Lower mean scores were expected using
the MID-60 as the questions are derived from the MID, which focuses more on
pathological dissociative symptoms, than the DES, which also focuses on dissociative
experiences that are more commonly found in the general population. Although the
DES measures ‘normal’ dissociation, these items are valuable in distinguishing people
who have clinical levels of dissociation from those who do not. For example, people
with DID have far higher scores on the 'normal' items than ‘normal’ people and
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therefore, they have ‘normal’ experiences (such as staring off into space and missing
part of a conversation) to a pathological degree.
Two other factors may contribute to the lower rate found here. Firstly, Kate et al.
(2020) found cross-country variation in mean DES scores with nations that afforded
personal safety and security to citizens having lower levels of dissociation. Australia’s
ranking (i.e., 20th out of 149 countries), was considerably more favorable than the mean
country ranking for personal safety across all studies (i.e., 45th). Australia had
correspondingly lower DES scores (M = 13.3). Hence, the lower rate may simply reflect
Australia being a relatively safe country. The second factor that may play a minor role is
age. Consistent with Van Ijzendoorn and Schuengel (1996), the present study found a
weak negative correlation between age and dissociation, although the findings indicate
this is due to specific dissociative symptoms and experiences such as angry intrusions
declining with age rather than a relationship between dissociative symptoms and age
per-se. Recalling that participants in the present study were, on average, ten years older
than that found in most other college population studies using the DES, the MID-60
score in the present study is highly similar to the mean DES scores of 12.4 and 12.1
found in two studies with similarly aged cohorts at the same Australian university
(Irwin 1998a; Irwin 1998b). These three factors (i.e., the MID-60 focus on dissociative
symptoms, national safety, and age of participants) all provide plausible explanations
for the slightly lower rate in the present study compared to those using the DES.
It was hypothesized that the rate of dissociation in the present study must be
slightly higher than that found in the general population. Indeed, the rate in the present
study is slightly higher than DES scores in normal adults (M = 11.05; Van Ijzendoorn &
Schuengel, 1996). The reason for higher levels of dissociation in college students
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compared to the general population has been attributed to age, but as this correlation is
only weak, it is likely student status may be a contributing factor given the higher
prevalence of mental health problems in college students compared to the general
population (Stallman, 2010).
Comparisons with the MID
The present study’s findings on the prevalence of dissociation in a university
population (M = 13.04) was less aligned with the MID than the DES. As expected, the
prevalence of dissociation was higher than that found in nonclinical adults using the
MID (M = 8.0; Dell et al., 2017).
Only one study has reported MID means in college populations, and that
produced results that are slightly inconsistent with Dell et al. (2017) and the present
study. Lauterbach et al. (2008) found that, compared to non-clinical adults, students in
the US had identical (rather than higher) levels of dissociation (M = 7.9%), and students
in Israel had slightly lower (rather than higher) levels of dissociation as assessed by the
Hebrew version of the MID (M = 5.9%). The difference was attributed to the lower
levels of abuse reported by the Israeli students compared to their American peers, but
this does not explain why the rates were lower in college students than in non-clinical
adults.
The statistics presented in Table 3 demonstrate broad consistencies between the
prevalence of symptoms and experiences for each subscale in the present sample and
Dell’s (2004) non-clinical and clinical samples (i.e., when comparing those scoring
between zero and 14 on the MID-60 to non-clinical adults, those scoring between 31
and to OSDD-1, and those scoring over 41 to DID). Although the means and standard
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deviations supported consistency between the two instrument across the majority of
susbcales, there were some exceptions. The higher means for the scales of self-
confusion and angry intrusions found in the present sample compared to Dell (2004)
may be attributed to our earlier finding that participants aged 24 or under had
significantly higher scores compared to their older peers on these two subscales,
coupled with the present sample having a higher proportion of younger people (M =
32.88, SD = 10.52) than samples with non-clinical adults (M = 49.0, SD = 14.4; Dell,
2006). It is likely that the reason DD-specific symptoms were less common in those
scoring between zero and 14 on the MID-60 compared to non-clinical adults is simply
that the ceiling of 14 provides a constraint on the scores that are possible. That is, if the
respondent scored higher on specific dissociative traits, their MID-60 score is likely to
be 15 or more, which would remove them from this category, whereas the sample of
non-clinical adults includes those scoring above 15 on the MID (M = 8.0; SD = 10.9;
Dell et al., 2017). Moderate differences in symptoms and experiences between those
with MID-60 scores in the range of OSDD-1 (i.e., 31– 40) and DID (i.e., 41+), and
Dell’s (2004) clinical groups are likely to reflect the wide range of MID scores seen in
those clinically diagnosed with DID (M = 51.3, SD = 18.7) and OSDD-1 (M = 39.0, SD
= 19.4; Dell et al. 2017), which demonstrates it is not uncommon for those with DID
and OSDD-1 to score less than 41 and 31 respectively. These findings are a reminder
that raw cut-off scores are useful for assessing the severity of dissociative symptoms,
but are no substitute for a full diagnostic assessment.
There may also be limitations in comparing Dell’s diagnosed DD groups with
those in the present sample with a symptom profile consistent with a DD who would
largely, if not exclusively, never been given a DD diagnosis (Brand et al., 2016). While
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general population studies show that people meeting DD diagnostic criteria (who would
predominantly have been undiagnosed prior to the study) do have clinically significant
impaired functioning (Johnson, Cohen, Kasen, & Brook, 2006), it could be expected
that individuals who have not ended up in the mental health care system with a DD
diagnosis are less symptomatic, on average, than individuals who have and are
clinically diagnosed with a DD. Support for this premise may be evidenced by the
present sample’s participation in tertiary education, which suggests a reasonably high
level of functioning. Secondly, although the mental health and quality of life of those
with DD is generally very poor (Mueller-Pfeiffer et al., 2012), it improves significantly
as a result of tri-phasic trauma-focussed psychotherapy (Brand et al., 2016). Hence,
diagnosed individuals may have, on average, a higher initial baseline of dissociation,
but this has the potential to reduce, whereas those with a DD in the present sample,
most of who would be undiagnosed (Brand et al., 2016), may have a lower initial
baseline of dissociation, but without the same opportunity for symptom reduction.
The prevalence of clinical levels of dissociation
The present study found 57 (18.2%) participants had levels of dissociation
consistent with a DD and/or PTSD diagnosis (i.e., these people reported experiencing
dissociative experiences and symptoms more than 21% of the time). However, as the
MID-60 is not a diagnostic instrument, the true percentage of participants meeting
diagnostic criteria is not known, as some in the group may have had PTSD or
subclinical levels of dissociation.
The 26 participants (8.3%) scoring over 31 had levels of dissociation consistent
with OSDD-1 or DID according to Dell et al. (2017). Therefore, 8.3% could be used as
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potential baseline for the rate of DDs in the sample as it seems likely that a person
experiencing dissociative symptoms nearly a third or more of the time would meet
criteria for a DD. The comparison between MID-60 and MID disorder-related subscales
in Table 2 supports the assertion that those scoring over 41 had marked dissociative
experiences and symptoms. While only two-thirds of those scoring above 41 met the
clinically significant cut-off for all four DID-specific subscales, and only one-third of
those scoring between 31 and 40 met the clinically significant cut-off for all three
OSDD-1 related subscales, a post-hoc analysis shows that 93% of those scoring over 41,
and 75% of those scoring between 31 and 40, had at least one clinically relevant
symptom from the subscales of amnesia and subjective awareness of alter personalities
and self-states. Hence, those in the sample scoring over 31 have a symptom profile that
is consistent with OSDD-1, DID, or another DD.
The true rate of DDs maybe higher as a subset of the 31 participants scoring
between 21 and 30 are likely to have a DD rather than having PTSD or subclinical
levels of dissociation. While three-quarters of the 31 individuals scoring between 21 and
30 reported clinically significant flashback-type symptoms, this PTSD or DD group had
noticeably higher mean scores on all DD-specific subscales compared to the MID group
with a PTSD diagnosis. This provides support for the clinical cut-off of 21 used in the
present study and by Dell et al. (2017), but also suggests that some in this group may
have PTSD and DD. The findings also provide support for the advice offered by Dell et
al. (2017) that a mild DD is possible in those scoring between 15 and 20, with 14% and
17% respectively of those scoring in this range in the present sample having symptoms
and experiences consistent with depersonalization / derealization disorder and
dissociative amnesia.
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On balance, it is likely that the true rate of DDs in this sample falls somewhere
between 8.3% and 18.2%. This finding is consistent with Kate et al. (2020) who found
16.6% of students (N = 4,061) had levels of dissociation that indicated a DD was likely
(i.e., scoring over 30 on the DES), and 11.4% (N = 2,148) met criteria for a DD based
on a clinical interview. The similarity in findings on the prevalence of clinical levels of
dissociation using the MID-60, the DES, and clinical interview suggests the instrument
has concurrent validity.
Convergent validity
The convergent validity of the MID-60 can be established by confirming a
relationship between variables considered to be antecedents of dissociation and DDs
(i.e., sexual or physical maltreatment, sudden unexpected negative events, frightening
parental behavior or parental abandonment; Dalenberg et al., 2014). Although the
convergent validity of the MID-60 was not explored in this paper, Kate’s (2018) use of
the present sample indicates the instrument has convergent validity. Kate (2018) was
able to predict 51% of MID-60 scores in females using self-reports of an insecure
attachment style, the number of sexual abuse episodes, being choked, and the number of
different types of sexual and physical abuse; and 53% of MID-60 scores in males based
on the number of sexual abuse episodes and negative parent-child dynamics. Kate
(2018) also found that the 20 females in the university group identified by the MID-60
as having pathological levels of dissociation (i.e., a score of 31 or more) had similar
MID-60 scores (M = 51.13, SD = 16.36) to a clinical sample of 30 females with a DD
diagnosis (M = 56.81, SD = 18.84). Furthermore, Kate (2018) found the MID-60 mean
found in female students scoring over 31 was identical to the MID mean in 76
individuals with a DID diagnosis (M = 51.3, SD = 18.7; Dell et al., 2017).
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Future research and clinical implications
It would be valuable to conduct a study that compares scores using the MID-60,
the full MID, the DES, and ideally clinical interview, in clinical and non-clinical
samples to establish, not only the relationships between scores on these instruments but
also whether the range of scores associated with normal and clinical levels of
dissociation are the same for the MID-60, the MID and the DES. Given the MID-60
captures a broader range of dissociative symptoms than the DES, it would be valuable
to confirm whether the scores indicating clinical levels of dissociation recommended by
Dell et al. (2017), and that have been applied here to the MID-60 (i.e., 21 and 31), are
indeed more effective than the DES in identifying less severe DDs, particularly
dissociative amnesia, and depersonalization/derealization disorder. To ensure these
disorders are not missed, the MID-60 will include the clinically significant cut-off
scores developed by Dell (2004) as part of the scoring of each item and subscale, to
draw attention to the symptoms and experiences that require further exploration by the
clinician or researcher. This will also enable clinically significant PTSD and conversion
symptoms to be identified, particularly given the latter may not attract a score of more
than 21. Item order was randomized in the present study. Items in the final instrument
are presented in the same order these appear in the MID. To ensure consistency with the
DES and MID, the opening sentence of the MID-60 was revised to refer only to
“experiences” rather than “dissociative experiences”. The final instrument and
accompanying scoring guidance is presented at the end of this paper. Guidance on
interpreting the mean MID-60 score was adapted from Dell et al. (2017) in light of the
present study’s findings.
Conclusion
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Preliminary findings suggest the MID-60 is a valid and reliable instrument for
measuring dissociative symptoms in a non-clinical population. However, further work
to validate the instrument would be valuable. The MID-60 was developed for its
potential application in research settings, but may prove useful in clinical settings where
clients and therapists may find it convenient and expedient to complete a short version.
If the mean MID-60 and subscale scores indicate a DD is likely, the respondent could
go on to complete the remaining questions in the full MID or be administered the SCID-
D or DDIS to provide diagnostic clarity.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders DSM-V Fifth Edition. Washington DC: American Psychiatric Publishing, Inc.
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.
Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., &
Middleton, W. (2016). Separating Fact from Fiction: An Empirical Examination of Six
Myths About Dissociative Identity Disorder. Harvard Review of Psychiatry, 24(4), 257-
270. doi:10.1097/hrp.0000000000000100
Carlson, E. B., Putnam, F. W., Ross, C. A., Torem, M., Coons, P. M., Bowman, E. S., . . . Braun, B.
G. (1993). Predictive validity of the Dissociative Experiences Scale. American Journal of
Psychiatry, 150, 1030-1036.
Coons, P. M., & Millstein, V. (1992). Psychogenic amnesia: A clinical investigation of 25 cases.
Dissociation, 5(2), 73-79.
Cortina, J. M. (1993). What is coefficient alpha? An examination of theory and applications.
Journal of Applied Psychology, 78(1), 98-104. doi:10.1037/0021-9010.78.1.98
Dell, P. F. (2004). Multidimensional Inventory of Dissociation (MID) analysis V3.8.
Dell, P. F. (2006). The multidimensional inventory of dissociation (MID): A comprehensive
measure of pathological dissociation. J Trauma Dissociation, 7(2), 77-106.
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-
V and beyond (pp. 403-428). Hoboken: Taylor & Francis.
Dell, P. F., Coy, D. M., & Madere, J. (2017). An Interpretive Manual for the Multidimensional
Inventory of Dissociation (MID). In (2nd ed.). http://www.mid-assessment.com/wp-
content/uploads/2017/08/Interpretive-Manual-for-the-MID-2nd-Edition.pdf.
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-V and beyond (pp. 667-692). Hoboken: Taylor & Francis.
Kate, M.-A. (2018). The prevalence of dissociation and Dissociative Disorders, and trauma and
parent-child dynamics as etiological factors: implications for the validity of the Trauma
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Model and Fantasy Model of dissociation (Unpublished doctoral dissertation),
University of New England, Armidale, NSW, Australia.
Kate, M.-A., Hopwood, T., & Jamieson, G. (2020). The prevalence of Dissociative Disorders and
dissociative experiences in college populations: a meta-analysis of 98 studies. Journal
of Trauma & Dissociation, 21(1), 16-61. doi:10.1080/15299732.2019.1647915
Krause-Utz, A., Frost, R., Winter, D., & Elzinga, B. M. (2017). Dissociation and Alterations in
Brain Function and Structure: Implications for Borderline Personality Disorder. Curr
Psychiatry Rep, 19(1), 6. doi:10.1007/s11920-017-0757-y
Lilienfeld, S. O., Lynn, S. J., MNamy, L. L., Jamieson, G., Marks, A., & Slaughter, V. (2014).
Psychology: From Inquiry to Understanding (S. O. Lilienfeld Ed. 3 ed.). Melbourne, VIC:
Pearson.
Mueller-Pfeiffer, C., Rufibach, K., Perron, N., Wyss, D., Kuenzler, C., Prezewowsky, C., . . . Rufer,
M. (2012). Global functioning and disability in dissociative disorders. Psychiatry Res,
200(2-3), 475-481. doi:10.1016/j.psychres.2012.04.028
Nilsen, W. J. (2000). The relationship between trauma and dissociation: Is the development of
dissociative symptoms mediated by family functioning? (PhD), Purdue University,
Ross, C. A., Heber, S., Norton, G. R., Anderson, D., Anderson, G., & Barchet, P. (1989). The
Dissociative Disorders Interview Schedule: A structured interview. Dissociation, 2(3),
169-189.
Ryan, L. G. (1988). Prevalence of dissociative disorders and symptoms in a university
population. (PhD), California Institute of Integral Studies, San Francisco, CA.
Siegel, D. J. (2013). Brainstorm: The power and purpose of the teenage brain. New York, NY:
Jeremy P. Tarcher/Penguin.
Simeon, D. (2009). Depersonalization Disorder. In P. F. Dell & J. A. O'Neil (Eds.), Dissociation
and the dissociative disorders: DSM-V and beyond (pp. 435-444). Hoboken: Taylor &
Francis.
Steinberg, M. (1994). Interviewer's Guide to the Structured Clinical Interview for DSM-IV®
Dissociative Disorders (SCID-D). Arlington, VA: American Psychiatric Association.
Steinberg, M., Rounsaville, B., & Cicchetti, D. V. (1990). The Structured Clinical Interview for
DSM-III-R Dissociative Disorders: preliminary report on a new diagnostic instrument.
Am J Psychiatry, 147(1), 76-82.
van Ijzendoorn, M. H., & Schuengel, C. (1996). The measurement of dissociation in normal and
clinical populations: Meta-analytic validation of the Dissociative Experiences Scale
(DES). Clinical Psychology Review, 16(5), 365-382. doi:http://dx.doi.org/10.1016/0272-
7358(96)00006-2
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Table 1.
Comparison of MID and DES scores in non-clinical and clinical populations
MID
DES
Studies
N
M
SD
Studies
N
M
SD
Normal
1 a
510
8.0
10.9
11 c
1578
11.05
10.63
College
2 b
142
6.9
8.0
81 d
26,821
16.62
11.0
OSDD-1
1 a
40
39.0
19.4
6 c
121
35.29
15.83
DID
1 a
79
51.3
18.7
18 c
472
45.63
20.26
Notes: a = Dell et al., 2017, b = Lauterbach et al., 2008, c = Van Ijzendoorn & Schuengel,
1996, d = Kate et al., 2020
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Table 2
University sample grouped by MID-60 score: percentage with clinically significant symptom clusters
MID-60 scoring range
0-14
15-20
21-30
31-40
41+
all
Equivalent MID mean score classification
Non-
dissociative
Mild
symptoms
PTSD or
DD
DD and PTSD
(OSDD-1)
DD and PTSD
(DID)
N
214
42
31
12
14
313
DID
Amnesia
0.94
16.67
29.03
50.00
64.29
10.58
DID / OSDD-1
- Subjective awareness of alter
personalities and self-states
0.47
2.38
19.35
33.33
71.43
7.03
- Angry intrusions
11.68
45.24
70.97
91.67
100
29.07
- Persecutory intrusions
4.21
30.95
51.61
66.67
92.86
18.85
- All three of the above
0
0
12.90
33.33
71.43
5.75
- All of the above plus Amnesia
0
0
6.25
8.33
57.14
3.53
Depersonalization / Derealization Disorder
- Derealization/Depersonalization
2.34
14.29
45.16
100
100
16.29
Dissociative Amnesia
- Distress about severe memory problems
2.34
45.24
61.29
100
100
22.04
- Loss of autobiographical memory
11.68
35.71
54.84
83.33
85.71
25.24
- Both of the above
0
16.67
29.03
83.33
85.71
12.14
PTSD
- Flashbacks
15.42
50.00
77.42
75.00
100
32.27
Conversion Disorder
- Body symptoms
10.75
12.20
35.48
41.67
71.43
17.31
- PNES (Pseudoseizures)
2.80
4.76
3.23
33.33
42.86
6.07
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Table 3
MID-60 and MID comparison of percentage of time the symptoms clusters described in subscales are being experienced
Cut
off
MID-60
MID
0-14
15-20
21-30
31-40
41+
Non-
clinical
PTSD
OSDD-1
DID
N
214
42
31
12
14
1359
M
SD
M
SD
M
SD
M
SD
M
SD
M
M
M
M
Loss of autobiographical
memory
34
11.32
17.32
28.14
25.44
42.71
28.46
52.67
24.38
65.29
29.14
18.91
30.36
51.42
66.41
Self-confusion
33.3
17.86
15.82
44.72
13.88
59.35
16.86
75.00
11.91
83.57
14.93
12.79
19.83
40.76
63.43
Distress about severe
memory problems
30
8.69
8.65
30.87
15.82
37.42
17.51
50.28
15.81
77.02
13.68
12.32
19.39
25.68
57.06
Angry intrusions
18
7.18
10.16
19.76
14.59
29.23
18.03
45.17
22.95
58.29
19.86
5.88
6.03
23.48
55.21
Flashbacks
16
6.84
10.44
21.14
20.37
30.58
23.11
38.67
31.19
60.86
26.56
8.50
23.04
32.99
54.17
Subjective awareness of alter
personalities & self-states
20
1.19
3.57
3.71
5.84
9.03
13.16
17.17
21.48
51.57
33.79
4.53
5.36
33.22
59.88
Persecutory intrusions
18
2.79
6.15
14.05
13.47
19.23
17.30
31.33
22.78
66.59
30.43
4.49
5.32
37.54
57.64
Derealization &
Depersonalization
20
4.03
5.01
14.05
8.42
22.46
15.24
37.81
10.47
70.00
18.72
4.30
4.91
24.72
44.75
Trance subscale
11.7
0.90
2.57
6.27
6.17
11.88
12.71
10.42
7.82
38.45
25.42
4.05
11.73
20.63
42.01
Amnesia
10
0.59
2.09
3.27
6.16
6.45
8.08
11.67
11.55
33.93
29.80
2.79
3.57
5.70
40.51
Body symptoms
10
2.59
5.12
3.29
4.86
9.68
11.76
7.92
8.78
38.04
28.07
1.99
3.06
8.73
22.72
Note: SD and group N not reported for MID subscales
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You will be asked 60 questions about experiences you may have had in the past or are continuing to have in
your life.
How often do you have the following experiences when you are not under the influence of alcohol or
drugs?
Please circle zero if the experience never happens to you. If it happens sometimes but not all the
time, circle a number between 1 and 9 that best describes how often it happens to you. Circle 10 if
the experience is always happening to you.
1
Forgetting what you did earlier in the day
0 1 2 3 4 5 6 7 8 9 10
2
Having an emotion (e.g., fear, sadness, anger, happiness)
that doesn't feel like it is "yours."
0 1 2 3 4 5 6 7 8 9 10
3
Hearing the voice of a child in your head
0 1 2 3 4 5 6 7 8 9 10
4
Reliving a traumatic event so vividly that you totally lose
contact with where you actually are (that is, you think
that you are "back there and then")
0 1 2 3 4 5 6 7 8 9 10
5
Having difficulty swallowing (for no known medical
reason)
0 1 2 3 4 5 6 7 8 9 10
6
Having trance-like episodes where you stare off into
space and lose awareness of what is going on around you
0 1 2 3 4 5 6 7 8 9 10
7
Being told of things that you had recently done, but with
absolutely no memory of having done those things
0 1 2 3 4 5 6 7 8 9 10
8
Not remembering what you ate at your last meal-or even
whether you ate
0 1 2 3 4 5 6 7 8 9 10
9
Things around you feeling unreal
0 1 2 3 4 5 6 7 8 9 10
10
Not being able to see for a while (as if you are blind) for
no known medical reason
0 1 2 3 4 5 6 7 8 9 10
11
Feeling very detached from your behavior as you "go
through the motions" of daily life
0 1 2 3 4 5 6 7 8 9 10
12
Feeling uncertain about who you really are
0 1 2 3 4 5 6 7 8 9 10
13
Feeling that other people, objects, or the world around
you are not real
0 1 2 3 4 5 6 7 8 9 10
14
Being paralyzed or unable to move (for no known
medical reason)
0 1 2 3 4 5 6 7 8 9 10
15
Being so bothered by flashbacks that it was hard to get
out of bed and face the day
0 1 2 3 4 5 6 7 8 9 10
16
Not remembering large parts of your childhood after age
5
0 1 2 3 4 5 6 7 8 9 10
17
Feeling disconnected from everything around you
0 1 2 3 4 5 6 7 8 9 10
18
Not being able to hear for a while (as if you are deaf) (for
no known medical reason)
0 1 2 3 4 5 6 7 8 9 10
19
Feeling that pieces of your past are missing
0 1 2 3 4 5 6 7 8 9 10
20
Immediately forgetting what other people tell you
0 1 2 3 4 5 6 7 8 9 10
21
Having difficulty walking (for no known medical reason)
0 1 2 3 4 5 6 7 8 9 10
22
Hearing a voice in your head that wants you to hurt
yourself
0 1 2 3 4 5 6 7 8 9 10
23
Feeling very confused about who you really are
0 1 2 3 4 5 6 7 8 9 10
24
Feeling that important things happened to you earlier in
your life, but you cannot remember them
0 1 2 3 4 5 6 7 8 9 10
25
Feeling as if you were looking at the world through a fog
so that people and objects felt far away or unclear
0 1 2 3 4 5 6 7 8 9 10
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Having seizures for which your doctor can find no reason
0 1 2 3 4 5 6 7 8 9 10
27
Going into trance so much (or for so long) that it
interferes with your daily activities and responsibilities
0 1 2 3 4 5 6 7 8 9 10
28
Words just flowing from your mouth as if they were not
in your control
0 1 2 3 4 5 6 7 8 9 10
29
Feeling that there are large gaps in your memory
0 1 2 3 4 5 6 7 8 9 10
30
Going into trance for hours
0 1 2 3 4 5 6 7 8 9 10
31
Bad memories coming into your mind and you can't get
rid of them
0 1 2 3 4 5 6 7 8 9 10
32
Drifting into trance without even realizing that it is
happening
0 1 2 3 4 5 6 7 8 9 10
33
Words come out of your mouth, but you didn't say them;
you don't know where those words came from
0 1 2 3 4 5 6 7 8 9 10
34
Being able to remember very little of your past
0 1 2 3 4 5 6 7 8 9 10
35
When you are angry, doing or saying things that you
don't remember (after you calm down)
0 1 2 3 4 5 6 7 8 9 10
36
Feeling that you have multiple personalities
0 1 2 3 4 5 6 7 8 9 10
37
Hearing a voice in your head that calls you names (e.g.,
wimp, stupid, whore, slut, bitch, etc.)
0 1 2 3 4 5 6 7 8 9 10
38
Poor memory causing serious difficulty for you
0 1 2 3 4 5 6 7 8 9 10
39
Having other people (or parts) inside you who have their
own names
0 1 2 3 4 5 6 7 8 9 10
40
Reliving a past trauma so vividly that you see it, hear it,
smell it, etc
0 1 2 3 4 5 6 7 8 9 10
41
Going into trance several days in a row
0 1 2 3 4 5 6 7 8 9 10
42
Discovering that you have changed your appearance
(e.g., cut your hair, or changed your hairstyle, or changed
what you are wearing, or put on cosmetics, etc.) with no
memory of having done so
0 1 2 3 4 5 6 7 8 9 10
43
Being bothered or upset by how much you forget
0 1 2 3 4 5 6 7 8 9 10
44
Hearing a voice in your head that wants you to die
0 1 2 3 4 5 6 7 8 9 10
45
Suddenly finding yourself somewhere odd at home (e.g.,
inside the closet, under a bed, curled up on the floor,
etc.) with no knowledge of how you got there
0 1 2 3 4 5 6 7 8 9 10
46
Feeling as if there is something inside you that takes
control of your behavior and speech
0 1 2 3 4 5 6 7 8 9 10
47
Totally forgetting how to do something that you know
very well how to do (e.g., how to drive, how to read, how
to use the computer, how to play the piano, etc.)
0 1 2 3 4 5 6 7 8 9 10
48
Suddenly finding yourself somewhere (e.g., at the beach,
at work, in a nightclub, in your car, etc.) with no memory
of how you got there
0 1 2 3 4 5 6 7 8 9 10
49
Feeling that there is another person inside who can come
out and speak if it wants
0 1 2 3 4 5 6 7 8 9 10
50
"Coming to" and finding that you have done something
you don't remember doing (e.g., smashed something, cut
yourself, cleaned the whole house, etc.)
0 1 2 3 4 5 6 7 8 9 10
51
Having difficulty staying out of trance
0 1 2 3 4 5 6 7 8 9 10
52
Suddenly not knowing how to do your job
0 1 2 3 4 5 6 7 8 9 10
53
Your body suddenly feeling as if it isn't really yours
0 1 2 3 4 5 6 7 8 9 10
54
Being bothered by flashbacks for several days in a row
0 1 2 3 4 5 6 7 8 9 10
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55
Being confused or puzzled by your emotions
0 1 2 3 4 5 6 7 8 9 10
56
Hearing a voice in your head that tells you to "shut up"
0 1 2 3 4 5 6 7 8 9 10
57
Having another part inside that has different memories,
behaviors, and feelings than you do
0 1 2 3 4 5 6 7 8 9 10
58
There were times when you "woke up" and found pills or
a razor blade (or something else to hurt yourself with) in
your hand
0 1 2 3 4 5 6 7 8 9 10
Hearing a voice in your head that calls you no good,
worthless, or a failure
0 1 2 3 4 5 6 7 8 9 10
60
Having a very angry part that "comes out" and says and
does things that you would never do or say
0 1 2 3 4 5 6 7 8 9 10
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For Peer Review Only
CALCULATING AND INTEPRETING THE MID-60: ADVICE FOR CLINICIANS AND RESEARCHERS
The mean MID-60 score is calculated by adding all items and dividing by 6. It represents the percentage of
time the person reports having dissociative experiences, and can be interpreted as follows:
0 – 7
Does not have dissociative experiences
7 – 14
Has few diagnostically significant dissociative experiences
15 – 20
Mild dissociative symptoms and experiences. PTSD or a mild dissociative disorder (such as
dissociative amnesia, depersonalization / derealization disorder) are possible
21 – 30
May have dissociative disorder and/or PTSD
31 – 40
May have a dissociative disorder (such as OSDD-1 or DID) and PTSD
41 – 64
Probably has DID or a severe dissociative disorder and PTSD
64 +
Severe dissociative and posttraumatic symptoms. High scores may also reflect neuroticism,
attention-seeking behavior, exaggeration or malingering of symptoms, or psychosis
To assist in your assessment, the scores for relevant MID- subscales can be calculated to determine whether
these are clinically significant.
Clinical
cut-off
DID
Amnesia
Add items 42, 45, 48, and 58 then divide by .4
10
DID / OSDD-1
Subjective awareness of alter
personalities and self-states
Add items 3, 36, 39, 49 and 57 then divide by .5
20
Angry intrusions
Add items 28, 33, 35, 46 and 60 then divide by .5
18
Persecutory intrusions
Add items 22, 37, 44, 56 and 59, then divide by .5
18
Depersonalization / Derealization
Disorder
Derealization/Depersonalization
Add items 2, 7, 9, 13, 25, 47, 50 and 53 then divide by .8
20
Dissociative Amnesia
Distress about severe memory
problems
Add items 1, 8, 20, 38, 43 and 52 then divide by .6
30
Loss of autobiographical memory
Add items 16, 19, 24, 29 and 34 then divide by .5
34
PTSD
Flashbacks
Add items 4, 15, 31, 40 and 54 then divide by .5
16
Conversion Disorder
Body symptoms
Add items 5, 10, 14 and 18 then divide by .4
10
Psychogenic nonepileptic seizures
Multiply item 26 by 10
10
General subscales
Trance
Add items 21, 27, 30, 32, 41 and 51 then divide by .6
11.7
Self-confusion
Add items 6, 11, 12, 17, 23 and 55 then divide by .6
33.3
CAUTION: The MID-60 is for screening purposes only. It is not a diagnostic tool. If the mean scores for the
MID-60 and relevant subscales indicate a dissociative disorder is likely, you may wish administer the
Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D) or Dissociative Disorders Interview
Schedule (DDIS), or ask the respondent to complete the full MID, to provide diagnostic clarity.
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An electronic copy of the MID-60 questionnaire, and a scoring template that automatically calculates the
score the MID-60 and its subscales and compares these to the clinical cut-offs, are available online at:
https://www.researchgate.net/profile/Mary_Anne_Kate/research
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