Download I. The MID Dissociation Scales Graph

An Interpretive
Mini-Manual for the
Multidimensional Inventory
of Dissociation (MID)
Paul F. Dell, Ph.D.
Psychotherapy Resources of Norfolk
1709 Colley Avenue
Suite 312
Norfolk, VA 23517
Phone: 757-640-0400
e-mail: [email protected]
Revised: 10-17-2012
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Quick Guide to Understanding Your MID Analysis Data
1. Click on MID Report and read the commentaries in the lower right hand corner.
2. Click on Line Charts and scroll down to the MID Diagnostic Graph. All scores of 100 or
higher are clinically significant; scores of 100 or higher indicate that the person
definitely has that symptom. Do you want to know which items led to those significant
scores? Of course you do.
3. Click on MID Report again and scroll further down to The Extended MID Report. What
you are about to examine will give you an excellent clinical ‘feel’ for the person who
took the test. As you scroll down, you will find a list of the items for each scale on the
MID. Now you can learn exactly what your patient reported; you can see exactly how he
or she obtained a clinically significant score on this scale or that scale. If you PRINT The
MID Report, you can circle the items that interest you—the items that you want to ask
the patient about in the next session.
4. Always do a detailed follow-up inquiry about any items of interest that the patient has
endorsed, especially amnesia items. That inquiry will usually resolve your questions
about the nature, quality, or reality of the person’s reported dissociative experiences.
5. Click on Line Charts again and look at the MID Diagnostic Graph again. On the left side of
the graph are the MID’s validity scales. Any scales with a score of 100 or higher are
clinically significant. Over 95% of the time, elevated validity scales simply point to
personality traits that affect how the person approached the MID. It is rare that
elevated validity scales mean that the person has produced an invalid MID protocol.
Further information on the validity scales can be found on page 6 of the Mini-Manual for
the MID.
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Multidimensional Inventory of Dissociation (MID)
The following pages provide a detailed description of the MID, its different scales, and the
meaning of a client’s scores. MID scores are depicted in three major graphs:
I.
The MID Dissociation Scales Graph:
The MID Scales Graph provides a profile of the person’s scores on the 23 MID dissociation
scales.
II.
The MID Diagnostic Graph:
The MID Diagnostic Graph has 6 validity scales and 23 dissociation scales. Each scale
indicates whether the client has a clinically significant level of that particular dissociative
symptom.
III. The MID Clinical Summary Graph:
The Clinical Summary Graph has five clusters of scales: (1) dissociation scales, (2) parts
and alters scales, (3) validity scales, (4) characterological scales, and (5)
functionality/impairment scales. These five clusters of scales help to explain the client’s
MID responses.
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I. The MID Dissociation Scales Graph
The MID’s fundamental assumption is that dissociation affects the entirety of human experience.
And, because DID is the prototypical dissociative disorder, the domain of symptoms of DID is
identical to the domain of pathological dissociation. The MID operationalizes the domain of
pathological dissociation (and the domain of symptoms of DID) via 23 dissociative symptoms
that are organized into three clusters of symptoms.
General Dissociative Symptoms:
General dissociative symptoms not only occur in persons with a dissociative disorder; they also
occur in certain nondissociative disorders: PTSD, somatization disorder, conversion disorder,
panic disorder, major depression, schizotypal personality disorder, and borderline personality
disorder.
1.
Memory Problems. Memory Problems include lack of memory for significant life
events, inability to recall substantial portions of childhood, and chronic day-to-day
forgetfulness. Research has shown that the Memory Problems Scale taps two separate
aspects of dissociative amnesia: amnesia for remote memory (e.g., childhood) and
amnesia for recent memory. About 95% of DID patients obtain a clinically significant
score on this MID scale.
2.
Depersonalization. Depersonalization involves odd changes of one’s experience of
self, mind, or body. Depersonalization experiences include feeling unreal, being a
detached observer of oneself, and feeling distant, changed, estranged, or disconnected
from one’s self, one’s mind, or one’s body. About 95% of DID patients obtain a
clinically significant score on this MID scale.
3.
Derealization. In derealization, the world feels unreal, strange, unfamiliar, distant, or
changed. About 92% of DID patients obtain a clinically significant score on this MID
scale.
4.
Flashbacks. Flashbacks typically manifest as sudden, intrusive memories, pictures,
internal ‘videotapes,’ nightmares, or body sensations of previous traumatic experiences.
During strongly dissociated flashbacks, a person may lose contact with here and now.
When this happens, the person is back ‘there and then,’ rather than here and now.
About 92% of DID patients obtain a clinically significant score on this MID scale.
5.
Somatic Symptoms. Somatic symptoms have been referred to as somatoform
dissociation by Nijenhuis. Specifically, these are bodily experiences and symptoms that
have no medical basis. Such somatic symptoms may affect vision, hearing, sight,
smell, taste, body sensation, body functions, or physical abilities. They are often a
partial re-experiencing of a past traumatic event. About 79% of DID patients obtain a
clinically significant score on this MID scale.
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6.
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Trance. Trance refers to episodes of staring off into space, thinking about nothing, and
being unaware of what is going on around oneself. During a trance, the person is so
‘out of touch’ with what is going on around him or her that it may be difficult to get
his/her attention. About 88% of DID patients obtain a clinically significant score on this
MID scale.
Consciously-Experienced INTRUSIONS FROM A DISSOCIATED SELF-STATE (i.e., the
domain of first-rank symptoms):
7.
Child Voices. The voice of a child is heard inside the head. The voice may speak or cry.
Research has shown that DID patients more often hear child voices than do
schizophrenia patients. About 93% of DID patients obtain a clinically significant score
on this MID scale.
8.
Voices/Internal Struggle. Dissociated parts may argue, or struggle with one another or
with host person. The internal struggle may manifest itself as voices that argue or as
non-auditory internal forces that struggle with one another (or with the person). This is
one of the two most frequently elevated scales in patients with a complex dissociative
disorder (i.e., DID and DDNOS-1) [the other most frequently elevated scale is SelfPuzzlement]. About 97% of DID patients obtain a clinically significant score on the
Voices/Internal Struggle Scale.
9.
Persecutory Voices. Persecutory voices call the person names, are harshly disparaging,
and command the person to commit acts of self-injury or suicide. About 87% of DID
patients obtain a clinically significant score on this MID scale.
10.
Speech Insertion. In speech insertion, a dissociated part intrudes into the executive
functioning of the host by seizing control of what is being said. The person typically
feels that the words coming out of his/her mouth are being controlled by someone or
something else. About 84% of DID patients obtain a clinically significant score on this
MID scale.
11.
Thought Insertion. In thought insertion, the ideas of a dissociated part suddenly
intrude into the person’s consciousness. Intruding thoughts feel like they have “come
from out of nowhere” and may feel like they do not really “belong” to the person.
About 93% of DID patients obtain a clinically significant score on this MID scale.
12.
‘Made’/Intrusive Feelings. Intrusive feelings are experienced as “coming from out of
nowhere,” often with no apparent reason. The person often experiences intrusive
emotions as not really “mine.” About 93% of DID patients obtain a clinically
significant score on this MID scale.
13.
‘Made’/Intrusive Impulses. Intrusive impulses are often strong, apparently
inexplicable, and may be experienced as not really “mine.” About 87% of DID patients
obtain a clinically significant score on this MID scale.
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14.
‘Made’/Intrusive Actions. Intrusive actions tend to feel as if they were done by
someone or something else inside the person. This is a particularly common, ego-alien
experience in patients with a complex dissociative disorder. About 96% of DID
patients obtain a clinically significant score on this MID scale.
15.
Temporary Loss of Well-Rehearsed Skills and Knowledge. Temporary loss of
knowledge or skill is a very puzzling phenomenon to the person. Suddenly and
inexplicably, he or she forgets things that one simply does not forget: how to do one’s
job, how to drive a car, one’s own name, etc. Unlike the other 10 consciouslyexperienced intrusions (which are positive symptoms), temporary loss of skills or
knowledge is a negative symptom. That is, what should be there (e.g., skill, knowledge
of one’s own name) is suddenly absent. Research has shown this to be a distinct
dimension of dissociative amnesia (distinguishable from amnesia for remote memory
and discovering the actions of a fully-dissociated self-state; see below). About 86% of
DID patients obtain a clinically significant score on this MID scale.
16.
Disconcerting Experiences of Self-Alteration. Sudden experiences of self-alteration
are, indeed, disconcerting. They involve very odd changes in one’s sense of self:
feeling like a different person, switching back and forth between feeling like a child and
an adult, switching back and forth between feeling like a man and a woman, seeing
someone else in the mirror, etc. About 96% of DID patients obtain a clinically
significant score on this MID scale.
17.
Self-Puzzlement. Unlike the other 10 consciously-experienced INTRUSIONS (i.e., 716), Self-puzzlement is not a dissociative symptom. It is the result of dissociative
experiences. The more dissociative experiences, the more self-puzzlement.
Dissociative individuals are recurrently puzzled by their inexplicable feelings,
reactions, behaviors, and so on. Self-Puzzlement is one of the two most frequently
elevated scales in patients with a complex dissociative disorder (i.e., DID and DDNOS1). The other most frequently elevated scale is Voices/Internal Struggle. Puzzlement
and confusion about him- or herself is significantly stronger in DID than in
schizophrenia or borderline personality disorder. About 97% of DID patients obtain a
clinically significant score on this MID scale.
DISCOVERING the Fully-Dissociated Activities of Another Self-State: Amnesia
18.
Time Loss. Time loss involves incidents of ‘losing time. The person DISCOVERS that
he or she cannot account for several hours, a day, or even longer. He or she has a total
blank for what happened during that period of time. About 86% of DID patients obtain
a clinically significant score on this MID scale.
19.
“Coming to”. The person suddenly “comes to” and (1) DISCOVERS that he or she
has done something, but has no memory of having done it, or (2) discovers that he or
she is in the middle of doing something that he/she has no memory of having started to
do in the first place. About 82% of DID patients obtain a clinically significant score on
this MID scale.
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20.
Fugues. Fugues are incidents where a person suddenly DISCOVERS that he/she is
somewhere, but has no memory whatsoever of going to that place. About 83% of DID
patients obtain a clinically significant score on this MID scale.
21.
Being Told of One’s Recent Actions. Persons with a major dissociative disorder may
be told about their recent actions, but have absolutely no memory of having done those
things. Thus, he or she DISCOVERS what he/she has done. About 87% of DID patients
obtain a clinically significant score on this MID scale.
22.
Finding Objects Among One’s Possessions. Persons with a major dissociative
disorder may DISCOVER objects, writings, or drawings among their possessions, but
have no idea where those objects came from. About 68% of DID patients obtain a
clinically significant score on this MID scale.
23.
Finding Evidence of Your Recent Behavior. Persons with a major dissociative
disorder may DISCOVER evidence of their recent actions, but you have no memory of
having done those things: e.g., things at home are moved around or changed; tasks have
been completed that only he or she could have done; previously unnoticed injuries are
discovered, even a fully-dissociated suicide attempt. About 78% of DID patients obtain
a clinically significant score on this MID scale.
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II. The MID Diagnostic Graph
Interpreting the MID Diagnostic Graph
The MID Diagnostic Graph is the core of the MID Report. It shows (1) whether each of the 23
dissociative symptoms is present or absent, and (2) whether the person shows a significant level
of response bias (as assessed by the six validity indicators).
The graph also shows the severity of each symptom. A score of 100 on the graph indicates that
the person definitely has that symptom; that is, the person ‘passed’ enough items on that scale to
show that he or she is definitely experiencing that symptom. A score of 200 means that the
person ‘passed’ twice as many items on that scale as are necessary to show that he or she has that
symptom. Thus, a score of 200 means that the person has a very high level of that symptom.
Conversely, a score of 50 means that the person ‘passed’ only half as many items on that scale as
are necessary for the MID to consider that symptom to be present. A score of less than 100
suggests that the person does not have that symptom.
Analysis of a client’s pattern of scores on the MID Diagnostic Graph allows the clinician to
diagnose PTSD, depersonalization disorder, dissociative identity disorder (DID), dissociative
disorder not otherwise specified Type 1b (DDNOS-1b; i.e., a DID-like dissociative disorder, but
without amnesia), and other types of DDNOS.
Validity Scales
The MID is designed to accurately diagnose patients who present with an admixture of
dissociative, posttraumatic, and borderline symptoms. The MID’s validity scales (and
characterological scales) assess the most common response biases that are exhibited by
dissociative, posttraumatic, and borderline patients: (1) defensiveness, denial, or minimization of
symptoms; (2) negative emotional reactivity; (3) attention-seeking disclosure or overemphasis of
symptoms; (4) indiscriminate endorsement of bizarre and unlikely symptoms; and (5)
exaggeration or frank malingering of symptoms, trauma, and abuse. The sixth validity scale, The
Borderline Personality Disorder Index (BPD Index), is a new, empirically-derived scale that
distinguish a subset of BPD patients who exaggerate and falsify their symptoms and history of
abuse (see below).
MID Analysis presents the Validity Scales on four different metrics:
(1) Number of items passed (See page 1 of The MID Report);
(2) Mean scale scores (0-100; see page 1 of The MID Report);
(3) Clinical Significance Score (see page 1 and the MID Diagnostic Graph);
(4) percent of items ‘passed’ on the validity scale (see MID Clinical Summary Graph).
Forensic evaluators prefer validity scales to be detectors of falsified responding. In contrast,
nonforensic, clinical evaluators prefer validity scales to assess response bias (rather than to
indicate when a test protocol should be rejected as invalid). Said differently, clinical evaluators
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want validity scales to tell them if a patient’s test responses have been skewed by a response bias
– usually a strong personality trait. Except in rare instance, the MID’s validity scales assess
response bias -- not invalid responding. Thus, they assess certain personality traits (e.g.,
repressive personality style, neuroticism, attention-seeking) and aspects of clinical severity (e.g.,
psychotic experiences) that can skew a person’s responses to MID items.
In the vast majority of instances, elevated MID validity scales should be interpreted from a
clinical point of view (see below) rather than a forensic one. Even the MID’s Factitious
Behavior Scale is more indicative of personality pathology than it is of invalid responding.
As will be discussed below, elevated validity scores primarily reflect clinically-important
personality traits (rather than an effort to defeat or falsify the test).
Extreme elevation of the Rare Symptoms Scale is probably the MID’s best indicator of truly
invalid responding (e.g., deliberate false endorsement of items; active psychosis). Nevertheless,
severe elevations of the Rare Symptoms Scale can also be caused by other factors (see below).
In short, an elevation of one or more validity scales on the MID indicates that the test-taker’s
dissociation scores cannot be blithely accepted by the clinician. Elevated validity scales reveal
that the test-taker’s responses to MID items are being significantly skewed by a response set. As
in any clinical situation, the clinician should explore what the person had in mind when he or she
endorsed those particular validity items. Only such follow-up will allow the clinician to
accurately understand the meaning of the test-taker’s answers to the MID.
Defensiveness Scale
The Defensiveness Scale assesses the person’s willingness to endorse normal cognitive
lapses, such as “Forgetting where you put something;” “Having to go back and correct
mistakes that you made;” and “Making decisions too quickly.” Each of us, to some degree,
must say “yes” to these items. Because these are universal shortcomings, a person shows
defensiveness whenever he or she gives a rating of “0” to such items. Consistently low
ratings of Defensiveness items (e.g., “0,” “1,” or “2”) indicate that the person is claiming a
remarkably low incidence of normal shortcomings.
Defensiveness Scale Mean Scores. Nondissociative individuals have a mean raw score of 3.6
on the 12 Defensiveness items; outpatients with DID have a mean raw score of 6.5. When
these scores are converted to a 0-100 metric (and inverted so that higher scores indicate
higher defensiveness), nondissociative individuals have a Defensiveness Scale mean score of
63.7; patients with DID have a Defensiveness Scale mean score of 35.5.
Defensiveness Scale Cut-off Score for Clinical Significance. On the MID Diagnostic
Graph, a Defensiveness Scale score of 70.00 receives a score of 100 (i.e., the cut-off score
for clinical significance). A Defensiveness Scale score of 70.00 falls at the 73rd percentile
of nondissociative individuals and the 97th percentile of outpatients with DID. Thus,
three percent of patients with DID manifest a clinically significant level of defensiveness on
the MID. Because nonclinical persons should report fewer cognitive shortcomings than do
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highly symptomatic dissociative patients, the cut-off score for a clinically significant level of
defensiveness should be set higher for them. A score of 83.00 or higher is a more appropriate
Defensiveness Scale cut-off score for the nonclinical population. A Defensiveness Scale
score of 83.00 falls at the 90th percentile of the nonclinical population. High
Defensiveness scores in this population usually indicate a character style that is largely
incompatible with dissociation. Persons who have a high Defensiveness score on the MID
tend to have high scores on measures of repressive personality style.
Emotional Suffering Scale
Emotional suffering is closely related to the personality trait of neuroticism or negative
affectivity. The MID Emotional Suffering Scale correlates .65 with the Neuroticism Scale of
the Eysenck Personality Questionnaire-Revised. Individuals with high emotional suffering
are quite reactive to the impingements and misfortunes of daily life. This reactivity
intensifies or amplifies their pain, suffering, and dysphoria. When these individuals encounter
major misfortune (e.g., trauma), their pain and distress is both intense and long-lasting. When
these individuals have repeatedly been hurt or traumatized, they usually develop a very
negative outlook on their daily life. Even when such emotional suffering is extreme, however,
it does not indicate deliberate exaggeration, falsification, or faking of distress. Emotional
suffering does, however, amplify and prolong pain and suffering. The distress of individuals
with high emotional suffering is quite genuine and quite intense. Many of the items on the
MID’s Emotional Suffering Scale have a borderline flavor (e.g., “Feeling empty and painfully
alone;” and “Wishing that somebody would finally realize how much you hurt.”).
Emotional Suffering Scale Mean Scores. Nondissociative individuals have a mean score of
28.9 on the Emotional Suffering Scale; outpatients with DID have a mean score of 54.7.
Emotional Suffering Scale Cut-off Score for Clinical Significance. On the MID Diagnostic
Graph, an Emotional Suffering Scale score of 73.3 receives a score of 100 (i.e., the cutoff
score for clinical significance). A score of 73.3 falls at the 95th percentile of
nondissociative individuals and the 77th percentile of outpatients with DID. Thus, 23%
of patients with DID have a clinically significant level of emotional suffering.
Attention-Seeking Behavior Scale
Attention-seeking is a strategy for obtaining attention and emotional gratification from others.
The items on the Attention-Seeking Scale measure:
(1) how frequently a person tells others about his or her misfortunes (e.g., “Talking to
others about very serious traumas that you have experienced”)
(2) how gratified the person is by receiving attention (e.g., “Being pleased by the
concern and sympathy of others when they hear about the traumas that you have
suffered”)
(3) how motivated the person is to engage in attention-seeking behavior (e.g., “Being
willing to do or say almost anything to get somebody to think that you are
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special”).
Attention-Seeking Behavior Scale Mean Scores. Nondissociative individuals have a mean
score of 15.3 on the Attention-Seeking Scale; patients with DID have a mean score of 20.9.
Attention-Seeking Behavior Scale Cut-off Score for Clinical Significance. On the MID
Diagnostic Graph, an Attention-Seeking Scale score of 32.9 receives a score of 100 (i.e., the
cut-off score for clinical significance). A score of 32.9 falls at the 90th percentile of
nondissociative individuals and the 78th percentile of outpatients with DID. Thus, 22
percent of outpatients with DID manifest a clinically significant level of attention-seeking
behavior.
Rare Symptoms Scale
The items of the Rare Symptoms Scale describe phenomena that are quite uncommon,
distinctly unlikely, and, in some cases, frankly bizarre [e.g., “Having flashbacks of poor
episodes of your favorite television show;” “Feeling that the color of your body is changing;”
“Part of your body (for example, arm, leg, head, etc.) seems to disappear and doesn’t reappear for several days.”].
Rare Symptoms Scale Mean Scores. Nondissociative individuals have a mean score of just
0.6 on the Rare Symptoms Scale; even patients with DID have a mean score of only 4.50.
Rare Symptoms Scale Cut-off Score for Clinical Significance. On the MID Diagnostic
Graph, a Rare Symptoms Scale score of 15.00 receives a score of 100 (i.e., the cut-off score
for clinical significance). A score of 15.00 falls at the 92nd percentile of outpatients with
DID and the 99th percentile of nondissociative individuals. Thus, 8 percent of patients
with DID endorse a clinically significant level of rare symptoms.
Interpreting an elevated score on the Rare Symptoms Scale. Although the Rare Symptoms
Scale was designed to detect deliberate exaggeration of symptoms, follow-up interviews have
identified eight reasons for a significantly elevated Rare Symptoms score:
(1) deliberate endorsement of very many symptoms in order to simulate extreme
psychopathology (most commonly in order to attract attention)
(2) a distress-driven “plea for help,” (i.e., desperate endorsement of very many items
as a means of communicating the intensity of the person’s need and pain)
(3) serious cognitive impairment or psychosis (i.e., symptom-driven distraction and
confusion while taking the test)
(4) random endorsement of test items
(5) a “game-playing” or hostile “screw you” approach to the test
(6) intentional false endorsement of rare symptoms by a persecutor alter (who wants
to discredit and harass the host alter)
(7) a “loose” cognitive style that causes idiosyncratic (and often inaccurate)
interpretation of test items (the “dreaded 5-7%” of test-takers who wreak havoc
on psychological tests with their loose thinking and wish to say “Yes.”)
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(8) extreme dissociative hypersensitivity that genuinely has produced many peculiar
symptoms.
These eight sources of an elevated score on the Rare Symptoms Scale are not mutually
exclusive. When a person attains an elevated Rare Symptoms score, more than one of
these factors may be ‘at work.’ The Rare Symptoms Scale is more likely (than any of the
MID’s other validity scales) to indicate the occurrence of truly invalid responding (i.e.,
deliberate false endorsement of items, or florid psychosis).
Factitious Behavior Scale
The Factitious Behavior Scale assesses deliberately exaggerated or faked reports of traumatic
life events, pain, physical illness, or psychological illness.
It is important to note that the factitious behavior items on the MID are not subtle.
These items are so harsh and socially undesirable that they can easily be ‘dodged’ by a testtaker who does not wish to admit to these behaviors. When endorsed, however, these items
suggest that the person may be willing to do almost anything to get attention and sympathy
from others. Items on this scale include:
“Exaggerating something bad that once happened to you (for example, rape, military
combat, physical or emotional abuse, sexual abuse, mistreatment by your spouse,
etc.) in order to get attention or sympathy;”
“Having to ‘stretch the truth’ to get your doctor’s concern or attention;”
“Pretending that something upsetting happened to you so that others would care about
you (for example, being raped, being adopted or orphaned, military combat, physical
or emotional abuse, sexual abuse, etc.).”
There is a subset of severe borderlines who readily endorse these items without shame.
Indeed, this subset of severe borderlines seems to endorse these items with an air of
righteous justification that says, “See how miserable and rejected I am? I frequently have to
do these things to get people to pay any attention to me at all!”
Factitious Behavior Scale Mean Scores. Nondissociative individuals have a mean score of
only 4.62 on the Factitious Behavior Scale; outpatients with DID have a mean score of 15.98.
Factitious Behavior Scale Cut-off Score for Clinical Significance. On the MID Diagnostic
Graph, a Factitious Behavior Scale score of 30.00 receives a score of 100 (i.e., the cut-off
score for clinical significance). A score of 30.00 falls at the 90th percentile of outpatients
with DID and the 97th percentile of nondissociative individuals. Thus, 10 percent of
patients with DID endorse a clinically significant level of factitious behaviors.
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Interpreting an elevated score on the Factitious Behavior Scale. Interpreting an elevated
score on the Factitious Behavior Scale is not always a straightforward undertaking. Although
the Factitious Behavior Scale was constructed to detect intentional exaggeration and/or
falsification of symptoms, follow-up interviews have identified four explanations for a
significantly elevated Factitious Behavior score:
(1) a genuine history of exaggerating and/or falsifying symptoms in order to gain
attention and sympathy
(2) random endorsement of test items
(3) severely guilty host alters who wrongly accuse themselves of “making too much”
of their traumas and their pain
(4) persecutor alters who falsely ‘admit’ to lying or exaggerating—in order to harass
and discredit the host.
In regard to Explanation #4, the clinician should keep in mind that persecutor alters
commonly tell the host that her memories (e.g., of abuse by a parent) are “not true.” With
regard to Explanation #1, remember that there is a subset of individuals with severe
borderline personality who readily admit to faking. They seem to believe that admitting to
such behavior is a justifiable and valid demonstration of how mistreated and desperately
unhappy they are.
The Borderline Personality Disorder Index (BPD Index)
The BPD Index does not assess borderline personality disorder. Rather, the BPD Index
assesses aspects of borderline pathology that are particularly problematic: attentionseeking behavior, factitious behavior, and reports of bizarre and unlikely symptoms. This
scale was empirically derived by comparing the MID protocols of 51 DID patients to those of
100 well-diagnosed BPD cases. The BPD Index consists of the 17 MID items that were
significantly associated with a diagnosis of BPD (rather than with a diagnosis of DID). It is
interesting to note that none of these 17 items assess dissociation; instead, all 17 come from
the MID’s validity scales.
Like the items on the Factitious Behavior Scale, many of which are included in the BPD
Index, the BPD Index items are not subtle. Many of these items are so harsh, so socially
undesirable, and/or so peculiar that they can easily be ‘dodged’ by a test-taker who does not
wish to admit to these behaviors. When endorsed, however, these items suggest that the
person is willing to do almost anything to get attention and sympathy from others. Items on
the BPD Index include all seven Factitious Behavior items, six of the seven AttentionSeeking Behavior items, three Rare Symptoms (e.g., alien abduction), and one item from the
Emotional Suffering Scale (i.e., being rejected by others).
BPD Index Mean Scores. BPD Index scores are reported in two forms: (1) Mean BPD Index
Score (see page 1 of the MID Report), and (2) BPD Index Clinical Significance Score (see
MID Diagnostic Graph). Mean BPD Index scores for four diagnostic groups are presented
below:
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Mean BPD Index Score
Nondissociative
Simple PTSD
DDNOS-1b
DID
BPD
Mean BPD Index
Clinical Significance Score
8.97
7.52
8.58
15.98
26.61
29.90
25.06
28.90
53.17
88.73
BPD Index Cut-off Score for Clinical Significance. On the MID Diagnostic Graph, a
BPD Index Score of 30.00 receives a BPD Clinical Significance Score of 100 (i.e., the cut-off
score for clinical significance). A Mean BPD Index Score of 30.00 falls at the 91st
percentile of DID patients and the 96th percentile of nondissociative individuals. Thus, 9
percent of patients with DID obtain a clinically significant score on the MID BPD Index. On
the other hand, 39% of outpatient borderlines obtain a MID BPD Index Clinical
Significance Score of 100 or higher (see the MID Diagnostic Graph). This is a very
important point: the MID BPD Index does not measure borderlineness per se; it measures
especially severe and problematic borderline behaviors. Thus, only 39% of borderline
patients obtain a clinically significant score on this measure. An elevated BPD Index is best
understood by consulting the guides (above) to interpreting the Attention-Seeking Behavior
Scale and the Factitious Behavior Scale.
CLINICAL MEANING OF BPD INDEX SCORES
0-10
No borderline pathology
10-20 A few problematic borderline traits
20-30 Several problematic borderline traits: May have BPD
30-40 Clinical cut-off: Many problematic borderline traits: Almost certainly has BPD
40-50 Severe borderline pathology: Severe BPD and other Axis II traits
50+
Extreme borderline pathology: Extreme BPD and other Axis II traits
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III. The Clinical Summary Graph:
The MID enables clinicians to make accurate diagnostic distinctions at the ‘messy’ clinical
interface between dissociation, PTSD symptoms, and borderline pathology. The MID Clinical
Summary Graph contains 27 scales that help to accomplish that goal. The Clinical Summary
Graph has five clusters of scales:
(1) dissociation scales
(2) self-states and alters scales
(3) validity scales
(4) characterological scales
(5) cognitive and behavioral functionality scales.
The 27 Clinical Summary Scales
1. The Clinical Summary Graph: Dissociation Scales
The dissociation cluster contains six major dissociation scales: (1) Mean MID Score, (2) MiniMID Score, (3) MID Severe Dissociation Score, (4) Depersonalization, (5) Derealization, and (6)
Amnesia. These scales cover overall dissociation and the three major components of dissociation
(i.e., depersonalization, derealization, and amnesia).
1.
Mean MID Score: The Mean MID Score assesses the frequency of occurrence of
dissociative symptoms. Mean MID scores are comparable to mean scores on the
Dissociative Experiences Scale (DES). To place MID scores on the same 0-100 metric
as the DES, MID scores have been multiplied by 10. Mean MID scores correlate .90 .93 with mean DES scores. The clinical difference between mean MID scores and
mean DES scores is that the MID contains no items that measure so-called ‘normal’
dissociation such as absorption, fantasizing, hypnotizability, and so on.
Interpreting mean MID scores:
0-7
8-14
15-20
21-30
31-40
41-64
65-
2.
Does not have dissociative experiences.
Has a few diagnostically-insignificant dissociative experiences. This level of
dissociation is common in therapy patients who do not have a dissociative disorder.
May have PTSD or a mild dissociative disorder.
May have DDNOS or DID. May have PTSD.
May have PTSD and either DDNOS or DID.
Probably has both DID and PTSD.
Usually indicates an admixture of severe dissociative, posttraumatic, and Axis II
symptoms. Accurate diagnosis requires a close examination of the validity scales and
a careful follow-up interview.
Mini-MID Score: The Mini-MID consists of the 19 dissociative items that most
strongly discriminate between persons with DID and nondissociative psychotherapy
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patients (i.e., with a MID score of less than 15). The Mini-MID Score presents the
person’s mean score on those 19 items.
3.
Severe Dissociation Score: A cut-off score for clinical significance has been
established for each of the MID’s 168 dissociation items. The Severe Dissociation
Score specifies how many dissociation items were ‘passed’ (see page 1 of The MID
Report).
The Clinical Summary Graph portrays the percentage of dissociation items that the
person ‘passed.’ Thus, a Severe Dissociation score of 82 on that graph means the
person gave clinically significant ratings to 137 (82%) of the MID’s 168 dissociation
items. The Severe Dissociation Score is highly related (r = .63) to a person’s reported
history of trauma.
4.
Depersonalization Scale. On the Clinical Summary Graph, the Depersonalization
Scale portrays the percentage of depersonalization items that the person ‘passed.’
Thus, a score of 75 indicates that the person gave clinically significant ratings to 9
(75%) of the 12 items on the Depersonalization Scale .
5.
Derealization Scale. On the Clinical Summary Graph, the Derealization Scale portrays
the percentage of derealization items that the person ‘passed.’ Thus, a score of 92
indicates that the person gave clinically significant ratings to 11 (92%) of the 12 items
on the Derealization Scale.
6.
Amnesia Scale. On the Clinical Summary Graph, the Amnesia Scale portrays the
percentage of amnesia items that the person ‘passed.’ Thus, a score of 87 indicates that
the person gave clinically significant ratings to 27 (87%) of the 31 amnesia items on the
MID.
2. The Clinical Summary Graph: Self-States and Alters Scales
These seven scales measure phenomena that indicate the presence/activity of ego states, selfstates, or alter personalities:
(1) Self-Alteration
(2) “I Have DID”
(3) “I Have Parts”
(4) Child Parts
(5) Helper Parts
(6) Angry Parts
(7) Persecutor Parts.
7.
Self-Alteration Scale. The Self-Alteration Scale portrays the mean score of the 12
self-alteration items.
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8.
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“I Have DID” Scale. The “I Have DID” Scale portrays the mean score of the four “I
Have DID” items. Patients who have not previously received a diagnosis of DID are
often reluctant to endorse the “I Have DID” items, but feel more comfortable endorsing
items from the “I Have Parts” Scale.
Item 138: “Feeling that you have multiple personalities.”
Item 149: “Having other people (or parts) inside you who have their own names.”
Item 174: “Feeling that there is another person inside you who can come out and speak if
it wants.”
Item 202: “Having another part inside that has different memories, behaviors, and
feelings than you do.”
9.
“I Have Parts” Scale. The “I Have Parts” Scale portrays the mean score of the six
items. These items are qualitatively different from the items on the “I Have DID”
Scale:
Item 8: “Having another personality that sometimes ‘takes over.’”
Item 28: “Feeling divided, as if there are several independent parts or sides of you.”
Item 112: “Feeling the presence of an angry part in your head that tries to control what
you do or say.”
Item 208: “Having a very angry part inside you that ‘comes out’ and says and does things
that you would never do or say.”
Item 212: “Feeling that another part or entity inside you tries to stop you from doing or
saying something.”
Item 215: “Feeling the presence of an angry part in your head that seems to hate you.”
10.
Child Parts Scale. The Child Parts Scale portrays the mean score of the seven items
on the Child Parts Scale. These items are a sensitive predictor of the presence and
activity of a child ego state, self-state, or alter:
Item 6: “Hearing the voice of a child in your head.”
Item 18: “Seeing images of a child who seems to ‘live’ in your head.”
Item 83: “Switching back and forth between feeling like an adult and feeling like a
child.”
Item 97: “Hearing a lot of noise or yelling in your head.”
Item 118: “Hearing voices crying in your head.”
Item 188: “Suddenly feeling very small, like a young child.”
Item 218: “Noticing the presence of a child inside you.”
11.
Helper Parts Scale. The Helper Parts Scale contains only one item:
Item 216: “Hearing a voice in your head that is soothing, helpful, or protective.”
12.
Angry Parts Scale. The Angry Parts Scale portrays the mean score of four items:
Item 99: “Words just flowing from your mouth as if they were not in your control.”
Item 112: “Feeling the presence of an angry part in your head that tries to control what
you do or say.”
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Item 129: “When you are angry, doing or saying things that you don’t remember (after
you calm down).”
Item 208: “Having a very angry part that ‘comes out’ and says and does things that you
would never do or say.”
13. Persecutor Parts Scale. The Persecutor Parts Scale portrays the mean score of seven
phenomena of auditory harassment and persecution:
Item 84: “Hearing a voice in your head that wants you to hurt yourself.”
Item 140: “Hearing a voice in your head that calls you names (for example, wimp,
stupid, whore, slut, bitch, etc.).”
Item 159: “Hearing a voice in your head that wants you to die.”
Item 171: “Hearing a voice in your head that calls you a liar or tells you that certain
things never happened.”
Item 199: “Hearing a voice in your head that tells you to ‘shut up.’”
Item 207: “Hearing a voice in your head that calls you no good, worthless, or a failure.”
Item 215: “Feeling the presence of an angry part in your head that seems to hate you.”
3. The Clinical Summary Graph: Validity Scales
The MID’s validity scales measure the response sets that most commonly bias the test responses
of patients who present with an admixture of dissociative, posttraumatic, and Axis II symptoms:
defensiveness, symptom exaggeration, attention-seeking, and symptom falsification.
On the Clinical Summary Graph, seven scales help to assess these response sets:
(1) Mean Defensiveness,
(2) Raw Defensiveness
(3) Rare Symptoms
(4) Psychosis Screen
(5) Attention-Seeking Behavior
(6) Factitious Behavior
(7) Emotional Suffering.
Pages 7-13 (see above) provide detailed information about the validity scales and their
interpretation. It should be noted that three of the validity scales (Attention-Seeking Behavior,
Factitious Behavior, and Emotional Suffering) are grouped with the Characterological Scales on
this graph.
14. Mean Defensiveness Scale. This scale portrays the reversed mean score of the 12
Defensiveness items. For a more detailed discussion of the Defensiveness Scale, see
page 8 above.
15. Raw Defensiveness Scale. This scale portrays the percentage of the Defensiveness
items that the person rated as “0.” Thus, a score of 50 indicates that the person gave a
rating of “0” to 6 of the 12 items on the Raw Defensiveness Scale (i.e., 50%).
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16. Rare Symptoms Scale. This scale portrays the percentage of the Rare Symptoms items
that the person rated as “1” or higher. Thus, a score of 33 indicates that the person gave
a rating of “1” or higher to 4 of the 12 items on the Rare Symptoms Scale (i.e., 33%).
For a more detailed discussion of the Rare Symptoms Scale, see page 10 above.
17. Psychosis Screen. This scale portrays the percentage of delusional items on the MID
that the person rated as “1” or higher. Thus, a score of 75 indicates that the person gave
a rating of “1” or higher to 3 of the 4 items on the Psychotic Screen (i.e., 75%).
A score of 75 on the Psychosis Screen falls above the 99th percentile of
nondissociative psychiatric patients and falls at the 97th percentile of outpatients with
DID. Thus, only 3% of DID outpatients endorse three or more of the items on the
Psychosis Screen. Research on DID patients and schizophrenia patients has shown that
Psychosis Screen scores are significantly correlated with a diagnosis of schizophrenia
(point-biserial r = .51).
Item 11: “Feeling that your mind or body has been taken over by a famous person (for
example, Elvis Presley, Jesus Christ, Madonna, President Kennedy, etc.).”
Item 26: “Your mind being controlled by an external force (for example, microwaves,
the CIA, radiation from outer space, etc.).”
Item 52: “Your thoughts being broadcast so that other people can actually hear them.”
Item 98: “Hearing voices, which come from unusual places (for example, the air
conditioner, the computer, the walls, etc.).”
4. The Clinical Summary Graph: Characterological Scales
Seven scales shed light on characterological functioning and Axis II pathology:
(1) Attention-Seeking Behavior
(2) Factitious Behavior
(3) Manipulativeness
(4) Interpersonal Intrusiveness
(5) Identity Confusion
(6) Emotional Suffering
(7) Abandonment Concerns.
Persons with borderline pathology, for example, tend to show elevations on all of these scales
except Factitious Behavior. A subset of severely borderline individuals have an elevated
Factitious Behavior Scale as well.
18. Attention-Seeking Behavior Scale. This scale portrays the percentage of attentionseeking items that the person ‘passed.’ Thus, a score of 71 indicates that the person
gave clinically significant ratings to 5 of the 7 items on the Attention-Seeking Behavior
Scale (i.e., 71%). For a more detailed discussion of the Attention-Seeking Behavior
Scale, see page 9 above.
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19. Factitious Behavior Scale. This scale portrays the percentage of factitiousness items
that the person ‘passed.’ Thus, a score of 57 indicates that the person gave clinically
significant ratings to 4 of the 7 items on the Factitious Behavior Scale (i.e., 57%). For a
more detailed discussion of the Factitious Behavior Scale, see page 11above.
20. Manipulativeness Scale. This scale portrays the mean score of the four
manipulativeness items:
Item 12: “Trying to make someone jealous.”
Item 21: “Pretending that something upsetting happened to you so that others would care
about you (for example, being raped, military combat, physical or emotional abuse,
sexual abuse, etc.).”
Item 38: “Pretending that you have a physical illness in order to get sympathy (for
example, flu, cancer, headache, having an operation, etc.).”
Item 75: “Hurting yourself so that someone would care or pay attention.”
21. Interpersonal Intrusiveness Scale. This scale portrays the mean score of the five
intrusiveness items:
Item 21: “Pretending that something upsetting happened to you so that others would
care about you (for example, being raped, being adopted or orphaned, military
combat, physical or emotional abuse, sexual abuse, etc.).”
Item 47: “Talking to others about how you have been hurt or mistreated.”
Item 52: “Your thoughts being broadcast so that other people can actually hear them.”
Item 132: “Being unable to recall something—then, something “jogs” your memory and
you remember it.”
Item 155: “Exaggerating something bad that once happened to you (for example, rape,
military combat, physical or emotional abuse, sexual abuse, mistreatment by your
spouse, etc.) in order to get attention or sympathy.”
22. Identity Confusion Scale. This scale portrays the mean score of the 12 identity
confusion items. These items focus on
(a) confusion and puzzlement about oneself, one’s behavior, and one’s emotions
(b) “not feeling together”
(c) uncertainty about who one is.
23. Emotional Suffering Scale. This scale portrays the mean score of the 12 emotional
suffering items. Emotional suffering is closely related to the personality trait of
neuroticism or negative affectivity. For a more detailed discussion of the Emotional
Suffering Scale, see page 9 above.
24. Abandonment Concerns Scale. This scale portrays the mean score of the six
abandonment items:
Item 29: “Nobody cares about you.”
Item 35: “Feeling empty and painfully alone.”
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Item 54:
Item 111:
Item 124:
Item 213:
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“Being rejected by others.”
“Desperately wanting to talk to someone about your pain or distress.”
“Feeling hurt.”
“Wishing that someone would finally realize how much you hurt.”
5. The Clinical Summary Graph: Functionality/Impairment Scales
Three scales assess impaired cognitive and behavioral functioning: Critical Items, Flashbacks,
and Cognitive Distraction. Elevations on one or more of these scales are consistently associated
with compromised cognitive and behavioral functioning. This compromised functioning is most
commonly a byproduct of severe PTSD, severe dissociative symptoms, and/or severe
characterological pathology.
25. Critical Items. The Critical Items are dissociative and posttraumatic symptoms that are
harmful or potentially dangerous. For example,
1. flashbacks that provoke impulses to self-harm
2. voices that tell you to die or to hurt yourself
3. fugues
4. fully-dissociated episodes of self-injury or suicide
The Critical Items Scale portrays the mean score of the 10 critical items on the MID.
Although this scale does not portray the number of critical items that were ‘passed,’ it is
useful to note that 99% of nondissociative patients ‘pass’ three or fewer critical items,
whereas 85% of DID patients ‘pass’ four or more critical items. Thus, unlike most
psychiatric patients, DID patients can routinely be expected to have several (or even
many) of these harmful or potentially dangerous symptoms.
26. Flashbacks Scale. This scale portrays the mean score of the 12 flashbacks items.
27. Cognitive Distraction Scale. This scale portrays the mean score of the 12 cognitive
distraction items. It should be noted that the Defensiveness Scale and the Cognitive
Distraction Scale are composed of the same 12 items. Extremely low scores on these
items indicate defensiveness, whereas very high scores indicate cognitive distraction.
Cognitive distraction is manifested by high levels of forgetfulness, distractibility,
absent-mindedness, being mistake-prone, and having difficulty sustaining concentration
and focus. Conversely, defensiveness is indicated by abnormally low levels of these
phenomena. Cognitive distraction (due to intrusive dissociative and posttraumatic
symptoms) is one of the hallmarks of DID. Most DID patients manifest clinically
significant levels of cognitive distraction; some suffer truly disabling levels of cognitive
distraction.
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Revised MID Norms (August, 2011)
Scale
Defensiveness
Rare Symptoms
Emotional Suffering
Attention-Seeking
Factitious Behavior
BPD Index
Psychotic Screen
SCID-D
DID
n = 76
SCID-D
DDNOS
n = 40
Nonclinical
n = 510
Mean SD
% YES
Mean SD
% YES
Mean SD
% YES
35.5 (16.0)
4.5 (8.7)
54.7 (23.0)
20.9 (20.4)
6.7 (11.8)
12.9 (12.8)
4.4 (10.5)
2.6
7.8
23.3
22.0
3.9
9.1
2.6
32.3 (19.0)
5.1 (8.2)
57.7 (22.9)
27.2 (18.2)
8.6 (11.5)
15.6 (11.0)
6.8 (11.7)
2.5
7.5
30.0
32.5
7.5
15.0
7.5
67.3 (17.9)
3.2 (8.2)
17.1 (16.0)
3.8 (13.9)
5.5 (9.8)
9.3 (10.1)
3.4 (9.1)
19.4
6.3
1.0
8.8
4.5
5.1
4.5
Mean MID
51.3 (18.7)
MID Severe
127.9 (32.7)
Dissociative Sx (23) 20.3 (4.4)
39.0 (19.4)
100.1 (39.2)
16.3 (6.4)
8.0 (10.9)
25.1 (33.3)
3.6 (6.0)
“I Have DID”
“I Have Parts”
70.2 (31.1)
62.5 (25.5)
36.0 (33.6)
42.8 (25.6)
4.4 (13.5)
7.5 (14.0)
Child Part
Helper Part
Angry Part
Persecutor Part
Opposite Sex
59.4 (28.4)
42.3 (35.6)
53.3 (27.1)
54.3 (30.1)
24.9 (31.9)
39.1 (23.0)
29.0 (32.7)
38.9 (28.4)
42.4 (31.3)
10.0 (22.8)
6.9 (12.6)
10.0 (21.3)
7.2 (13.5)
5.1 (13.2)
4.2 (14.8)
Mean Amnesia
Amnesia items (33)
41.5 (22.5)
21.8
26.7 (22.0)
14.1
5.1 (9.3)
3.2
Clinical Significance Scores: > 100 = clinically significant (i.e., the symptom is present)
Memory Problems
Depersonalization
Derealization
Flashbacks
Somatoform
Trance
195.5 (53.8)
226.6 (69.3)
229.6 (77.3)
202.1 (58.7)
145.1 (74.6)
186.1 (60.6)
94.7
94.7
92.1
92.1
79.0
88.2
175.5 (69.4)
187.5 (82.8)
191.9 (91.7)
165.5 (83.5)
130.6 (81.9)
160.0 (79.5)
85.0
90.0
87.5
67.5
77.5
46.5 (57.6)
43.9 (67.1)
41.8 (77.5)
41.8 (61.6)
41.8 (66.4)
41.9 (55.4)
19.2
17.8
27.1
18.6
16.1
17.5
Child Voices
Internal Struggle
Persecutory Voices
Speech Insertion
Thought Insertion
Made Emotions
Made Impulses
Made Actions
Loss of Knowledge
Self-Alteration
Self-Puzzlement
240.8 (95.5)
253.5 (62.6)
190.1 (82.5)
123.7 (45.8)
144.7 (38.7)
148.4 (37.7)
126.3 (39.6)
195.7 (46.1)
187.5 (78.8)
231.3 (70.0)
231.6 (55.2)
93.4
97.4
86.8
84.2
93.4
93.4
86.8
96.1
85.5
96.1
97.4
180.0 (122.4)
197.5 (88.5)
140.0 (95.5)
91.3 (60.9)
120.0 (53.8)
117.5 (58.3)
95.0 (51.6)
158.1 (64.6)
126.3 (88.4)
177.5 (74.2)
204.2 (70.5)
77.5
85.0
65.0
67.5
70.0
67.5
67.5
85.0
62.5
87.5
90.0
33.3 (72.1)
48.5 (76.0)
22.0 (56.0)
27.2 (43.0)
28.1 (45.6)
29.2 (48.5)
23.3 (42.1)
40.7 (56.4)
32.3 (58.0)
43.7 (67.9)
48.7 (71.5)
21.7
20.6
11.4
14.3
13.7
13.7
11.9
16.1
15.9
16.9
22.5
Time Loss
165.1 (61.7)
Coming to
147.4 (68.3)
Fugues
170.4 (88.4)
Disremembered Beh139.5 (63.4)
Finding Objects
127.6 (81.0)
Forgotten Behavior 150.0 (84.1)
85.5
81.6
82.9
86.8
68.4
77.6
118.8 (74.0)
101.3 (76.4)
102.5 (94.7)
90.0 (71.8)
80.0 (82.3)
87.5 (85.3)
70.0
60.0
50.0
50.0
50.0
45.0
24.2 (46.3)
22.5 (43.8)
22.1 (51.8)
22.9 (47.1)
17.3 (41.6)
19.5 (48.4)
12.9
11.0
10.4
11.0
8.6
8.6