The Clinician Administered Dissociative States Scale (CADSS)

J. Douglas Bremner, M.D., Emory University, March 4, 2014

Instructions for Administration

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

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

undergoing a cognitive or pharmacological challenge. Baseline scores on the CADSS were

significantly different for patients with PTSD (M=18.9, SD=118.3) versus patients with
schizophrenia (M=3.7, SD=5.2), affective disorders (M=7.5 , SD=9.6), as well as healthy
controls (M=1.5, SD=2.5) and Vietnam combat veterans without PTSD (M=1.3 , SD=3.9)
(F=8.25; df=4,119; p<.0001), as determined with one-way analysis of variance and Duncans
multiple range test. A subgroup (N=39) of patients with PTSD showed a significant increase in
dissociative symptomatology following exposure to a traumatic memories group in comparison
to baseline (M=35.0, SD=21.9 vs. M=21.8, SD=18.8) (paired t-test:t=4.03; df=37; p=.0003).

Items 1-23 are subjective items. The interviewer reads the item out loud to the subject,
and the subject responds to the question with the help of anchors. The anchors are intended for
use as a guide. They are not meant to make the process more cumbersome. For instance, if a
patient is read an item, and he does not recognize it as being similar to his or her experience,
there is no need to read through all of the anchors. The interviewer should circle the number that
best corresponds to how an individual is feeling at the current time. The instrument can also be
used retrospectively. For instance, immediately after viewing trauma-related slides, the
interviewer can prompt the subject, During the slides, did things seem to be moving in slow
motion?, etc.
Item 7. Does your sense of your own body feel changed; for instance, does you body
feel unusually large or unusually small? The rater may prompt the subject with bodily changes
which are specific to the individual, for instance some individuals may say that they become
large like a giant, or that their arms become like toothpicks, or their chests swell to enormous
sizes, etc.

Item 12. Do things seem to take much longer than you would have expected? The
interviewer can point out the true elapsed time since the initiation of the administration of the
CADSS in order to assist the subject with this question.
Items 21-23 represent an addendum to the CADSS for which psychometric information
has not been obtained. Items 21 & 23 are specifically identity confusion/alteration items which
may be useful in some protocols or clinical situations where this aspect of dissociation is
particularly pertinant. Item 22 is a supplementary amnesia item.
Items 24-28 are objective items. The interviewer fills them out based on their
observations of the patient during the interview. The interviewer does not read the items out loud
to the patient, or give it to the patient to fill out. Readings from the bibliography can be helpful in
administration of this section. The objective items should be completed as an honest assessment
of the patients behavior during the interview, not as a second guessing of the interviewers view
about whether the patient has dissociative symptoms or not. The subjective experience of
dissociation is typically more marked than objective behavioral reactions which are characteristic
of dissociation, and this is reflected in responses to subjective and objective items of the CADSS.
We have found that many patients will be having marked dissociative symptoms on almost a
daily basis, but have little or no external manifestation of their experience. Patients often do not
spontaneously discuss their experiences unless prompted with questions from the interview.
However, we have found a correlation between the subjective and objective components of the
CADSS. Subtle behaviors which are captured in the objective section are often associated with
more marked subjective experiences of dissociation.

Recommendations

We have developed the CADSS as a clinician administered questionnaire as in our

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

Suggested Readings:

Bernstein, E., Putnam, T. (1986). Development, reliability, and validity of a dissociation

scale. J. Nerv. Ment. Dis. 174:727-735.

Braun, B. (1984). Towards a theory of multiple personality and other dissociative

phenomena. Psychiatr. Clin. N.A. 7:171-193.

Bremner, J.D., Southwick, S.M., Brett, E., Fontana, A., Rosenheck, R., Charney, D.S.
(1992). Dissociation and posttraumatic stress disorder in Vietnam combat veterans. Am. J.
Psychiatry. 1992;149:328-333.

Bremner, J.D., Steinberg, M., Southwick, S.M., Johnson, D.R., Charney, D.S. (1993).
Use of the Structured Clinical Interview for DSMIV-Dissociative Disorders for systematic
assessment of dissociative symptoms in posttraumatic stress disorder. Am. J. Psychiatry.
150:1011-1014.

Bremner JD, Krystal JH, Putnam F, Marmar C, Southwick SM, Lubin H, Charney DS,
Mazure CM: Measurement of dissociative states with the Clinician Administered Dissociative
States Scale (CADSS). J. Trauma. Stress 1998; 11:125-136.

Cardena, E., and Spiegel, D. (1989). Dissociative reactions to the San Francisco Bay
Area earthquake of 1989. Am. J. Psychiatry. 150:474-478.

Carlson, E.B., and Rosser-Hogan, R. (1991). Trauma experiences, posttraumatic stress,

dissociation, and depression in Cambodian refugees. Am. J. Psychiatry. 148:1548-1552.

Chu, J.A., Dill, D.L. (1990). Dissociative symptoms in relation to childhood physical and
sexual abuse. Am. J. Psychiatry. 147:7, 887-892.

Kihlstrom, J. (1993). Dissociative disorders, in Comprehensive Handbook of

Psychopathology, 2nd edition, Sutker P and Adams H (ed.). New York, Plenum.

Kluft, R.P. (1984). Treatment of multiple personality disorder: a study of 33 cases. Psychiatr.
Clin. North Am. 7:9-29.

Kluft, R.P. (Ed.). Childhood Antecedents of Multiple Personality Disorder. Washington D.C.,
American Psychiatric Press, 1985.

Koopman, C., Classen, C., and Spiegel, D. (1994). Predictors of posttraumatic stress
symptoms among survivors of the Oakland/Berkeley, Calif., firestorm. Am.J. Psychiatry. 151:888894.

Marmar, C.R., Weiss, D.S., Schlenger, D.S., Fairbank, J.A., Jordan, B.K., Kulka, R.A., and
Hough, R.L. (1994). Peritraumatic dissociation and posttraumatic stress in male Vietnam theater
veterans. Am. J. Psychiatry. 1994;151:902-907.

Nemiah, J.C. (1989). Janet redivivus: the centenary of l'Automatisme Psychologique. Am. J.
Psychiatry. 146:1527-1530.

Putnam, F.W., Guroff, J.J., Silberman, E.K., Barban, L., and Post, R.M. (1986). The clinical
phenomenology of multiple personality disorder: a review of 100 recent cases. J. Clin. Psychiatry.
47:285-293.

Putnam, F.W. (1989). Diagnosis and Treatment of Multiple Personality Disorder. New York,
Guilford Press.

Ross, C.A., Joshi, S., and Currie, R. (1990). Dissociative experiences in the general
population. Am. J. Psychiatry. 147:1547-1552.

Spiegel, D. (1984). Multiple personality as a posttraumatic stress disorder. Psych Clin NA

7:101-110.

Spiegel D (ed.). Dissociation: Culture, Mind, and Body. Washington D.C., American
Psychiatric Press, 1994.

van der Kolk, B.A. (Ed.) (1987). Psychological Trauma. American Psychiatric Press,
Washington.