Severity of Dissociative Symptoms - Adult

Severity of Dissociative Symptoms - Adult*

*Brief Dissociative Experiences Scale (DES-B) - Modified
Name*

First NameMiddle NameLast Name
Medical Record #*
Date

MonthDayYear
Date

Instructions: For each statement below, please check (✓) the box that best answers each question to show how much eachthing has happened to you in the past SEVEN (7) DAYS.

	Not at all	Once or twice	Almost every day	About once a day	More than once a day
I find myself staring into space and thinking of nothing.
People, objects, or the world around me seem strange or unreal.
I find that I did things that I do not remember doing.
When I am alone, I talk out loud to myself.
I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.
I am able to ignore pain.
I act so differently from one situation to another that it is almost as if I were two different people.
I can do things very easily that would usually be hard for me.

Total / Partial Raw Score:
# of Questions Answered (8 total)*
Prorated Total Raw Score:
Average Total Score
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