ptsd & assessment

J I L L I A N F I S H , E M I LY S H I E L D S , J E N N I E G O O D W I N & B R I A N R I E S T E R

PTSD & ASSESSMENT

DSM-5 CRITERIA

Criterion A: stressorThe person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required)

1. Direct exposure.2. Witnessing, in person.3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the

event involved actual or threatened death, it must have been violent or accidental.4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the

course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptomsThe traumatic event is persistently re-experienced in the following way(s): (one required)

5. Recurrent, involuntary, and intrusive memories. Note: Children older than six may express this symptom in repetitive play.

6. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).

7. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.

8. Intense or prolonged distress after exposure to traumatic reminders.9. Marked physiologic reactivity after exposure to trauma-related stimuli.

DSM-5 CRITERIA CONT.

Criterion C: avoidancePersistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

1. Trauma-related thoughts or feelings.2. Trauma-related external reminders (e.g., people, places, conversations, activities,

objects, or situations).

Criterion D: negative alterations in cognitions and moodNegative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)

3. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).

4. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").

5. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).Markedly diminished interest in (pre-traumatic) significant activities.Feeling alienated from others (e.g., detachment or estrangement).Constricted affect: persistent inability to experience positive emotions.

DSM-5 CRITERIA CONT.

Criterion E: alterations in arousal and reactivityTrauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

1. Irritable or aggressive behavior2. Self-destructive or reckless behavior3. Hypervigilance4. Exaggerated startle response5. Problems in concentration6. Sleep disturbance

Criterion F: durationPersistence of symptoms (in Criteria B, C, D, and E) for more than one month.

Criterion G: functional significanceSignificant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: exclusionDisturbance is not due to medication, substance use, or other illness.

Specify if: With dissociative symptoms.

CLINICIAN-ADMINISTERED PTSD SCALE FOR DSM-5

CAPS-5

ABOUT THE CAPS-5

• Clinician Administered PTSD Scale• Semi Structured Interview• Also helps with diagnosing acute stress disorder• Assesses severity and frequency of symptoms, as

well as other factors• Is a 30 item scale that takes 30-45 minutes

ABOUT THE CAPS-5 CONT.

• Works well with research as well as diagnosing and treatment planning• Assesses the impact of symptoms on social and

occupational aspects of clients life• Provides means to check the validity of the

ratings they have obtained• There is a number of different algorithms for

scoring

CAPS-5 PSYCHOMETRIC PROPERTIES

Reliability• Test-Retest• Intraclass correlations ranged from

.86 < r .87 for frequency

.86 < r .92 for intensity

.88 < r .91 for severity• Across all 17 symptoms, intraclass correlations were .93 for

total frequency, .95 for total intensity, and .95 for total severity.

• Inter-rater

• .92 < k .99 among the three symptom clusters

• Internal Consistency• .73 < .85 among the three symptom clustersCadrobbi Pupo, M., Roberto Jorge, M., Ferri Schoedl, A., Affonseca Bressan, R., Baxter Andreoli, S.,

Feijo Mello, M., & de Jesus Mari, J. (2011). The accuracy of the Clinician-Administered PTSD Scale (CAPS) to identify PTSD cases in victims of urban violence. Psychiatry Research, 85, 157-160. Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156.

CAPS-5 PSYCHOMETRIC PROPERTIES

Validity• Convergent• The Mississippi Scale (r = .70)• The PK Scale of the MMPI-II (r = .84)• The CES (r = .42)• IES Total Score (r = .62)

Structure • Factor Analysis • Construct has a four-factor structure

• Re-experiencing, avoidance, numbing, and hyper arousal

Cadrobbi Pupo, M., Roberto Jorge, M., Ferri Schoedl, A., Affonseca Bressan, R., Baxter Andreoli, S., Feijo Mello, M., & de Jesus Mari, J. (2011). The accuracy of the Clinician-administered PTSD scale (CAPS) to identify PTSD cases in victims of urban violence. Psychiatry Research, 85, 157-160. Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-Administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156.

MULTICULTURAL CONSIDERATIONS

❖ The CAPS-5 has been used widely with a range of populations and types of trauma, including victims of crimes, rape, motor vehicle accidents, and torture (Shalev et. al, 1997; Foa & Tolin, 2000; Schnyder & Moergeli, 2002; Ost & Paunovic, 2005, as cited in Pupo et. al, 2011).

❖ A 2011 study (Pupo et. al) showed that the CAPS-5 is an accurate and reliable instrument for detecting PTSD in civilian populations ➢ Population: Brazilian victims of urban violence➢ High internal consistency - Cronbach’s alpha coefficient of 0.97➢ Sensitivity = 90% (95% Confidence Interval); Specificity = 95.7%

(95% C.I.)

❖ CAPS-5 has been thoroughly tested and researched with veteran and civilian populations, and numerous trauma populations. Overall, the research indicates it is a quality measure of PTSD symptoms.

❖ Limitation: CAPS-5 is a lengthy assessment that can take up to an hour to complete - this may be a barrier for clients who have trouble with attention span or chronic pain

❖ Has been used to study ethnic differences among female veterans (C’de Baca, Castillo, & Qualls, 2012).

DAVIDSON TRAUMA SCALEDTS

ABOUT THE DTS

• 17-item self-report measure that assesses the 17 DSM-IV symptoms of PTSD

• Items are rated on • 5-point frequency (0 = "not at all" to 4 = "every day") • severity scales (0 = "not at all distressing" to 4 = "extremely

distressing")

• Respondents asked to identify the trauma that is most disturbing to them and to rate, in the past week, how much trouble they have had with each symptom

* Not updated for DSM-5 yet *

ABOUT THE DTS CONT.

• The DTS yields the following:• frequency score - ranging from 0 to 68• severity score - ranging from 0 to 68 • total score - ranging from 0 to 136

• Purpose of DTS: preliminary determination about whether the symptoms meet DSM criteria for PTSD

• Scores can also be calculated for each of the 3 PTSD symptom clusters (i.e., B, C, and D).

• Sample Item: Have you had painful images, memories or thoughts of the event?• (Respondents rate how much trouble they have had with each

symptom)

DTS PSYCHOMETRIC PROPERTIES

• Reliability• Test-Retest• r = .86

• Internal Consistency • .97 < .99

• Validity• Convergent• The CAPS (r = .78)• IES (r = .64)

• Structure• Factor Analysis• Construct has been shown to have a four to seven factor

structureDavidson, J. R. T., Book, S. W., Colket, J. T., Tupler, L. A., Roth, S., David, D., … Feldman, M. E. (1997). Assessment of a new self-rating scale for posttraumatic stress disorder. Psychological Medicine, 27, 153-160. Davidson, J. R. T., Tharwani, H. M., & Connor, K. M. (2002). Davidson Trauma Scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trials. Depression and Anxiety, 15, 75-78. McDonald, S. D., Beckham, J. C., Morey, R. A., & Calhoun, P. S. (2009). The validity and diagnostic efficiency of the Davidson Trauma Scale in military veterans who have served since September 11th, 2001. Journal of Anxiety Disorders, 23, 247-255.


❖ DTS can successfully differentiate between those with PTSD and those without PTSD (Davidson, Tharwani, & Connor, 2002).➢ Although it does have many strengths, including the

ability to track changes and treatment outcomes (Adkins, Weathers, McDevitt-Murphy, & Daniels, 2008).

➢ Has shown good validity and reliability with different trauma-exposed groups (veterans, rape victims, natural disasters, and mixed trauma exposure), (Davidson, Tharwani, & Connor, 2002).

More psychometric research should be conducted to help determine if the DTS is generalizable to different populations, such as ethnic and racial groups

PTSD SYMPTOM SCALE - INTERVIEW

PSS- I

ABOUT THE PSS-I

• Also a semi structured interview• Takes about 20 minutes to administer and has 17

questions• Used to link distress to a trauma• Also can be used to identify a trauma• Can be used in reference to the past but is

important that questions reference a 2 week period• Also takes in account clinicians opinion on

severity and frequency of symptoms


PSS-I PSYCHOMETRIC PROPERTIES

• Reliability• Internal Consistency• .65 < .86 among all subscales

• Inter-rater • .91 < k .93 on all subscales

• Validity• Concurrent• The CAPS-5 and the PSS-I (r = .87)

• Convergent• The PTSD section of the SCID (r = .73)

Foa, E. B., & Tolin, D. F. (2000). Comparison of the PTSD symptom scale interview version and the clinician-administered PTSD scale. Journal of Traumatic Stress, 13, 181-191.


❖ The PSS-I has been tested with civilian populations and in comparison with the CAPS-5 (a longer PTSD assessment)➢ Determined that the PSS-I may be used in place of the

CAPS-5 as a diagnostic instrument➢ Performs equally well as a measure of PTSD (Foa & Tolin,

2000)➢ Correlates strongly with several other self-report measures

for PTSD, depression, and anxiety (Foa & Yadin, 2011)❖ PSS-I has been used to evaluate trauma in Rwandan survivors

of the 1994 genocide and former prisoners accused of participating in the genocide➢ Culturally sensitive measure➢ Accurately detects symptomology and identifies specific

events (Reider & Elbert, 2013)

STRUCTURED INTERVIEW FOR PTSD

SIP

ABOUT THE SIP

• 19 Item scale • Takes 20-30 minutes to administer• Can be administered by mental health

professionals or by paraprofessionals after some training• Includes two items correlated to trauma related

guilt• Each item is answered on a 0-4 rating scale

making the highest possible score 76• Responses can be used to make a determination

about whether client's symptoms meet DSM criteria B, C, and D for PTSD


SIP PSYCHOMETRIC PROPERTIES

• Reliability

• Internal Consistency• = .80

• Test-Retest• r = .89

• Inter-rater• k = .90

Davidson, J. R. T., Malik, M. A., & Travers, J. (1997). Structured interview for PTSD (SIP): Psychometric validation for DSM-IV criteria. Depression and Anxiety, 5, 127-129.

SIP PSYCHOMETRIC PROPERTIES

• Validity• Concurrent• DTS (r = .67)• IES (r = .49)• Hamilton Depression Scale (r = .42)• Hamilton Anxiety Scale (r = .48)• Disability measures (r = .25 - .33)

• Structure• Factor Analysis• Construct has a seven factor structure

• Recurrent intrusive recollections, phasic hyper arousal, flashbacks, psychogenic amnesia, lack of sleep, lack of startle, and presence of irritability.

Davidson, J. R. T., Malik, M. A., & Travers, J. (1997). Structured interview for PTSD (SIP): Psychometric validation for DSM-IV criteria. Depression and Anxiety, 5, 127-129.


❖ Research has shown that the SIP has the ability to detect differences in treatment effect and distinguish between those with PTSD and those without (Davidson, Malik & Travers, 1997)

❖ Civilian and combat veteran populations➢ Is sensitive to the numerous types of trauma

an individual might experience (Foa & Yadin, 2011)

PTSD CHECKLIST FOR DSM-5PCL-5

ABOUT THE PCL-5

• The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD.

• Purposes of the PCL-5 include:• Monitoring symptom change during and after treatment• Screening individuals for PTSD• Making a provisional PTSD diagnosis

• The PCL-5 can be scored to provide a provisional PTSD diagnosis, given before the CAPS-5.

• Administered in one of three formats:• Without Criterion A (stressor) appropriate when trauma exposure is

measured by some other method• With a brief Criterion A assessment• With the revised Life Events Checklist for DSM-5 (LEC-5) and extended

Criterion A assessment

ABOUT THE PCL-5 CONT.

• Can be completed in waiting room prior to a session or by participants as part of a research study• Approximately 5-10 minutes to complete• Interpretation should be made by a clinician• The PCL-5 can be scored in several ways including:• A total symptom severity score, range of 0-80 summing the scores

for item • DSM-5 symptom cluster severity scores summing the scores for the

items within a given cluster • Cluster B (items 1-5) / Cluster C (items 6-7) / Cluster D (items 8-14) / Cluster

E (items 15-20)

• A provisional PTSD diagnosis treat each item rated as 2 = "Moderately" or higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires at least: 1 B item (questions 1-5), 1 C item (questions 6-7), 2 D items (questions 8-14), 2 E items (questions 15-20)

IMPORTANT REVISIONS FROM DSM-IV PCL TO PCL-5

• PCL for DSM-IV has three versions:• PCL-M (military), PCL-C (civilian), and PCL-S (specific)• PCL-5 is most similar to the PCL-S (specific) version. There are no

corresponding PCL-M or PCL-C versions of PCL-5

• Three formats of the PCL-5 measure; one without a Criterion A component, one with a Criterion A component, and one with the LEC-5 and extended Criterion A component

• The wording of PCL-5 items reflects both changes to existing symptoms and the addition of new symptoms in DSM-5

• Rating scale went from 1-5 in the DSM-IV to 0-4 for each symptom. Descriptors remain the same.

• Due to the changes, PCL-5 scores are not compatible with PCL for DSM-IV scores and cannot be used interchangeably

PCL PSYCHOMETRIC PROPERTIES

Military Version• Reliability• Test-Retest• r > .70

• Internal Consistency• .75 < .80

• Validity• Convergent • The PTSD section of the SCID (r = .64)

• Structure• Factor Analysis• Construct has been shown to have a two factor and four factor

structureRuggiero, K. J., Del Ben, K., Scotti, J. R., & Rabalais, A. E. (2003). Psychometric properties of the PTSD checklist - civilian version. Journal of Traumatic Stress, 16, 495- 502. Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28, 596-606.

PCL PSYCHOMETRIC PROPERTIES

Civilians• Reliability• Test-Retest• .80 > r .70

• Internal Consistency• > .75

• Validity• Convergent• The CAPS (r = .79)• The Mississippi (r = .90)

• Structure• Factor Analysis• Construct has a four factor structureRuggiero, K. J., Del Ben, K., Scotti, J. R., & Rabalais, A. E. (2003). Psychometric properties of the PTSD checklist -

civilian version. Journal of Traumatic Stress, 16, 495- 502. Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28, 596-606.


❖ Widely adopted and extensively evaluated with numerous trauma populations

❖ Used by the Veterans Administration❖ Has been evaluated as a quality measure for diagnosing PTSD in

college-age individuals (Adkins, Weathers, McDevitt-Murphy, & Daniels, 2008)➢ Caucasian, African American, and “Other” racial groups

❖ Limitations➢ Some studies suggest that the reading level of the PCL may

impede individuals’ ability to complete the assessment accurately (Wilkins et. al, 2011)

➢ Those with less education, intellectual deficits, TBI, or whose first language is not English may struggle with the vocabulary and wording

➢ Additional research with female populations (military, veteran, and civilian) is necessary (Wilkins et. al, 2011)

REFERENCES:

Adkins, J. W., Weathers, F. W., McDevitt-Murphy, M., & Daniels, J. B. (2008). Psychometric properties of seven self-report measures of posttraumatic stress disorder in college students with mixed civilian trauma exposure. Journal of Anxiety Disorders, 22(8), 1393-1402. doi:10.1016/j.janxdis.2008.02.002

Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Klauminzer, D., Chamey, D., ... Buckley, T. C. (2000). Instruction manual clinician-administered PTSD scale. National Center for Posttraumatic Stress Disorder.

C'de Baca, J., Castillo, D., & Qualls, C. (2012). Ethnic differences in symptoms among female veterans diagnosed with PTSD. Journal of Traumatic Stress, 25(3), 353-357. doi:10.1002/jts.21709

Davidson, J. R. T., Book, S. W., Colket, J. T., Tupler, L. A., Roth, S., David, D., … Feldman, M. E. (1997). Assessment of a new self-rating scale for posttraumatic stress disorder. Psychological Medicine, 27, 153-160.

Davidson, J. R. T., Tharwani, H. M., & Connor, K. M. (2002). Davidson Trauma Scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trials. Depression and Anxiety, 15, 75-78.

Davidson, J. R. T., Malik, M. A., & Travers, J. (1997). Structured interview for PTSD (SIP): Psychometric validation for DSM- IV criteria. Depression and Anxiety, 5, 127-129.

Engelhard, I. M., Arntz, A., & Van den Hout, M. A. (2007). Low specificity of symptoms on the post-traumatic stress disorder (PTSD) symptom scale: A comparison of individuals with PTSD, individuals with other anxiety disorders and individuals without psychopathology. British Journal Of Clinical Psychology, 46(4), 449-456. doi:10.1348/014466507X206883

Feeny, N. C., & Foa, E. (2002). Manual for the administration and scoring of the PTSD symptom scale-interview. PSS-I Manual.

REFERENCES:

Foa, E. B., & Tolin, D. F. (2000). Comparison of the PTSD symptom scale interview version and the clinician-administered PTSD scale. Journal of Traumatic Stress, 13, 181-191.

Foa, E.B., & Yadin, E. (2011). Assessment and diagnosis of post-traumatic stress disorder: An overview of measures. Psychiatric Times, 28(7), 63. Retrieved from http://pro.psychcentral.com/2012/assessment-and-diagnosis-of-posttraumatic-stress-disorder/00724.html#

McDonald, S. D., Beckham, J. C., Morey, R. A., & Calhoun, P. S. (2009). The validity and diagnostic efficiency of the Davidson Trauma Scale in military veterans who have served since September 11th, 2001. Journal of Anxiety Disorders, 23, 247-255.

Pupo, M., Jorge, M., Schoedl, A., Bressan, R., Andreoli, S., Mello, M., & Mari, J. (2011). The accuracy of the clinician-administered PTSD scale (CAPS) to identify PTSD cases in victims of urban violence. Psychiatry Research, 185(1/2), 157-160. doi:10.1016/j.psychres.2009.11.006

Rieder, H., & Elbert, T. (2013). Rwanda - lasting imprints of a genocide: trauma, mental health and psychosocial conditions in survivors, former prisoners and their children. Conflict & Health, 7(1), 1-13. doi:10.1186/1752- 1505-7-6

Ruggiero, K. J., Del Ben, K., Scotti, J. R., & Rabalais, A. E. (2003). Psychometric properties of the PTSD checklist - civilian version. Journal of Traumatic Stress, 16, 495- 502.

Schnurr, P. P. (n.d.). PTSD: National center for PTSD. Retrieved from http://www.ptsd.va.gov

Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Clinician-administered PTSD Scale: A review of the first ten years of research. Depression and Anxiety, 13, 132-156.

Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD Checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28, 596-606.

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