Therapeutic Assessment of PTSD

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Therapeutic Assessment of PTSD
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Therapeutic Assessment of PTSD
Prevalence of trauma

• Review of studies of prevalence of potentially
  traumatic events in U.S. shows rates of exposure
  vary from moderate to high, depending on
  population sampled and methods used to define and
  ask about the experiences (Green, 1994)
• Random young adults, urban area in Midwest
  experience event outside range of normal humans
  experience?
• 40 Yes (Breslau, Davis, Andreski,
  Peterson, 1991)
• J. of Traumatic Stress)
• Random sample women in S. Carolina interviewed
  34 had at least one experience of sexual abuse
  lt18yo (Saunders, Villeponteaux, Lipovsky
  Veronen, 1992)
• College women across U.S. 27 had been sexually
  assaulted or raped at least once since age 14
  (Koss, Gidcz, Wisniewski, 1987)

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Therapeutic Assessment of PTSD Prevalence of
trauma

• Review of studies of prevalence of potentially
  traumatic events in U.S. shows rates of exposure
  vary from moderate to high, depending on
  population sampled and methods used to define and
  ask about the experiences (Green, 1994)
• Random young adults, urban area in Midwest
  experience event outside range of normal humans
  experience?
• 40 Yes (Breslau, Davis, Andreski,
  Peterson, 1991)
• J. of Traumatic Stress)
• Random sample women in S. Carolina interviewed
  34 had at least one experience of sexual abuse
  lt18yo (Saunders, Villeponteaux, Lipovsky
  Veronen, 1992)
• College women across U.S. 27 had been sexually
  assaulted or raped at least once since age 14
  (Koss, Gidcz, Wisniewski, 1987)

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Therapeutic Assessment of PTSD Prevalence of
trauma

• Community sample of men women asked about
  experience with a wide range of potentially
  traumatic events- 69 reported exposed to at
  least one potentially traumatic event (Norris,
  1992)
• Community sample lifetime exposure was also 69
• (Resnick, Kilpatrick, Dansky, Saunders, Best,
  1993)
• People seeking treatment Sample psychiatric
  outpatients asked if experience outside range of
  normal human experience 81 reported one or
  more (Davidson Smith, 1990)
• Two studies psychiatric outpatients found 64-68
  of those sampled reported childhood physical
  sexual assault when they were asked directly
  (Jacobson, 1989 Surrey, Swett, Micheals,
  Leven, 1990)

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Therapeutic Assessment of PTSD Prevalence of
trauma

• Similar studies of psychiatric inpatients found
  63-81 (Bryer, Nelson, Miller, Krol, 1987 Chu
  Dill, 1990 Craine, Henson, Colliver, McLean,
  1988 Jacobson Richardson, 1987)
• Reviews of research on rates of traumatic stress
  responses estimate 25-30 of those exposed to
  extreme stressors develop PTSD (Green, 1994
  Tomb, 1994)
• No research yet that shows what proportion of
  those who experience stressors develop other
  trauma-related disorders, e.g. disssociative
  disorders, acute stress disorder. (Carlson, 1997)

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Therapeutic Assessment of PTSDPrevalence of
Trauma

• If 60-80 of psychiatric treatment and 25-30 of
  those exposed develop PTSD than we can expect at
  least 15 of our patients to have current or past
  trauma related symptoms (Carlson, 1997)
• The task of assessing trauma responses is one we
  all face. (Carlson, 1997 Trauma Assessments)

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• The relationships between trauma experiences,
  moderating variables that influence the response
  to a traumatic experience, the responses to
  trauma, individual characteristics, and the
  symptoms we observe are quite complex.
• PTSD is a fluctuating, episodic,
  multidimensional stress-
• response pattern that affects integrative
  psychological functioning on many levels
• 1) memory, cognition, information processing,
• 2) perception 3) affect regulation, 4)
  motivational striving
• 5) coping and ego defense functioning 6) ego
  processes
• and personal identity 7) stress tolerance
  capacities
• 8) interpersonal relations and capacity for
  attachment
• 9) life course trajectory in the epigenesis
  of ego and personality development. (Wilson,
  Friedman, Lindy, 2001)

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• e.g. Traumatic experiences vary in type,
  intensity, duration, frequency, meaning, physical
  context, whether they are man made or not, who
  was there and who wasnt and other factors.
• e.g. Two people can have the same experience,
  perceive them differently and show very different
  responses.
• e.g. A person can grow up with very solid
  values, advise and experience, develop PTSD but
  remain positive, motivated, and insightful.

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Kings NIMH Etiology Studies combined thoughts
from Keane ( February, 2006) Purpose To specify
and evaluate a fully integrated model that
incorporates all variables (Meta analyses of
Combat-related PTSD in Vietnam Veterans)
PRE-WAR RISK FACTORS Psychological
Socioeconomic status, Relationship with father,
Family dysfunction, Early childhood Trauma,
Childhood antisocial behavior, Age at entry to
Vietnam, Physiological vulnerabilities
predisposed to anxiety or depression, ETOH
abuse,gender
POST WAR RESILIENSE/RECOVERY VARIABLES
Additional stressful life events, Hardiness,
Structural social support, Functional social
support
wAR ZONE STRESSORS
Combat events, Atrocities/abusive
violence, Perceived threat, Malevolent
environment, harassment-sexual, racial,
ethnic, toxic exposure, family
concerns

PTSD
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Kings NIMH Etiology Studies What causes PTSD?
Some results (Combat-related PTSD in Vietnam
Veterans)

• For men, the most potent variable set accounting
  for PTSD was war-zone stressors, followed by
  post-war factors, (e.g. social support) followed
  by pre-war factors (early family life).
• For women, the post-war factors were most
  salient, followed by war-zone stressors, and then
  pre-war factors.
• Current PTSD may be tied to multiple exposures to
  stressful events.
• Depletion of resources was a general theme in the
  models.
• Resilience/recovery variable are very potent.
• In the final interated model, about 70 of the
  variance in PTSD symptoms was accounted for,
  about 50 by war zone stressors.

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Need more studies Purpose To specify and
evaluate a fully integrated model that
incorporates all variablesand types of trauma
PRE-WAR RISK FACTORS Psychological
Socioeconomic status, Relationship with father,
Family dysfunction, Early childhood Trauma,
Childhood antisocial behavior, Age at entry to
Vietnam, Physiological vulnerabilities
predisposed to anxiety or depression, ETOH
abuse,gender
POST WAR RESILIENSE/RECOVERY VARIABLES
Additional stressful life events, Hardiness,
Structural social support, Functional social
support
OTHER TRAUMAS Neglect Verbal Abuse Physical
abuse Sexual Abuse Mugging MVA Kidnapping Combat

No disorder Acute Stress Disorder PTSD and
Complicated PTSD Dissociative disorder Other
disorders
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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Knowledge of trauma theory aids in assessment
• Keeps patient in our office long enough to
  assess, influences the accuracy of our diagnosis,
  choices of treatment methods, timing of
  interventions, and more detailed aspects of
  assessment such as issues of perception, trust,
  the role of suddenness, lack of control, types of
  responses at time of trauma. Some of the
  literature focuses on particular types of
  traumas, some focuses on theoretical models, some
  overlap types of trauma and theoretical models
  and some are research oriented and look for
  causality in those complex relationships.
  Theories of trauma are there but not as
• well developed as for other disorders.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Studies so far indicate that there is a clear
  relationship between trauma experiences and later
  reports of dissociation particularly with more
  severe cases of PTSD. Pathological gaps in
  awareness, depersonalization, derealization, lack
  of research about affective, behavioral and
  physiologic dissociation. This information is not
  available in PTSD measures.
• Knowledge of trauma is essential to treatment,
  e.g. some empirical evidence supporting this,
  e.g. recalling and processing trauma memories
  (via exposure, oral or written) more effective in
  reducing symptoms than alternative methods and
  has caused significant lowering of distress and
  physical symptoms. No research evidence for
  treatment of PTSD without the use of recall.
• E.g. Unresolved childhood traumas may need to be
  addressed prior to military traumas because that
  is the priority for the patient. May do it
  yourself or refer to childhood trauma specialist
  and take them back later when this is no longer
  an obstacle.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Most mental health professionals dont receive
  much training or experience with these disorders
  during graduate training and its still a new area
  to explore. Research didnt begin until the late
  1980s.
• Accuracy of measures and norms
• Presenting symptoms may be misleading many
  symptoms PTSD overlap with other disorders,
  personality disorders psychosis, mood disorders.
  dissociative disorders
• Comorbity associated with trauma disorders

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Increasing pressure since the 90s on clinicians
  to assess and treat clients quickly and
  cost-effectively. In many settings, it is no
  longer possible to conduct or order a full
  psychological evaluation or complete a complete
  battery of tests on every client because the time
  and resources are simply not available.
• There is variability in the responses of patient
  over time, they are re-experiencing during one
  period but may be avoidant during another. If
  presenting with numbing or avoidant symptoms,
  then it may not be diagnosed at all. You look
  fine.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Responses to discrete and chronic traumas vary.
  Finding out will make a difference in treatment.
  EMDR exposure work better with single trauma
  patients.
• Pt may deny problem due to history of not
  observing self and only focused outward due to
  hypervigilance and having not noticed changes
  occurring during combat, feels he/she are just
  normal. Denial may also be a defense mechanism.
• Inconsistencies in patients and collaterals
  reporting and documentation. Collateral report
  may seem more accurate when this in fact may not
  be true at all.
• Memory problems controversial for some still.
  Stems from recovered memory research. Research
  data is based on lab data and on non-traumatic
  memory. Researchers havent found data for
  amnesia in their studies. Trauma researchers and
  clinicians report amnesia for childhood and adult
  traumas, sometimes partial amnesia quite
  common. Clinicans often forget that this is a
  symptom of PTSD and other trauma disorders as
  well.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Reports of trauma are questioned because there is
  typically little evidence, abuse usually occurs
  in secrecy or family in denial or because victims
  were asked not to tell.
• Children remember a lot more than people think.
  Study of invasive urinary tract exams 3-7 yo who
  recalled 83 of the details of the exam and
  denied 93 of the details that never occurred.
• Memories of traumas can come back very gradually
  or all of a sudden opened pandoras box. May
  have inconsistencies in patients own reports.
• DD214s dont always show correct MOS or the MOS
  may not sound like a dangerous one. You dont
  have to be infantry to be traumatized in a combat
  theater.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Report of patient inconsistent with family,
  family may not be aware of whats happening with
  veteran there may be no medical and police
  reports to validate e.g. someone was raped.
• Extreme fear may interfere with memory
  consolidation.
• Because traumatic experiences seem bizarre or
  outrageous, That could ever happen. Because you
  have had no traumatic experience yourself doesnt
  mean someone else didnt. Military traumas are
  especially hard to believe because they occur
  under circumstances that non-combatants will
  never be privy to. (C130, collecting body parts
  and putting them in a sardine can) Veterans
  thought to be compensation seeking. Need maintain
  humility, empathy, trust, and openness to
  understanding and learning. My rule Trust until
  find evidence to mistrust.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Sometimes memories begin to frighten them and
  they turn around and deny it. I didnt do that.
  It wasnt me. That must have been someone else.
  Shock of trauma remains.
• Children may be confused about what was happening
  when they were sexually abused and so their
  memories may not be complete or they are halting
  in their description.
• If patient embellishes a report it does not mean
  they didnt suffer a trauma. They could be
  expressing anger - feel no trauma worse then
  theirs. Sometimes testing your knowledge, ability
  to handle the content of their traumas, test your
  reactions to see if they find an empathetic ear
  and some caring or someone who will judge them.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Malingering. Sometimes it happens. Usually a
  person who needs income. Psychotic patients
  sometimes will recount pieces of traumas but
  never served in combat (attempt to strengthen
  ego. Sometimes vets do come here just for
  compensation and a therapeutic assessment
  process allows an opportunity for them to learn
  about their problems (which may be severe and the
  cause of their need for income) and then they
  realize they need and can obtain help. Sometimes
  they are just seeking compensation and this
  should be included in your assessment.
• For routine clinical practice with
  treatment-seeking patients, it would be too
  time-consuming and expensive to administer a full
  battery of malingering assessments. It is
  suggested that clinicians administer to their
  patients the M-FAST (taking only 510 min) and a
  diagnostic interview, such as the SCID-IV.

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Therapeutic Assessment of PTSDObstacles to
Understanding Assessment of Trauma Responses

• Available background material such as previous
  clinical records should also be reviewed, and
  significant others such as spouses could be
  interviewed. For the proportion of patients in
  which these measures provide hints of
  malingering, then a more detailed evaluation
  could be conducted, such as the SIRS, MMPI-2, or
  both.
• Compensation is a benefit. My opinion and that of
  other trauma therapists and researchers is that
  if we just do our job and a good assessment then
  patients can use our notes however they want.

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Suspicion therapists are putting ideas into
  patients heads. Some people accuse therapists of
  teaching PTSD to their patients. Patients need to
  understand their symptoms and why they occur and
  how to change them. Cannot change what you dont
  recognize.
• There are therapists which have inadvertently
  influenced their patients to over-report. More
  and more people are becoming aware of the impact
  of trauma on victims and how poorly victims have
  been treated in the past. Need understand what
  the issue means to you so your own emotions dont
  cloud your judgment. A few symptoms do not
  necessarily mean a patient has been traumatized
  or that they have PTSD, or other trauma related
  disorders, e.g. acute stress disorder,
  dissociative disorder
• Assessment is continual through assessment and
  treatment process. Some patients wont reveal
  their traumas until 6 months or five years later.
  

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Therapeutic Assessment of PTSD Obstacles to
Understanding Assessment of Trauma Responses

• Techniques hypnosis, age regression, guided
  imagery, dream analysis, sodium amytal interviews
  may cause over-reporting unless the clinician is
  methodical, asks open-ended questions, and is
  objective about the procedure. Depends on how the
  clinician uses the instrument as usual.
• Non-systematic assessment methods create errors
  in trauma reports questions are vague or
  unclear. DSM-IV criteria A usually is not
  understandable by most patients. They might say
  no because they never consider the trauma to be
  outside the range of human behavior or they dont
  understand the word traumatic. We dont even
  know what that is sometimes and we have a hard
  time explaining it to patients!

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Therapeutic Assessment of PTSDAssessment Process

• Strategy of assessment depends on your purpose
  research, forensic, clinical. You may want
  qualitative, quantitative information, details
  about the frequencies of symptoms or not.
  Memories are more useful to treatment planning
  than forensic or research data. You may want to
  use pre- and post-treatment measures to study
  treatment outcome.
• Standardized measures developed by experts in
  trauma and psychometrics strongly recommended
  (e.g. CAPS,
• CES, PCL-M, DES). However tests like MMPI-2,
  PAI, MCMI-III are also recommended. Although they
  are not specifically focused on assessing trauma,
  they help assess co-morbid disorders, provide
  some validity to PTSD tests, help make
  differential diagnoses.

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Therapeutic Assessment of PTSD Assessment Process

• Subjective information from your patient is
  essential.
• A thorough clinical interview is invaluable.
  Wounded veterans have a higher rate of PTSD and
  pain complicates the picture often exacerbating
  PTSD symptoms. Assessing relationships between
  deceased and patient very helpful in
  understanding responses. Ask who, what, when (how
  old were you), where, what like for you - if
  patient shares a trauma. Details for two or three
  traumas is enough. How has that changed your
  life?
• Self-reports and interviews are helpful. More
  known now about reliability and validity and how
  to interpret results. Some use DSM diagnostic
  criteria A first to quickly screen for trauma,
  others use specific trauma lists. You can use
  self-report over structured interview but you
  cannot adequately assess trauma responses without
  finding out more about symptoms.
• Physiological measures heart rate, BP, EEG,
  Cerebral Blood Flow, brain metabolism, stress
  hormones, neurotransmitter function PTSD vs
  controls, almost all researcher was done on
  veterans. Labor intensive and typically
  unavailable. The use of virtual reality where you
  present the individual with standardized stimuli
  or personalized cues of traumas is developing
  quickly.

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Therapeutic Assessment of PTSD Assessment
Process

• Official records, collateral sources Military
  records not always accurate and MOS doesnt
  reflect whether someone has had trauma or not.
  Spouses are excellent sources of information even
  if somewhat biased especially if you know theory
  about the impact of trauma on the family system.
  There are predictable responses in spouses and
  children.
• Records and collateral reports are a double-edged
  sword, might damage therapeutic relationship,
  even with clients permission, threatens sense of
  control, reduce trust in you, make patient
  anxious about privacy. May not be worth benefit.
  Collateral information may make you think the
  patients report is inaccurate when it is the
  collaterals that is. On the other hand it could
  be very useful and therapeutic to have spouse in
  office as part of the assessment especially if
  the veteran is telling you he doesnt know his
  symptoms and he trusts his wife. This can lead to
  couples therapy and make an excellent therapeutic
  tool for interventions.

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Therapeutic Assessment of PTSDAssessment Process

• You could assess all the possible traumatic
  experiences, all potential symptoms, all of the
  affected domains of your patients life.
  Realistically dont have the time. Assess the
  most likely and the primary traumatic symptoms.
  Youll have time for these during treatment.
• Often responses to recent events are exacerbated
  by unresolved earlier traumas. Years after a
  trauma has occurred it can resurface in response
  to a recent stressor so this might be the trauma
  of highest priority.
• Assessing symptom domains Acute Stress Disorder,
  PTSD, Dissociative Disorder are cardinal
  responses to trauma. PTSD used to be considered a
  dissociative disorder due to flashbacks,
  intrusive memories.

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Therapeutic Assessment of PTSDAssessment Process

• Common co-morbid disorders are Panic Disorder,
  Dysthymic Disorder, Major Depressive Disorder,
• Substance Abuse Disorders, sometimes see
  veterans with severe PTSD whose guilt has become
  so pathological that it causes the patient to
  experience their guilt as psychotic when under
  stress. Happens especially with chronic severe
  PTSD when someone has gone for years without any
  treatment. Then the differential diagnosis
  becomes psychosis or PTSD with psychotic
  features. If left untreated the patient can
  regress from PTSD to Psychosis. Most clinicians
  arent aware of this possibility.
• When assessing for PTSD, dont forget to inquire
  about associated features which are very
  important for treatment (guilt primitive and
  survivor shame, etc.)

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Therapeutic Assessment of PTSDAssessment Process

• Multimodal assessment has been promulgated since
  1985 when Keane was at Jackson, Mississippi VA
  and refined at Bostons NCTPSD. All measures of a
  disorder are imperfectly related to the condition
  and multiple measures from different domains
  improve diagnostic accuracy and confidence. You
  must also USE YOUR CLINICAL JUDGMENT!
• Military-related PTSD Typical parameters for
  assessment include the individuals level of
  functioning within the developmental, social,
  familial, educational, vocational, medical,
  cognitive, interpersonal, behavioral, and
  emotional domains across time periods prior to,
  during, and after the military service. To
  determine if exposed to a potentially traumatic
  event during military service, need detailed
  descriptions of military duties and experiences.

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Therapeutic Assessment of PTSDAssessment Process

• CES used in military population to measure trauma
  exposure. Many others developed but few
  empirically validated. Review military documents.
  War zone guerilla warfare experiences outside
  traditional military combat activities, i.e.
  exposure to grotesque death and mutilation, and
  many forms of abusive violence are important to
  consider in terms of severity of PTSD symptoms.
  Military Stress Scale (Watson, Kucula, Manifold,
  Vassar, Juba, 1988) and the CES due this.
  Graves Registration Duty Scale (Sutker et al.,
  1994), Atrocity Scale (Brett et. al, 1992)
  Abusive Violence Scale (Hendrix Schumm, 1990),
  War Events Scale, (Unger et al, 1998)
• Malevolent conditions, deprivation food water,
  adverse climate,
• lack of hygiene, lack of sleep, homecoming
  experience contribute
• to clinical picture in assessing severity as
  well as intervention.
• Vietnam Era Stress Inventory, Specific Stressor
  subscale (Wilson Krause, 1980)

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Therapeutic Assessment of PTSDAssessment Process

• DOD, 1995, largest study of sexual trauma during
  military duty, annual rates for sexual harassment
  78 among women and 38 among men (43 overall).
  Attempted or completed sexual assault 6 for
  women, 1 for men (2 overall). ODS rate sexual
  assault 7, physical sexual harassment 33,
  verbal sexual harassment 66 - all higher than
  peacetime military samples (Wolfe al, 1998).
  The Sexual Experiences Questionnaire DOD
• (Fitzgerald et al, 1999), meets standards of
  reliability and validity.
• Deployment Risk Resilience Inventory (King, et
  al, 2003)
• is being used now. 201 items, combines 14
  measures that assess risk and resilience factors
  associated with possible deployment with two
  pre-deployment pre-war factors, 10
• Deployment /war zone factors, two
  post-deployment/ post-war factors.

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Therapeutic Assessment of PTSDAssessment Process

• Acute Stress Disorder duration one month, need
  only one from each cluster of the PTSD criteria.
  Onset is not par of the definition.
• The B set of criteria for dissociative symptoms
  uses the word distressing event not
  traumatic. The dissociative symptom may occur
  during the event or after it. When these
  responses occur around the time of the trauma, it
  is referred to as peritraumatic dissociation and
  post-traumatic dissociation. E.g altered sense
  of time, time slowed or speeding up, profound
  feeling that this is not real, or that you are a
  victim of the event, depersonalization, out of
  body experiences, altered pain perception,
  altered body image or feelings , disconnected
  from body, and tunnel vision.

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Therapeutic Assessment of PTSDAssessment Process

• Measures
• Highly structured interviews
• a) Diagnostic Interview Schedule
  (DIS-IV)(Robins, Helzer, Croughan, Ratcliff,
  1981) is the parent of survey interview
  approach. Used in community epidemiological
  studies for NIMH. Has kept up with changes in
  DSM. Variety of psychiatric illness including
  PTSD. Asks if experienced 1 of 13 specific or
  any other stressful events, if gt1 event endorsed,
  ask which worse, Asked if symptoms linked to
  specific events and if they started after the
  event. The psychometric properties are pretty
  reliable but not consistently high in validity.
  NVVRS used SCI-PTSD but Kulka et. al (1991)
  found it to have poor sensitivity to Vietnam
  veteran sin community
• b) Structured Clinical Interview for DSM-III-R
  PTSD Module (SCID PTSD Spitzer Williams, 1986,
  developed by NVVRS) The SCID PTSD module is the
  first semi-structured clinical interview to
  support a diagnosis of PTSD and it is the most
  frequently used to evaluate the presence or
  absence of PTSD. Provides specific operational
  criteria for the 17 symptoms of PTSD within the
  re-experiencing, numbing/avoidance, and increased
  arousal criterion categories (Kulka et al., 1991)
  kappa .93 reflecting high interrater agreement.
  Lifetime and current symptoms.

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Therapeutic Assessment of PTSDAssessment Process

• c) Clinician Administered PTSD Scale (CAPS)
  (Blake et al., 1990) established reliability and
  validity which assesses current and lifetime PTSD
  symptom severity. Clinicians assign ratings on a
  5-point scale (0-4) for both frequency and
  intensity of PTSD symptoms. This is gold standard
  for PTSD clinics. It has been used in gt 200
  studies.
• Blake et. al require a frequency score of 1
  (scale 0 none of the time to 4 most or all of
  the time) and an intensity score of 2 (scale 0
  none to 4 extreme) for a particular symptom
  to meet the criterion. A severity score for each
  symptom is calculated by summing the frequency
  and intensity scores. The total range of the
  instrument is 0-136. For each symptom, frequency
  and intensity scores are also used to obtain both
  current and lifetime diagnoses. Test-retest
  reliability from .77 - .96, coeff alpha for
  entire scale - .94. Convergent validity for CAPS
  and MMPI-2 Pk (.77) and M-PTSD (.91).

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Therapeutic Assessment of PTSDAssessment Process

• Acute Stress Disorder duration one month, need
  only one from each cluster of the PTSD criteria.
  Onset is not par of the definition.
• The B set of criteria for dissociative symptoms
  uses the word distressing event not
  traumatic. The dissociative symptom may occur
  during the event or after it. When these
  responses occur around the time of the trauma, it
  is referred to as peritraumatic dissociation and
  post-traumatic dissociation. E.g altered sense
  of time, time slowed or speeding up, profound
  feeling that this is not real, or that you are a
  victim of the event, depersonalization, out of
  body experiences, altered pain perception,
  altered body image or feelings , disconnected
  from body, and tunnel vision.

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Therapeutic Assessment of PTSD

• Self-report scales (Symptoms)
• a) Mississippi Scale for Combat- Related PTSD
  (M-PTSD) Keane, Caddell, Taylor, 1988 35
  item Likert-scaled questionnaire originally
  developed to assess DSM-III PTSD symptoms and
  various associated features. It has performed
  well in clinical settings in distinguishing PTSD
  cases from others and in field or community
  studies such as the National Vietnam Veterans
  Readjustment Study. High internal consistency
  .94, test-retest reliability .97, sensitivity .93
  and specificity .89 in clinical samples of
  Vietnam veterans

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Therapeutic Assessment of PTSD

• b) Impact of Events Scale (IES Horowitz,
  Wilner, Alvarez, 1979) Developed with a
  non-combat sample. 15 item scale to measure two
  core psychological effects of traumatic events
  Intrusion (cognitive and affective reexperiencing
  of the traumatic event) and Avoidance (defensive
  denial and avoidance of trauma-related memories
  and feelings).
• Use a traumatic event as anchor point and rate
  the frequency with which they experience various
  trauma-related symptoms. Items are coded 0,1,3,5
  for those marked not at all, rarely,
  sometimes, and often respectively. (Zilberg,
  Weiss, and Horowitz, 1982. Codes then summed to
  yield a total self reported PTSD symptom score.
  Can use separate scale scores or total
  (totalsplit-half reliability of .86 per
  Horowitz, et al, 1979).
• Less useful diagnostic utility than either
  MMPI-2 Pk or Mississippi.

38
Therapeutic Assessment of PTSD

• c) M-PTSD, IES, MMPI Pk PTSD subscale were
  found
• to be strongly correlated with each other
  SCID-based
• PTSD symptoms (McFall, Smith, Mackay, Tarver,
  1990
• McFall, Smith, Roszell, Tarver Malas, 1990
  Watson et al.,
• 1994). This subscale used often in research. The
  MMPI-2 Pk
• scale consists of 46 true-false items which are
  essentially
• equivalent to the 49 item MMPI Pk score
  although the
• MMPI-e Pk score may be lower among highly
  symptomatic
• patients. (Litz et al, 1991)
• d) MMPI Ps PTSD scale (Schlenger Kulka,
  1989) highly
• correlated with the Pk scale (r.95),
  Performance
• equivalent even in community samples.

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Therapeutic Assessment of PTSD

• e) PTSD Checklist Military version (PCL-M
  Weathers, Litz, Herman, Huska Keane, 1993).
  Measure directly reflects the diagnostic criteria
  for PTSD as outlined in the DSM-IV. Overall
  cut-off score of 50 recommended to diagnose PTSD
  but the cut off score has differed depending on
  the patient population.
• f) Combat Exposure Scale (CES Keane, Fairbank,
  Caddell, Zimering, Taylor Mora, 1989) 7 items
  reflecting frequency of exposure to life
  threatening combat experiences. Most accurate for
  infantry but not very useful for Navy and other
  MOSs.
• g) The Purdue Post-traumatic Stress Scale-Revised
  (PPTSD-Rl Lauterbach Vrana, 1996)
• h) The Self-Rating Inventory for PTSD (SIP
  Hovens et al, 2002) includes PTSD symptoms and
  associated features.

40
Therapeutic Assessment of PTSD

• Multidimensional Anger Inventory (Miller,
  Jenkins, Kaplan Salonen, 1995 Siegel, 1986)
  Conflict Tactics Scale (Straus, 1979) and
  hostility subscale of the SCL-90-R measures core
  trauma responses that are not measured by the
  PTSD scales. Anger and aggression a common
  response. Self-harming behavior, substance abuse,
  disordered eating, sexual impulsiveness.
• Beck Depression Inventory (BDI) or subscales of
  MCMI-III, MMPI-2 or SCL-90-R. Depression common
  and not measured well by PTSD scales.

41
Therapeutic Assessment of PTSD

• Several measures perform well in predicting PTSD
  diagnosis that are not directly based on DSM
  diagnostic criteria. Two of the primary
  self-report measures in the NVVRS were the MMPI
  Pk scale (Keane, Malloy Fairbank, 1984) and the
  Mississippi Scale for Combat-related PTSD (Keane,
  Caddell, Taylor, 988) one of the most used
  scales for assessing veteran population.

42
Therapeutic Assessment of PTSD

• Cultural Considerations
• Be sensitive to ethnic issues and be aware of
  your own prejudices and biases. Go beyond
  comparing categories of ethnic groups as the only
  means of understanding ethnocultural variability.
  Remember the level of the individuals
  acculturation to the dominant culture must be
  assessed rather than assumed by their ethnic
  identity. Instruments must be developed that
  maintains equivalence across several different
  culture groups.
• Know how ethnic groups have been misdiagnosed,
  e.g. AA mens responses to MMPI might be
  interpreted as paranoid schizophrenia.

43
Therapeutic Assessment of PTSD

• Cultural Considerations
• Assessment of Military Related PTSD need
  instruments that are culturally sensitive. Over
  the past 20 yrs the military population has
  changed with increased number of women by 15 and
  the percentage of African Americans has doubled
  from 10 to 20 . Important to know that AA and
  Hispanics have a higher rate of PTSD than other
  minorities and Caucasians.

44
Therapeutic Assessment of PTSD

• Also important to note that family is more often
  involved in the assessment process in Hispanic
  and AA veteran population. More difficult for a
  Hispanic male to talk with a women. Racial
  conflicts, discrimination, bicultural struggles,
  and identification with the enemy have all been
  cited as stressors commonly experienced by
  minority veterans.
• Differences in the level of exposure to war-zone
  stressors and the severity of PTSD symptoms
  experienced between ethnic minority groups and
  Caucasian veterans has been empirically
  documented. Some investigators have begun to
  identify possible mediators of the effect of
  ethnicity on the development of PTSD, such as
  discrimination and alienation (Ruef, Litz
  Schlenger, 2000).

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