Download PTSD Symptomatology – Self Report Measures

PTSD Symptomatology – Self Report Measures
At the current time, the PTSD diagnostic gold standard remains structured clinical
interview to predefined criteria (DSM-IV). However, standardised interview is not
always practically possible at ICU follow-up, and the administration of self-report
inventories allows the identification of PTSD symptomatology. Thus, a variety of selfreport measures have been used to screen for the symptoms of PTSD, and some of these
are described below.
Davidson Trauma Scale (DTS)
Description
The Davidson Trauma Scale (DTS) is a 17-item self-report measure that assesses all 17
primary DSM-IV symptoms of PTSD relating to the three main symptom areas
(intrusion, avoidance and hyperarousal). It can be used to make a preliminary
determination about whether the symptoms meet DSM-IV criteria for PTSD.
Administration
The DTS is a self-report measure designed to assess current subjective distress for any
specific life event and only takes a few minutes to complete. The instructions are given at
the top of the questionnaire.
Scoring
Items are rated on 5-point frequency (0 = "not at all" to 4 = "every day") and severity
scales (0 = "not at all distressing" to 4 = "extremely distressing") [1]. Respondents are
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. The DTS yields a frequency score
(ranging from 0 to 68), severity score (ranging from 0 to 68), and total score (ranging
from 0 to 136). Scores can also be calculated for each of the 3 PTSD symptom clusters
(i.e., B, C, and D).
Interpretation
It has been suggested that a score of 40 or above (sensitivity 0.69; specificity 0.95;
efficiency 0.83) can be used to identify patients in whom a diagnosis of PTSD according
to DSM-IV criteria is highly likely [1][2]. A score of 27 or above (sensitivity 0.81;
specificity 0.82; efficiency 0.81) can be used to identify individuals with high levels of
specific psychopathology who may or may not meet DSM-IV diagnostic criteria for
PTSD [1][2].
References
1
1. Davidson JR, Book SW, Colket JT, Tupler LA, Roth S, David D, Hertzberg M,
Mellman T, Beckham JC, Smith RD, Davison RM, Katz R, Feldman ME (1997)
Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med
27:153-160
2. Cuthbertson BH, Hull A, Strachan M, Scott J (2004) Post-traumatic stress disorder
after critical illness requiring general intensive care. Intensive Care Med 30:450-455
Impact of Event Scale (IES)
Description
The Impact of Events Scale (IES) is the most widely used self-report measure of specific
responses to trauma [1]. The IES is a 15 item questionnaire and has two subscales, which
look separately at avoidance and intrusion. Seven items measure intrusive symptoms
(intrusive thoughts, nightmares, intrusive feelings and imagery) and eight items measure
avoidance symptoms (numbing of responsiveness, avoidance of feelings, situations,
ideas). All items of the IES are anchored to a specific stressor, and together the subscales
give a total impact of event score reflecting the extent to which a traumatic event is
affecting the individual’s thought processes.
Administration
The IES is a self-report measure designed to assess current subjective distress for any
specific life event and only takes a few minutes to complete. The instructions are given at
the top of the questionnaire.
Scoring
The questions are scored as follows: 0 = not at all; 1 = rarely; 3 =sometimes; 5 = often.
The scoring key provided after the questionnaire can be used to calculate the subscale
scores and the total score. In the original paper the mean total stress score was 39.5
(SD=17.2, range 0-69), the intrusion subscale mean was 21.4 (SD = 9.6, range 0-35) and
the avoidance subscale mean was 18.2 (SD = 10.8, range 0-38) [1].
Interpretation
The time scale of the scale is seven days and thus it is designed to assess current
symptoms – regardless of when the traumatic event took place. It cannot be used to
diagnose PTSD. It is recommended for use in the clinical setting as a measure of
symptom severity or symptom change. There are no cut-off points as it is a descriptive
rather than a diagnostic tool.
Psychometric details
2
The IES was originally tested on 66 adults seeking psychotherapy for stress response
syndromes in an outpatient setting. Nearly half of the group were bereaved, the remainder
had personal injuries from violence, accidents, illness or surgery. The split-half reliability
of the IES scale was high (r=0.86) [1].The subscales of the IES show very good internal
consistency based on 2 separate sample groups [2]. The coefficients ranged from 0.79 to
0.92, with an average of 0.86 for the intrusive subscale and 0.90 for the avoidance
subscale.
Internal consistency of the subscales, calculated using Cronbach's Alpha, was also high
(r= 0.78 intrusion, r = 0.82 avoidance). A correlation of 0.42 (p>0.0002) between the
intrusion and avoidance subscales indicates that the two subsets are associated, but do not
measure identical dimensions. The IES has also displayed the ability to discriminate a
variety of traumatised groups from non-traumatised groups [3].
References
1. Horowitz M, Wilner M, Alvarez W (1979) Impact of Event Scale: A measure of
subjective stress. Psychosomatic Medicine. 41; 209-218.
2. Weiss D, Marmar C (1997) The Impact of Event Scale -Revised. In J. Wilson & T.
Keane (Eds), Assessing psychological trauma and PTSD. New York: Guildford.
3. Briere J (1997) Psychological assessment of adult posttraumatic states. Washington,
D.C.: American Psychological Association.
3
The Impact of Event Scale
Below is a list of comments made by people after stressful life events. Using the
following scale, please indicate how frequently each of these comments was true for you
DURING THE PAST SEVEN DAYS.
.
Not at
all
Rarely Sometimes
Often
I thought about it when I didn't mean to
.
.
.
.
I avoided letting myself get upset when I thought about it
or was reminded of it
.
.
.
.
I tried to remove it from memory
.
.
.
.
I had trouble falling asleep or staying asleep because of
pictures or thoughts about it that came into my mind
.
.
.
.
I had waves of strong feelings about it
.
.
.
.
I had dreams about it
.
.
.
.
I stayed away from reminders of it
.
.
.
.
I felt as if it hadn't happened or wasn't real
.
.
.
.
I tried not to talk about it
.
.
.
.
Pictures about it popped into my mind
.
.
.
.
Other things kept making me think about it
.
.
.
.
4
I was aware that I still had a lot of feelings about it, but I
didn't deal with them
.
.
.
.
I tried not to think about it
.
.
.
.
Any reminder brought back feelings about it
.
.
.
.
My feelings about it were kind of numb
.
.
.
.
Scoring:
Not at all = 0; Rarely = 1;
Total = total the scores.
Sometimes = 3;
Often = 5
5
Impact of Event Scale - Revised (IES-R)
Description
The original Impact of Events Scale (IES) only screened for 2 of the 4 criteria set out for
PTSD in the DSM-IV: intrusion and avoidance [1]. The Impact of Events Revised (IESR) was developed in 1997 to parallel the DSM-IV criteria for PTSD and screen for the
fourth criterion for PTSD, the hyperarousal cluster of symptoms [2]. The IES-R has 22
items, 7 items having being added to the original 15-item IES [2]. The 7 items comprise 6
that measure hyperarousal symptoms (such as anger and irritability, heightened startle
response, difficulty concentrating, hypervigilance) and one new intrusion item that
measures dissociative like reactions.
Administration
The IES-R is similar to IES in that it is a self-report measure designed to assess current
subjective distress for any specific life event and only takes a few minutes to complete.
The instructions are given at the top of the questionnaire.
Scoring
The questions are scored as follows: 0 = not at all; 1 = a little bit; 2 =moderately; 3 =
quite a bit; 4 = extremely. The scoring key provided after the questionnaire can be used to
calculate the subscale scores and the total score. The sum of the avoidance and intrusion
subscales can be used for valid comparisons with scores from the IES.
Interpretation
The time scale of the scale is seven days and thus it is designed to assess current
symptoms – regardless of when the traumatic event took place. It cannot be used to
diagnose PTSD. It is recommended for use in the clinical setting as a measure of
symptom severity or symptom change. There are no cut-off points as it is a descriptive
rather than a diagnostic tool.
Psychometric details
In their study of 4 different population samples, Weiss and Marmar reported satisfactory
reliability of the IES-R [2]. Internal consistency of the 3 subscales was found to be very
high, with intrusion alphas ranging from 0.87 to 0.92, avoidance alphas ranging from
0.84 to 0.86, and hyperarousal alphas ranging from 0.79 to 0.90. Test-retest reliability
was also satisfactory for 2 of the samples in the Weiss and Marmar study [2]. Data from
sample 1 (n = 429) yielded the following test-retest correlation co-efficients for the
subscales: r = 0.57 intrusion, r = 0.51 avoidance, r = 0.59 hyperarousal. From sample 2
(n = 197) the correlation coefficients were considerably higher: r = 0.94 intrusion,
avoidance = 0.89 avoidance, r =0.92 hyperarousal. The hyperarousal subscale has
6
demonstrated good predictive validity with regard to trauma and the intrusion and
avoidance subscales have been shown to detect change in repondents' clinical status over
time and detect relevant differences in the response to traumatic events of varying
severity [1][2].
References
1. Horowitz M, Wilner M, Alvarez W (1979) Impact of Event Scale: A measure of
subjective stress. Psychosomatic Medicine 41: 209-218.
2. Weiss D, Marmar C (1997) The Impact of Event Scale -Revised. In J. Wilson & T.
Keane (Eds), Assessing psychological trauma and PTSD. New York: Guildford.
7
The Impact of Event Scale - Revised
Below is a list of difficulties people sometimes have after stressful life events. Please
read each item, and then indicate how distressing each difficulty has been for you
DURING THE PAST SEVEN DAYS with respect to ___________________________,
how much were you distressed or bothered by these difficulties?
Not at all
A little bit
Moderately
Quite a bit
Extremely
Any reminder brought
back feelings about it
0
1
2
3
4
I had trouble staying
asleep
0
1
2
3
4
Other things kept
making me think about
it
0
1
2
3
4
I felt irritable and angry
0
1
2
3
4
I avoided letting myself
get upset when I thought
about it or was reminded
of it
0
1
2
3
4
I thought about it when I
didn’t mean to
0
1
2
3
4
I felt as if it hadn’t
happened or wasn’t real
0
1
2
3
4
I stayed away from
reminders about it
0
1
2
3
4
Pictures about it popped
into my mind
0
1
2
3
4
I was jumpy and easily
startled
0
1
2
3
4
I tried not to think about
it
0
1
2
3
4
I was aware that I still
had a lot of feelings
about it, but I didn’t deal
with them
0
1
2
3
4
My feelings about it
were kind of numb
0
1
2
3
4
8
I found myself acting or
feeling as though I was
back at that time
0
1
2
3
4
I had trouble falling
asleep
0
1
2
3
4
I had waves of strong
feelings about it
0
1
2
3
4
I tried to remove it from
my memory
0
1
2
3
4
I had trouble
concentrating
0
1
2
3
4
Reminders of it caused
me to have physical
reactions, such as
sweating, trouble
breathing, nausea, or a
pounding heart
0
1
2
3
4
I had dreams about it
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
I felt watchful or onguard
I tried not to talk about it
Scoring:
Avoidance Subscale = mean of items 5, 7, 8, 11, 12, 13, 17, 22
Intrusion Subscale = mean of items 1, 2, 3, 6, 9, 14, 16, 20
Hyperarousal Subscale = mean of items 4, 10, 15, 18, 19, 21
9
Post Traumatic Stress Syndrome 10-Questions Inventory (PTSS-10)
Description
The Post Traumatic Stress Syndrome 10-questions inventory (PTSS-10) was originally
designed to diagnose PTSD, according to Diagnosis and Statistical Manual of Mental
Disorders (DSM)-III criteria, in victims of natural disasters [1], and it was subsequently
validated in Norwegian seaman after they had undergone torture in Libya [2]. The PTSS10 has since been validated in patients with acute respiratory distress disorder (ARDS)
after ICU treatment using the Structured Clinical Interview for DSM-IV (SCID) [3]. The
questionnaire records the presence and intensity of 10 post-traumatic stress symptoms:
sleep disturbance, nightmares, depression, hyperalertness, withdrawal, generalized
irritability, frequent changes in mood, guilt, avoidance of activities prompting recall of
possible traumatizing events and increased muscle tension.
Administration
The PTSS-10 is a self-report measure designed to assess current subjective distress for
any specific life event and only takes a few minutes to complete. The instructions are
given at the top of the questionnaire. It can be administered by non mental-health trained
professionals and is comparable whether administered by face to face interview of over
the telephone.
Scoring and Interpretation
The questionnaire consists of 10 items, each with a Likert scale ranging from 1 ('never')
to 7 ('always'). A summated score with a range between 10 and 70 is calculated, with
higher scores indicating more PTSD-related symptoms. A score of 35 or greater is
considered an adequate cutoff for PTSD-related symptomology [3], whereas patients with
scores between 27 and 35 on PTSS-10 were considered to have borderline PTSD
symptomology.
Psychometric properties
The PTSS-10 demonstrates a high internal consistently (Crohnbach’s alpha of 0.85), and
a high test-retest reliability (intraclass correlation coefficient alpha of 0.89) [3]. The
PTSS-10 has good construct validity. Criterion validity has been demonstrated by ROC
curve analyses resulting in a sensitivity of 77% and a specificity of 97.5% for the
diagnosis of PTSD at a PTSS-10 threshold score of 35 or greater [3]. The positive
predictive value of the PTSS-10 at the threshold of 35 or greater was 91% ((5%
confidence interval 74-100%) with an accuracy 92% [3].
References
10
1. Weisaeth L (1989) The stressors and the post-traumatic stress syndrome after an
industrial disaster. Acta Psychiatr Scand Suppl 355: 25-37
2. Weisaeth L (1989) Torture of a Norwegian ship's crew. The torture, stress reactions
and psychiatric after-effects. Acta Psychiatr Scand Suppl 355: 63-72
3. Stoll C, Kapfhammer HP, Rothenhausler HB, Haller M, Briegel J, Schmidt M,
Krauseneck T, Durst K, Schelling G (1999) Sensitivity and specificity of a screening test
to document traumatic experiences and to diagnose post-traumatic stress disorder in
ARDS patients after intensive care treatment. Intensive Care Med 25: 697-704
11
POSTTRAUMATIC SYMPTOM SCALE
(PTSS-10)
This questionnaire deals with your present well-being and asks about typical reactions that occur
as a result of strain or stress.
Please mark the number that expresses what best applies for you.
Please mark “1” if the condition has not occurred; “2” if allusively; until “7“ if you are always
confronted with the problem and if this is very burdensome for you.
Presently (this means in the past few days) I suffer from:
1. sleep problems
Never
always
1
2
3
4
5
6
7
2. nightmares
Never
always
1
2
3
4
5
6
7
3. depression, I feel dejected/down-trodden
Never
always
1
2
3
4
5
6
7
4. jumpiness, I am easily frightened by sudden sounds I hear or sudden movements I see
Never
always
1
2
3
4
5
6
7
5. the need to withdraw from others
Never
always
1
2
3
4
5
6
7
6. irritability, that is, I am easily agitated / annoyed and angry
Never
always
1
2
3
4
5
6
7
7. frequent mood swings
Never
always
1
2
3
4
5
6
7
8. a bad conscience, blame myself, have guilt feelings
Never
always
1
2
3
4
5
6
7
9. fear of places and situations, which remind me of the Intensive Care Unit
Never
always
1
2
3
4
5
6
7
10. muscular tension
Never
always
1
2
3
4
5
6
7
12