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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