Posttraumatic Stress Disorder (PTSD) Assessment Abigail A. Goldsmith, PhD Program Director,...

Posttraumatic Stress Disorder (PTSD) Assessment

Abigail A. Goldsmith, PhDProgram Director, OEF/OIF/OND PTSD Clinic,

VA San Diego Healthcare SystemAssistant Clinical Professor of Psychiatry,

University of California, San Diego School of Medicine

VETERANS HEALTH ADMINISTRATION

Objectives

• List considerations for choosing PTSD assessment measures

• Identify additional assessment domains that are associated with PTSD

• List and differentiate between common self-report and interview assessments for PTSD

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PTSD Assessment Introduction

• Accurate assessment of PTSD is necessary for:– Clinical treatment planning– Research and models of PTSD– Policy development– Disability status



• Potential barriers to accurate PTSD assessment– Mental health stigma– Confidentiality concerns– Secondary gains

• Presence of potential barriers does not automatically indicate underreporting or overreporting



• General assessment recommendations– Develop rapport– Convey limits to confidentiality– Provide psychoeducation– Utilize evidence based assessment– Consider multiple assessment modalities

• E.g., interview, observation, physiological measures (BP)• Integrate data from multiple sources • Allow for multiple assessment sessions if possible


Objectives




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Considerations for Choosing PTSD Assessment Measures

• Questions to consider:– Why are you assessing?– Who are you assessing?– What are you assessing?


Considerations: Why are you assessing?

• Assessments should be tailored to setting and individual needs

• Research vs Clinical Settings– Consider allowable time for assessment– Consider resources

• Training and consultation to learn assessments• Cost and availability of measures


Considerations: Why are you assessing?

• To screen for PTSD (Brewin, 2005)• To diagnose PTSD• To assess severity of PTSD symptoms– To examine treatment outcomes: effectiveness/efficacy

• To examine PTSD-related functional impairment– To examine disability or return to work status


Considerations: Who are you assessing?

• Consider population-specific measures– Children/Adolescents– Veterans/Military– Older adults– Culture-specific (language)


Considerations: What are you assessing?

• Trauma exposure• Deployment experiences• Functional impairment• Response to stimuli – physiological reactivity• PTSD symptoms


Objectives




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PTSD Comorbidity• High rates of comorbid psychopathology in combat

Veterans indicate that post-combat psychopathology manifests through a myriad of symptoms and disorders (Seal et al., 2009).

• Individuals with co-occurring posttraumatic disorders tend to fare worse than those diagnosed with a single disorder (Holtzheimer et al., 2005).

• Thorough PTSD assessment should assess additional, often comorbid domains.


Additional Assessment Domains • Suicidality• Dissociation• Depression • Grief• Anger• Guilt & Shame• Alcohol & Substance Use• TBI & Cognition• Readiness for change


Objectives




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PTSD assessment: Self-Report• Generally brief

• Several psychometrically sound measures

• May be sensitive to response bias and inaccuracy– Not paying attention to instructions– Random responding– Minimizing or exaggerating

• Good for assessing treatment outcomes and clinical change


PTSD assessment: Self-Report• Common self-report measures:

• PTSD Checklist (PCL; Weathers, 1993) – Most frequently used self-report measure– Assesses how much one was “bothered by” PTSD symptoms in

previous month• Does not assess frequency of occurrence

– PCL-Civilian (PCL-C), PCL Military (PCL-M), & PCL Specific (PCL-S)– Scoring review: McDonald & Calhoun, 2010– Available on PTSD Coach App

• Davidson Trauma Scale (DTS; Davidson, 1997)– Assesses frequency & intensity for past week


PTSD assessment: Self-Report• Common self-report measures:

• Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1996)– 22 items but not all 17 PTSD sxs, assesses level of distress in past week– screening measure

• Mississippi Scale (Keane, Caddell, & Taylor, 1988)– 35 items (PTSD + substance use, depression), assess statements from

“extremely true to not at all true,” no temporal instructions– Not event-specific, combat or civilian versions


PTSD assessment: Interview• Most often utilized in clinical practice

– Vary from structured, semi-structured, to unstructured– Often require training

• Common interview assessments:

• Structured Clinical Interview for DSM-IV-TR (SCID-IV; First et al., 2002)– Dichotomous ratings of specific symptom presence– Limitations

• No frequency or intensity ratings• Only symptoms related to “worst event” are assessed• Single gate keeping question – lower validity assessing PTSD


PTSD assessment: Interview• Mini-International Neuropsychiatric Interview (MINI; Sheehan

et al., 1998)– Dichotomous ratings of 11 PTSD symptoms – screening tool– Gate keeping/skip-out questions throughout interview

• PTSD Symptom Scale Interview (PSSI; Foa, Riggs, Dancu, & Rothbaum, 1993)– Frequency scale of PTSD symptoms over previous 2 weeks– Instructions to “probe then qualify”

• Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) – “Gold standard” for PTSD assessment– Thorough & psychometrically sound


Assessment Steps Summary

• Identify Needs• Choose Measures– Note strengths and limitations of measures

• Conduct Assessment– Multimethod approach suggested

• Integrate Results of Assessment– Follow-up on inconsistent results (interview vs self-report)

• Report and Disseminate Conclusions

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ResourcesNational Center for PTSD

Intranet - http://vaww.ptsd.va.gov/Assessment.aspInternet - http://www.ptsd.va.gov/professional/pages/assessments/assessment.asp

PILOTS Database Instrument Authority List

http://www.ptsd.va.gov/professional/pilots-database/pilots-pdf/PILOTS_Instrument_Author.pdf

Further ReadingLitz, B.T., Penk, W.E., Gerardi, R.J., & Keane, T.M. (1992). Assessment of

posttraumatic stress disorder. In P.A. Saigh (Ed.). Posttraumatic Stress Disorder: A Behavioral Approach to Assessment and Treatment (pp. 50-84). Needham Heights, MA: Allyn and Bacon.

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ReferencesBlake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al.

(1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75−90.

Brewin, C. R. (2005). Systematic review of screening instruments for adults at risk of PTSD. Journal of Traumatic Stress, 18, 53−62.

Davidson, J. R. T., Book, S. W., Colket, J. T., Tupler, L. A., Roth, S., David, D., Hertzberg, M., Mellman, T., Beckham, J. C., Smith, R., Davison, R. M., Katz, R., & Feldman, M. (1997). Assessment of a new self-rating scale for post-traumatic stress disorder. Psychological Medicine, 27, 153-160.

First, M. B., Spitzer, R. L., Miriam, G., & Williams, J. B. W. (2002). Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition With Psychotic Screen (SCID-I/P W/ PSY SCREEN). New York: Biometrics Research, New York State Psychiatric Institute. Science & Business Media.

Foa, E., Riggs, D., Dancu, C., & Rothbaum, B.(1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459-474.

Holtzheimer, P. E., Russo, J., Zatzick, D., Bundy, C., & Roy-Byrne, P. P. (2005). The impact of comorbid posttraumatic stress disorder on short-term clinical outcome in hospitalized patients with depression. American Journal of Psychiatry, 162(5), 970-976.

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ReferencesKeane, T. M., Caddell, J. M., & Taylor, K. L. (1988) Mississippi Scale for Combat-Related

Posttraumatic Stress Disorder: three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 56, 85-90.

McDonald, S. D., & Calhoun, P. S. (2010). The diagnostic accuracy of the PTSD Checklist: A critical review. Clinical Psychology Review, 30, 976-987.

Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S., & Marmar, C. R. (2009). Trends and risk factors for mental health diagnoses among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, 2002-2008. American Journal of Public Health, 99(9), 1651.

Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(Suppl 20), 22−33.

Weathers, F., Litz, B., Herman, D., Huska, J., and Keane, T. (1993, October). The PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX.

Weiss, D. S., & Marmar, C. R. (1996). The Impact of Event Scale - Revised. In J. Wilson & T. M. Keane (Eds.), Assessing psychological trauma and PTSD (pp. 399-411). New York: Guilford.

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Posttraumatic Stress Disorder (PTSD) Assessment Abigail A. Goldsmith, PhD Program Director,...

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