Posttraumatic Stress Disorder (PTSD) Assessment

1. Posttraumatic Stress Disorder (PTSD) Assessment Abigail A. Goldsmith, PhD Program Director, OEF/OIF/OND PTSD Clinic, VA San Diego Healthcare System Assistant Clinical Professor of Psychiatry, University of California, San Diego School of Medicine

2. 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

3. PTSD Assessment Introduction • Accurate assessment of PTSD is necessary for: • Clinical treatment planning • Research and models of PTSD • Policy development • Disability status

4. PTSD Assessment Introduction • Potential barriers to accurate PTSD assessment • Mental health stigma • Confidentiality concerns • Secondary gains • Presence of potential barriers does not automatically indicate underreporting or overreporting

5. PTSD Assessment Introduction • 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

6. 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

7. Considerations for Choosing PTSD Assessment Measures • Questions to consider: • Why are you assessing? • Who are you assessing? • What are you assessing?

8. 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

9. 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

10. Considerations: Who are you assessing? • Consider population-specific measures • Children/Adolescents • Veterans/Military • Older adults • Culture-specific (language)

11. Considerations: What are you assessing? • Trauma exposure • Deployment experiences • Functional impairment • Response to stimuli – physiological reactivity • PTSD symptoms

12. 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

13. 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.

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Resources National Center for PTSD Intranet - http://vaww.ptsd.va.gov/Assessment.asp Internet - 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 Reading Litz, 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.

23. References Blake, 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.

24. References Keane, 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.