POSTTRAUMATIC STRESS DISORDER

DIAGNOSIS AND ASSESSMENT

Subcommittee on Posttraumatic Stress Disorder

of the

Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu



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Posttraumatic Stress Disorder: Diagnosis and Assessment POSTTRAUMATIC STRESS DISORDER DIAGNOSIS AND ASSESSMENT Subcommittee on Posttraumatic Stress Disorderof the Committee on Gulf War and Health: Physiologic, Psychologic, and Psychosocial Effects of Deployment-Related Stress Board on Population Health and Public Health Practice INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Posttraumatic Stress Disorder: Diagnosis and Assessment THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101(93)P-2155 between the National Academy of Sciences and the Department of Veterans Affairs. Any opinions, findings, or conclusions expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-10207-3 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624– 6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Posttraumatic Stress Disorder: Diagnosis and Assessment “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Posttraumatic Stress Disorder: Diagnosis and Assessment THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J.Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm.A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J.Cicerone and Dr. Wm.A.Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Posttraumatic Stress Disorder: Diagnosis and Assessment SUBCOMMITTEE ON POSTTRAUMATIC STRESS DISORDER RICHARD MAYEUX, MD, MS (Chair), Gertrude H.Sergievsky Professor of Neurology, Psychiatry, and Epidemiology, Director, Sergievsky Center, and Co-Director, Taub Institute, College of Physicians and Surgeons, Columbia University KATHRYN KARUSAITIS BASHAM, PhD, MSW, Professor, Smith College School for Social Work DENNIS S.CHARNEY, MD, Dean of Research and Anne and Joel Ehrenkranz Professor, Departments of Psychiatry, Neuroscience, and Pharmacology and Biological Chemistry, Mount Sinai School of Medicine MICHAEL DAVIS, PhD, Robert W.Woodruff Professor of Psychiatry, Behavioral Sciences and Psychology, Emory University DWIGHT L.EVANS, MD, Ruth Meltzer Professor and Chairman, Department of Psychiatry, Medicine and Neuroscience, University of Pennsylvania School of Medicine JACK GORMAN, MD, President and Psychiatrist-in-Chief, McLean Hospital JANICE L.KRUPNICK, PhD, Professor, Department of Psychiatry, Georgetown University BRUCE S.MCEWEN, PhD, Alfred E.Mirsky Professor and Head, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University CAROL S.NORTH, MD, MPE, Professor of Psychiatry and Nancy and Ray L.Hunt Chair in Crisis Psychiatry, University of Texas Southwestern Medical Center Department of Psychiatry (resigned October 2005) JERROLD F.ROSENBAUM, MD, Psychiatrist-in-Chief and Stanley Cobb Professor of Psychiatry, Massachusetts General Hospital, Harvard Medical School

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Posttraumatic Stress Disorder: Diagnosis and Assessment COMMITTEE ON GULF WAR AND HEALTH: PHYSIOLOGIC, PSYCHOLOGIC, AND PSYCHOSOCIAL EFFECTS OF DEPLOYMENT-RELATED STRESS RICHARD MAYEUX, MD, MS (Chair), Gertrude H.Sergievsky Professor of Neurology, Psychiatry, and Epidemiology, Director, Sergievsky Center, and Co-Director, Taub Institute, College of Physicians and Surgeons, Columbia University JAMES C.ANTHONY, MS, PhD, Professor and Chair, College of Human Medicine, Michigan State University (resigned March 2006) KATHRYN KARUSAITIS BASHAM, PhD, MSW, Professor, Smith College for Social Work EVELYN J.BROMET, PhD, Professor, Department of Psychiatry and Behavioral Science, State University of New York at Stony Brook GREGORY L.BURKE, MD, MS, Professor and Director, Public Health Sciences, Wake Forest University School of Medicine DENNIS S.CHARNEY, MD, Dean of Research and Anne and Joel Ehrenkranz Professor, Departments of Psychiatry, Neuroscience, and Pharmacology and Biological Chemistry, Mount Sinai School of Medicine MICHAEL DAVIS, PhD, Robert W.Woodruff Professor of Psychiatry Behavioral Sciences and Psychology, Emory University DOUGLAS A.DROSSMAN, MD, Professor of Medicine and Psychiatry and Co-Director, University of North Carolina Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina School of Medicine DWIGHT L.EVANS, MD, Ruth Meltzer Professor and Chairman, Department of Psychiatry, Medicine, and Neuroscience, University of Pennsylvania School of Medicine VINCENT J.FELITTI, MD, Physician and Founder, Department of Preventive Medicine, Kaiser Permanente Medical Care Program, San Diego

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Posttraumatic Stress Disorder: Diagnosis and Assessment JACK GORMAN, MD, President and Psychiatrist-in-Chief, McLean Hospital KERRY L.KNOX, PhD, Associate Professor, University of Rochester School of Medicine JANICE L.KRUPNICK, PhD, Professor, Georgetown University WILLIAM B.MALARKEY, MD, Professor of Internal Medicine and Molecular Virology, Immunology and Medical Genetics, and Director, Clinical Research Center, Ohio State University BRUCE S.MCEWEN, PhD, Alfred E.Mirsky Professor and Head, Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology, Rockefeller University CAROL S.NORTH, MD, MPE, Professor of Psychiatry and Nancy and Ray L.Hunt Chair in Crisis Psychiatry, University of Texas Southwestern Medical Center Department of Psychiatry (resigned October 2005) THOMAS G.PICKERING, MD, DPhil, Professor of Medicine, Department of Medicine, Columbia University JERROLD F.ROSENBAUM, MD, Psychiatrist-in-Chief and Stanley Cobb Professor of Psychiatry, Massachusetts General Hospital BERNARD TIMOTHY WALSH, MD, William and Joy Ruane Professor of Pediatric Psychopharmacology, Department of Psychiatry, Columbia University

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Posttraumatic Stress Disorder: Diagnosis and Assessment STAFF CAROLYN E.FULCO, MS, IOM Scholar, Senior Program Officer ROBERTA WEDGE, MS, Senior Program Officer SANDRA GOODBODY, MSW, Senior Program Officer ROSE MARIE MARTINEZ, ScD, Director, Board on Population Health and Public Health Practice HOPE R.HARE, MA, Administrative Assistant DEEPALI PATEL, Senior Program Associate PETER JAMES, Research Associate DAMIKA WEBB, Research Assistant DAVID TOLLERUD, Project Assistant NORMAN GROSSBLATT, Senior Editor CONSULTANTS MIRIAM DAVIS, PhD, Independant Medical Writer, Silver Spring, Maryland CAROL S.NORTH, MD, MPE, Professor of Psychiatry and Nancy and Ray L.Hunt Chair in Crisis Psychiatry, University of Texas Southwestern Medical Center Department of Psychiatry (as of October 2005)

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Posttraumatic Stress Disorder: Diagnosis and Assessment REVIEWERS This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: MICHAEL ALEXANDER, MD, Professor of Neurology, Beth Israel Deaconess Medical Center EDNA B.FOA, PhD, Professor and Director, Center for the Treatment and Study of Anxiety, University of Pennsylvania JUDITH HERMAN, MD, Harvard Medical School, Victims of Violence Program, Cambridge Hospital JOHN H.KRYSTAL, MD, Professor of Clinical Pharmacology, Yale University School of Medicine, VA Connecticut Healthcare System, Ribicoff Research Facilities, Connecticut Mental Health Center BARBARA ROTHBAUM, PhD, Director, Trauma and Recovery Program, The Emory Clinic, and Professor, Department of Psychiatry and Behavioral Sciences, Emory University DAVID SILBERSWEIG, MD, Department of Psychiatry, Weill Medical College of Cornell University

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Posttraumatic Stress Disorder: Diagnosis and Assessment Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by ELAINE L.LARSON, PhD, RN. Appointed by the National Research Council, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the author committee and the institution.

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Posttraumatic Stress Disorder: Diagnosis and Assessment CONTENTS     SUMMARY   1      Characteristics of Posttraumatic Stress Disorder,   2      Current Diagnostic Criteria,   2      Clinical Diagnosis and Assessment,   3      Assessment Instruments,   5 1   INTRODUCTION   7      Characteristics of Posttraumatic Stress Disorder,   8      Committee’s Task and Approach,   9      Organization of the Report,   10      References,   10 2   DIAGNOSIS AND ASSESSMENT   13      Current Diagnostic Criteria,   14      Clinical Diagnosis,   16      Assessment,   20      Biomarkers of Posttraumatic Stress Disorder,   23      Conclusion,   24      References,   24 3   ASSESSMENT INSTRUMENTS   29      Diagnostic Interviews,   30      Self-Reports of Traumatic Events,   32      Nondiagnostic Assessment and Screening Instruments,   33      Conclusion,   36      References,   36

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Posttraumatic Stress Disorder: Diagnosis and Assessment                APPENDIXES     A   SPECIFIC QUESTIONS POSED BY THE DEPARTMENT OF VETERANS AFFAIRS TO THE INSTITUTE OF MEDICINE   41      Reference,   46 B   ESTABLISHING POSTTRAUMATIC STRESS DISORDER AS A PSYCHIATRIC DISORDER   47      Core Clinical Features,   49      Differentiating Posttraumatic Stress Disorder from Other Disorders,   50      Conducting Laboratory Studies of Posttraumatic Stress Disorder,   52      Demonstrating Temporal Stability of Posttraumtic Stress Disorder,   52      Determining Whether Posttraumatic Stress Disorder Aggregates in Families,   53      Conclusion,   55      References,   55 C   RISK AND PROTECTIVE FACTORS   59      Risk Factors,   59      Protective Factors,   67      Conclusion,   68      References,   68