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Appendix C Measures Used in the Assessment of Posttraumatic Stress Disorder Table begins on next page. 169
170 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Anxiety Disorders â¢ Assesses anxiety and affective Interview disorders Schedule-Revised â¢ Structured diagnostic interview (ADIS-R) (DiNardo â¢ Likert rating scales and Barlow, 1988) Clinician â¢ Most widely used measure of PTSD â¢ Confirmatory factor Administered PTSD (Weathers et al., 2001) analyses supported Scale (CAPS) (Blake â¢ Assesses all DSM-IV PTSD symptoms, fit of two-factor et al., 1990) impact on functioning, response structure (Buckley et validity, lifetime diagnosis, and overall al., 1998): PTSD severity â¢ Intrusion and â¢ Original version, based on DSM- avoidance, III-R criteria: CAPS-1 (current and hyperarousal, and lifetime diagnosis, symptoms over numbing past, or worst month since trauma) â¢ Confirmatory factor CAPS-2 (symptoms over past week for analyses comparing repeated assessments) solutions suggested â¢ DSM-IV revision with user feedback an oblique 4-factor, incorporated: CAPS-1 renamed CAPS- first-order solution DX (diagnostic version) and CAPS-2 as the best fit to data renamed CAPS-SX (symptom status (King et al., 1998): version) â¢ Reexperiencing, â¢ Current version, CAPS, combined effortful avoidance, CAPS-1 and CAPS-2 emotional numbing, â¢ Structured interview hyperarousal â¢ 45â60 minute administration by trained (para)professionals â¢ 34 items (17 items on frequency, 17 items on intensity) â¢ Dichotomous (diagnosis present/ absent) and continuous assessment â¢ Five-point Likert ratings of symptom severity (0â4) â¢ Time frames for assessment include: past week, month, or worst month since trauma â¢ Initially validated on combat veterans, subsequently applied in a wide variety of trauma populations including victims of rape, crime, motor vehicle accidents, incest, torture, and cancer (Weathers et al., 2001)
APPENDIX C 171 Psychometric Properties Scoring and Interpretation Guidelines Sensitivity: 1.0 (Blanchard et al., 1986) Specificity: .91 (Blanchard et al., 1986) â¢ Inconsistent findings from two studies, better statistics in combat veterans than community-based study (Keane et al., 2000) Sensitivity: >.8, often >.9 (Weathers et al., â¢ Frequency scores: 0â68 2001) â¢ Intensity scores: 0â136 Specificity: >.8, often >.9 (Weathers et al., â¢ Rating scales summed to create 9-point 2001) (0â8) severity score for each symptom Kappa: >.7 (criterion: SCID; Weathers et â¢ Total Severity Score: al., 2001) 0â19: asymptomatic/few symptoms Internal consistency (alpha): typically .8â.9 20â39: mild PTSD/subthreshold for three clusters and for entire syndrome 40â59: moderate PTSD/threshold (Weathers et al., 2001) 60â79: severe PTSD symptoms Test-retest reliability: .9â.98 (Weathers et â¥80: extreme PTSD symptoms al., 1992) â¢ Clinically significant change: â¥15 pt Interrater reliability: â¥.9 (continuous); change in CAPS total severity score comparable, up to 100% (diagnosis) â¢ Symptom Endorsement Scoring Rules: (Weathers et al., 2001) F1/I2: freq. â¥â1â, inten. â¥2 â¢ â¥.7 (typically .8â.9) correlations with Rule of 2: severity â¥2 self-report PTSD measures (Mississippi, Rule of 3: severity â¥3 Impact of Event Scale [IES], PTSD Rule of 4: severity â¥4 Checklist [PCL], Davidson Trauma â¢ Diagnostic Rules Scale [DTS], Minnesota Multiphasic âBâ â¥1, âCâ â¥3, âDâ â¥2 Personality Inventory [MMPI-2] Keane TSEV65: total severity â¥65 Scale, Structured Clinical Interview â¢ Nine diagnostic scoring rules yield for PTSD [SCID-PTSD]) (for review: different prevalence rates (research Weathers et al., 2001) setting: 26â49%, clinical: 47â82%) (Weathers et al., 1999) â¢ F1/I2 most lenient in clinical sample, second in research, clinician rating-based rules most stringent (Weathers et al., 1999) â¢ Explicit reporting and use of several scoring rules recommended â¢ Lenient rules recommended for screening purposes, while stringent rules appropriate for confirming diagnosis or creating case groups (Weathers et al., 1999) continued
172 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Clinical Global â¢ Assesses treatment response in Impression (CGI) psychiatric patients (Guy, 1976) â¢ 5-minute administration by trained rater or clinician â¢ 3-item scale â¢ Clinician rates severity of illness at time of assessment (severity of illness), how much the patientâs illness has improved/worsened since baseline (global improvement) and compares patientâs baseline condition with a ratio of current therapeutic benefit to severity of side effects (efficacy index) â¢ Administered at initial assessment and at least once after treatment is initiated â¢ Clinical Global Impression Improvement Scale (CGI-I) â¢ Clinical Global Impression Severity Scale (CGI-S) Diagnostic â¢ Assesses DSM III-R/IV â¢ PTSD section Interview Schedule symptomatology (DIS) (Robins et al., â¢ Primarily used in community settings 1981) (Newman et al., 1996) â¢ Semistructured interview â¢ 15-minute administration by trained lay interviewer â¢ Dichotomous (yes/no) symptom ratings â¢ Does not assess symptom severity, can be used for diagnosis â¢ Requires patient to associate each symptom with a specific traumatic event Davidson Trauma â¢ Assesses DSM-IV PTSD criteria (BâD) â¢ Principal Scale (DTS) â¢ Self-report questionnaire components factor (Davidson et al., â¢ 17 items, 5-point (1â4) Likert rating analysis yielded a 1997) scales 2-factor solution â¢ <10 minute administration for general sample and a 6âfactor solution with PTSD population (Davidson et al., 1997)
APPENDIX C 173 Psychometric Properties Scoring and Interpretation Guidelines â¢ Item 1. Severity of Illness: 7-point scale (1 = normal to 7 = extremely ill) â¢ Item 2. Global Improvement: 7-point scale (1 = very much improved to 7 = very much worse) â¢ Item 3. Efficacy Index: 4-point scale (ânoneâ to âoutweighs therapeutic effectâ) Sensitivity: community .22; clinical .81â.89, .23â.89 Specificity: community .98, clinical .92â.94, .92â.98 (Kulka et al., 1991) Diagnostic accuracy: 83% â¢ Frequency: 0â68 Internal consistency (alpha): .99 (Davidson â¢ Severity: 0â68 et al., 1997) â¢ Total: 0â136 Test-retest reliability: .73â.93 (Wildes, â¢ Diagnostic cutoff score: 40 (Davidson et 2007) al., 1997) â¢ Low to strong correlations with measures of similar constructs â¢ Effect sizes equal to or greater than those found for IES, CAPS, and SI-PTSD (Davidson et al., 2002) â¢ Strong association with SCID-DSM-III-R diagnosis (Wildes, 2007) continued
174 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Impact of Event â¢ Assesses 14/17 DSM-III-R and DSM- â¢ Intrusion, avoidance, Scale-Revised IV PTSD criteria (BâD) hyperarousal (IES-R) (Horowitz â¢ Widely used PTSD-related scale across â¢ CFA et al., 1979; Weiss trauma populations (Newman et al., and Marmar, 1997) 1996) â¢ Self-report questionnaire â¢ 15 items, 4-point (0â5) Likert rating scales Los Angeles â¢ Assesses for PTSD symptoms and â¢ 17-item PTSD index Symptom Checklist associated features including signs of (LASC) (King et al., distress and functional problems 1995) â¢ Self-report questionnaire â¢ 43 items, Likert scales â¢ Dichotomous and continuous assessment â¢ Studied across populations (e.g., males, females, various traumas) (Keane et al., 2000) Minnesota â¢ Originally composed of 29 items, Multiphasic revised for MMPI-2 by deleting 3 item Personality repetitions Inventory, Keane â¢ Self-report questionnaire PTSD Scale â¢ 46 MMPI items (PK) (Keane et al., â¢ Norms available for different 1984; Lyons and populations Keane, 1992) Mississippi Scale â¢ Assesses DSM-III combat-related â¢ Principal components for Combat-related PTSD and related features (e.g., factor analysis PTSD suicidality, depression, substance (Keane et al., 1988): (M-PTSD) (Keane abuse) Factor 1 (9 items): et al., 1988) â¢ Self-report questionnaire Intrusive memories â¢ 35 items, 5-point Likert scale and depressive â¢ 10â15 minute administration symptomatology â¢ Civilian Mississippi Scale for PTSD Factor 2 (5 items): version Interpersonal adjustment problems Factor 3 (3 items): Lability of affect and memory Factors 4 and 5 (3 items each): Ruminative features Factor 6 (2 items): Sleep problems
APPENDIX C 175 Psychometric Properties Scoring and Interpretation Guidelines Internal consistency (alpha): .75â.93 â¢ Total score: 0â75 (Wildes) â¢ Two scoring systems available (Green, Test-retest reliability: .87 1991) Split-half reliability: .86 (Wildes, 2007) â¢ Low to moderate correlations with measures of similar constructs, strong correlation with CAPS Sensitivity: .74 (PTSD index; King et al., 1995) Specificity: .77 (PTSD index, King et al., 1995) Internal consistency (alpha): .88â.95 (King et al., 1995) Test-retest reliability: .9â.94 Sensitivity: .57â.90 (Newman et al., 1996) â¢ Optimal cutoff score: 8.5â30 across Specificity: .55â.95 (Newman et al., 1996) populations and studies (Newman et al., Diagnostic accuracy: 82% (Keane et al., 1996) 1984; Watson et al., 1986) Internal consistency (alpha): .85â.87 (Graham, 1990); .95â.96 (combat, Newman et al., 1996) Test-retest reliability: .86â.94 (combat, Newman et al., 1996) Sensitivity: .77â.93 (Newman et al., 1996) â¢ Total: 35â175 Specificity: .83â.89 (Newman et al., 1996) â¢ Diagnostic cutoff score: 107 (Keane et Diagnostic Accuracy: .9 (Keane et al., 1988) al., 1988) Internal consistency (alpha): .94 Split-half: .93 Test-retest reliability: .97 (Keane et al., 1988) â¢ Low to strong correlations with measures of similar constructs â¢ Predictive of SCID-DSM-III-R diagnosis (McFall et al., 1990) continued
176 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Penn Inventory for â¢ Self-report questionnaire Posttraumatic Stress â¢ 26 items (Hammerberg, â¢ Primarily used with male patients, 1992) including accident victims, veterans, and general psychiatric patients (Keane et al., 2000) Posttraumatic â¢ Assesses DSM-IV PTSD criteria Diagnostic Scale â¢ Self-report questionnaire (PTDS) (Foa et al., â¢ 17 questions, including 12-item 1997) checklist of traumatic events â¢ 4-point Likert rating for frequency of PTSD symptoms in the past month and self-ratings of impairment across nine areas of functioning â¢ Validated across several populations, including combat veterans and sexual and nonsexual-assault survivors (Keane et al., 2000) PTSD Checklist â¢ Assesses DSM PTSD diagnostic criteria â¢ Principal components (PCL) (Weathers et â¢ Self-report questionnaire analysis indicated al., 1993) â¢ 10 minute administration 1-factor solution â¢ 17 items, 5-point (0â4) Likert rating (Wildes, 2007) for past month â¢ PTSD Checklist-Military version (PCL-M) PTSD Interview â¢ Structured clinical interview (Watson et al., â¢ Dichotomous and continuous 1991) assessment â¢ Patient given a copy of scale to read along with interviewer and asked to give subjective ratings for each symptom
APPENDIX C 177 Psychometric Properties Scoring and Interpretation Guidelines â¢ Sensitivity comparable to Mississippi scale, specificity slightly lower (Keane et al., 2000) Sensitivity: .89 Specificity: .75 Kappa: .65 (criterion: SCID) Internal consistency (alpha): .92 Test-retest reliability: .74 (diagnosis), .83 (symptom severity) Sensitivity: .82 â¢ Individual symptom score: 0â8 Specificity: .83 â¢ Symptom endorsement cutoff: 3 or 4 Overall diagnostic efficiency: .9 (criterion: (Blanchard et al., 1995; Forbes et al., CAPS) (Blanchard et al., 1996) 2001) Internal consistency (alpha): .97 (Weathers â¢ Total severity: 17â85 et al., 1993) â¢ Diagnostic cutoff score: 50 in veteran Test-retest reliability: .96 (Weathers et al., population (Blanchard et al., 1996; 1993) Forbes et al., 2001) â¢ Moderate to strong correlations, r > .75, with measures of similar constructs (Mississippi, PK, IES, CAPS) (Blanchard et al., 1996; Weathers et al., 1993) â¢ Reductions in diagnostic accuracy as symptoms improve and approach threshold for diagnostic criteria (Forbes et al., 2001) Sensitivity: .89 Specificity: .94 Kappa: .82 (Criterion: DIS) (Watson et al., 1991) Internal consistency (alpha): .92 Test-retest reliability: .95 continued
178 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors PTSD Symptom â¢ Assesses DSM criteria of PTSD â¢ Subscales: Scale Interview â¢ Semistructured interview reexperiencing (5 items) (PSS-I) (Foa et al., â¢ 20â30 minute administration avoidance (7 items) 1993) â¢ Self-report questionnaire version (PSS- arousal (5 items) S): 10 minute administration â¢ Likert rating scales for criterion symptoms â¢ Dichotomous and continuous assessment â¢ 2-week time frame Symptom â¢ Assesses a broad range of â¢ 9 primary symptom Checklistâ90âR psychological problems, symptoms of dimensions, 3 global (SCL-90-R) psychopathology, patient progress, and indices (Derogatis, 1977) treatment outcomes â¢ 28-item Crime- â¢ Self-report questionnaire Related PTSD Scale â¢ 12â15 minute administration (Saunders et al., â¢ 90 items, 5-point Likert rating 1990) â¢ Global Severity Index: summary of test â¢ 12-item PTSD Subscale for Disaster Survivors (Green, 1991) â¢ 25-item War-Zone- Related PTSD Scale (Weathers et al., 1996) Structured Clinical â¢ Assesses prevalence, absence, and Interview (SCID) subthreshold presence of PTSD PTSD Module â¢ Used across trauma populations (Spitzer et al., â¢ Semistructured interview 1990) â¢ 25 minute administration â¢ Permits only dichotomous rating (present/absent) of symptoms, does not assess severity of symptoms
APPENDIX C 179 Psychometric Properties Scoring and Interpretation Guidelines Sensitivity: .88 (PSS-I), .62 (PSS-S) Specificity: .96 (PSS-I) (Criterion: DIS; Foa et al., 1993) Internal consistency (alpha): .86 (PSS-I- total), .65â.74 (PSS-I subscales) (Foa and Tolin, 2000) Test-retest reliability: Strong (Foa et al., 1993) Interrater reliability: 98.3% (Foa and Tolin, 2000) â¢ Good agreement with CAPS and SCID (Foa and Tolin, 2000) â¢ War-Zone-Related PTSD Scale is only SCL-90 PTSD scale that has greater predictive validity than the Global Severity Index (Green, 1991) Sensitivity: .81 Specificity: .98 Kappa: .68 (Keane et al., 1998) â¢ Agreement across lifetime, current, and never PTSD 78% (Keane et al., 1998) â¢ Highly correlated with other measures of PTSD continued
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