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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence (2008)

Chapter: Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder

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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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Suggested Citation:"Appendix C: Measures Used in the Assessment of Posttraumatic Stress Disorder." Institute of Medicine. 2008. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press. doi: 10.17226/11955.
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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 • Assesses anxiety and affective Interview disorders Schedule-Revised • Structured diagnostic interview (ADIS-R) (DiNardo • Likert rating scales and Barlow, 1988) Clinician • Most widely used measure of PTSD • Confirmatory factor Administered PTSD (Weathers et al., 2001) analyses supported Scale (CAPS) (Blake • 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 • Intrusion and • 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) • Confirmatory factor CAPS-2 (symptoms over past week for analyses comparing repeated assessments) solutions suggested • 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) • Reexperiencing, • Current version, CAPS, combined effortful avoidance, CAPS-1 and CAPS-2 emotional numbing, • Structured interview hyperarousal • 45–60 minute administration by trained (para)professionals • 34 items (17 items on frequency, 17 items on intensity) • Dichotomous (diagnosis present/ absent) and continuous assessment • Five-point Likert ratings of symptom severity (0–4) • Time frames for assessment include: past week, month, or worst month since trauma • 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) • 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., • Frequency scores: 0–68 2001) • Intensity scores: 0–136 Specificity: >.8, often >.9 (Weathers et al., • Rating scales summed to create 9-point 2001) (0–8) severity score for each symptom Kappa: >.7 (criterion: SCID; Weathers et • Total Severity Score: al., 2001) 0–19: asymptomatic/few symptoms Internal consistency (alpha): typically .8–.9 20–39: mild PTSD/subthreshold for three clusters and for entire syndrome 40–59: moderate PTSD/threshold (Weathers et al., 2001) 60–79: severe PTSD symptoms Test-retest reliability: .9–.98 (Weathers et ≥80: extreme PTSD symptoms al., 1992) • Clinically significant change: ≥15 pt Interrater reliability: ≥.9 (continuous); change in CAPS total severity score comparable, up to 100% (diagnosis) • Symptom Endorsement Scoring Rules: (Weathers et al., 2001) F1/I2: freq. ≥“1”, inten. ≥2 • ≥.7 (typically .8–.9) correlations with Rule of 2: severity ≥2 self-report PTSD measures (Mississippi, Rule of 3: severity ≥3 Impact of Event Scale [IES], PTSD Rule of 4: severity ≥4 Checklist [PCL], Davidson Trauma • Diagnostic Rules Scale [DTS], Minnesota Multiphasic “B” ≥1, “C” ≥3, “D” ≥2 Personality Inventory [MMPI-2] Keane TSEV65: total severity ≥65 Scale, Structured Clinical Interview • Nine diagnostic scoring rules yield for PTSD [SCID-PTSD]) (for review: different prevalence rates (research Weathers et al., 2001) setting: 26–49%, clinical: 47–82%) (Weathers et al., 1999) • F1/I2 most lenient in clinical sample, second in research, clinician rating-based rules most stringent (Weathers et al., 1999) • Explicit reporting and use of several scoring rules recommended • 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 • Assesses treatment response in Impression (CGI) psychiatric patients (Guy, 1976) • 5-minute administration by trained rater or clinician • 3-item scale • Clinician rates severity of illness at time of assessment (severity of illness), how much the patient’s illness has improved/worsened since baseline (global improvement) and compares patient’s baseline condition with a ratio of current therapeutic benefit to severity of side effects (efficacy index) • Administered at initial assessment and at least once after treatment is initiated • Clinical Global Impression Improvement Scale (CGI-I) • Clinical Global Impression Severity Scale (CGI-S) Diagnostic • Assesses DSM III-R/IV • PTSD section Interview Schedule symptomatology (DIS) (Robins et al., • Primarily used in community settings 1981) (Newman et al., 1996) • Semistructured interview • 15-minute administration by trained lay interviewer • Dichotomous (yes/no) symptom ratings • Does not assess symptom severity, can be used for diagnosis • Requires patient to associate each symptom with a specific traumatic event Davidson Trauma • Assesses DSM-IV PTSD criteria (B–D) • Principal Scale (DTS) • Self-report questionnaire components factor (Davidson et al., • 17 items, 5-point (1–4) Likert rating analysis yielded a 1997) scales 2-factor solution • <10 minute administration for general sample and a 6‑factor solution with PTSD population (Davidson et al., 1997)

APPENDIX C 173 Psychometric Properties Scoring and Interpretation Guidelines • Item 1. Severity of Illness: 7-point scale (1 = normal to 7 = extremely ill) • Item 2. Global Improvement: 7-point scale (1 = very much improved to 7 = very much worse) • Item 3. Efficacy Index: 4-point scale (“none” to “outweighs therapeutic effect”) Sensitivity: community .22; clinical .81–.89, .23–.89 Specificity: community .98, clinical .92–.94, .92–.98 (Kulka et al., 1991) Diagnostic accuracy: 83% • Frequency: 0–68 Internal consistency (alpha): .99 (Davidson • Severity: 0–68 et al., 1997) • Total: 0–136 Test-retest reliability: .73–.93 (Wildes, • Diagnostic cutoff score: 40 (Davidson et 2007) al., 1997) • Low to strong correlations with measures of similar constructs • Effect sizes equal to or greater than those found for IES, CAPS, and SI-PTSD (Davidson et al., 2002) • Strong association with SCID-DSM-III-R diagnosis (Wildes, 2007) continued

174 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Impact of Event • Assesses 14/17 DSM-III-R and DSM- • Intrusion, avoidance, Scale-Revised IV PTSD criteria (B–D) hyperarousal (IES-R) (Horowitz • Widely used PTSD-related scale across • CFA et al., 1979; Weiss trauma populations (Newman et al., and Marmar, 1997) 1996) • Self-report questionnaire • 15 items, 4-point (0–5) Likert rating scales Los Angeles • Assesses for PTSD symptoms and • 17-item PTSD index Symptom Checklist associated features including signs of (LASC) (King et al., distress and functional problems 1995) • Self-report questionnaire • 43 items, Likert scales • Dichotomous and continuous assessment • Studied across populations (e.g., males, females, various traumas) (Keane et al., 2000) Minnesota • Originally composed of 29 items, Multiphasic revised for MMPI-2 by deleting 3 item Personality repetitions Inventory, Keane • Self-report questionnaire PTSD Scale • 46 MMPI items (PK) (Keane et al., • Norms available for different 1984; Lyons and populations Keane, 1992) Mississippi Scale • Assesses DSM-III combat-related • 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) • Self-report questionnaire Intrusive memories • 35 items, 5-point Likert scale and depressive • 10–15 minute administration symptomatology • 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): .75–.93 • Total score: 0–75 (Wildes) • Two scoring systems available (Green, Test-retest reliability: .87 1991) Split-half reliability: .86 (Wildes, 2007) • 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): .88–.95 (King et al., 1995) Test-retest reliability: .9–.94 Sensitivity: .57–.90 (Newman et al., 1996) • Optimal cutoff score: 8.5–30 across Specificity: .55–.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): .85–.87 (Graham, 1990); .95–.96 (combat, Newman et al., 1996) Test-retest reliability: .86–.94 (combat, Newman et al., 1996) Sensitivity: .77–.93 (Newman et al., 1996) • Total: 35–175 Specificity: .83–.89 (Newman et al., 1996) • 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) • Low to strong correlations with measures of similar constructs • 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 • Self-report questionnaire Posttraumatic Stress • 26 items (Hammerberg, • Primarily used with male patients, 1992) including accident victims, veterans, and general psychiatric patients (Keane et al., 2000) Posttraumatic • Assesses DSM-IV PTSD criteria Diagnostic Scale • Self-report questionnaire (PTDS) (Foa et al., • 17 questions, including 12-item 1997) checklist of traumatic events • 4-point Likert rating for frequency of PTSD symptoms in the past month and self-ratings of impairment across nine areas of functioning • Validated across several populations, including combat veterans and sexual and nonsexual-assault survivors (Keane et al., 2000) PTSD Checklist • Assesses DSM PTSD diagnostic criteria • Principal components (PCL) (Weathers et • Self-report questionnaire analysis indicated al., 1993) • 10 minute administration 1-factor solution • 17 items, 5-point (0–4) Likert rating (Wildes, 2007) for past month • PTSD Checklist-Military version (PCL-M) PTSD Interview • Structured clinical interview (Watson et al., • Dichotomous and continuous 1991) assessment • 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 • 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 • Individual symptom score: 0–8 Specificity: .83 • 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 • Total severity: 17–85 et al., 1993) • Diagnostic cutoff score: 50 in veteran Test-retest reliability: .96 (Weathers et al., population (Blanchard et al., 1996; 1993) Forbes et al., 2001) • Moderate to strong correlations, r > .75, with measures of similar constructs (Mississippi, PK, IES, CAPS) (Blanchard et al., 1996; Weathers et al., 1993) • 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 • Assesses DSM criteria of PTSD • Subscales: Scale Interview • Semistructured interview reexperiencing (5 items) (PSS-I) (Foa et al., • 20–30 minute administration avoidance (7 items) 1993) • Self-report questionnaire version (PSS- arousal (5 items) S): 10 minute administration • Likert rating scales for criterion symptoms • Dichotomous and continuous assessment • 2-week time frame Symptom • Assesses a broad range of • 9 primary symptom Checklist‑90‑R psychological problems, symptoms of dimensions, 3 global (SCL-90-R) psychopathology, patient progress, and indices (Derogatis, 1977) treatment outcomes • 28-item Crime- • Self-report questionnaire Related PTSD Scale • 12–15 minute administration (Saunders et al., • 90 items, 5-point Likert rating 1990) • Global Severity Index: summary of test • 12-item PTSD Subscale for Disaster Survivors (Green, 1991) • 25-item War-Zone- Related PTSD Scale (Weathers et al., 1996) Structured Clinical • Assesses prevalence, absence, and Interview (SCID) subthreshold presence of PTSD PTSD Module • Used across trauma populations (Spitzer et al., • Semistructured interview 1990) • 25 minute administration • 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), .65–.74 (PSS-I subscales) (Foa and Tolin, 2000) Test-retest reliability: Strong (Foa et al., 1993) Interrater reliability: 98.3% (Foa and Tolin, 2000) • Good agreement with CAPS and SCID (Foa and Tolin, 2000) • 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) • Agreement across lifetime, current, and never PTSD 78% (Keane et al., 1998) • Highly correlated with other measures of PTSD continued

180 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Measure Description Scales/Factors Structured • Assesses DSM PTSD criteria (re- • Treatment Outcome Interview for PTSD experiencing, avoidance and numbing, PTSD Scale (TOP- (SI-PTSD or SIP) and hyperarousal) and functional 8) (Connor and (Davidson et al., impairment Davidson, 1999; 1989) • Structured interview, including initial Davidson and probes, behavioral observations and Colket, 1997) follow-up questions assesses treatment • 20 minute administration response: 8 items • Severity and frequency of symptoms endorsed frequently rated on 5-point (0–4) Likert scale and responded • Dichotomous and continuous to treatment over assessment time, drawn from 3 • Assesses lifetime PTSD by “worst symptom clusters ever” symptomatology REFERENCES Blake, D. D., F. W. Weathers, L. M. Nagy, D. G. Kaloupek, G. Klauminzer, D. S. Charney, and T. M. Keane. 1990. A clinical rating scale for assessing current and lifetime PTSD: The CAPS-1. Behavior Therapist 18:187-188. Blanchard, E. B., R. J. Gerardi, L. C. Kolb, and D. H. Barlow. 1986. The utility of the anxiety disorders interview schedule (ADIS) in the diagnosis of the post-traumatic stress disorder in Vietnam veterans. Behaviour Research and Therapy 18:187-188. Blanchard, E. B., E. J. Hickling, A. E. Taylor, C. A. Forneris, W. R. Loos, and J. Jaccard. 1995. Effects of varying scoring rules of the clinician-administered PTSD scale (CAPS) for the diagnosis of post-traumatic stress disorder in motor vehicle accident victims. Behaviour Research and Therapy 33:471-475. Blanchard, E. B., J. Jones-Alexander, T. C. Buckley, and C. A. Forneris. 1996. Psychometric properties of the PTSD checklist (PCL). Behaviour Research and Therapy 34:669-673. Buckley, T. C., E. B. Blanchard, and E. J. Hickling. 1998. A confirmatory factor analysis of posttraumatic stress symptoms. Behavioral Research and Therapy 36:1091-1099. Connor, K. M., and J. R. Davidson. 1999. Further psychometric assessment of the TOP-8: A brief interview-based measure of PTSD. Depression and Anxiety 9:135-137. Davidson, J. R., and J. T. Colket. 1997. The eight-item treatment-outcome post-traumatic stress disorder scale: A brief measure to assess treatment outcome in post-traumatic stress disorder. International Clinical Psychopharmacology 12:41-45. Davidson, J. R. T., R. D. Smith, and H. S. Kudler. 1989. Validity and reliability of the DSM-III criteria for posttraumatic stress disorder: Experience with a structured interview. Journal of Nervous and Mental Disease 177:336-341. Davidson, J. R. T., S. W. Book, J. T. Colket, L. A. Tupler, S. Roth, D. David, M. Hertzberg, T. Mellman, J. C. Beckham, R. D. Smith, R. M. Davison, R. Katz, and M. E. Feldman. 1997. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychologi- cal Medicine 27(1):153-160. Davidson, J. R. T., H. M. Tharwani, and K. M. Connor. 2002. Davidson trauma scale (DTS): Normative scores in the general population and effect sizes in placebo-controlled SSRI trials. Depression and Anxiety 15(2):75-78. Derogatis, L. R. 1977. The scl-90 manual: Vol. 1. Scoring, administration and procedures for the SCL-90. Baltimore, MD: Johns Hopkins University School of Medicine, Clinical Psychometrics Unit.

APPENDIX C 181 Psychometric Properties Scoring and Interpretation Guidelines Sensitivity: .96 • Diagnostic cutoff score: 20 Specificity: .8 (Davidson et al., 1989) DiNardo, P. A., and D. H. Barlow. 1988. Anxiety disorders interview scale-revised. Albany, NY: Center for Phobia and Anxiety Disorders. Foa, E. B., and D. F. Tolin. 2000. Comparison of the PTSD symptom scale-interview version and the clinician-administered PTSD scale. Journal of Traumatic Stress 13(2):181-191. Foa, E. B., D. S. Riggs, C. V. Dancu, and B. O. Rothbaum. 1993. Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress 6:459-473. Foa, E. B., L. Cashman, L. Jaycox, and K. Perry. 1997. The validation of a self-report mea- sure of posttraumatic stress disorder: The posttraumatic diagnostic scale. Psychological Assessment 9:445-451. Forbes, D., M. Creamer, and D. Biddle. 2001. The validity of the PTSD checklist as a mea- sure of symptomatic change in combat-related PTSD. Behaviour Research and Therapy 39:977-986. Graham, J. R. 1990. MMPI-2: Assessing personality and psychopathology. New York: Oxford University Press. Green, B. L. 1991. Evaluating the effects of disasters. Psychological Assessment: A Journal of Consulting and Clinical Psychology 3:538-546. Guy, W. 1976. Clinical global impression, ECDEU assessment manual for psychopharmacol- ogy, revised. Rockville, MD: National Institute of Mental Health. Hammerberg, M. 1992. Penn inventory for posttraumatic stress disorder: Psychometric prop- erties. Psychological Assessment 4:67-76. Horowitz, M. J., N. R. Wilner, and W. Alvarez. 1979. Impact of event scale: A measure of subjective distress. Psychosomatic Medicine 41(208-218). Keane, T. M., P. F. Malloy, and J. A. Fairbank. 1984. Empirical development of an MMPI subscale for the assessment of combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 52:888-891. Keane, T. M., J. M. Caddell, and K. L. Taylor. 1988. Mississippi scale for combat-related PTSD: Three studies in reliability and validity. Journal of Consulting and Clinical Psy- chology 56:85-90.

182 TREATMENT OF POSTTRAUMATIC STRESS DISORDER Keane, T. M., L. C. Kolb, D. G. Kaloupek, S. P. Orr, E. B. Blanchard, R. G. Thomas, F. W. Hsieh, and P. W. Lavori. 1998. Utility of psychophysiological measurements in the diag- nosis of post-traumatic stress disorder: Results from a Department of Veterans Affairs cooperative study. Journal of Consulting and Clinical Psychology 66:914-923. Keane, T. M., F. W. Weathers, and E. B. Foa. 2000. Diagnosis and assessment. In Effective treatments for PTSD. Edited by E. B. Foa, T. M. Keane, and M. J. Friedman. New York: Guilford Publications. Pp. 18-36. King, D. W., G. A. Leskin, and F. W. Weathers. 1998. Confirmatory factor analysis of the c ­ linician-administered PTSD scale: Evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment 10:90-96. King, L. A., D. W. King, G. A. Leskin, and D. W. Foy. 1995. The Los Angeles symptom check- list: A self-report measure of posttraumatic stress disorder. Assessment 2:1-17. Kulka, R. A., W. E. Schlenger, J. A. Fairbank, B. K. Jordan, R. L. Hough, C. R. Marmar, and D. S. Weiss. 1991. Assessment of posttraumatic stress disorder in the community: Pros- pects and pitfalls from recent studies of Vietnam veterans. Psychological Assessment: A Journal of Consulting and Clinical Psychology 3:547-560. Lyons, J. A., and T. M. Keane. 1992. Keane PTSD scale: MMPI and MMPI-2 update. Journal of Traumatic Stress 5:111-117. McFall, M. E., D. E. Smith, P. W. Mackay, and D. J. Tarver. 1990. Reliability and validity of Mississippi scale for combat-related posttraumatic stress disorder. Psychological Assess- ment 2:114-121. Newman, E., D. G. Kaloupek, and T. M. Keane. 1996. Assessment of posttraumatic stress disorder in clinical and research settings. In Traumatic stress. Edited by B. A. van der Kolk, A. C. McFarlane, and L. Weisaeth. Pp. 242-275. Robins, L. N., J. E. Helzer, J. L. Croughan, and K. S. Ratliff. 1981. National institute of mental health diagnostic interview schedule: Its history, characteristics and validity. Archives of General Psychiatry 38:381-389. Saunders, B. E., C. M. Arata, and D. G. Kilpatrick. 1990. Development of a crime-related post-traumatic stress disorder scale for women within the symptom checklist-90- revised. Journal of Traumatic Stress 3:439-448. Spitzer, R. L., J. B. Williams, M. Gibbon, and M. B. First. 1990. Structured clinical interview for DSM-III-R- patient edition (SCID-P). New York: Biometrics Research Department, New York State Psychiatric Institute. Watson, C. G., T. Kucala, and V. Manifold. 1986. A cross-validation of the Keane and Penk MMPI scales as measures of post-traumatic stress disorder. Journal of Clinical Psychol- ogy 42:727-732. Watson, C. G., M. P. Juba, V. Manifold, T. Kucala, and P. E. Anderson. 1991. The PTSD interview: Rationale, description, reliability, and concurrent validity of a DSM-III-based technique. Journal of Clinical Psychology 47:179-188. Weathers, F. W., D. D. Blake, K. E. Krinsley, W. Haddad, J. A. Huska, and T. M. Keane. 1992 (November). The clinician-administered PTSD scale: Reliability and construct validity. Paper presented at 26th annual convention of the Association for Advancement Behavior Therapy, Boston, MA. Weathers, F. W., B. T. Litz, D. S. Herman, J. A. Huska, and T. M. Keane. 1993 (October). The PTSD checklist (PCL): Reliability, validity and diagnostic utility. Paper presented at 9th Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX. Weathers, F. W., B. T. Litz, D. S. Herman, J. A. Huska, and T. M. Keane. 1996. The utility of the SCL-90-R for the diagnosis of war-zone-related post-traumatic stress disorder. Journal of Traumatic Stress 9:111-128.

APPENDIX C 183 Weathers, F. W., A. M. Ruscio, and T. M. Keane. 1999. Psychometric properties of nine scor- ing rules for the clinician-administered post-traumatic stress disorder scale. Psychological Assessment 11:124-133. Weathers, F. W., T. M. Keane, and J. R. T. Davidson. 2001. Clinician-administered PTSD scale: A review of the first ten years of research. Depression and Anxiety 13:132-156. Weiss, D. S., and C. R. Marmar. 1997. The impact of event scale-revised. In Assessing psy- chological trauma and PTSD. Edited by J. P. Wilson and T. M. Keane. New York: The Guilford Press. Pp. 399-428. Wildes, K. R. 2007. Comparison of PTSD symptom assessment instruments. http://www. hsrd.research.va.gov/for_researchers/measurement/practice/ptsd_measures.cfm (accessed May 17, 2007).

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Mental disorders, including posttraumatic stress disorder (PTSD), constitute an important health care need of veterans, especially those recently separated from service. Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence takes a systematic look the efficacy of pharmacologic and psychological treatment modalities for PTSD on behalf of the Department of Veterans Affairs. By reviewing existing studies in order to draw conclusions about the strength of evidence on several types of treatment, the Committee on the Treatment of Posttraumatic Stress Disorder found that many of these studies were faulty in design and performance, and that relatively few of these studies have been conducted in populations of veterans, despite suggestions that civilian and veteran populations respond differently to various types of treatment. The committee also notes that the evidence is scarce on the acceptability, efficacy, or generalizability of treatment in ethnic and cultural minorities, as few studies stratified results by ethnic background.

Despite challenges in the consistency, quality, and depth of research, the committee found the evidence sufficient to conclude the efficacy of exposure therapies in treating PTSD. The committee found the evidence inadequate to determine efficacy of different types of pharmacotherapies, of three different psychotherapy modalities, and of psychotherapy delivered in group formats. The committee also made eight critical recommendations, some in response to the VA's questions related to recovery and the length and timing of PTSD treatment, and others addressing research methodology, gaps in evidence and funding issues.

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