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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Appendix C
Measures Used in the Assessment of Posttraumatic Stress Disorder
Table begins on next page.
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
Anxiety Disorders Interview Schedule-Revised (ADIS-R) (DiNardo and Barlow, 1988)
Assesses anxiety and affective disorders
Structured diagnostic interview
Likert rating scales
Clinician Administered PTSD Scale (CAPS) (Blake et al., 1990)
Most widely used measure of PTSD (Weathers et al., 2001)
Assesses all DSM-IV PTSD symptoms, impact on functioning, response validity, lifetime diagnosis, and overall PTSD severity
Original version, based on DSM-III-R criteria: CAPS-1 (current and lifetime diagnosis, symptoms over past, or worst month since trauma) CAPS-2 (symptoms over past week for repeated assessments)
DSM-IV revision with user feedback incorporated: CAPS-1 renamed CAPS-DX (diagnostic version) and CAPS-2 renamed CAPS-SX (symptom status version)
Current version, CAPS, combined CAPS-1 and CAPS-2
Structured interview
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)
Confirmatory factor analyses supported fit of two-factor structure (Buckley et al., 1998):
Intrusion and avoidance, hyperarousal, and numbing
Confirmatory factor analyses comparing solutions suggested an oblique 4-factor, first-order solution as the best fit to data (King et al., 1998):
Reexperiencing, effortful avoidance, emotional numbing, hyperarousal
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
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., 2001)
Specificity: >.8, often >.9 (Weathers et al., 2001)
Kappa: >.7 (criterion: SCID; Weathers et al., 2001)
Internal consistency (alpha): typically .8–.9 for three clusters and for entire syndrome (Weathers et al., 2001)
Test-retest reliability: .9–.98 (Weathers et al., 1992)
Interrater reliability: ≥.9 (continuous); comparable, up to 100% (diagnosis) (Weathers et al., 2001)
≥.7 (typically .8–.9) correlations with self-report PTSD measures (Mississippi, Impact of Event Scale [IES], PTSD Checklist [PCL], Davidson Trauma Scale [DTS], Minnesota Multiphasic Personality Inventory [MMPI-2] Keane Scale, Structured Clinical Interview for PTSD [SCID-PTSD]) (for review: Weathers et al., 2001)
Frequency scores: 0–68
Intensity scores: 0–136
Rating scales summed to create 9-point (0–8) severity score for each symptom
Total Severity Score:
0–19: asymptomatic/few symptoms
20–39: mild PTSD/subthreshold
40–59: moderate PTSD/threshold
60–79: severe PTSD symptoms
≥80: extreme PTSD symptoms
Clinically significant change: ≥15 pt change in CAPS total severity score
Symptom Endorsement Scoring Rules:
F1/I2: freq. ≥“1”, inten. ≥2
Rule of 2: severity ≥2
Rule of 3: severity ≥3
Rule of 4: severity ≥4
Diagnostic Rules
“B” ≥1, “C” ≥3, “D” ≥2
TSEV65: total severity ≥65
Nine diagnostic scoring rules yield different prevalence rates (research 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)
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
Clinical Global Impression (CGI) (Guy, 1976)
5-minute administration by trained
Assesses treatment response in psychiatric patients 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 Interview Schedule (DIS) (Robins et al., 1981)
Assesses DSM III-R/IV symptomatology
Primarily used in community settings (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
PTSD section
Davidson Trauma Scale (DTS) (Davidson et al., 1997)
Assesses DSM-IV PTSD criteria (B–D)
Self-report questionnaire
17 items, 5-point (1–4) Likert rating scales
<10 minute administration
Principal components factor analysis yielded a 2-factor solution for general sample and a 6-factor solution with PTSD population (Davidson et al., 1997)
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
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%
Internal consistency (alpha): .99 (Davidson et al., 1997)
Test-retest reliability: .73–.93 (Wildes, 2007)
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) diagnosis (Wildes, 2007)
Strong association with SCID-DSM-III-R
Frequency: 0–68
Severity: 0–68
Total: 0–136
Diagnostic cutoff score: 40 (Davidson et al., 1997)
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
Impact of Event Scale-Revised (IES-R) (Horowitz et al., 1979; Weiss and Marmar, 1997)
Assesses 14/17 DSM-III-R and DSM-IV PTSD criteria (B–D)
Widely used PTSD-related scale across trauma populations (Newman et al., 1996)
Self-report questionnaire
15 items, 4-point (0–5) Likert rating scales
Intrusion, avoidance, hyperarousal
CFA
Los Angeles Symptom Checklist (LASC) (King et al., 1995)
Assesses for PTSD symptoms and associated features including signs of distress and functional problems
Self-report questionnaire
43 items, Likert scales
Dichotomous and continuous assessment
Studied across populations (e.g., males, females, various traumas) (Keane et al., 2000)
17-item PTSD index
Minnesota Multiphasic Personality Inventory, Keane PTSD Scale (PK) (Keane et al., 1984; Lyons and Keane, 1992)
Originally composed of 29 items, revised for MMPI-2 by deleting 3 item repetitions
Self-report questionnaire
46 MMPI items
Norms available for different populations
Mississippi Scale for Combat-related PTSD (M-PTSD) (Keane et al., 1988)
Assesses DSM-III combat-related PTSD and related features (e.g., suicidality, depression, substance abuse)
Self-report questionnaire
35 items, 5-point Likert scale
10–15 minute administration
Civilian Mississippi Scale for PTSD version
Principal components factor analysis
(Keane et al., 1988):
Factor 1 (9 items):
Intrusive memories and depressive symptomatology
Factor 2 (5 items):
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
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Psychometric Properties
Scoring and Interpretation Guidelines
Internal consistency (alpha): .75–.93 (Wildes)
Test-retest reliability: .87
Split-half reliability: .86 (Wildes, 2007)
Low to moderate correlations with measures of similar constructs, strong correlation with CAPS
Total score: 0–75
Two scoring systems available (Green, 1991)
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)
Specificity: .55–.95 (Newman et al., 1996)
Diagnostic accuracy: 82% (Keane et al., 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)
Optimal cutoff score: 8.5–30 across populations and studies (Newman et al., 1996)
Sensitivity: .77–.93 (Newman et al., 1996)
Specificity: .83–.89 (Newman et al., 1996)
Diagnostic Accuracy: .9 (Keane et 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)
Total: 35–175
Diagnostic cutoff score: 107 (Keane et al., 1988)
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
Penn Inventory for Posttraumatic Stress (Hammerberg, 1992)
Self-report questionnaire
26 items
Primarily used with male patients, including accident victims, veterans, and general psychiatric patients (Keane et al., 2000)
Posttraumatic Diagnostic Scale (PTDS) (Foa et al., 1997)
Assesses DSM-IV PTSD criteria
Self-report questionnaire
17 questions, including 12-item 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 (PCL) (Weathers et al., 1993)
Assesses DSM PTSD diagnostic criteria
Self-report questionnaire
10 minute administration
17 items, 5-point (0–4) Likert rating for past month
PTSD Checklist-Military version (PCL-M)
Principal components analysis indicated 1-factor solution (Wildes, 2007)
PTSD Interview (Watson et al., 1991)
Structured clinical interview
Dichotomous and continuous assessment
Patient given a copy of scale to read along with interviewer and asked to give subjective ratings for each symptom
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
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
Specificity: .83
Overall diagnostic efficiency: .9 (criterion: CAPS) (Blanchard et al., 1996)
Internal consistency (alpha): .97 (Weathers et al., 1993)
Test-retest reliability: .96 (Weathers et al., 1993)
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)
Individual symptom score: 0–8
Symptom endorsement cutoff: 3 or 4 (Blanchard et al., 1995; Forbes et al., 2001)
Total severity: 17–85
Diagnostic cutoff score: 50 in veteran population (Blanchard et al., 1996; Forbes et al., 2001)
Sensitivity: .89
Specificity: .94
Kappa: .82 (Criterion: DIS) (Watson et al., 1991)
Internal consistency (alpha): .92
Test-retest reliability: .95
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
PTSD Symptom Scale Interview (PSS-I) (Foa et al., 1993)
Assesses DSM criteria of PTSD
Semistructured interview
20–30 minute administration
Self-report questionnaire version (PSS-S): 10 minute administration
Likert rating scales for criterion symptoms
Dichotomous and continuous assessment
2-week time frame
Subscales:
reexperiencing (5 items)
avoidance (7 items)
arousal (5 items)
Symptom Checklist-90-R (SCL-90-R) (Derogatis, 1977)
Assesses a broad range of psychological problems, symptoms of psychopathology, patient progress, and treatment outcomes
Self-report questionnaire
12–15 minute administration
90 items, 5-point Likert rating
Global Severity Index: summary of test
9 primary symptom dimensions, 3 global indices
28-item Crime-Related PTSD Scale (Saunders et al., 1990)
12-item PTSD Subscale for Disaster Survivors (Green, 1991)
25-item War-Zone-Related PTSD Scale (Weathers et al., 1996)
Structured Clinical Interview (SCID) PTSD Module (Spitzer et al., 1990)
Assesses prevalence, absence, and subthreshold presence of PTSD
Used across trauma populations
Semistructured interview
25 minute administration
Permits only dichotomous rating (present/absent) of symptoms, does not assess severity of symptoms
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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
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Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence
Measure
Description
Scales/Factors
Structured Interview for PTSD (SI-PTSD or SIP) (Davidson et al., 1989)
Assesses DSM PTSD criteria (reexperiencing, avoidance and numbing, and hyperarousal) and functional impairment
Structured interview, including initial probes, behavioral observations and follow-up questions
20 minute administration
Severity and frequency of symptoms rated on 5-point (0–4) Likert scale
Dichotomous and continuous assessment
Assesses lifetime PTSD by “worst ever” symptomatology
Treatment Outcome PTSD Scale (TOP-8) (Connor and Davidson, 1999; Davidson and Colket, 1997) assesses treatment response: 8 items endorsed frequently and responded to treatment over time, drawn from 3 symptom clusters
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Psychometric Properties
Scoring and Interpretation Guidelines
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