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. VETERANS HEALTH ADMINISTRATION 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 1

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

4. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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 5

7. VETERANS HEALTH ADMINISTRATION Considerations for Choosing PTSD Assessment Measures Questions to consider: – Why are you assessing? – Who are you assessing? – What are you assessing?

8. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION Considerations: Who are you assessing? Consider population-specific measures – Children/Adolescents – Veterans/Military – Older adults – Culture-specific (language)

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

12. VETERANS HEALTH ADMINISTRATION 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 11

13. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION Additional Assessment Domains Suicidality Dissociation Depression Grief Anger Guilt & Shame Alcohol & Substance Use TBI & Cognition Readiness for change

15. VETERANS HEALTH ADMINISTRATION 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 14

16. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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. VETERANS HEALTH ADMINISTRATION 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 20

22. VETERANS HEALTH ADMINISTRATION 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. 21

23. VETERANS HEALTH ADMINISTRATION 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. 22

24. VETERANS HEALTH ADMINISTRATION 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. 23