Partial PTSD versus full PTSD: an empirical examination of associated impairment

BACKGROUND

Partial PTSD, employed initially in relation to Vietnam veterans, has been recently extended to civilian victims of trauma. We examined the extent to which partial PTSD is distinguishable from full DSM-PTSD with respect to level of impairment.

METHOD

A representative sample of 2181 persons was interviewed by telephone to record lifetime traumatic events and to assess DSM-IV PTSD criteria. Partial PTSD was defined as > or = 1 symptom in each of three symptom groups (criteria B, C and D) and duration of > or = 1 month. Impairment in persons with PTSD and partial PTSD was measured by number of work-related and personal disability days during the 30-day period when the respondent was most upset by the trauma.

RESULTS

Compared to exposed persons with neither PTSD nor partial PTSD, increment in work-loss days associated with PTSD was 11.4 (S.E. =0.6) days and with partial PTSD, 3.3 (S.E. =0.4) days (adjusted for sex, education and employment). Similar disparities were found across other impairment indicators. Persons who fell short of PTSD criteria by one symptom of avoidance and numbing reported an increment of 5.0 (S.E. =0.7) work-loss days, 6.0 fewer than full PTSD. PTSD was associated with excess impairment, controlling for number of symptoms. A significantly lower proportion of persons with partial PTSD than full PTSD experienced symptoms for more than 2 years. A lower proportion of persons with partial PTSD than full PTSD had an etiologic event of high magnitude.

CONCLUSIONS

PTSD identifies the most severe trauma victims, who are markedly distinguishable from victims with subthreshold PTSD.

On the threshold of disorder: a study of the impact of the DSM-IV clinical significance criterion on diagnosing depressive and anxiety disorders in clinical practice

BACKGROUND

Two recent reanalyses of epidemiologic studies found that adding a clinical significance criterion reduced disorder prevalence. Patients presenting for clinical care are usually distressed or impaired by their symptoms; thus, the DSM-IV clinical significance criterion might have little impact on diagnosis in clinical practice. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the impact of the DSM-IV clinical significance criterion on diagnostic frequencies of depressive and anxiety disorders in psychiatric outpatients.

METHOD

1500 psychiatric outpatients were evaluated with the Structured Clinical Interview for DSM-IV. We determined the percentage of patients who met symptom criteria but did not meet the DSM-IV clinical significance criterion for major depressive disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder, and obsessive-compulsive disorder.

RESULTS

No patient who met the symptom criteria for current major depressive disorder or PTSD failed to meet the clinical significance criterion. Less than 2% of patients meeting the symptom criteria for current GAD did not meet the clinical significance criterion. There was variability among the remaining anxiety disorders in the percentage of symptomatic patients who met the clinical significance criterion.

CONCLUSION

In psychiatric patients, the clinical significance criterion had little impact on diagnosing major depressive disorder, GAD, and PTSD, disorders that are defined, in part, by disruptions of daily regulatory domains such as sleep, appetite, energy, and concentration. In contrast, the clinical significance criterion had a greater impact in determining whether phobic fears, obsessive thoughts, and panic attacks were sufficiently distressing or impairing to qualify for disorder status.

Emotion-specific and emotion-non-specific components of posttraumatic stress disorder (PTSD): implications for a taxonomy of related psychopathology

Many cognitive theories of posttraumatic stress disorder (PTSD), including our own SPAARS model, propose that one basis of the disorder is the cognitive system's persistent failure to resolve discrepancies between trauma-related information and the content of pre-existing mental representations, such as schemas. This leads to the characteristic PTSD symptom pattern of re-experiencing and avoidance of trauma-related material. Furthermore, the nature of this unresolved discrepancy revolves around appraisals of threat and the corresponding emotion profile in PTSD is therefore predominantly intense fear and anxiety. This paper argues that this general framework can be extended to discrepancies around other appraisal dimensions such as loss, and consequently to other emotions such as sadness. A localized taxonomy is therefore proposed comprising emotional disorders that resemble PTSD in their basic patterns of re-experiencing and avoidance symptoms--what we call their 'emotion-non-specific component'--but that differ from PTSD in terms of the core emotions involved--what we call their 'emotion-specific component'. The clinical and nosological implications of this argument are discussed.

Domestic Violence and Post-Traumatic Stress Disorder Severity for Participants of a Domestic Violence Rehabilitation Program

Domestic violence has been a long-standing problem for our nation's active duty and military veterans. The purpose of this article is to describe participants of a domestic violence program, the program design to help lessen attrition, and the completers and noncompleters of the program. There was a significant relationship between post-traumatic stress disorder (PTSD) and domestic violence severity for the sample. PTSD severity was also related to reports of domestic violence in the family of origin. Completers and noncompleters were compared on demographic and violence variables and on nine research measures. Completers were more likely younger than 35 years old, employed, had higher self-ratings of relationship mutuality, lower levels of stress and post-traumatic stress, and were regularly court monitored. The results of a logistic regression significantly predicted completers and noncompleters based on age, relationship mutuality, PTSD, and court-monitored status (model chi2 statistic of 31.08, p = 0.0000).

The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index

Over the past decade, the University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index has been one of the most widely used instruments for the assessment of traumatized children and adolescents. This paper reviews its development and modifications that have been made as the diagnostic criteria for post-traumatic stress disorder have evolved. The paper also provides a description of standard methods of administration, procedures for scoring, and psychometric properties. The Reaction Index has been extensively used across a variety of trauma types, age ranges, settings, and cultures. It has been broadly used across the US and around the world after major disasters and catastrophic violence as an integral component of public mental health response and recovery programs. The Reaction Index forms part of a battery that can be efficiently used to conduct needs assessment, surveillance, screening, clinical evaluation, and treatment outcome evaluation after mass casualty events.

Comparing traditional and Rasch analyses of the Mississippi PTSD Scale: revealing limitations of reverse-scored items

This study examined whether Rasch analysis could provide more information than true score theory (TST) in determining the usefulness of reverse-scored items in the Mississippi Scale for Posttraumatic Stress Disorder (M-PTSD). Subjects were 803 individuals in inpatient PTSD units at 10 VA sites. TST indicated that the M-PTSD performed well and could be improved slightly by deleting one item. Factor analysis using raw scores indicated that the reverse-scored items formed the second factor and had poor relationships with normally scored items. However, since item-total correlations supported their usefulness, they were kept. The subsequent Rasch analysis indicated that five of the seven worst fitting items were reverse-scored items. We concluded that using reversed items with disturbed patients can cause confusion that reduces reliability. Deleting them improved validity without loss of reliability. The study supports the use of Rasch analysis over TST in health research since it indicated ways to reduce respondent burden while maintaining reliability and improving validity.

Abstracts of the 45th Annual and 4th Mediterranean Meeting, Scandinavian College of Neuro-Psychopharmacology. 21-24 April 2004

Post-traumatic stress disorder (PTSD) has been included in the DSM category of psychiatric diagnoses since 1980, classified as an anxiety disorder. Since that time, its definition has undergone considerable change and today many physicians are not aware of its current diagnostic criteria or the clinical significance of its high degree of comorbidity with other psychiatric and somatic conditions. PTSD can appear in different forms, and its many manifestations often identified and dealt with, while the underlying pathological trauma and psychological damage continues unrecognized and untreated, resulting in negative consequences for the patient and society. The extent of the problem is considerable in North America but prevalence studies in Europe are practically non-existent amongst the general population, with the subsequent result being that the degree and severity of the problem in Europe remains unknown. This article briefly looks at the history and metamorphosis of PTSD and discusses its present niche in relation to primary healthcare.

Psychic disorders in former prisoners of war

AIM

To analyze the kind and the representation of psychic disorders in former prisoners of war and war veterans who were not detained in camps.

METHODS

The analyzed sample consisted of 160 respondents divided into two groups. A group of 100 former prisoners of war and a group of 60 war veterans who had not been detained in camps. All the respondents are males and were psychically in healthy condition prior to the war. The modified Harvard Trauma Questionnaire was used to diagnose traumatic experience, and a questionnaire according to the DSM IV criteria was used to diagnose posttraumatic stress disorder. The Depressiveness Scale D-92 was used to diagnose depressiveness; the questionnaire STAI was used to diagnose anxiety; CAGE Questionnaire was used to diagnose alcoholism.

RESULTS

The former prisoners of war had traumatic experience at a higher level as compared to the war veterans who had not been detained in camps (P < 0.05). The symptoms of PTSD were manifested by 55% of camp inmates as compared to 33.3% of war veterans (P < 0.05). Depressive disorder was diagnosed in 52% of camp inmates and 31.7% of war veterans (P < 0.05). No statistically significant difference was found among the analyzed groups relating to anxiety and alcohol drinking.

CONCLUSIONS

The former prisoners of war were living through a severer stage and had a more sundry traumatic experience. Severer stage of traumatic experience conditioned statistically higher representation of psychic disorders (PTSD and depressiveness) in the former prisoners of war as compared to the war veterans.

A descriptive analysis of PTSD chronicity in Vietnam veterans

This study examined the chronicity of PTSD in 530 male and female Vietnam veterans who were drawn from 2 large, ethnically diverse samples. Delayed onset was common, as was a failure to fully remit: 78% of the 239 veterans with full or partial lifetime PTSD were symptomatic in the 3 months prior to assessment. Cluster analysis identified 4 subtypes of posttraumatic response, with women most likely to be in a delayed onset cluster, and minority men most likely to be in a severe chronic cluster. The extent of chronicity observed in this sample underscores the need for treatments that address the persistence of posttraumatic symptoms.

Pers�nlichkeitsst�rungen und die Psychopathologie in der Folge von Traumen

Pervasive personality disorders have been shown to be long-term sequelae of cumulative childhood physical and sexual traumatization. This finding is not reflected in DSM-IV and ICD-10 classifications where post-traumatic stress disorder is confined to intrusions, avoidance, numbing, and hyperarousal. However, there is growing evidence that trauma etiology should be taken into account in planning treatment for personality disorders. It is not yet clear whether childhood traumatization is more strongly associated with borderline personality disorder than with other personality disorders. The finding of a substantial overlap between borderline personality disorder and dissociative identity disorder gives rise to discussions concerning the relationship of these two pathologies.

Follow-up of young road accident victims

The aim of this study was to follow-up a group of children and young people previously examined for psychological sequelae following road traffic accidents. The group was assessed 18-month postaccident to assess the severity of continuing symptoms and examine any emergence of delayed onset of posttraumatic stress reactions. Participants (N = 31) completed the Revised Impact of Event Scale and the Child Posttraumatic Stress Reaction Index. Parents completed the Child Behavior Check-List and participated in a semistructured interview. Symptoms of PTSD were noted in a quarter of participants as was delayed onset of symptoms. The role of avoidance in symptom reporting and continuing disorder is discussed.

The clinical relevance of a partial remission specifier for posttraumatic stress disorder

The clinical relevance of a partial remission specifier for posttraumatic stress disorder (PTSD) was examined. Using a subgroup of outpatients from the Rhode Island Methods to Improve Diagnostic Assessment and Services project who met criteria for lifetime PTSD (N = 261), participants with current PTSD, PTSD in partial remission, and PTSD in full remission were compared on various indices of impairment. A substantial number (n = 75) of patients met criteria for PTSD in partial remission (28.7%). Outpatients in partial remission of PTSD displayed comparable levels of social and employment functioning as those with current PTSD, and over half of these patients requested treatment for their symptoms. Results support the clinical utility of a partial remission specifier for PTSD.

Spirituality, resilience, and anger in survivors of violent trauma: a community survey

This study evaluates the relationship between spirituality, resilience, anger and health status, and posttraumatic symptom severity in trauma survivors. A community sample (N = 1,200) completed an online survey that included measures of resilience, spirituality (general beliefs and reincarnation), anger, forgiveness, and hatred. In survivors of violent trauma (n = 648), these measures were evaluated with respect to their relationship to physical and mental health, trauma-related distress, and posttraumatic symptom severity. Using multivariate regression models, general spiritual beliefs and anger emerged in association with each outcome, whereas resilience was associated with health status and posttraumatic symptom severity only. Forgiveness, hatred, and beliefs in reincarnation were not associated with outcome. The importance of these findings to treating trauma survivors is discussed.

Criterion validity of the self-rating inventory for posttraumatic stress disorder (SRIP) in the community of older adults

BACKGROUND

A validated screening instrument for PTSD in community dwelling older people is lacking. This study evaluates a newly developed measure, the self-rating inventory for posttraumatic stress disorder (SRIP) on its usefulness in survey research. The predictive value of the SRIP in a community setting is investigated.

METHODS

In a two-phase epidemiologic design the criterion validity of the SRIP was tested against diagnosis made with the comprehensive international diagnostic interview (CIDI) in 1721 older (55-90 years) inhabitants of the Netherlands. Optimal sensitivity and specificity was determined using a weighted receiver operator characteristic (ROC)-curve.

RESULTS

Optimal sensitivity (74.2%) and specificity (81.4%) was reached with a cut-off of 39 points.

LIMITATIONS

According to a strictly applied CIDI algorithm the number of 'true' cases was limited.

CONCLUSION

Overall findings indicate that posttraumatic stress disorder can be identified adequately in a community-based population of older adults using the SRIP. Use of the SRIP may improve recognition and diagnosis of posttraumatic stress disorder in the community.

Pediatric emergency department assessment of psychological trauma and posttraumatic stress

OBJECTIVES

This study aimed to describe the kinds of stressors and the extent of symptoms of posttraumatic stress disorder (PTSD) that were reported by children and their parents in a pediatric emergency department and to examine the response rate to an emotional trauma questionnaire in this setting.

METHODS

Three self-report questionnaires were given to patients aged eight to 21 years and to their primary caretakers: a brief assessment of service use, the Posttraumatic Stress Reaction Index (PTSRI), and the Impact of Event Scale (IES).

RESULTS

Sixty-four of 81 families who were approached agreed to participate (consent rate of 79 percent), and 62 completed the questionnaires. Fifty-six patients reported at least one event that met DSM-IV-TR criteria for emotional trauma. The average number of reported events per child was 3.14 (range, 0 to 7). Eighteen patients met threshold criteria for severity of PTSD symptoms. Twenty-five patients reported that the most distressing traumatic event that they experienced was related to a medical illness. Patients with PTSD reported exposure to more adverse life events than patients without PTSD. IES scores reported by caretakers who identified the same event as their child as the most stressful were as high as those of caretakers who reported a different event as the most stressful.

CONCLUSIONS

Exposures to emotionally traumatic events and PTSD symptoms are commonly reported in the pediatric emergency department. Asking children and their parents about their history of emotional trauma when they visit the emergency department is possible and can be well received.

Dimensions of trauma associated with posttraumatic stress disorder (PTSD) caseness, severity and functional impairment: a study of Bosnian refugees resettled in Australia

Refugee survivors of inter-ethnic warfare vary greatly in the extent and range of their trauma experiences. Discerning which experiences are most salient to generating and perpetuating disorders such as posttraumatic stress disorder (PTSD) is critical to the mounting rational strategies for targeted psychosocial interventions. In a sample of Bosnian Muslim refugees (n=126) drawn from a community centre and supplemented by a snowball sampling method, PTSD status and associated disability were measured using the clinician-administered PTSD Scale (CAPS) for DSM-IV. A principal components analysis (PCA) based on a pool of trauma items yielded four coherent trauma dimensions: Human Rights Violations, Threat to Life, Traumatic Loss and Dispossession and Eviction. A cluster analysis identified three subgroupings according to extent of trauma exposure. There were no differences in PTSD risk for the group most exposed to human rights violations (internment in concentration camps, torture) compared to the general war-exposed group. Logistic regression analysis using the dimensions derived from the PCA indicated that Threat to Life alone of the four trauma factors predicted PTSD status, a finding that supports the DSM-IV definition of a trauma. Both Threat to Life and Traumatic Loss contributed to symptom severity and disability associated with PTSD. It may be that human rights violations pose a more general threat to the survivor's future psychosocial adaptation in areas of functioning that extend beyond the confines of PTSD.

Screening for risk of persistent posttraumatic stress in injured children and their parents

CONTEXT

Injury, a leading health threat to children, is also a common cause of posttraumatic stress disorder (PTSD) in childhood. Most injured children with PTSD are not diagnosed or treated.

OBJECTIVE

To develop a stand-alone screening tool for use by clinicians during acute trauma care to identify injured children and their parents who are at risk of significant, persistent posttraumatic stress symptoms.

DESIGN

The Screening Tool for Early Predictors of PTSD (STEPP) was derived from a 50-item risk factor survey administered within 1 month of injury as part of a prospective cohort study of posttraumatic stress in injured children and their parents. Symptoms of PTSD were assessed at least 3 months after injury.

SETTING

Urban, pediatric level I trauma center.

PARTICIPANTS

A sample of 269 children aged 8 to 17 years admitted for treatment of traffic-related injuries between July 1999 and October 2001, and one parent per child, completed a risk factor survey assessing potential predictors of PTSD outcome. One hundred seventy-one families (63%) completed a follow-up assessment.

MAIN OUTCOME MEASURES

The Clinician-Administered PTSD Scale for Children and Adolescents and the PTSD Checklist served as criterion standards for child and parent outcomes, respectively. Positive cases were defined as those meeting criteria for at least subsyndromal PTSD with continuing impairment ("persistent traumatic stress").

RESULTS

The STEPP contains 4 dichotomous questions asked of the child, 4 asked of one parent, and 4 items obtained easily from the emergency medical record. STEPP sensitivity in predicting posttraumatic stress was 0.88 for children and 0.96 for parents, with negative predictive values of 0.95 for children and 0.99 for parents. The odds ratio for prediction of persistent traumatic stress was 6.5 (95% confidence interval [CI], 1.8-22.8) in children and 26.6 (95% CI, 3.5-202.1) in parents.

CONCLUSIONS

The STEPP represents a new method to guide clinicians in making evidence-based decisions for the allocation of scarce mental health resources for traumatic stress. Its brevity and simple scoring rule suggest that it can be easily administered in the acute care setting.

Measurement precision of the clinician administered PTSD scale (CAPS): a RASCH model analysis

The Clinician Administered PTSD Scale (CAPS), originally developed as a diagnostic tool, is frequently used to evaluate treatment responses. Defining a case and measuring symptom changes are different processes that require different attributes for the instrument. Measuring symptom changes requires precision in measurement. Using the Rasch rating scale model, we evaluated this instrument for construct validity in a veteran sample. The distribution of the veteran measures did not align with the distribution of the item measures in the CAPS instrument. Separate analysis of the CAPS Frequency subscale and Intensity subscale were conducted. The Frequency subscale produced measures that encompassed the level of severity found in the veteran sample. Items from this instrument can be used to develop an equal interval scale to provide precise measurements for treatment evaluations and to identify clinical cut points for diagnostic purposes.

[The so-called trauma criterium (A--Criterium in DSM-IV) of post-traumatic stress disorder and its significance for social and legal insurance (II)]

Since the diagnosis post traumatic stress disorder (PTSD) was included in the American diagnosis system DSM-III in 1980, the ongoing scientific discussion has led to a shift in the definition of the so called A-criterion (trauma criterion) away from the general theory that the disease-causing event has to be outside normal human experience towards the point of view that it is more or less determined by the subjective experience of the individual. Without wishing to become involved in the discussion, in the publication the author tries to explain, on the basis of references to basic concepts found in insurance law (accident, initial damage, suitability of event, objectivity, epidemiological considerations), that in social insurance as well as in non-life insurance an objective insured event which has a severe emotional impact on the individual is a prerequisite for payment. The conclusion is that not every mental disorder which occurs after an insured event and which has quite rightly been classified as PTSD (or partial PTSD) on the basis of the symptoms involved in accordance with ICD-10/DSM-IV (criteria B-D) necessarily results in payment under insurance law.

Clinical presentations in combat veterans diagnosed with posttraumatic stress disorder

This article investigated subtypes of symptom patterns among male combat veterans diagnosed with posttraumatic stress disorder (PTSD) through a cluster analysis of their Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Graham, Ben-Porath, Tellegen, Dahlstrom, & Kaemmer, 2001) clinical and validity scales. Participants were 126 veterans seeking outpatient treatment for combat-related PTSD at a Veterans Affairs Medical Center. Two well-fitting MMPI-2 cluster solutions (a four-cluster solution and a three-cluster solution) were evaluated with several statistical methods. A four-cluster solution was determined to best fit the data. Follow-up analyses demonstrated between-cluster differences on MMPI-2 "fake bad" scales and content scales, the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), Dissociative Experiences Scale (DES; Bernstein & Putnam, 1986), Mississippi Combat PTSD scale (M-PTSD; Keane, Caddall, & Taylor, 1988), and Clinician-Administered PTSD Scale (CAPS-1; Blake et al., 1990). Clusters also were different in disability-seeking status, employment status, and income. Implications for research and clinical practice using the MMPI-2 with combat veterans presenting with PTSD are briefly addressed.

The development of the Chinese version of Impact of Event Scale--Revised (CIES-R)

BACKGROUND

This is an exploratory study on the psychometric properties and normative data of the Chinese translation of the Impact of Event Scale - Revised (CIES-R).

METHODS

The original Impact of Event Scale - Revised was translated into Chinese and the comparability of content was verified through back-translation procedures. The study consisted of a sample of 116 patients from the Accident and Emergency Department.

RESULTS

The reliability of the Chinese version was verified. The validity of the Chinese version as a measure of psychological distress was supported by the positive correlations between the various subscale scores of CIES-R (i. e., Intrusion, Avoidance, and Hyperarousal) and General Health Questionnaire-20. However, the independence of the three subscales was not supported.

CONCLUSIONS

The present result suggests that normative information for different age groups and clinical samples might be different. Further study with clinical sample and investigation of the relationship between CIES-R and other diagnostic measures of PTSD are discussed.