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Post-Traumatic Stress Disorder Acute Stress Disorder I: by Shawn P. Cahill, PHD, and Kristin Pontoski, Ba
Post-Traumatic Stress Disorder Acute Stress Disorder I: by Shawn P. Cahill, PHD, and Kristin Pontoski, Ba
Dr. Cahill is Assistant Professor of Psychology in Psychiatry and Ms. Pontoski is a Research
AssistantBoth from University of Pennsylvania, Philadelphia, Pennsylvania.
Post-Traumatic
Stress Disorder
and Acute
Stress Disorder I
ADDRESS FOR CORRESPONDENCE:
Shawn P. Cahill, PhD, Center for the Treatment and Study of Anxiety
3535 Market St., 6th Floor, Philadelphia, PA 19104
Phone: (215) 746-3327; Fax: (215) 746-3311;
E-mail: scahill@mail.med.upenn.edu
14 Psychiatry 2005 [ A P R I L ]
Their Nature and
Assessment Considerations
POST-TRAUMATIC STRESS DISORDER (PTSD)
is a common and often chronic and disabling
anxiety disorder that can develop after
exposure to highly stressful events
characterized by actual or threatened harm to
the self or others. This is the first of two
articles summarizing the nature and treatment
of PTSD and the associated condition of acute
stress disorder (ASD). The present article
presents the diagnostic criteria for PTSD and
ASD, summarizes the epidemiology of
exposure to trauma and resulting PTSD/ASD,
discusses implications of these data for
assessment and treatment, and provides a
summary of several useful assessment
instruments. A companion paper to be
published in a future issue of Psychiatry 2005
will provide a summary of empirically
supported treatments, both psychological and PILOT PRAYING AFTER PLANE CRASH
pharmacological, for PTSD and ASD. U.S. Navy photo courtesy of GeekPhilosopher.com.
16 Psychiatry 2005 [ A P R I L ]
a potentially traumatic experience PTSD. By the final assessment, injured that is experienced during
is necessary for the development approximately three months after a criminal victimization and actual
of PTSD, it is not sufficient. One the assault, 47 percent met criteria receipt of physical injury during
major reason is that not all poten- for chronic PTSD. Thus, the major- the crime each separately
tially traumatic events are equally ity of people exposed to a traumat- increased the likelihood of having a
associated with the development of ic event and who experience lifetime diagnosis of PTSD.4
PTSD, with some of the most com- immediate symptoms of PTSD Women who neither experienced
monly experienced events being experience natural recovery from fear of injury/death nor received
among the least likely to be associ- their symptoms within 1 to 3 injury had a lifetime PTSD preva-
ated with the development of months of the event, although the lence of 19 percent, compared to
PTSD. For example, again from the rate at which symptoms decline between 27 and 30 percent when
NCS, lifetime prevalence of being decreases over time so that by one of these factors was present,
in an accident, natural disaster or three-months post-trauma, individ- and 45 percent when both were
fire, and witnessing someone badly uals with PTSD are likely to remain present. In a recent meta-analysis
injured or killed (prevalence rates symptomatic without appropriate of risk factors for PTSD, Brewin
ranging between 1436%, depend- treatment (to be reviewed in a and colleagues7 found the largest
ing on gender and the specific future companion article). These effect sizes for severity of the trau-
event) are all greater than the and similar data provide support ma, lack of social support following
prevalence of being raped (less for the utility of the current con- the trauma, and life stress follow-
than 1% for men and approximate- vention of not diagnosing PTSD in ing the trauma, although the mag-
ly 9% for women). However, the first month following the event, nitude of the effect sizes varied
among individuals expe-
riencing these different
events, prevalence of
PTSD related to rape
was 46 percent for men
Epidemiological studies indicate that exposure to
and 65 percent for
women, compared to potentially traumatic events...is common in the
less than 10 percent for
each of being in an acci- general population and that PTSD is one of
dent, natural disaster or
fire, and witnessing
someone badly injured
the most prevalent anxiety
or killed for both men
and women.
A second major rea-
disorders.
son is that most reac-
tions to potentially trau-
matic events, even those most like- as high symptoms in the immedi- substantially across studies.
ly to be associated with PTSD, ate aftermath of a potentially trau- Smaller but more consistent effects
such as rape, are transient and matic event can be normative, and were found for personal psychi-
resolve within 4 to 12 weeks after for differentiating between acute atric history (see also section
the event. For example, Rothbaum, and chronic PTSD, as those who below on comorbidity), family psy-
et al.,6 longitudinally followed still have PTSD three months after chiatric history, and personal histo-
female rape victims and evaluated the trauma are not likely to experi- ry of abuse in childhood.
them weekly for the presence and ence recovery in the absence of Several recent investigations
severity of PTSD symptoms. At the treatment. have attempted to identify biologi-
first assessment, approximately 12 In addition to the type of trau- cal markers or risk factors for the
days after the assault, 94 percent ma and sex of the victim, several development of PTSD, with the
met full symptom criteria, but not other factors have been identified two most promising being low cor-
the duration criterion, for PTSD. as predictors of the development tisol levels in the acute aftermath
By the fourth assessment occur- of PTSD. For example, in the of the trauma and elevated resting
ring approximately one month National Womens Survey, a large- heart rate shortly after the trauma.
after the assault, the point at scale (N=4,008) nationally repre- Yehuda8 has proposed a model that
which participants could formally sentative epidemiological study of implicates dysregulation of the H-
be diagnosed with PTSD, 64 per- trauma and PTSD in the United P-A axis in PTSD. Specifically,
cent met full criteria for acute States, fear of being killed or exposure to a stressful event
18 Psychiatry 2005 [ A P R I L ]
H), which specifies the disturbance either ASD or PTSD at each of the ASD criteria (A-E) in predicting
must last at least two days but last two assessments: Full syndrome PTSD found strongest positive pre-
no more than four weeks, and must (meets all criteria for ASD at the dictive power for the dissociative
occur within four weeks of the initial assessment or meets all cri- cluster (0.71), followed by reexpe-
trauma. DSM-IV is explicit that teria for PTSD at the follow-up riencing and avoidance (0.52 for
either the symptoms must resolve assessment), subclinical (meets each), arousal (0.31), and expo-
within four weeks after the conclu- criteria for four of the five ASD sure to trauma (0.27). Negative
sion of the traumatic event or the symptom clusters, or two of the predictive power was higher than
diagnosis is changed. three PTSD symptom clusters at positive predictive power for all
As Harvey and Bryant have dis- the corresponding time point), or symptom clusters, with values
cussed in detail,12,13 the addition of no diagnosis. Among participants ranging between 0.86 and 0.94, and
ASD to DSM-IV has engendered with subclinical ASD, 78.9 percent negative predictive power for dis-
considerable controversy. For failed to meet the requirement of sociation (0.86) was numerically
example, the question has been at least one dissociative symptom, lower than for the more character-
raised whether it is justifiable to whereas among participants with istic PTSD symptom clusters of
distinguish between two diagnoses subclinical PTSD, 100 percent reexperiencing (0.93), avoidance
that share symptoms on the basis failed to meet the requirement of (0.93), and arousal (0.94).
of duration of the symptoms. On at least three avoidance symptoms. In summary, individuals who
one hand, including the diagnosis The utility of the ASD diagnosis meet full ASD criteria are highly
would potentially facilitate patients was strongest for the cases in likely, although not inevitably, to
with PTSD-like symptoms in which (1) full ASD criteria were develop chronic PTSD in the
receiving early interventions that met and (2) cases where the per- absence of appropriate treatment;
may reduce the duration of those son did not meet criteria for even individuals who do not meet crite-
symptoms and prevent the devel- subclinical ASD. Specifically, ria for even subclinical ASD are
opment of chronic PTSD. On the among participants meeting full highly unlikely, although not entire-
other hand, the symptom duration ASD criteria at the initial assess- ly, to develop chronic PTSD or
criterion was introduced in the ment, 77.8 percent met full criteria even subclinical PTSD; and individ-
PTSD diagnosis specifically to pre- for chronic PTSD at the follow-up uals meeting criteria for all ASD
vent the pathologizing of what may assessment and 22.2 percent did symptom clusters but one are
be normal and transient reactions. not meet criteria for even subclini- somewhat more likely than not, but
The concern about pathologizing cal PTSD. Among participants who again not inevitably, to subsequent-
transient reactions is of particular did not meet criteria for even sub- ly develop either chronic or sub-
concern given that ASD was added clinical ASD at the initial assess- clinical PTSD. Overall, there is
to the DSM without compelling evi- ment, 87.2 percent did not meet greater negative predictive power
dence of its utility in predicting criteria for even subclinical PTSD for the ASD diagnosis than positive
PTSD or for the centrality of disso- at the follow-up assessment and predictive power. In other words,
ciation in the development of only 4.3 percent met full criteria absence of significant symptoms of
PTSD. for PTSD. The utility of the ASD ASD in the aftermath of a traumat-
Inclusion of ASD in DSM-IV diagnosis was less clear in cases of ic event is a better predictor of
does, however, seem to have had subclinical ASD. Specifically, subsequent outcome (absence of
the positive effect of stimulating among participants with subclinical PTSD) than is their presence. In
research that addresses the issues ASD at the initial assessment, 60 addition, while the dissociative
raised above. In one such study, percent met full criteria for chronic symptom cluster may have higher
Harvey and Bryant14 assessed 92 PTSD at the follow-up assessment, positive predictive value than other
consecutive motor vehicle accident 20 percent met criteria for subclin- symptom clusters, their presence is
victim admissions (ages 1665) to cal PTSD, and 20 percent did not not necessary for the development
a major trauma hospital for ASD meet criteria for even subclinical of chronic PTSD.
symptomology. All initial assess- PTSD. Of theoretical significance is Translating the above findings
ments took place within four weeks the fact, reported above, that the into clinical guidelines, it would
of the accident and the average majority of participants meeting seem appropriate that individuals
time between the accident and the criteria for subclinical ASD had meeting full criteria for ASD at
initial assessment was 6.85 days failed to meet the dissociation cri- least one week after the trauma be
(standard deviation was 5.81 days). teria, raising into question the cen- offered treatment (if the appropri-
Seventy-one of the participants trality of dissociation in the ASD ate services are available) and that
were also assessed for PTSD six construct. Analyses conducted to those not meeting criteria for even
months later. The researchers uti- evaluate the positive and negative subclinical ASD be educated that
lized a tripartite classification for predictive power for each of the treatment is probably unnecessary
20 Psychiatry 2005 [ A P R I L ]
ders, other anxiety disorders, and Remembering Trauma16). For ment response, dimensional
alcohol/substance use disorders. example, patients who lose con- assessment utilizing reliable and
In principle, each of these con- sciousness during the trauma or valid assessment instruments is
tent areas can be assessed were under the influence of drugs frequently more helpful than sim-
through clinician interviews, self- or alcohol may have gaps in their ple diagnostic decisions and clini-
report measures, or a combina- knowledge for what happened, cian impressions of severity as
tion of the two. In general, clini- but such gaps may be due to they provide greater information,
cian administered interviews are either a failure to encode the rele- are more sensitive to change
considered the gold standard in vant memory or normal sources of (either worsening or improving),
research. In part, this is because forgetting, rather than the kind of and treatment effects observed in
it is assumed that clinicians will cognitive avoidance mechanism the clinic can be compared with
have a better understanding of envisioned in the diagnostic crite- treatment effects reported in the
the diagnostic criteria and will ria. The primary disadvantage of research literature to help the cli-
better able to judge whether or clinician-administered measures nician set reasonable expectations
not a particular patient complaint is that they can be time consum- with the patient and for both the
falls within the category. For ing to administer. Self-report clinician and the patient to under-
example, DSM differentiates measures, which are often validat- stand how their symptom level or
recurrent, intrusive, distressing ed against interview measures, treatment response compares to
thoughts or recollections about have the advantage that they can that of others. Accordingly, we
the trauma (Criterion
B1) from flashbacks
(Criterion B3). The dif-
ference between these
two symptoms is that The assessment of PTSD and ASD
flashbacks have a quali-
ty of feeling as though it requires at minimum an assessment of the
is happening right now,
whereas intrusive recol-
lections are clearly rec-
persons trauma history and the persons
ognized as a memory
for a past event.
subjective reaction, the persons current
Patients, however, may
not make this differenti-
symptoms, and the temporal relationship between
ation and, as a result,
may rate the same the traumatic event and the persons symptoms.
event as two separate
symptoms and thereby
elevate the overall
severity score. Similarly, patients be mailed to patients ahead of recommend clinicians incorporate
who wake up from nightmares time and filled out at their leisure the use of formal assessment
may double code the same sleep or completed while waiting to see instruments into their practice
disturbances caused by the night- the clinician. and, to this end we provide a brief
mares, once in response to the With regard to assessing review of commonly used assess-
question about recurrent night- PTSD/ASD and associated psy- ment instruments. For even
mares (Criterion B2) and again in chopathology, some assessment greater detail on the assessment
response to questions about sleep measures provide primarily a of psychological trauma and
disturbance (Criterion D1). As a dichotomous diagnostic decision PTSD, the interested reader is
final example of this difficulty, (meets criteria, does not meet cri- referred to Wilson and Keane.17
patients may have gaps in their teria) with limited information Another excellent resource on
memory for important details of about severity, whereas others assessment is the assessment web
the traumatic event, but not all provide dimensional information page on the National Center for
such instances will meet the crite- on symptom severity, and still PTSD website,18 which contains
ria for dissociative amnesia others will be able to provide both information on several of the
(Criterion C3; see greater discus- types of information. With regard assessment instruments discussed
sion of dissociative amnesia in the to offering patients information below as well as many other
DSM IV on pages 478481, and about prognosis, monitoring natu- instruments not covered in this
McNally's review on ral recovery, or evaluating treat- review, along with contact infor-
22 Psychiatry 2005 [ A P R I L ]
make the diagnosis are present, with one another (r=0.8023), and frame to the last one or two weeks
and symptoms result in no more the PSS-I is highly correlated with in order to assess symptom change
than minor impairment), moderate the CAPS (r=0.87) but requires over the course of treatment, par-
(symptoms or functional impair- approximately half the time to ticularly when visits are scheduled
ment between mild and severe), administer.24 Brewin and relatively close together.
or severe (many symptoms in colleagues25 have modified the PSS- One final self-report measure
excess of those required to make SR for use as a brief screening that deserves mention because of
the diagnosis, or several that are instrument to detect likely cases of its good psychometric properties
particularly severe, are present, or PTSD. This scale, called the and common use in both research
result in marked impairment.) Trauma Screening Questionnaire and clinical practice is the Impact
Several other measures have the (TSQ), consists of 10 items from of Event Scale (IES).27 It was
clinician or patient rate the severi- the PSS-SR that are rated by the developed more than a decade
ty and/or frequency of each symp- patient in simple yes or no fashion prior to the introduction of PTSD
tom according to some kind of based on whether or not the in DSM III1 based on Horowitzs28
Likert-type scale yielding a broader patient experienced any of the theory of the stress response syn-
range of severity scores. One of the items at least two times in the past drome in which he hypothesized
most commonly used measures in week. Using the cut-off score of 6 that the normal stress reaction
research, indeed often referred to or greater, TSQ was found to have consists of a person alternating
as the gold standard in PTSD excellent sensitivity, specificity, between intrusive states, charac-
assessment, is the Clinician terized by many of what we
Administered PTSD Scale now call the reexperiencing
DIAGNOSTIC INSTRUMENTS FOR ASSESSING PTSD
(CAPS).21 The administer- and some of the hyper-
SYMPTOMS
ing clinician asks the arousal symptoms of PTSD,
patient about the frequen- and denial states, character-
The Structured Clinical Interview for DSM IV (SCID-IV)
cy and severity of each ized by many of what com-
The Clinician Administered PTSD Scale (CAPS)
symptom and then makes prise the avoidance/numbing
The Davidson Trauma Scale (DTS)
separate ratings for fre- symptoms of PTSD. The IES
The PTSD Symptom Scale Interview (PSSI)
quency and severity on a 0 is a 15-item questionnaire in
The PTSD Symptom Scale Self-Report (PSS-SR)
to 4 scale, yielding a total which each item is scored
The Trauma Screening Questionnaire (TSQ)
score that ranges between for frequency of the symp-
The Post-Traumatic Stress Diagnostic Scale
0 to 136. Several treatment tom in the past week follow-
The Impact of Event Scale (IES)
outcome studies that have ing the unusual convention
used the CAPS as the pri- of 0=not at all, 3=moderate,
mary outcome measure and 5=severe and yields
require a minimum score of 50 for and power (index values ranging separate scores for the seven-item
entry into the study and a com- between 0.760.91 across two sam- intrusion and eight-item avoidance
monly agreed upon score reflecting ples) relative to a PTSD diagnosis subscales. Because the IES items
a good outcome is a score less than derived from a clinician interview do not entirely correspond with
20. The Davidson Trauma Scale with the CAPS.21 The Post- current DSM symptom criteria for
(DTS) is a similarly designed self- Traumatic Stress Diagnostic Scale
22 26
PTSD, this instrument cannot be
report measure that has the is a commercially available revision used to derive diagnostic informa-
patient separately rate the fre- of the PSS-SR that provides a com- tion. However, it has been found in
quency and severity of each PTSD prehensive self-report assessment several outcome studies to be sen-
symptom on a 0 to 4 scale, and of all DSM-IV PTSD criteria includ- sitive to treatment-related changes
thus yields scores with the same ing trauma history, determination in post-trauma symptomology fol-
range as the CAPS. of whether the event meets both lowing psychotherapy29 and phar-
The PTSD Symptom Scale the objective and subjective crite- macotherapy.30 Weiss and Marmar31
Interview (PSS-I) and PTSD ria to qualify as a traumatic event, have developed a revised version of
Symptom Scale Self-report (PSS- and assessment of the symptom, the IES in which they added sever-
SR) are a pair of measures that duration, and impairment criteria. al items to fully cover the hyper-
combine information about fre- Whether assessing PTSD severity arousal symptoms, so the measure
quency and severity of each symp- by interview or self-report, it is now yields three subscales that
tom which is then rated on a 0 to 3 common to use the last month as strongly (but not entirely) resem-
scale, thus yielding a total score the time frame for the initial ble the DSM symptom structure,
that ranges between 0 to 51.23 The assessment to insure that duration and they recommended replacing
interview and self-report versions criteria has been met. However, it the 0, 1, 3, 5 scoring scheme with a
of the PSS are highly correlated is common to reduce the time more conventional 0 to 4 scheme.
24 Psychiatry 2005 [ A P R I L ]
5. Kessler RC, Sonnega A, Bromet E, et al. BO. Reliability and validity of a brief
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