Suicidal Behavior After Severe Trauma. Part 1: PTSD Diagnoses, Psychiatric Comorbidity, and Assessments of Suicidal Behavior

The study comprises 149 refugees from various countries, reporting exposure to severe traumata, who were referred for psychiatric diagnosis and assessment of suicide risk. The stressors reported comprised both personal experience of and/or forced witnessing of combat atrocities (including explosions or missile impacts in urban areas), imprisonment (including isolation), torture and inflicted pain, sexual violence, witnessing others' suicide, and of summary and/or mock executions. Posttraumatic stress disorder (PTSD) was diagnosed in 79% of all cases, other psychiatric illness in 16% and no mental pathology in 5%. The prevalence of suicidal behavior was significantly greater among refugees with principal PTSD diagnoses than among the remainder. PTSD patients with depression comorbidity reported higher frequency of suicidal thoughts; PTSD nondepressive patients manifested increased frequency of suicide attempts.     

Cross-cultural care for PTSD: Research,training, and service needs for the future

Treating the consequences of violence in refugees, immigrants, and other minority groups is complicated by several factors. One of these factors involves the treatment of such problems, which are often related to both past violence as well as to current adverse conditions or precipitants. Another factor relates to cross-cultural assessment and treatment, which requires special education, experience, and supervision. Thirdly, there is usually the matter of concurrent acculturation, which may be undermined by biopsychosocial maladjustment due to past violence and which may in turn precipitate psychiatric syndromes that are related to previous violence. The future implications of these factors for research, training, and service needs are reviewed in this paper.This is a revised version of a paper prepared for a conference on Long-Term Effects of Mass Violence: Cross-Cultural Treatment and Research Issues in PTSD, for National Institutes of Mental Health April 1986.     

Screening for PTSD in a Substance Abuse Sample: Psychometric Properties of a Modified Version of the PTSD Symptom Scale Self-Report

The high rate of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients has been documented in research protocols, but there is evidence that it is markedly under-diagnosed in clinical settings. To address the need for a brief self-report measure to identify SUD patients who may benefit from further assessment and/or treatment for PTSD, the psychometric properties of a modified version of the PTSD Symptom Scale Self-Report (PSSSR) were examined in a treatment-seeking SUD sample (N = 118). The modified version of the PSS-SR, which measures both frequency and severity of PTSD symptoms, demonstrated good internal consistency reliability and was correlated with other self-report measures of trauma-related symptomatology. Comparisons between a structured PTSD diagnostic interview and the modified PSS-SR indicated that 89% of the PTSD positive patients were correctly classified by the modified PSS-SR. The clinical relevance of these findings was discussed.     

MMPI Scales for Diagnosing Acute and Chronic PTSD in Civilians

To develop new Minnesota Multiphasic Personality Inventory (MMPI) scales for diagnosing acute and chronic posttraumatic stress disorder (PTSD), 237 civilians with PTSD or panic disorder (controls) completed the MMPI-R. All 399 items were submitted to chi-square analysis to select those differentiating acute or chronic PTSD from controls. The analyses yielded an MMPI Acute PTSD scale (32 items) and a MMPI Chronic PTSD scale (41 items). Discriminating between acute PTSD and controls, the MMPI Acute PTSD scale had a hit rate of 83% and the MMPI Chronic PTSD scale produced a hit rate of 75% to 80%. Cross-validation produced similar hit rates. These scales scores were not substantially influenced by gender or types of traumatic events, and only the MMPI Acute PTSD scale seemed to not be sensitive to co-morbidity.     

Assessment of older combat veterans with the Clinician-Administered PTSD Scale

A study of the posttraumatic stress disorder (PTSD) among older combat veterans of World War II and the Korean Conflict was conducted. The Clinician-Administered PTSD Scale (CAPS) was given to 125 older combat veterans, along with a computerized variant of the Structured Clinical Interview for DSM-III-R for PTSD, the SCID-DTREE. (The SCID-DTREE was itself validated against the full SCID). Results showed the CAPS to be a good discriminator of PTSD: Out of the 125 cases, only 9 were misclassified using the SCID-DTREE as the base measure, a 93% efficiency. An alpha on the full CAPS was .95. This suggests that the CAPS is an appropriate scale for use with older combat veterans.     

PTSD in those who care for the injured

BackgroundPost Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD.MethodsA system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession.Results546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P < 0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD.ConclusionThe results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.     

The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: examination of comorbidity with anxiety and depression

Previous research has indicated a relationship between posttraumatic stress disorder (PTSD) and somatic complaints. We examined whether this relationship is a result of shared comorbidity with anxiety and depression. Local doctors interviewed a random, community sample of 526 tortured and 526 nontortured Bhutanese refugees living in U.N. refugee camps in Nepal. The interview covered demographics, torture, somatic complaints, and PTSD, depression, and anxiety measures. Number of PTSD symptoms, independent of depression and anxiety, predicted both number of reported somatic complaints and number of organ systems involving such complaints. Physicians need to screen for PTSD when survivors of extreme stressors present nonspecific somatic complaints.     

The potential for faking on the Mississippi Scale for Combat-Related PTSD

The Mississippi Scale for Combat-Related PTSD is widely used in the assessment of post-traumatic stress disorder (PTSD). The high face-validity of the scale may make it vulnerable to faking, however. The present study found that the scores of individuals instructed to respond as if they had PTSD did not differ from the scores of veterans with PTSD. Furthermore, although veterans who were diagnosed as having PTSD were found to have significantly higher Mississippi Scale scores than those who did not meet diagnostic criteria for PTSD, the mean score for all groups (veteran and non-veteran) exceeded the originally recommended diagnostic cut-off score of 107. A cutoff score of 121 was found to best differentiate veterans with PTSD from veterans who did not meet diagnostic criteria for the diagnosis, with high sensitivity but relatively low specificity.Portions of this paper were previously presented at the annual meeting of the American Psychological Association, New Orleans, August 1989 and the annual meeting of the Society for Traumatic Stress Studies, San Francisco, October 1989.     

Keane PTSD scale: MMPI and MMPI-2 update

This paper addresses questions regarding the use and interpretation of the Keane MMPI PTSD scale. Particular focus is placed on issues to consider when using various versions of the MMPI including Form R, the group form, and the new MMPI-2.     

Odor-induced EEG changes in PTSD Vietnam veterans

Electroencephalogram (EEG) changes in response to trauma and non-traumarelated odors were examined in five Vietnam veterans with a DSM-III-R diagnosis of Post-traumatic Stress Disorder (PTSD) and in five Vietnam veterans with adjustment-related problems (non-PTSD). Period analysis of the EEG indicated that the odors differentially affected the PTSD group's theta and alpha activity compared to the non-PTSD group. The greatest EEG and self-report odor and PTSD effects were found in response to a trauma odor which simulated burning flesh. These findings have important implications in the detection of veterans who attempt to feign deliberately the psychophysiological response pattern associated with PTSD.     

Psychometric Properties of the Civilian Version of the Mississippi PTSD Scale

The psychometric properties of the Civilian Mississippi Posttraumatic Stress Disorder (PTSD) Scale were explored. The Mississippi is internally consistent ( .89, split-half r .80), and it can discriminate between traumatized and nontraumatized respondents. However, its relationship with measures of PTSD was weaker than its relationship with measures of depression and anxiety, suggesting that it may be more of a general measure of distress. The results of a series confirmatory factor analyses provided mixed results. These findings were discussed along with recommendations for use of this instrument.     

Childhood abuse experiences and combat-related PTSD

Current literature on the etiology of combat-related PTSD strongly implicates combat trauma exposure as a primary etiological factor. However, studies of premilitary variables have produced conflicting results, perhaps in part due to methodological inconsistencies and failure to employ standardized measures. The present study examines one premilitary variable, childhood physical abuse history. Using a standardized measure developed by child abuse researchers, forty-five percent of veterans with PTSD were identified as recipients of abusive physical punishment during childhood. A positive correlation between physical abuse history and severity of combat-related PTSD was found. These preliminary findings set the stage for further investigation of the child abuse variable and underscore the need for treatment of veterans with combat-related PTSD which addresses developmental traumagenic events.A version of this paper was presented at the Seventh Annual Meeting of the International Society for Traumatic Stress Studies at Washington, DC, October 26, 1991, 11:30 a.m.Correspondence concerning this paper should be addressed to the first author at 7507 18th Avenue NE, Seattle, Washington 98115.     

Chronicity in Posttraumatic Stress Disorder (PTSD) and Predictors of Course of PTSD in Patients with Anxiety Disorders

The purpose of this study was to examine the course of comorbid posttraumatic stress disorder (PTSD) in 54 patients with another anxiety disorder. Using a prospective longitudinal design, the present study found that during the first 5 years of follow-up the probability of full remission from a chronic episode of PTSD was .18. Findings from this and other research confirm clinical impressions that a substantial number of people never fully remit from their PTSD even after many years. Variables associated with a longer time to remit from an episode of chronic PTSD were a history of alcohol abuse and a history of childhood trauma.     

Female Partners' Estimations of Male Veterans' Combat-Related PTSD Severity

This study investigated concordance between male Vietnam veterans' and their female partners' reports of veterans' posttraumatic stress disorder (PTSD) symptoms. Fifty male Vietnam combat veterans and their partners rated the severity of their own PTSD symptoms. Also, partners rated the severity of veterans' symptoms. Results indicated modest levels of agreement in reports of symptom presence/absence. Partner ratings of veterans' PTSD severity were positively correlated with veteran reports and partners' own self-reported PTSD symptoms. After controlling for veterans' self-reported symptoms, partners' symptoms significantly predicted their estimates of veterans' avoidance symptoms, but not veterans' reexperiencing or hyperarousal symptoms. Theoretical and practical implications of these findings are discussed.     

Avoidant symptoms cloaking the diagnosis of PTSD in patients with severe accidental injury

In a pilot study of seriously injured accident victims, 15 patients selected in initial intake interviews were followed at 9- to 10-week intervals for 9 months after admission to a community shock-trauma center. Psychiatric diagnoses were based on a structured psychiatric interview. A total of six patients met criteria for PTSD. In two cases, PTSD was not diagnosed until 3 to 6 months after injury, primarily because of severe avoidant symptomatology. In another case, intrusive and arousal symptoms were not immediately explainable as a manifestation of PTSD, because it was mistakenly believed that the patient had been unconscious during the accident. Diagnosis in two of these would probably have been missed without frequent follow-up interviews. Findings suggest that avoidant symptoms of PTSD can interfere with diagnosis. This has important consequences for outcome studies. It is suggested that frequent follow-up after a traumatic event may reduce the level of false negatives in population studies.Presented at the 7th annual convention, International Society for Traumatic Stress Studies, October 25, 1991, Washington, D.C.     

Symptom exaggeration in a PTSD inpatient population: Response set or claim for compensation

This study examines the relationship between service-connection (financial compensation) and exaggeration of PTSD symptoms. Sixty inpatient Vietnam combat veterans in PTSD treatment comprised three groups: those financially compensated for PTSD, those financially compensated for physical or other mental problems, and those not financially compensated. Results indicate that those veterans who are not service-connected do not exaggerate symptoms on the MMPI F-scale more than those who are service-connected. Also, F scores reported for inpatient PTSD were higher than previously established cut-off criteria found chiefly in outpatient populations. Implications for therapists' biases concerning financial compensation and symptom claims are discussed in terms of their clinical relevance.     

Multidimensional assessment of combat-related PTSD: Phenomenological,psychometric, and psychophysiological considerations

The literature on assessment of PTSD in combat veterans is discussed as it relates to several major diagnostic issues. Studies bearing on the validity of the PTSD diagnosis are presented. Additionally, a multidimensional assessment of PTSD is described in detail. The major assessment instruments currently used are discussed and the research supporting the selection of each of the assessment tools is presented.     

Dimensionality and Reliability of the Civilian Mississippi Scale for PTSD in a Postearthquake Community

This study examines psychometric properties of the Civilian Mississippi Scale for posttraumatic stress disorder when administered in a community survey of 656 persons following the 1989 Loma Prieta earthquake. Internal consistency was lower (Cronbach's = .73) than for previous analyses of civilian and combat versions of the Mississippi Scale. The analysis produced one strong factor composed of 25 items with regular wording and a second, weaker factor composed of 10 items with reversed wording. Internal consistency was higher when the 10 reversed items were removed (Cronbach's = .86); the two factors were negatively correlated. Traumatic experiences and psychological distress measures explained more variance in the 25-item factor than in the 35-item scale. Further studies should focus on content analysis and performance of the reversed items.     

The civilian version of the Mississippi PTSD Scale: A psychometric evaluation

This three-part study examined the reliability and validity of the civilian version of the Mississippi Scale for Combat-Related PTSD using data from the nonveteran participants in the National Vietnam Veterans Readjustment Study. The Civilian Mississippi Scale had a raw score distribution that was roughly symmetric, with an acceptable degree of dispersion and a reasonably high internal consistency reliability coefficient. Overall, however, measurement precision was weaker than that for the military version of the instrument, and confirmatory factor analytic findings differed from those found for the military version. Preliminary investigations of validity were in the form of correlations with indices of stressful life events, a PTSD symptom count, and measures of demoralization and active expression of hostility. The Civilian Mississippi Scale emerged from the various analyses as a PTSD measure with potential but requiring further validational study and perhaps some refinement.     

Ethical challenges in the treatment of traumatized refugees

The psychological plight of the large numbers of children and families who have immigrated to new lands has received increased professional attention. Among the multiple challenges confronting therapists who work with refugees, there is a growing need to be sensitive to ethical concerns unique to this population. This article addresses three representative ethical issues encountered in clinical work with traumatized refugees: the problem of informed consent, the resolution of conflicting cultural values, and the survivor's search for the meaning of inhumanity.This paper was inspired by an international conference. How to Interview Refugee Children, sponsored by the Allmanna Barnhuset on March 5–17, 1990 in Satra Bruk, Sweden, at which the author was a featured speaker. This paper will be presented at the 144th Annual Meeting of the American Psychiatric Association, New Orleans, May 1991.