Terence M. Keane

The development of a clinician-administered PTSD scale

Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.

Clinical evaluation of a measure to assess combat exposure.

The Combat Exposure Scale (CES) was constructed as an attempt to measure the subjective report of wartime stressors experienced by combatants

Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam veterans: hardiness, postwar social support, and additional stressful life events.

Structural equation modeling procedures were used to examine relationships among several war zone stressor dimensions, resilience-recovery factors, and post-traumatic stress disorder symptoms in a national sample of 1,632 Vietnam veterans (26% women and 74% men). A 9-factor measurement model was specified on a mixed-gender subsample of the data and then replicated on separate subsamples of female and male veterans. For both genders, the structural models supported strong mediation effects for the intrapersonal resource characteristic of hardiness, postwar structural and functional social support, and additional negative life events in the postwar period. Support for moderator effects or buffering in terms of interactions between war zone stressor level and resilience-recovery factors was minimal.

Psychometric Properties of Nine Scoring Rules for the Clinician- Administered Posttraumatic Stress Disorder Scale

The use of structured interviews that yield continuous measures of symptom severity has become increasingly widespread in the assessment of posttraumatic stress disorder (PTSD). To date, however, few scoring rules have been developed for converting continuous severity scores into dichotomous PTSD diagnoses. In this article, we describe and evaluate 9 such rules for the Clinician-Administered PTSD Scale (CAPS). Overall, these rules demonstrated good to excellent reliability and good correspondence with a PTSD diagnosis based on the Structured Clinical Interview for Diagnostic and Statistical Manual ofMental Disorders (3rd ed., rev.; DSM-III-R; American Psychiatric Association, 1987). However, the rules yielded widely varying prevalence estimates in 2 samples of male Vietnam veterans. Also, the use of DSM-III-R versus DSM-IV criteria had negligible impact on PTSD diagnostic status. The selection of CAPS scoring rules for different assessment tasks is discussed.

Implosive (flooding) therapy reduces symptoms of PTSD in Vietnam combat veterans

In a randomized clinical trial, 24 Vietnam veterans with a diagnosis of post-traumatic stress disorder (PTSD) were randomly assigned either to a group receiving 14 to 16 sessions of implosive (flooding) therapy or to a waiting-list control. Standard psychometrics were administered before, following, and six months after treatment, and therapist ratings of symptomotology were concurrently obtained in personal interviews. When compared to the waiting-list control, those subjects receiving implosive therapy showed significant improvement across many of the psychometric measures and the therapist ratings of psychopathology. Specific changes in the re-experiencing dimension of PTSD, anxiety, and depression were notable, while treatment did not seem to influence the numbing and social avoidance aspects of PTSD. The results are discussed with respect to the importance of systematic exposure to traumatic memories, as one component of comprehensive treatment of combat-related PTSD, and the need for skills training interventions directed at improving social competence in interpersonal interactions.

Review of Child and Adolescent Refugee Mental Health

OBJECTIVE To review stressful experiences and stress reactions among child and adolescent refugees, as well as interventions and ethical considerations in research and clinical work, within the framework of the chronological experiences of child refugees; namely, the phases of preflight, flight, and resettlement. Highlighted are special refugee populations such as unaccompanied minors, asylum seekers, and former child soldiers. Pertinent medical findings are summarized. METHOD The authors reviewed articles from 1990 to 2003 addressing the topics above. Literature was gathered from databases including PsycINFO, Medline, and SocioFile. Pertinent earlier papers and those from other disciplines cited in database-identified articles were also included. RESULTS Child and adolescent refugees suffer from significant conflict-related exposures. Reactions to stress may be mediated by coping strategies, belief systems, and social relations. CONCLUSIONS More research is needed on interventions, specifically on efficacy and cultural relevance. Interventions that have an impact on multiple ecological levels need further development and evaluation.

Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: risk factors, war-zone stressors, and resilience-recovery variables.

: Relationships among pretrauma risk factors (e.g., family instability, childhood antisocial behavior), war-zone stressors (e.g., combat, perceived threat), posttrauma resilience-recovery variables (e.g., hardiness, social support), and posttraumatic stress disorder (PTSD) symptom severity were examined. Data from a national sample of 432 female and 1,200 male veterans were analyzed using structural equation modeling. For both genders, direct links to PTSD from pretrauma, war-zone, and posttrauma variable categories were found; several direct associations between pretrauma and posttrauma variables were documented. Although war-zone stressors appeared preeminent for PTSD in men, posttrauma resilience-recovery variables were more salient for women. Researchers, policymakers, and clinicians are urged to take a broad view on trauma and its sequelae, especially regarding possible multiple exposures over time and the depletion and availability of important resources.

An examination of the relationship between chronic pain and post-traumatic stress disorder

Chronic pain and post-traumatic stress disorder (PTSD) are frequently observed within the Department of Veterans Affairs healthcare system and are often associated with a significant level of affective distress and physical disability. Clinical practice and research suggest that these two conditions co-occur at a high rate and may interact in such a way as to negatively impact the course of either disorder; however, relatively little research has been conducted in this area. This review summarizes the current literature pertaining to the prevalence and development of chronic pain and PTSD. Research describing the comorbidity of both conditions is reviewed, and several theoretical models are presented to explain the mechanisms by which these two disorders may be maintained. Future directions for research and clinical implications are discussed.

Utility of Psychophysiological Measurement in the Diagnosis of Posttraumatic Stress Disorder: Results From a Department of Veterans Affairs Cooperative Study

This multisite study tested the ability of psychophysiological responding to predict posttraumatic stress disorder (PTSD) diagnosis (current, lifetime, or never) in a large sample of male Vietnam veterans. Predictor variables for a logistic regression equation were drawn from a challenge task involving scenes of combat. The equation was tested and cross-validated demonstrating correct classification of approximately 2/3 of the current and never PTSD participants. Results replicate the finding of heightened psychophysiological responding to trauma-related cues by individuals with current PTSD, as well as differences in a variety of other domains between groups with and without the disorder. Follow-up analyses indicate that veterans with current PTSD who do not react physiologically to the challenge task manifest less reexperiencing symptoms, depression, and guilt. Discussion addresses the value of psychophysiological measures for assessment of PTSD.

Guidelines for treatment of PTSD

These treatment guidelines were developed under the auspices of the PTSD Treatment Guidelines Task Force established by the Board of Directors of the International Society for Traumatic Stress Studies (ISTSS) in November 1997. Our goal was to develop a set of treatment guidelines based on an extensive review of the clinical and research literature prepared by experts in one field. The book by Foa, Keane, and Friedman consists of two parts. The first comprises the position papers that describe the salient literature; the second, the much briefer treatment guidelines. These guidelines are intended to inform the clinician on what we determined were the best practices in the treatment of individuals with a diagnosis of posttraumatic stress disorder (PTSD). PTSD is a serious psychological condition that occurs as a result of experiencing a traumatic event. The symptoms that characterize PTSD are reliving the traumatic event or frightening elements of it; avoidance of thoughts, memories, people, and places associated with the event; emotional numbing; and symptoms of elevated arousal. Often accompanied by other psychological disorders, PTSD is a complex condition that can be associated with significant morbidity, disability, and impairment of life functions. In the development of these practice guidelines, the Task Force acknowledged that traumatic experiences can lead to the development of several different disorders, including major depression, specific phobias, disorders of extreme stress not otherwise specified (DESNOS), personality disorders such as borderline anxiety disorder, and panic disorder. Yet the focus of these guidelines is specifically on the treatment of PTSD and its symptoms as defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994).