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The Many Presentations of Posttraumatic Stress Disorder: An Empirical Examination of Theoretical Possibilities

The Many Presentations of Posttraumatic Stress Disorder: An Empirical Examination of Theoretical... Posttraumatic stress disorder (PTSD) has been a controversial diagnosis, with concerns including the sheer number of possible minimal diagnostic combinations (1,750), increasing to >10,000 theoretical possibilities in Diagnostic and Statistical Manual of Mental Disorders (5th ed.) proposals. This study examined whether the theoretical combinations postulated actually occur in a large sample of military personnel. The design of the study was a retrospective examination of PTSD checklists from 3,810 participants who, based on scores, endorsed symptoms consistent with probable PTSD. Combinations of PTSD Checklist– Civilian Version (PCL-C) symptom clusters were identified using data from active-duty military personnel who completed the 2005 and the 2008 Department of Defense (DoD) Health Related Behaviors Among Active Duty Military Personnel Survey. The study examined (a) occurrence of combinations, (b) unique minimum combinations, (c) most frequent combinations, and (d) replication of symptom combinations and clusters. The PCL-C scores showed 1,837 unique scoring combinations, 83.5% (1,533/1,837) of the observed unique scoring combinations occurred just once. The most frequently occurring combination (17/17 endorsed) accounted for 955 participants (25.1%), the second most frequent (16/17 endorsed) accounted for 75 participants (2.0%). PTSD most often presented as a unique constellation of symptom clusters, either capturing symptoms while allowing for considerable variability in its presentation, reflecting different severities of the disorder, or raising concerns about the classification itself, and any future classification that Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) might develop. Keywords military, posttraumatic stress disorder, healthcare survey Posttraumatic stress disorder (PTSD) has been a controver- This problem of number and allowable combination of sial diagnosis since its entry into the Diagnostic and Statisti- symptoms holds considerable concern for diagnostic utility, cal Manual of Mental Disorders (3rd ed.; DSM-III; American with such heterogeneity of symptoms making understanding Psychiatric Association [APA], 1980). Arguments over the about what we mean when someone is said to have PTSD nature of the traumatic event, the number and types of symp- nearly impossible. Which symptoms are being described? toms, and how PTSD should be categorized have continued What and how does each variant of the disorder respond to a to this day (Rosen, 2004; Rosen & Lilenfeld, 2008; Weathers treatment? Which cluster of symptoms are we even agreeing & Keane, 2007). Proposed changes for PTSD in Diagnostic to be inherent and acceptable variations? It is possible that and Statistical Manual of Mental Disorders (5th ed.; DSM- these broad diagnostic allowances, needed to capture the het- V) have potentially added to the confusion with new symp- erogeneity of symptoms that can follow a traumatic event, toms slated for inclusion. Rosen, Lilenfeld, Frueh, McHugh, affect our research and treatment outcomes. The unreliability and Spitzer (2010) have pointed out that the three criteria of reaching a diagnosis has not gone unnoticed, with and 17 symptoms that make up PTSD provide 1,750 possible growing concerns over what are normal reactions to trauma, unique minimal combinations that allow for a diagnosis of PTSD. If the proposed changes to PTSD for DSM-V nosol- Bay Pines Veteran Affairs Healthcare System, FL, USA ogy include the expected 5 additional symptoms, 10,500 James A. Haley Veterans Hospital, Tampa, FL, USA possible minimal symptom combinations for the same dis- Uniformed Services University of the Health Sciences, Bethesda, MD, USA order will result. While other disorders hold numerous paths Corresponding Author: to cover possible presentations of a disorder (e.g., depression Scott D. Barnett, James A. Haley VAMC, HSR&D/RR&D Research Center has 112 possible combinations, generalized anxiety disorder of Excellence, 8900 Grand Oaks Circle (118M), Tampa, FL 33637-1022, 20 combinations, etc.), no disorder in current psychiatric USA. classifications contains this apparent diversity. Email: Scott.Barnett2@va.gov 2 SAGE Open possible overlap with other disorders, potential compensa- and Statistical Manual of Mental Disorders (4th ed.; tory gain, and the lack of correlation with confirmable DSM-IV; APA, 1994) symptoms of PTSD (Blanchard, trauma being only some of the problems identified (Barglow, Jones-Alexander, Buckley, & Forneris, 1996). Of the total Bowman, & Friedlander, 2006; Frueh et al., 2005; Wilson & survey participants (N = 40,836), 3,810 were included in the Barglow, 2009). If PTSD has a true occurrence in the clinical analysis if they met both PCL-C total score ≥44 and DSM-IV world holding the entire symptom combinations theoreti- (APA, 1994) criterion endorsement for PTSD (n = 6,566). cally argued, this reality would hold considerable sway to The PCL has received considerable attention in the literature reconsider the ramifications of the classification schema in regarding its ability to accurately estimate true PTSD preva- place and in any future proposals. The theoretical versus lence (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008). actual presentation of symptoms is a testable occurrence. If In an effort to satisfy reasonable estimation of the occur- there truly are more than 1,750 varieties of the same disor- rence of PTSD, both the cutting score and symptoms match- der, this might explain why some “varieties” of PTSD ing for criterion were utilized. It is important to understand respond to some treatments and not others, and could offer that at best, this still leaves an estimate of “probable PTSD” an empirical option for criterion selection that holds practi- rather than a diagnostic inclusion based on a gold standard cal, theoretical, and heuristic value. such as the Clinician Administered PTSD Scale (CAPS; This study examined two large data sets of active-duty Weathers, Ruscio, & Keane, 1999). military personnel to determine the (a) occurrence of unique PTSD symptom combinations and (b) replication of symp- Unique Combination tom combinations and clusters. A “unique combination” refers to a unique, specific item endorsement pattern of the 17-item PCL-C. For example, a Method participant endorsing all items in Criterion b, Items 6, 7, 8, Participants and 9 but not Items 10, 11, or 12, in Criterion C, and Items 13, 14, and 15, but not Items 16 or 12 would have a specific This research utilized a retrospective analysis of data from combination “11111-1111000-11100.” active-duty military health care personnel who anonymously completed the 2005 and 2008 Department of Defense (DoD) Selected Participants Survey of Health Related Behaviors Among Active Duty Military Personnel (henceforth HRB survey; DoD, 2005, The use of the PCL-C score and meeting DSM-IV criterion 2008). The HRB survey, conducted every 2 to 4 years, resulted in a total of 3,810 eligible participants for analysis. included all military personnel who were on active duty at The combined 2005-2008 sample consisted of 40,836 use- the time of data collection. Recruits, academy cadets, and able questionnaires (9,566 Army; 11,264 Navy; 8,473 personnel absent without leave (AWOL), incarcerated, or Marine Corps; and 11,533 Air Force) and reflected an undergoing a permanent change of station (PCS) were overall response of 51%. Each of the 17 items were dichot- excluded. In brief, using a two-stage, 10% random of omized as yes (scores ≥3) or no (<3). Items were then selected service personnel from over 500 military installa- concatenated in test order to create each unique combina- tions worldwide, the 2005 and 2008 surveys attempted to tion of scores with domains separated by hyphens. The reflect healthcare attitudes and beliefs of all active-duty overall response rate was 51.8% for 2005 and 71.6% for military personnel at time of survey. The survey was initially 2008. For this work, probable PTSD was defined as a total administered on-site at more than 500 military installations PCL-C score ≥44 and DSM-IV criterion: one endorsed worldwide to selected service members and any identified (item score ≥3) item from Items 1 to 5, three endorsed participating personnel not completing survey at their desig- items from Items 7 to 12, and two endorsed items from nated installation was solicited through a mailed question- Items 13 to 17. naire. An estimated 14% of all eligible U.S. service personnel completed the study. Results Participant Characteristics Measure The PTSD Checklist–Civilian Version (PCL-C) was used to Survey participants were on average 26.7 ± 7.0 years of age assess PTSD (Weathers, Litz, Huska, & Keane, 1994). The (2005: 26.7 ± 7.2; 2008: 26.7 ± 7.0), 65.1% White (2005: 2005 and 2008 HRB surveys used the Civilian rather than 58.0%; 2008: 68.0%) and 44.5% married (2005: 43.6%; Military Version (PCL-M) to capture PTSD symptoms that 2008: 44.9%). Thirty-two percent of participants represented may be the result of either military or nonmilitary traumatic the Army (2005: 33.6%; 2008: 32.1%) and 25.0% the Navy exposures (i.e., that occurred before enlistment; DoD, 2005, (2005: 26.5%; 2008: 24.4%). Average PCL-C scores were 2008).The PCL-C is a 17-item measure of the Diagnostic 60.0 ± 11.6 (2005: 57.7 ± 10.7; 2008: 60.9 ± 11.8). Hickling et al. 3 Table 1. Frequency Scoring Positive (≥3) per Item Using PCL/DSM-IV Items (N = 3,810). All participants (N = 3,810) 2005 (n = 1,118) 2008 (n = 2,692) PCL-C item n (%) n (%) n (%) Criterion B: Reexperiencing 1. Repetitive thoughts 3,235 (84.9) 934 (83.5) 2,301 (85.5) 2. Dreams 2,891 (75.9) 816 (73.0) 2,075 (77.1) 3. Flashbacks 2,716 (71.3) 771 (69.0) 1,945 (72.3) 4. Upset at reminders 3,321 (87.2) 950 (84.6) 2,371 (88.1) 5. Physiologic reactions 2,952 (77.5) 813 (72.7) 2,139 (79.5) Criterion C: Avoidance/numbing 6. Avoid thoughts 3,347 (87.8) 966 (86.4) 2,381 (88.5) 7. Avoid activities 3,093 (81.2) 867 (77.6) 2,226 (82.7) 8. Difficult recall 2,519 (66.2) 673 (60.2) 1,846 (68.5) 9. Loss of interest 3,261 (85.6) 850 (76.0) 2,167 (80.5) 10. Feels distant 3,147 (82.6) 957 (85.6) 2,304 (85.6) 11. Numbing 3,147 (82.6) 891 (79.7) 2,256 (83.8) 12. Short future 2,836 (74.4) 810 (72.5) 2,026 (75.3) Criterion D: Increased arousal 13. Sleep disturbance 3,384 (88.8) 984 (88.0) 2,400 (89.2) 14. Irritable and angry 3,324 (87.2) 964 (86.2) 2,360 (87.7) 15. Decreased concentration 3,364 (88.3) 960 (85.9) 2,404 (89.0) 16. Hypervigilance 2,993 (78.6) 877 (78.4) 2,116 (78.6) 17. Startle 2,841 (74.6) 810 (72.5) 2,031 (75.5) Note: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.); PTSD = posttraumatic stress disorder; PCL-C = PTSD Checklist–Civilian Version. For the combined 2005 and 2008 surveys, only 5 of 3,810 minimum criteria that are required to obtain a diagnosis of (0.13%) total participants presented for the minimum score PTSD using the DSM-IV item scoring criteria. From these consistent with possible PTSD with 1 endorsed item for 3,810 participants identified in the combined 2005 and 2008 reexperiencing, 3 items for avoidance/numbing, and 2 items data sets as having probable PTSD, we identified 1,837 for increased arousal. Considered as separate domains, only unique combinations—83.5% occurred just once 234 of 3,810 (6.1%) participants presented with the mini- (1,533/1,837). Stratified by year for 2005, from 1,118 par- mum score of 1 endorsed item for reexperiencing, 390 ticipants identified as having probable PTSD, 714 unique (10.2%) for 3 items for avoidance/numbing, and 355 (9.3%) combinations were identified. For 2008, from these 2,692 for 2 items for increased arousal. For all participants, aver- participants identified as having probable PTSD, 1,303 age item score for Criterion B, reexperiencing, was M ± SD unique combinations were identified. = 3.9 ± 1.3; the most frequently endorsed items were Item 4, upset at reminders of the stressful experience (87.2%), and Replication of Symptom Combinations and Item 1, repeated disturbing memories, thoughts, or images Clusters (84.9%). For Criterion C, avoidance/numbing, M ± SD = 5.6 ± 1.4; the most frequently endorsed items were Item 6, The top 10 most frequently occurring unique combinations avoiding talking or thinking about stressful experience were comprised by 1,332 participants (35.0%; Table 2). The (87.8%), and Item 9, loss of interest in activities that used to first (17/17 endorsed, 955 participants) and second (16/17 be enjoyed (85.6%); and for Criterion D, increased arousal, endorsed, 75 participants) most frequently occurring unique M ± SD = 4.2 ± 1.0; the most frequently endorsed items were combinations accounted for 25.1% and 2.0%, respectively. Item 13, trouble falling or staying asleep (88.8%), and Item In all, 83.5% (1,533/1,837) of the unique combinations 15, difficulty concentrating (88.3%; Table 1). occurred once; 9.1% (167/1,837) occurred twice; and 92.5% (1,700/1,837) occurred only once or twice. The top 2 PCL-C unique combinations were shared by both 2005 and 2008 Occurrence of Unique PTSD Symptom samples. However, compared with the 2005 sample, the top Combinations 2 unique combinations for the 2008 sample year accounted There are 10 unique scoring combinations for the PCL-C for a greater percentage of the respective sample years but only 1,750 unique combinations for obtaining the (28.9% vs. 22.8%). 4 SAGE Open Table 2. Top 10 Most Frequently Occurring Combinations of Items Using DSM-IV Item Scoring Criteria Among U.S. Military Personnel Identified With Probable PTSD (N = 3,810), 2005-2008. Unique PCL-C combination Overall rank Overall N (%) 2005 rank 2005 n (%) 2008 rank 2008 n (%) +++++ - +++++++ - +++++ 1 955 (25.1) 1 232 (20.8) 1 723 (26.9) +++++ - ++0++++ - +++++ 2 75 (1.9) 2 22 (2.0) 2 53 (2.0) +++++ - +++++++ - ++++0 3 42 (1.1) 3 13 (1.2) 4 29 (1.1) +++++ - ++++++0 - +++++ 4 40 (1.0) 5 11 (1.0) 4 29 (1.1) +++++ - +++++++ - +++0+ 5 34 (0.9) 9 4 (0.4) 3 30 (1.1) ++0++ - +++++++ - +++++ 6 27 (0.8) 7 8 (0.7) 5 21 (0.8) ++++0 - +++++++ - +++++ 6 27 (0.8) 4 12 (1.1) 7 15 (0.6) 0++++ - +++++++ - +++++ 7 23 (0.6) 6 6 (0.5) 7 15 (0.6) +0+++ - +++++++ - +++++ 7 23 (0.6) 7 6 (0.5) 6 18 (0.7) +++++ - +++++++ - +++00 8 20 (0.5) 7 6 (0.6) 10 12 (0.4) +++++ - +++++0+ - +++++ 9 18 (0.5) 8 5 (0.4) 9 13 (0.5 000++ - +++++++ - +++++ 10 16 (0.4) 11 2 (0.2) 8 14 (0.5) +++++ - +++0+++ - +++++ 10 16 (0.4) 8 5 (0.4) 11 11 (0.4) +++++ - +++++00 - +++++ 10 16 (0.4) 10 3 (0.3) 14 8 (0.3) Total NA 1,332 (35.0) NA 335 (30.1) NA 991 (37.0) Note: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.); PTSD = posttraumatic stress disorder; PCL-C = PTSD Checklist–Civilian Ver- sion. A “+” represents an affirmative to a specific item (e.g., ≥3). The items left to right correspond to Items 1 to 17, grouped (“ - ”) by Criterions B, C, and D. For 2005, the top 10 most frequently occurring unique scores. However, while theoretically concerning, the number combinations were accounted for by 397 participants (35.5%; of combinations that meet minimal criterion are in actuality Table 2).The first (17/17 endorsed, n = 232) and second quite small. In contrast, the number of unique presentations (16/17 endorsed, 22 participants) most frequently occurring is large, with about 80% of the respondents having a unique unique combination accounted for 20.8% and 2.0%, respec- combination of symptoms, and approximately 90% exhibit- tively. Ninety percent (647/714) of the unique combinations ing the combination with someone once, or in isolation. The occurred once; 5.2% (37/714) occurred twice; and 95.8% overall clusters seem to capture symptoms while allowing for (684/714) occurred only once or twice. considerable variability in what exactly it means to have For 2008, the top 10 most frequently occurring unique PTSD. The most frequent presentation was an endorsement combinations were accounted for by 999 participants (37.1%; of all possible symptoms (increasing from 2005 to 2008 in Table 2). The first (17/17 endorsed, 723 participants) and sec- this military population, 20.8%-26.5%); followed by endorse- ond (16/17 endorsed, 53 participants) most frequently occur- ment of 16 out of 17 symptoms (2% both in 2005 and 2008). ring unique combinations accounted for 26.9% and 2.0%, These patterns were well replicated and rankings of the top respectively. Eighty-four percent (1,097/1,303) of the unique combinations were fairly consistent in both data sets. These combinations occurred once; 8.9% (116/1,303) occurred two patterns of endorsement of unique combinations may twice; and 93.1% (1,213/1,303) occurred only once or twice. represent a combination of severity, with maximal threshold For the top five most frequently occurring unique PCL-C of endorsement of symptoms presented, while those with less combinations (Table 1), we compared participant characteris- endorsement may represent either lesser severity of PTSD tics. Age among participants who endorsed all 17 items (26.2 presentation or a distinctly different classification schema. ± 6.9) was not significantly different from the overall study The pattern of endorsing all possible symptoms is common sample or the next four most frequently occurring unique in clinical practice. The recognition of higher PCL-C scores PCL-C combinations. Furthermore, these participants endors- found from this pattern of endorsement is something that ing all 17 items were similar to the overall study sample for clinical practice has long recognized and conjectured as to race (White, 73.3%), married (45.9%), and equally distrib- whether it reflects a severe presentation of psychological uted across service branch (Army, 35.9%; Navy, 26.6%; distress, an over response for reasons of possible secondary Marine Corps, 24.7; Air Force, 12.8%). No difference was gains, and/or a call for help by the respondent. Alternatively, observed among these top five groups for any of these char- the unique combinations with lesser endorsement of symp- acteristics or was any difference observed from 2005 to 2008. tom combinations may represent some variation of response to a traumatic event and further illustrate qualitatively differ- ent clusters of symptoms that would still, in the present Discussion nosology, qualify for a diagnosis of PTSD. This study confirmed that there were in fact a great number One can argue either (a) that the breadth of the current of possible combinations of PTSD drawing from PCL-C criterion allows one to flexibly capture what is agreed to be Hickling et al. 5 PTSD or (b) so many unique clusters reflect such diverse our current classification schemas for clinical, research, and groupings of symptoms, that the disorder has lost meaning as nosological applications. a useful classification schema. These findings provide an Authors’ Notes empirical response to the concern that the theoretical combi- nations of symptoms and their presentation in actual data are The views expressed in this manuscript are those of the authors and extremely large. Furthermore, these findings have signifi- do not reflect the official policy or position of the Uniformed cant implications for both practical and theoretical applica- Services University, the Department of Defense, the Department of tion. The findings are also thought timely given the Veterans Affairs. or the U.S. Government. consideration of how additional symptoms in DSM-V will Declaration of Conflicting Interests impact potential use in clinical and research applications (Rosen et al., 2010). The authors declared no potential conflicts of interest with respect to A reasonable alternative interpretation of the results might the research, authorship, and/or publication of this article. be that the PCL-C scores instead of diversity reflect different Funding severities of the disorder. As such, the data might allow a qualifier to be added to the DSM classification system, as a The authors disclosed receipt of the following financial support for severity rating, as opposed or in addition to current codes the research and/or authorship of this article: Partial funding was (i.e., acute vs. chronic). The data support that at least for a provided by a grant from Veterans Health Administration Health military population, the endorsement of symptoms has been Services Research Development and Rehabilitation Research and increasing. However, the pattern of scores has remained Development Grant HFP09-156 (Edward J. Hickling and Scott D. remarkably similar. The findings allow for a data-driven dis- Barnett). cussion of what is present in how PTSD shows up in the real References world to be added to the theoretical views at this point in time. This discussion might include how the reaction to a American Psychiatric Association. (1980). Diagnostic and statis- stressor is better thought of as a dimensional response rather tical manual of mental disorders (3rd ed.). Washington, DC: than a dichotomous presentation of agreed upon clusters and Author. symptom thresholds to meet a categorical diagnosis of PTSD American Psychiatric Association. (1994). Diagnostic and statis- (Wakefield & Horwitz, 2010). However, the intent of this tical manual of mental disorders (4th ed.). Washington, DC: article was simply to illustrate that the heretofore theoretical Author. combinations of symptoms in the present classification Barglow, P., Bowman, M., & Friedlander, J. (2006). Is post-trau- scheme for PTSD in fact occur in clinical presentations. matic stress disorder a valid psychiatric diagnosis? Scientific The use of PCL data contains known limits in reaching a Review of Alternative Medicine, 10, 36-44. diagnosis of PTSD. Future studies utilizing a structured Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, interview such as the CAPS would be important to see if C. A. (1996). Psychometric properties of the PTSD check- there are differences in how self-report data vary from list (PCL). Behaviour Research and Therapy, 34, 669-673. endorsement of comparable items for PTSD symptoms when doi:10.1016/0005-7967(96)00033-2 given by a trained interviewer (Wakefield & Horwitz, 2010; Department of Defense. (2005). Survey of health related behaviors Weathers, Keane, & Davidson, 2001). However, the use of among active duty military personnel. Retrieved from http:// stringent criteria for probable PTSD when using the PCL-C, www.ha.osd.mil/special_reports/2005_health_behaviors_sur- having both severity of endorsement and criterion clusters of vey_1-07.pdf symptoms, at least allows for a discussion of how people Department of Defense. (2008) Survey of health related behaviors self-report posttraumatic stress symptoms. Furthermore, the among active duty military personnel. Retrieved from http:// use of a military population may limit generalizability to www.tricare.mil/tma/2008HealthBehaviors.pdf other populations. Any comparisons with other trauma popu- Frueh, B. C., Elhai, J. D., Grubaugh, A. L., Monnier, J., Kashdan, lations could now be tested empirically. T. B., Sauvageot, J. A., . . . Arana, G. W. (2005). Documented combat exposure of US veterans seeking treatment for combat- related post-traumatic stress disorder. British Journal of Psy- Conclusion chiatry, 186, 467-475. doi:10.1192/bjp.186.6.467 The study has replicated the patterns of PCL-C scores in Rosen, G. M. (2004). Traumatic events, criterion creep, and the cre- two relatively large data sets with diverse trauma histories. ation of pretraumatic stress disorder. Scientific Review of Men- The findings support the concern that the theoretical possi- tal Health Practice Journal, 3, 46-47. bilities of combinations in the DSM-IV symptoms needed Rosen, G. M., & Lilenfeld, S. O. (2008). Posttraumatic stress dis- for PTSD present in a diverse number of groupings while order: An empirical analysis of core assumptions. Clinical Psy- still meeting criterion for PTSD. The study provides a plat- chology Review, 28, 837-868. doi:10.1016/j.cpr.2007.12.002 form from which to use observations of clinically relevant Rosen, G. M., Lilenfeld, S. O., Frueh, C. B., McHugh, P. R., & data for future examination and discussions of the utility of Spitzer, R. L. (2010). Reflections on PTSD’s future in DSM-5. 6 SAGE Open British Journal of Psychiatry, 197, 343-344. doi:10.1192/bjp. Wilson, D., & Barglow, P. (2009). PTSD has unreliable diag- bp.110.079699 nostic criteria. Psychiatric Times (Online document). Terhakopian, A., Sinaii, N., Engel, C. C., Schnurr, P. P., & Hoge, C. Retrieved from http://www.psychiatrictimes.com/display/arti- W. (2008). Estimating population prevalence of posttraumatic cle/10168/1426942 stress disorder: An example using the PTSD checklist. Journal Author Biographies of Traumatic Stress, 21, 290-300. doi:10.1002/jts.20341 Wakefield, J. C., & Horwitz, A. V. (2010). Normal reactions to Edward J. Hickling received his Doctorate in Clinical Psychology adversity or symptoms of disorder? In G. M. Rosen & B. C. from the University of Denver and completed his internship at the Frueh (Eds.), Clinician’s guide to posttraumatic stress disorder Albany Psychology Internship consortium. He is currently a staff (pp. 33-50). Hoboken, NJ: John Wiley. psychologist at the PTSD Programs, Center for Sexual Trauma Weathers, F. W., & Keane, T. M. (2007). The Criterion A problem Services (CSTS) at the Bay Pines Veterans Veteran’s Affairs revisited: Controversies and challenges in defining and mea- Healthcare system in Bay Pines, Florida. suring psychological trauma. Journal of Traumatic Stress, 20, 107-121. doi:10.1002/jts.20297 Scott D. Barnett received his Doctorate in Epidemiology and Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Biostatistics from the University of South Florida. He has served as Clinician administered PTSD scale: A review of the first a biostatistician/epidemiologist for over 18 years with expertise in ten years of research. Depression and Anxiety, 13, 132-156. database design, research methodologies and biostatistics. He has doi:10.1002/da.1029 been with the Research Center of Excellence at James A. Haley Weathers, F. W., Litz, B. T., Huska, J. A., & Keane, T. M. (1994). Veteran’s Hospital in Tampa Florida since 2009. The PTSD Checklist–Civilian Version (PCLC). Boston, MA: National Center for PTSD. Susanne Gibbons received her Doctorate in Nursing from the Weathers, F. W., Ruscio, A. M., & Keane, T. M. (1999). Psychomet- Catholic University of America. She is an Assistant Professor in the ric properties of nine scoring rules for the clinician-administered USU Graduate School of Nursing and holds the concurrent position posttraumatic stress disorder scale. Psychological Assessment, of Research Director in the Adult Psychiatric Mental Health Nurse 11, 124-133. doi:10.1037/1040-3590.11.2.124 Practitioner Program. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

The Many Presentations of Posttraumatic Stress Disorder: An Empirical Examination of Theoretical Possibilities

SAGE Open , Volume 3 (1): 1 – Feb 27, 2013

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Abstract

Posttraumatic stress disorder (PTSD) has been a controversial diagnosis, with concerns including the sheer number of possible minimal diagnostic combinations (1,750), increasing to >10,000 theoretical possibilities in Diagnostic and Statistical Manual of Mental Disorders (5th ed.) proposals. This study examined whether the theoretical combinations postulated actually occur in a large sample of military personnel. The design of the study was a retrospective examination of PTSD checklists from 3,810 participants who, based on scores, endorsed symptoms consistent with probable PTSD. Combinations of PTSD Checklist– Civilian Version (PCL-C) symptom clusters were identified using data from active-duty military personnel who completed the 2005 and the 2008 Department of Defense (DoD) Health Related Behaviors Among Active Duty Military Personnel Survey. The study examined (a) occurrence of combinations, (b) unique minimum combinations, (c) most frequent combinations, and (d) replication of symptom combinations and clusters. The PCL-C scores showed 1,837 unique scoring combinations, 83.5% (1,533/1,837) of the observed unique scoring combinations occurred just once. The most frequently occurring combination (17/17 endorsed) accounted for 955 participants (25.1%), the second most frequent (16/17 endorsed) accounted for 75 participants (2.0%). PTSD most often presented as a unique constellation of symptom clusters, either capturing symptoms while allowing for considerable variability in its presentation, reflecting different severities of the disorder, or raising concerns about the classification itself, and any future classification that Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-V) might develop. Keywords military, posttraumatic stress disorder, healthcare survey Posttraumatic stress disorder (PTSD) has been a controver- This problem of number and allowable combination of sial diagnosis since its entry into the Diagnostic and Statisti- symptoms holds considerable concern for diagnostic utility, cal Manual of Mental Disorders (3rd ed.; DSM-III; American with such heterogeneity of symptoms making understanding Psychiatric Association [APA], 1980). Arguments over the about what we mean when someone is said to have PTSD nature of the traumatic event, the number and types of symp- nearly impossible. Which symptoms are being described? toms, and how PTSD should be categorized have continued What and how does each variant of the disorder respond to a to this day (Rosen, 2004; Rosen & Lilenfeld, 2008; Weathers treatment? Which cluster of symptoms are we even agreeing & Keane, 2007). Proposed changes for PTSD in Diagnostic to be inherent and acceptable variations? It is possible that and Statistical Manual of Mental Disorders (5th ed.; DSM- these broad diagnostic allowances, needed to capture the het- V) have potentially added to the confusion with new symp- erogeneity of symptoms that can follow a traumatic event, toms slated for inclusion. Rosen, Lilenfeld, Frueh, McHugh, affect our research and treatment outcomes. The unreliability and Spitzer (2010) have pointed out that the three criteria of reaching a diagnosis has not gone unnoticed, with and 17 symptoms that make up PTSD provide 1,750 possible growing concerns over what are normal reactions to trauma, unique minimal combinations that allow for a diagnosis of PTSD. If the proposed changes to PTSD for DSM-V nosol- Bay Pines Veteran Affairs Healthcare System, FL, USA ogy include the expected 5 additional symptoms, 10,500 James A. Haley Veterans Hospital, Tampa, FL, USA possible minimal symptom combinations for the same dis- Uniformed Services University of the Health Sciences, Bethesda, MD, USA order will result. While other disorders hold numerous paths Corresponding Author: to cover possible presentations of a disorder (e.g., depression Scott D. Barnett, James A. Haley VAMC, HSR&D/RR&D Research Center has 112 possible combinations, generalized anxiety disorder of Excellence, 8900 Grand Oaks Circle (118M), Tampa, FL 33637-1022, 20 combinations, etc.), no disorder in current psychiatric USA. classifications contains this apparent diversity. Email: Scott.Barnett2@va.gov 2 SAGE Open possible overlap with other disorders, potential compensa- and Statistical Manual of Mental Disorders (4th ed.; tory gain, and the lack of correlation with confirmable DSM-IV; APA, 1994) symptoms of PTSD (Blanchard, trauma being only some of the problems identified (Barglow, Jones-Alexander, Buckley, & Forneris, 1996). Of the total Bowman, & Friedlander, 2006; Frueh et al., 2005; Wilson & survey participants (N = 40,836), 3,810 were included in the Barglow, 2009). If PTSD has a true occurrence in the clinical analysis if they met both PCL-C total score ≥44 and DSM-IV world holding the entire symptom combinations theoreti- (APA, 1994) criterion endorsement for PTSD (n = 6,566). cally argued, this reality would hold considerable sway to The PCL has received considerable attention in the literature reconsider the ramifications of the classification schema in regarding its ability to accurately estimate true PTSD preva- place and in any future proposals. The theoretical versus lence (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008). actual presentation of symptoms is a testable occurrence. If In an effort to satisfy reasonable estimation of the occur- there truly are more than 1,750 varieties of the same disor- rence of PTSD, both the cutting score and symptoms match- der, this might explain why some “varieties” of PTSD ing for criterion were utilized. It is important to understand respond to some treatments and not others, and could offer that at best, this still leaves an estimate of “probable PTSD” an empirical option for criterion selection that holds practi- rather than a diagnostic inclusion based on a gold standard cal, theoretical, and heuristic value. such as the Clinician Administered PTSD Scale (CAPS; This study examined two large data sets of active-duty Weathers, Ruscio, & Keane, 1999). military personnel to determine the (a) occurrence of unique PTSD symptom combinations and (b) replication of symp- Unique Combination tom combinations and clusters. A “unique combination” refers to a unique, specific item endorsement pattern of the 17-item PCL-C. For example, a Method participant endorsing all items in Criterion b, Items 6, 7, 8, Participants and 9 but not Items 10, 11, or 12, in Criterion C, and Items 13, 14, and 15, but not Items 16 or 12 would have a specific This research utilized a retrospective analysis of data from combination “11111-1111000-11100.” active-duty military health care personnel who anonymously completed the 2005 and 2008 Department of Defense (DoD) Selected Participants Survey of Health Related Behaviors Among Active Duty Military Personnel (henceforth HRB survey; DoD, 2005, The use of the PCL-C score and meeting DSM-IV criterion 2008). The HRB survey, conducted every 2 to 4 years, resulted in a total of 3,810 eligible participants for analysis. included all military personnel who were on active duty at The combined 2005-2008 sample consisted of 40,836 use- the time of data collection. Recruits, academy cadets, and able questionnaires (9,566 Army; 11,264 Navy; 8,473 personnel absent without leave (AWOL), incarcerated, or Marine Corps; and 11,533 Air Force) and reflected an undergoing a permanent change of station (PCS) were overall response of 51%. Each of the 17 items were dichot- excluded. In brief, using a two-stage, 10% random of omized as yes (scores ≥3) or no (<3). Items were then selected service personnel from over 500 military installa- concatenated in test order to create each unique combina- tions worldwide, the 2005 and 2008 surveys attempted to tion of scores with domains separated by hyphens. The reflect healthcare attitudes and beliefs of all active-duty overall response rate was 51.8% for 2005 and 71.6% for military personnel at time of survey. The survey was initially 2008. For this work, probable PTSD was defined as a total administered on-site at more than 500 military installations PCL-C score ≥44 and DSM-IV criterion: one endorsed worldwide to selected service members and any identified (item score ≥3) item from Items 1 to 5, three endorsed participating personnel not completing survey at their desig- items from Items 7 to 12, and two endorsed items from nated installation was solicited through a mailed question- Items 13 to 17. naire. An estimated 14% of all eligible U.S. service personnel completed the study. Results Participant Characteristics Measure The PTSD Checklist–Civilian Version (PCL-C) was used to Survey participants were on average 26.7 ± 7.0 years of age assess PTSD (Weathers, Litz, Huska, & Keane, 1994). The (2005: 26.7 ± 7.2; 2008: 26.7 ± 7.0), 65.1% White (2005: 2005 and 2008 HRB surveys used the Civilian rather than 58.0%; 2008: 68.0%) and 44.5% married (2005: 43.6%; Military Version (PCL-M) to capture PTSD symptoms that 2008: 44.9%). Thirty-two percent of participants represented may be the result of either military or nonmilitary traumatic the Army (2005: 33.6%; 2008: 32.1%) and 25.0% the Navy exposures (i.e., that occurred before enlistment; DoD, 2005, (2005: 26.5%; 2008: 24.4%). Average PCL-C scores were 2008).The PCL-C is a 17-item measure of the Diagnostic 60.0 ± 11.6 (2005: 57.7 ± 10.7; 2008: 60.9 ± 11.8). Hickling et al. 3 Table 1. Frequency Scoring Positive (≥3) per Item Using PCL/DSM-IV Items (N = 3,810). All participants (N = 3,810) 2005 (n = 1,118) 2008 (n = 2,692) PCL-C item n (%) n (%) n (%) Criterion B: Reexperiencing 1. Repetitive thoughts 3,235 (84.9) 934 (83.5) 2,301 (85.5) 2. Dreams 2,891 (75.9) 816 (73.0) 2,075 (77.1) 3. Flashbacks 2,716 (71.3) 771 (69.0) 1,945 (72.3) 4. Upset at reminders 3,321 (87.2) 950 (84.6) 2,371 (88.1) 5. Physiologic reactions 2,952 (77.5) 813 (72.7) 2,139 (79.5) Criterion C: Avoidance/numbing 6. Avoid thoughts 3,347 (87.8) 966 (86.4) 2,381 (88.5) 7. Avoid activities 3,093 (81.2) 867 (77.6) 2,226 (82.7) 8. Difficult recall 2,519 (66.2) 673 (60.2) 1,846 (68.5) 9. Loss of interest 3,261 (85.6) 850 (76.0) 2,167 (80.5) 10. Feels distant 3,147 (82.6) 957 (85.6) 2,304 (85.6) 11. Numbing 3,147 (82.6) 891 (79.7) 2,256 (83.8) 12. Short future 2,836 (74.4) 810 (72.5) 2,026 (75.3) Criterion D: Increased arousal 13. Sleep disturbance 3,384 (88.8) 984 (88.0) 2,400 (89.2) 14. Irritable and angry 3,324 (87.2) 964 (86.2) 2,360 (87.7) 15. Decreased concentration 3,364 (88.3) 960 (85.9) 2,404 (89.0) 16. Hypervigilance 2,993 (78.6) 877 (78.4) 2,116 (78.6) 17. Startle 2,841 (74.6) 810 (72.5) 2,031 (75.5) Note: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.); PTSD = posttraumatic stress disorder; PCL-C = PTSD Checklist–Civilian Version. For the combined 2005 and 2008 surveys, only 5 of 3,810 minimum criteria that are required to obtain a diagnosis of (0.13%) total participants presented for the minimum score PTSD using the DSM-IV item scoring criteria. From these consistent with possible PTSD with 1 endorsed item for 3,810 participants identified in the combined 2005 and 2008 reexperiencing, 3 items for avoidance/numbing, and 2 items data sets as having probable PTSD, we identified 1,837 for increased arousal. Considered as separate domains, only unique combinations—83.5% occurred just once 234 of 3,810 (6.1%) participants presented with the mini- (1,533/1,837). Stratified by year for 2005, from 1,118 par- mum score of 1 endorsed item for reexperiencing, 390 ticipants identified as having probable PTSD, 714 unique (10.2%) for 3 items for avoidance/numbing, and 355 (9.3%) combinations were identified. For 2008, from these 2,692 for 2 items for increased arousal. For all participants, aver- participants identified as having probable PTSD, 1,303 age item score for Criterion B, reexperiencing, was M ± SD unique combinations were identified. = 3.9 ± 1.3; the most frequently endorsed items were Item 4, upset at reminders of the stressful experience (87.2%), and Replication of Symptom Combinations and Item 1, repeated disturbing memories, thoughts, or images Clusters (84.9%). For Criterion C, avoidance/numbing, M ± SD = 5.6 ± 1.4; the most frequently endorsed items were Item 6, The top 10 most frequently occurring unique combinations avoiding talking or thinking about stressful experience were comprised by 1,332 participants (35.0%; Table 2). The (87.8%), and Item 9, loss of interest in activities that used to first (17/17 endorsed, 955 participants) and second (16/17 be enjoyed (85.6%); and for Criterion D, increased arousal, endorsed, 75 participants) most frequently occurring unique M ± SD = 4.2 ± 1.0; the most frequently endorsed items were combinations accounted for 25.1% and 2.0%, respectively. Item 13, trouble falling or staying asleep (88.8%), and Item In all, 83.5% (1,533/1,837) of the unique combinations 15, difficulty concentrating (88.3%; Table 1). occurred once; 9.1% (167/1,837) occurred twice; and 92.5% (1,700/1,837) occurred only once or twice. The top 2 PCL-C unique combinations were shared by both 2005 and 2008 Occurrence of Unique PTSD Symptom samples. However, compared with the 2005 sample, the top Combinations 2 unique combinations for the 2008 sample year accounted There are 10 unique scoring combinations for the PCL-C for a greater percentage of the respective sample years but only 1,750 unique combinations for obtaining the (28.9% vs. 22.8%). 4 SAGE Open Table 2. Top 10 Most Frequently Occurring Combinations of Items Using DSM-IV Item Scoring Criteria Among U.S. Military Personnel Identified With Probable PTSD (N = 3,810), 2005-2008. Unique PCL-C combination Overall rank Overall N (%) 2005 rank 2005 n (%) 2008 rank 2008 n (%) +++++ - +++++++ - +++++ 1 955 (25.1) 1 232 (20.8) 1 723 (26.9) +++++ - ++0++++ - +++++ 2 75 (1.9) 2 22 (2.0) 2 53 (2.0) +++++ - +++++++ - ++++0 3 42 (1.1) 3 13 (1.2) 4 29 (1.1) +++++ - ++++++0 - +++++ 4 40 (1.0) 5 11 (1.0) 4 29 (1.1) +++++ - +++++++ - +++0+ 5 34 (0.9) 9 4 (0.4) 3 30 (1.1) ++0++ - +++++++ - +++++ 6 27 (0.8) 7 8 (0.7) 5 21 (0.8) ++++0 - +++++++ - +++++ 6 27 (0.8) 4 12 (1.1) 7 15 (0.6) 0++++ - +++++++ - +++++ 7 23 (0.6) 6 6 (0.5) 7 15 (0.6) +0+++ - +++++++ - +++++ 7 23 (0.6) 7 6 (0.5) 6 18 (0.7) +++++ - +++++++ - +++00 8 20 (0.5) 7 6 (0.6) 10 12 (0.4) +++++ - +++++0+ - +++++ 9 18 (0.5) 8 5 (0.4) 9 13 (0.5 000++ - +++++++ - +++++ 10 16 (0.4) 11 2 (0.2) 8 14 (0.5) +++++ - +++0+++ - +++++ 10 16 (0.4) 8 5 (0.4) 11 11 (0.4) +++++ - +++++00 - +++++ 10 16 (0.4) 10 3 (0.3) 14 8 (0.3) Total NA 1,332 (35.0) NA 335 (30.1) NA 991 (37.0) Note: DSM-IV = Diagnostic and Statistical Manual of Mental Disorders (4th ed.); PTSD = posttraumatic stress disorder; PCL-C = PTSD Checklist–Civilian Ver- sion. A “+” represents an affirmative to a specific item (e.g., ≥3). The items left to right correspond to Items 1 to 17, grouped (“ - ”) by Criterions B, C, and D. For 2005, the top 10 most frequently occurring unique scores. However, while theoretically concerning, the number combinations were accounted for by 397 participants (35.5%; of combinations that meet minimal criterion are in actuality Table 2).The first (17/17 endorsed, n = 232) and second quite small. In contrast, the number of unique presentations (16/17 endorsed, 22 participants) most frequently occurring is large, with about 80% of the respondents having a unique unique combination accounted for 20.8% and 2.0%, respec- combination of symptoms, and approximately 90% exhibit- tively. Ninety percent (647/714) of the unique combinations ing the combination with someone once, or in isolation. The occurred once; 5.2% (37/714) occurred twice; and 95.8% overall clusters seem to capture symptoms while allowing for (684/714) occurred only once or twice. considerable variability in what exactly it means to have For 2008, the top 10 most frequently occurring unique PTSD. The most frequent presentation was an endorsement combinations were accounted for by 999 participants (37.1%; of all possible symptoms (increasing from 2005 to 2008 in Table 2). The first (17/17 endorsed, 723 participants) and sec- this military population, 20.8%-26.5%); followed by endorse- ond (16/17 endorsed, 53 participants) most frequently occur- ment of 16 out of 17 symptoms (2% both in 2005 and 2008). ring unique combinations accounted for 26.9% and 2.0%, These patterns were well replicated and rankings of the top respectively. Eighty-four percent (1,097/1,303) of the unique combinations were fairly consistent in both data sets. These combinations occurred once; 8.9% (116/1,303) occurred two patterns of endorsement of unique combinations may twice; and 93.1% (1,213/1,303) occurred only once or twice. represent a combination of severity, with maximal threshold For the top five most frequently occurring unique PCL-C of endorsement of symptoms presented, while those with less combinations (Table 1), we compared participant characteris- endorsement may represent either lesser severity of PTSD tics. Age among participants who endorsed all 17 items (26.2 presentation or a distinctly different classification schema. ± 6.9) was not significantly different from the overall study The pattern of endorsing all possible symptoms is common sample or the next four most frequently occurring unique in clinical practice. The recognition of higher PCL-C scores PCL-C combinations. Furthermore, these participants endors- found from this pattern of endorsement is something that ing all 17 items were similar to the overall study sample for clinical practice has long recognized and conjectured as to race (White, 73.3%), married (45.9%), and equally distrib- whether it reflects a severe presentation of psychological uted across service branch (Army, 35.9%; Navy, 26.6%; distress, an over response for reasons of possible secondary Marine Corps, 24.7; Air Force, 12.8%). No difference was gains, and/or a call for help by the respondent. Alternatively, observed among these top five groups for any of these char- the unique combinations with lesser endorsement of symp- acteristics or was any difference observed from 2005 to 2008. tom combinations may represent some variation of response to a traumatic event and further illustrate qualitatively differ- ent clusters of symptoms that would still, in the present Discussion nosology, qualify for a diagnosis of PTSD. This study confirmed that there were in fact a great number One can argue either (a) that the breadth of the current of possible combinations of PTSD drawing from PCL-C criterion allows one to flexibly capture what is agreed to be Hickling et al. 5 PTSD or (b) so many unique clusters reflect such diverse our current classification schemas for clinical, research, and groupings of symptoms, that the disorder has lost meaning as nosological applications. a useful classification schema. These findings provide an Authors’ Notes empirical response to the concern that the theoretical combi- nations of symptoms and their presentation in actual data are The views expressed in this manuscript are those of the authors and extremely large. Furthermore, these findings have signifi- do not reflect the official policy or position of the Uniformed cant implications for both practical and theoretical applica- Services University, the Department of Defense, the Department of tion. The findings are also thought timely given the Veterans Affairs. or the U.S. Government. consideration of how additional symptoms in DSM-V will Declaration of Conflicting Interests impact potential use in clinical and research applications (Rosen et al., 2010). The authors declared no potential conflicts of interest with respect to A reasonable alternative interpretation of the results might the research, authorship, and/or publication of this article. be that the PCL-C scores instead of diversity reflect different Funding severities of the disorder. As such, the data might allow a qualifier to be added to the DSM classification system, as a The authors disclosed receipt of the following financial support for severity rating, as opposed or in addition to current codes the research and/or authorship of this article: Partial funding was (i.e., acute vs. chronic). The data support that at least for a provided by a grant from Veterans Health Administration Health military population, the endorsement of symptoms has been Services Research Development and Rehabilitation Research and increasing. However, the pattern of scores has remained Development Grant HFP09-156 (Edward J. Hickling and Scott D. remarkably similar. The findings allow for a data-driven dis- Barnett). cussion of what is present in how PTSD shows up in the real References world to be added to the theoretical views at this point in time. This discussion might include how the reaction to a American Psychiatric Association. (1980). Diagnostic and statis- stressor is better thought of as a dimensional response rather tical manual of mental disorders (3rd ed.). Washington, DC: than a dichotomous presentation of agreed upon clusters and Author. symptom thresholds to meet a categorical diagnosis of PTSD American Psychiatric Association. (1994). Diagnostic and statis- (Wakefield & Horwitz, 2010). However, the intent of this tical manual of mental disorders (4th ed.). Washington, DC: article was simply to illustrate that the heretofore theoretical Author. combinations of symptoms in the present classification Barglow, P., Bowman, M., & Friedlander, J. (2006). Is post-trau- scheme for PTSD in fact occur in clinical presentations. matic stress disorder a valid psychiatric diagnosis? Scientific The use of PCL data contains known limits in reaching a Review of Alternative Medicine, 10, 36-44. diagnosis of PTSD. Future studies utilizing a structured Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, interview such as the CAPS would be important to see if C. A. (1996). Psychometric properties of the PTSD check- there are differences in how self-report data vary from list (PCL). Behaviour Research and Therapy, 34, 669-673. endorsement of comparable items for PTSD symptoms when doi:10.1016/0005-7967(96)00033-2 given by a trained interviewer (Wakefield & Horwitz, 2010; Department of Defense. (2005). Survey of health related behaviors Weathers, Keane, & Davidson, 2001). However, the use of among active duty military personnel. Retrieved from http:// stringent criteria for probable PTSD when using the PCL-C, www.ha.osd.mil/special_reports/2005_health_behaviors_sur- having both severity of endorsement and criterion clusters of vey_1-07.pdf symptoms, at least allows for a discussion of how people Department of Defense. (2008) Survey of health related behaviors self-report posttraumatic stress symptoms. Furthermore, the among active duty military personnel. Retrieved from http:// use of a military population may limit generalizability to www.tricare.mil/tma/2008HealthBehaviors.pdf other populations. Any comparisons with other trauma popu- Frueh, B. C., Elhai, J. D., Grubaugh, A. L., Monnier, J., Kashdan, lations could now be tested empirically. T. B., Sauvageot, J. A., . . . Arana, G. W. (2005). Documented combat exposure of US veterans seeking treatment for combat- related post-traumatic stress disorder. British Journal of Psy- Conclusion chiatry, 186, 467-475. doi:10.1192/bjp.186.6.467 The study has replicated the patterns of PCL-C scores in Rosen, G. M. (2004). Traumatic events, criterion creep, and the cre- two relatively large data sets with diverse trauma histories. ation of pretraumatic stress disorder. Scientific Review of Men- The findings support the concern that the theoretical possi- tal Health Practice Journal, 3, 46-47. bilities of combinations in the DSM-IV symptoms needed Rosen, G. M., & Lilenfeld, S. O. (2008). Posttraumatic stress dis- for PTSD present in a diverse number of groupings while order: An empirical analysis of core assumptions. Clinical Psy- still meeting criterion for PTSD. The study provides a plat- chology Review, 28, 837-868. doi:10.1016/j.cpr.2007.12.002 form from which to use observations of clinically relevant Rosen, G. M., Lilenfeld, S. O., Frueh, C. B., McHugh, P. R., & data for future examination and discussions of the utility of Spitzer, R. L. (2010). Reflections on PTSD’s future in DSM-5. 6 SAGE Open British Journal of Psychiatry, 197, 343-344. doi:10.1192/bjp. Wilson, D., & Barglow, P. (2009). PTSD has unreliable diag- bp.110.079699 nostic criteria. Psychiatric Times (Online document). Terhakopian, A., Sinaii, N., Engel, C. C., Schnurr, P. P., & Hoge, C. Retrieved from http://www.psychiatrictimes.com/display/arti- W. (2008). Estimating population prevalence of posttraumatic cle/10168/1426942 stress disorder: An example using the PTSD checklist. Journal Author Biographies of Traumatic Stress, 21, 290-300. doi:10.1002/jts.20341 Wakefield, J. C., & Horwitz, A. V. (2010). Normal reactions to Edward J. Hickling received his Doctorate in Clinical Psychology adversity or symptoms of disorder? In G. M. Rosen & B. C. from the University of Denver and completed his internship at the Frueh (Eds.), Clinician’s guide to posttraumatic stress disorder Albany Psychology Internship consortium. He is currently a staff (pp. 33-50). Hoboken, NJ: John Wiley. psychologist at the PTSD Programs, Center for Sexual Trauma Weathers, F. W., & Keane, T. M. (2007). The Criterion A problem Services (CSTS) at the Bay Pines Veterans Veteran’s Affairs revisited: Controversies and challenges in defining and mea- Healthcare system in Bay Pines, Florida. suring psychological trauma. Journal of Traumatic Stress, 20, 107-121. doi:10.1002/jts.20297 Scott D. Barnett received his Doctorate in Epidemiology and Weathers, F. W., Keane, T. M., & Davidson, J. R. T. (2001). Biostatistics from the University of South Florida. He has served as Clinician administered PTSD scale: A review of the first a biostatistician/epidemiologist for over 18 years with expertise in ten years of research. Depression and Anxiety, 13, 132-156. database design, research methodologies and biostatistics. He has doi:10.1002/da.1029 been with the Research Center of Excellence at James A. Haley Weathers, F. W., Litz, B. T., Huska, J. A., & Keane, T. M. (1994). Veteran’s Hospital in Tampa Florida since 2009. The PTSD Checklist–Civilian Version (PCLC). Boston, MA: National Center for PTSD. Susanne Gibbons received her Doctorate in Nursing from the Weathers, F. W., Ruscio, A. M., & Keane, T. M. (1999). Psychomet- Catholic University of America. She is an Assistant Professor in the ric properties of nine scoring rules for the clinician-administered USU Graduate School of Nursing and holds the concurrent position posttraumatic stress disorder scale. Psychological Assessment, of Research Director in the Adult Psychiatric Mental Health Nurse 11, 124-133. doi:10.1037/1040-3590.11.2.124 Practitioner Program.

Journal

SAGE OpenSAGE

Published: Feb 27, 2013

Keywords: military; posttraumatic stress disorder; healthcare survey

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