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Carla L. Storr, ScD, MPH, is a Professor at the University of Maryland Baltimore School of Nursing
(UMSON) and adjunct Professor at Johns Hopkins Bloomberg School of Public Health (JHSPH).
Dr. Storr has over 25 years of research experience and prior to
joining the faculty at UMSON, was an associate research scientist
in the Department of Mental Health at JHSPH. She continues to
collaborate with JHSPH colleagues on several NIH grants.
Her work illustrates a familiarity with the complexities of survey
design, longitudinal research, and an ability to use alternative
novel approaches. One line of her research is based on the
exploration of early childhood markers or signs that might
discriminate between differing levels or degrees of involvement
with drugs or other psychiatric disorders, such as PTSD. Other
areas of interest include exploring the influence of environmental
factors, such as work demands and neighborhood disadvantage
on mental health, exploring the dimensional quality of psychiatric
syndromes, and several of her articles explore the emergence of
clinical features of drug dependence among recent-onset users.
2
Epidemiology of Stress Disorders
Overview
  Evolution of stress disorders
  Core concepts of DSM classifications
  Traumatic events: ‘community’ vs ‘individual’
  Prevalence estimates
  Correlates, risk & protective factors
  Comorbidity / vulnerability
  Measurement and design issues
4
Section A
Historical Background and Diagnosis
Historical Background
The idea that stress could contribute to psychiatric conditions existed
even before formal nosologic classification systems were created.
Moral suspicion or personal fault
• Civil War and World War I veterans developed “soldier’s heart”, “irritable
heart”, “shell shock”
• During World War II, "combat neurosis" and "operational fatigue"
described combat-related symptoms
• Following World War II, DSM-I (1952) introduced “gross stress reaction”
• DSM-II (1968) “transient situational disturbance”
Risk factors, vulnerability, and resilience
Post-Vietnam era and child/women abuse issues focused attention on
post traumatic stress disorder (PTSD)
1980 DSM III marked beginning of contemporary research on psychiatric
responses to trauma
6
Post Traumatic Stress Disorder (DSM-IV)
PTSD is a natural emotional reaction to a deeply shocking and
disturbing experience after which it
can be difficult
to believe that life will ever be the same again.
The essential features of PTSD according to the DSM-IV™
A. Exposure to traumatic event
B. Re-experiencing traumatic event (symptom clusters)
C. Avoidance of stimuli associated with the trauma or
numbing of responsiveness (symptom clusters)
D. Increased arousal (symptom clusters)
E. Duration of a month or more
F. Significant distress or impairment
Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV™)
7
Traumatic Event (DSM-III& IIIR)
Population
No
Exposure
Exposure
No PTSD
PTSD
DSM-III: Existence of a recognizable stressor that
would evoke significant symptoms of stress in
almost anyone.
DSM-IIIR: Event that is outside the range of usual
human experience and that would be
markedly distressing to almost anyone.
8
Criterion A: Traumatic Event (DSM-IV)
Experience, witness, or confronted with an event
- Involved actual or serious injury, or a threat to the physical
integrity of others
- Response involved intense fear, helplessness, or horror
[in children, it may be expressed instead by
disorganized or agitated behavior]
Examples:
  ‘Community’ events: war/combat, technological disasters,

natural disasters, mass violence/terrorism
‘Individual’ events: violence/crime, accidents
9
Criterion B: Re-Experiencing (One out of Five)
Unable to process the extreme emotions brought
about by the trauma, the person graphically
re-experiences the trauma.
1)
2)
3)
4)
Recurrent and intrusive recollections
Recurrent nightmares
Flashbacks
Psychological distress (upset/anxious) in response to cues
that resemble event
5)  Physiologic distress (heart pounding, sweat, become ill) in
response to cues that resemble event
10
Criterion D: Increased Arousal (2 out of 5)
State of nervousness with the individual being
prepared for "fight or flight"
1)
2)
3)
4)
5)
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hyper-vigilance
Exaggerated startle response (jumpiness)
11
Additional Criteria
  Criterion E: Duration of a month or more
Duration of disturbance (symptoms in criteria B, C,
and D) is more than one month
  Criterion F: Significant distress/impairment
The disturbance causes clinically significant
distress or impairment with daily functioning
•  Work and social impairment
•  Physical limitation, decreased well-being, lower
employment
•  Negative impact on personal relationships, daily
activities, and work performance
•  Impaired vitality, mental health, and social
functioning compared with major depressive
disorder and obsessive-compulsive disorder
Solomon SD, Davidson JRT. J Clin Psychiatry. 1997;58(suppl 9):5-11; Davidson JRT, et al. Psychol Med. 1991;21:713-721; Zatzick
DF, et al. Am J Psychiatry. 1997;154:1690-1695; North CS, et al. JAMA. 1999;282:755-762; Malik ML, et al. J Trauma Stress.
1999;12:387-393.
12
Acute Stress Disorder (DSM IV)
  Exhibit PTSD-like symptoms immediately after the
trauma
  Persist for a minimum of two days to up to four weeks
within a month of the trauma.
  If symptoms persist after a month, the diagnosis
becomes PTSD
Chance that a person diagnosed with ASD will develop
PTSD is about 80%;
Chance that they will develop PTSD after cognitivebehavioral therapy is only about 20%.
13
Acute Stress Disorder (DSM IV)
Summary of prospective studies of Acute Stress Disorder
Follow-up
Prop. of ASD
developing
PTSD
Prop. of PTSD
who had ASD
Harvey & Bryant, 1998
6 mos.
78%
39%
MVA
Holeva et al., 2001
6 mos.
72%
59%
MVA
Creamer et al., 2004
6 mos.
30%
34%
MVA
Schnyder et al., 2001
6 mos.
34%
10%
MVA
Harvey & Bryant, 1999
2 yrs.
82%
29%
Brain
injury
Bryant & Harvey, 1998
6 mos.
83%
40%
Brain
injury
Harvey & Bryant, 2000
2 yrs.
80%
72%
Cancer
Kangas & Bryant (unpub.)
6 mos.
53%
61%
Assault
Brewin et al., 1999
6 mos.
83%
57%
Typhoon
Staab et al., 1996
8 mos.
30%
37%
Trauma
type
Study
MVA
Bryant RA. Biol Psychiatry. 2003;53(9):789-95.
14
Neurobiology of PTSD
Dysregulation of
•  Neurotransmitters (serotonin, norepinephrine)
•  Central & autonomic nervous system (HPA axis, amygdala)
Causing
•  Altered brainwave activity
•  Disturbances in perception, learning, and memory
15
Neurobiology of PTSD
16
Neurobiology of PTSD
Cause
  Hyperarousal and increased sensitivity of startle reflex
  Decreased capacity to respond normally to emotional
arousal or external stressors
  Sleep abnormalities
17
Neurobiology of PTSD
18
Memories formed under emotionally
arousing situations behave differently from
those that are not.
19
Section B
Epidemiology of Traumatic events and PTSD
‘Community events’
‘Community’ traumatic events
  War: combat, refugee, civilians
  Mass violence/terrorism
 Technological /industrial accidents
 Natural disasters
21
Traumatic Exposures: War/combat
Draft table being assembled by Storr et al, 2009
22
Traumatic Exposures: War/combat
Combat duty in Iraq and Afghanistan
Before deployment
% PTSD
OR (95% CI)
9.4
1.0
11.5
1.2 (1.0, 1.5)
18.0
2.1 (1.7, 2.7)
19.9
2.4 (1.9, 3.0)
Army
After deployment to Afghanistan
After deployment to Iraq
Marines
After deployment to Iraq
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. N Engl J Med 2004 Jul 1;351(1):13-22.
23
Traumatic Exposures: War/combat
Prevalence of PTSD
Draft table being assembled by Storr et al, 2009
24
Traumatic Exposures: War refugees
25
Traumatic Exposures: War refugees
DEPRESSION
PTSD
Mollica, Richard; Poole, Charles; Tor, Svang (1998). Symptoms, functioning, and health problems in a massively traumatized
Population: the legacy of the Cambodian tragedy, chapter 2 34-51 in Dohrenwend, Bruce. Adversity, stress, and psychopathology.
26
Traumatic Exposures: War refugees
PTSD, Depression Epidemic Among Cambodian Immigrants
More than two decades after fleeing the Khmer Rouge reign of terror, most
Cambodian refugees who resettled in the United States remain traumatized.
Marshall GN, Schell TL, Elliott MN, et al.. JAMA 294(5):571-9, 2005.
27
Traumatic Exposures: Civilian chemical warfare
Iran sustained ~387 chemical attacks over the 8-yr Iran-Iraq war.
3 towns with different exposure
•  Oshnaviyeh: low-intensity warfare
•  Rabat: high-intensity warfare but no chemical exposure
•  Sardasht: high intensity warfare & chemical exposure (250kg sulfur
mustard warheads exploded in center of town: 4500 exposed)
Hashemian F, et al. JAMA 2006 Aug 2;296(5):560-6.
28
Traumatic Exposures: Civilian chemical warfare
Hashemian F, et al. JAMA 2006 Aug 2;296(5):560-6.
29
Traumatic Exposures: Mass violence/terrorism
  means of inducing fear and intimidation, which has the goal of
generating negative psychological effects in the targeted population
  in addition to immediate threat also a persistent threat of more
violence
Author
Event
North 1999,
2004
1995 Oklahoma City bombing
Galea 2002
NYC Sept 11, 2001
North 2002
1991 Killeen TX mass
shootings
Ohtani 2004
1995 Tokyo subway
Miquel Tobol
2006
2004 Madrid train bombing
Time
PTSD prevalence
6 mos
17 mos
34%
31%
4-6 wks
1-2 mos
14% symptoms
8% symptoms
6-8 wks
28%
1 yr
18%
5 yrs
17%
1-3 mos
2%
30
Traumatic Exposures: Technological disasters
  ‘caused by human beings, but without intent to harm’
Draft table being assembled by Storr et al, 2009
31
Traumatic Exposures: Natural disasters
Naturally occurring weather and geological events
(e.g., earthquakes, tsunami, hurricanes, floods, tornadoes)
Degree of destruction depends on
  intensity of the event
  the population density
where the events occurs
  degree of preparation
available (architectural
strength & warning systems)
http://www.unisdr.org/eng/media-room/press-release/2009/pr-2009-01-disaster-figures-2008.pdf
Natural disasters in US are often thought to occur at random,
though there are regions that are more prone to certain types s
  hurricanes in the Southeast and Mid-Atlantic region
  earthquakes on the West Coast
  wildfires throughout the West
32
Traumatic Exposures: Natural disasters
Author
Earthquake
Richter
Scale
Time
PTSD
Prevalence
Wang 2000
1998 China
8.2
9 mos
24%
Durkin 1993
1985 Chile
8.2
8-12 mos
19%
Cao 2003
1988 China
7.6
5 mos
14%
Chou 2007
1999 Taiwan
7.3
6 mos
2 yrs
8%
10%
4%
50%
1988 Armenia
6.9
3 yrs
2 years
Sharan 1996
1993 India
6.8
1 mo
23%
Durkin 1993
1983 California
6.7
15-22 mos
3%
McMillen 2000
1994 California
6.7
11-32 wks
14%
Armenian 2000,
2002
Bass J, Azur M, Person C. (2005) Mental health consequences of disasters. In Mental Health Aspects of Disaster:
Public Health Preparedness and Response. eds: Everly GS, Parker CL
Chou et al. Psychiatry Clin Neurosci. 2007 Aug;61(4):370-8.
33
Traumatic Exposures: Natural disasters
The Spitak [Armenia] earthquake Dec 7, 1988, named after the city closest to the
epicenter, was one of the most devastating natural disasters of this century. Magnitude of
6.9 on the Richter Scale lasted approximately 1 minute, followed by an aftershock 4
minutes later of magnitude 5.8. It caused the destruction of four cities and 350 villages,
killing at least 25,000 people according to Soviet estimates and as many as 100,000
according to some European sources, leaving 530,000 people homeless
34
Traumatic Exposures: Natural disasters
Draft table being assembled by Storr et al, 2009
35
Traumatic Exposures: Natural disasters
December 26, 2004 - Undersea earthquake (9.3) NW of Indonesia resulting in
Tsunami hitting Southern Thailand
• Phang Nga 4200 dead
• Krabi 721 dead
• Phuket 279 dead
van Griensven F, et al. JAMA. 2006 Aug 2;296(5):537-48.
36
Traumatic Exposures: Natural disasters
Children (7-14 yrs) : symptoms 2 mo after Tsunami
Thienkrua, W. et al.. JAMA 2006;296:549-559.
37
Prevalence in disasters
Prevalence of PTSD
  among direct victims of disaster: 30%–40%
  among rescue workers: 10%-20%
In at least 33% of direct victims of disasters, PTSD
will persist for more than 2 years
Galea S, Nandi A, Vlahov D. Epidemiol Revs 2005; 27:78-91
38
Section C
Epidemiology of Traumatic events and PTSD
‘Individual events’ ~ General population
Young Adult population samples
A.  Detroit Area Survey
•  1200 young adults (21-30 years old) sampled from
rolls of HMO in Southeast Michigan
•  1007 participated in baseline interview in 1989
•  >95% followed up in 1992 and 1995
B. Mid Atlantic Urban sample
•  1698 young adults (mean age 21) sampled from two
cohorts followed since entering first grade
•  first grade teacher ratings, 3rd/4th grade self reports
•  75% followed up in 2000/02
Breslau, et al. Arch Gen Psychiatry, 1991; Breslau et al. Arch Gen Psychiatry, 2006
40
Traumatic Exposures in general population
Breslau N, Wilcox HC, Storr CL, Lucia V, Anthony JC. (2004), J Urban Health.
41
Frequency of Trauma by Age
Breslau et al.,
42
Conditional probability of PTSD across event types
Breslau N, Wilcox HC, Storr CL, Lucia V, Anthony JC. (2004), J Urban Health.
43
Lifetime Prevalence of exposure and PTSD
Exposure to trauma
Conditional risk of PTSD
44
Prevalence of Traumatic Exposure and PTSD
in Population-Based Studies
45
Prevalence of trauma and probability of PTSD
46
Lifetime Prevalence of Trauma Experience (II)
Kessler, et al. Arch Gen Psychiatry, 1995
47
Trauma by medical procedures
Patients that may also be at risk of developing PTSD are those who have
undergone untoward medical procedures, such as a traumatic birth,
hospitalization, ICU/ICC stay, or intubation, or a surgery during which the
patient awakened because of insufficient anesthesia.
Accidental injuries1
Cardiac surgery2
PTSD
prevalence
PTSD
prevalence
1 month
5%
Pre-op
6 months
4%
Discharge
18%
12 months
2%
12 months
7%
1 Hepp U et al., 2005; 2 Rothenhäusler HB, et al., 2005
9%
48
Trauma by medical procedures
Prevalence of PTSD in survivors of critical illness in
medical intensive care units
Author
Study design
Time
Prevalence
Cutherson, 2004
prospective cohort
3 mo
14%
Kapfhammer, 2004
retrospective cohort
8 yrs
24%
Capuzzo, 2005
prospective cohort
3 mo
5%
Deja, 2006
retrospective cohort
57 mo
29%
Girard, 2007
prospective cohort
6 mo
14%
Sukantarat, 2007
prospective cohort
9 mo
24-38%
Excerpt from Kross, et al, 2008
49
Remission of PTSD
About 50% of cases of PTSD remit within 6 months. For the remainder, the
disorder typically persists for years and can dominate the sufferer’s life.
Breslau et al, Arch Gen Psychiatry 1998
50
Prevalence in the General Population
  Prevalence of exposure to traumatic events:
50% – 85% depending on definition
  Approximately 25 – 30% of victims of traumatic
events develop symptoms of PTSD
  Prevalence of PTSD: 7%–10%
  Conditional risk of PTSD given exposure: ~ 25%
(rape victims~ 47%).
  About 50% of cases of PTSD remit within 6 months. For
the remainder, the disorder typically persists for years
and can dominate the sufferer’s life.
51
Prevalence traumatic events & PTSD worldwide
Draft table being assembled by Storr et al, 2009; samples largely general
population or large community samples
52
Section D
Correlates, risk and protective factors
Correlates, risk and protective factors
Gender
  Females usually affected more adversely than males (2:1)
  Lifetime PTSD prevalence NCS 10% vs 5%
  Effects of gender tend to be greatest within samples from
traditional cultures and in the context of severe exposure.
  Suggestion of a sex and assaultive violence exposure
interaction
54
Correlates of Lifetime PTSD
Age and Experience
Bromet, et al., Am J Epidemiol. 1998
Continued
55
Correlates, risk and protective factors
Age and Experience continued
  Cross-cultural research suggests that the effects of age may
differ across countries according to social, political, and
economic context
  Prior experience with the specific type of event may reduce
anxiety and have a stress inoculation effect that strengthens
an individuals protective factors, e.g. higher levels of hazard
preparedness and are more likely to evacuate when told
  Professionalism and training increase the resilience
56
Correlates, risk and protective factors
Immigrants and refugees: Specifically, poor English-speaking skills,
unemployment, being in retirement or disabled, and living in poverty were
associated with higher rates of PTSD and major depression.
57
Correlates, risk and protective factors
Socioeconomic Status (SES)
as manifest in education, income, literacy, or occupational
prestige
  lower SES greater distress
  effect of SES has been found to grow stronger as
the severity of exposure increases
58
Correlates, risk and protective factors
59
Correlates, risk and protective factors
Social/family risk factors
  Early separation from parents
  Abusive family environments
  Being a parent, especially for events involving uncertain threats;
mothers were especially at risk for substantial distress and children
are highly sensitive to parental psychopathology
  Family psychopathology
A higher prevalence of PTSD, but not trauma exposure, has been
found in adult offspring of Holocaust survivors with PTSD
compared to children of Holocaust-exposed parents without
PTSD---low cortisol levels. (Yehuda R)
60
Correlates of Lifetime PTSD
  No longer being married was a risk factor for both men
and women
Bromet, et al., Am J Epidemiol 1998
61
Event related factors
PTSD: 1988 Armenia earthquake and its impact
Experience
Impact
Severity
Distance
Armenian HK, Morikawa M, Melkonian AK, et al. Acta Psychiatr Scand. 2000 Jul;102(1):58-64.
62
Event related factors
Breslau N, Chilcoat HD, Kessler RC, Davis GC. 1999
Breslau N, Chilcoat HD, Kessler RC, Davis GC. 1999
63
Event related factors
Breslau N, Chilcoat HD, Kessler RC, Davis GC. 1999
64
Section E
Comorbidity / Vulnerability
Comorbidity
More medical comorbidity/worse physical health
  Higher lifetime prevalence of gastrointestinal,
cardiovascular, respiratory, neurologic, non-STD
infectious diseases
More psychiatric comorbidity
  Higher rates of somatization disorder, schizophrenia/
schizophreniform disorder,
panic and other anxiety disorders,
major depression, substance abuse disorders
More attempted suicide
Davidson JRT, et al. Psychol Med. 1991;21:713-721; Boscarino JA. Psychosom Med. 1997;59:605-614; Zatzick DF, et al. Am J
Psychiatry. 1997;154:1690-1695; Malik ML, et al. J Trauma Stress. 1999;12:387-393; North CS, et al. JAMA. 1999;282:755-762
66
Lifetime Comorbidity: general population
Breslau, et al., Arch Gen Psychiatry 1991
67
Comorbidity
As many as 50% of adults with both alcohol use disorders and
PTSD also have one or more other serious psychological or
physical problems.
Up to 80% of Vietnam veterans seeking PTSD treatment have
alcohol use disorders.
Adolescents with PTSD are 4 times more likely than
adolescents without PTSD to experience alcohol abuse or
dependence, 6 times more likely to experience marijuana
abuse or dependence, and 9 times more likely to experience
hard drug abuse or dependence.
68
PTSD Comorbidity
Traumatic Event
PTSD
Are individuals with PTSD at
increased risk for other disorders?
Comorbid Disorder
69
PTSD Comorbidity
PTSD was estimated to increase the risk of major depression
and although the odds were weaker in the direction of
increased risk for other disorders.
Breslau
70
PTSD Comorbidity
Breslau, 2000
Preliminary
Detroit HMO survey Urban cohort, young adult
PTSD and exposure time dependent covariates
PTSD was estimated to increase the risk of major depression.
Preliminary unpublished results Storr
71
PTSD Comorbidity
Prior traumatic
exposure and PTSD
Suicide Attempt
Urban cohort, young adult
%
RR (95 CI)
No exposure
5.0
1.0
Exposed, no PTSD
8.0
0.8 (0.5, 1.4)
PTSD
26.0
2.7 (1.3, 5.5)
Adjusted for demographics, Major Depressive Episode, Alcohol Abuse/Dependence, and
Drug Abuse/Dependence that occurred prior to PTSD
PTSD, Major Depressive Episode, Alcohol Abuse/Dependence, and Drug Abuse/
Dependence were time dependent covariates
PTSD was estimated to increase the risk of suicide attempt.
Wilcox HC, Storr CL, Breslau N. Arch Gen Psych. 2009.
72
PTSD Comorbidity
Traumatic Event
Do pre-existing psychiatric disorders,
increase the risk for exposure to
traumatic events?
Comorbid
Disorder
Do pre-existing psychiatric
disorders, increase the
vulnerability to PTSD following
exposure to traumatic events?
PTSD
Comorbid Disorder
73
Comorbidity
  Alcohol and drug dependence
  risk factor for exposure to adverse events (such
as automobile accidents)
  but was not a risk factor for the development of
PTSD in exposed populations
  Prior history of depression
  was not a risk factor for exposure to adverse
events
  risk factor for PTSD in an exposed population
Breslau et al., 1991
74
MDD Comorbidity
Breslau, 2000
Detroit HMO
Preliminary
Urban cohort
Breslau, 2000
Detroit HMO
Preliminary
Urban cohort
Prior history of depression
was not a risk factor for exposure to adverse events
But is a risk factor for PTSD in an exposed population
Adjusted for sex, race, SES/education with MDD time dependent covariate;
Preliminary Urban cohort also adjusted for personality facets
75
  Externalizing behaviors (adjustment & behavior
problems) have been associated with PTSD and exposure
to traumatic events.
  Anxiety, depression, and personality traits, such as
neuroticism, have been associated with increased risk of
PTSD.
76
Pre-existing psychopathology increase risk of exposure?
Assaultive violence
Assaultive violence only
Relative
%
Risk 95% CI
Aggressive/disruptive behavior
and other traumas
Other traumas only
Relative
Relative
% Risk 95% CI
% Risk 95% CI
Lowest quartile
3.6 1.0
32.6 1.0
41.5 1.0
Second quartile
3.4 1.0 0.4-2.3
42.4 1.4
0.9-2.6
33.3 0.8 0.5-1.4
Third quartile
4.2 1.7 0.9-3.3
45.6 2.1** 1.3-3.3
35.4 1.3 0.8-2.0
Highest quartile
6.4 3.1* 1.4-6.6
50.6 2.6** 1.7-4.0
30.0 1.2 0.8-1.8
Anxious/depressed mood
Low depression & low anxiety
4.4 1.0
41.6 1.0
36.8 1.0
High depression, low anxiety
4.7 1.0 0.5-2.1
40.1 0.9 0.6-1.3
36.4 0.9 0.6-1.3
High anxiety, low depression
2.8 0.6 0.2-1.4
46.0 0.8 0.5-1.4
32.9 1.0 0.6-1.8
High depression & high anxiety
4.9 1.0
0.6-1.8
42.9 0.8 0.6-1.1
33.7 1.0 0.7-1.3
Storr CL, Ialongo NS, Anthony JC, Breslau N. Am J Psychiatry. 2007 Jan;164(1):119-25.
77
Pre-existing psychopathology predispose to PTSD?
Conditional Probability of PTSD by Childhood Antecedents (N=1372)
Relative
n
%
Risk 95% CI
Aggressive/disruptive behavior
Lowest quartile
319
7.8
1.0
Second quartile
268 10.8 1.4 0.7-2.8
Third quartile
325 10.2 1.3 0.6-2.8
Highest quartile
305
7.2
0.9 0.4-2.1
Anxious/depressed mood
Low depression & low anxiety
High depression, low anxiety
High anxiety, low depression
High depression & high anxiety
353
256
202
258
Storr CL, Ialongo NS, Anthony JC, Breslau N. Am J Psychiatry. 2007 Jan;164(1):119-25.
8.2
6.6
9.4
12.0
1.0
0.8 0.5-1.3
1.2 0.6-2.2
1.5 1.0-2.4
78
Developmental course of pre-existing psychopathology
Early childhood behavior trajectories and the risk of
experiencing a traumatic event by young adulthood.
JHU Prevention Center Cohorts 1&2
Males
Chronic high
(19%)
Increasing
(47%)
Stable low (34%)
Teacher rated behavior
Adjusted for subsidized lunch, race, peer rejection,
reading achievement, attention-concentration
Storr CL, Schaeffer CM, Petras H, Ialongo NS, Breslau N. Soc Psych Epidemiol. 2009
79
Section F
Measurement and design issues
Measurement: Assessments
Administration/costs
 Structured clinical interviews (SCID)
 Structured lay interviews (DIS and CIDI)
 Checklists—self-report (Mississippi scale for post-traumatic stress)
Stress symptoms vs diagnostic criteria
  structured interviews assess psychiatric disorders and have a format that
requests information about the frequency and intensity of the core
symptoms and of some common associated symptoms, which may have
important implications for treatment and recovery.
  checklists provide scores representing the amount of distress an
individual is experiencing.
81
Measurement: Adult assessments
No. of
Items
Time of
Admin
(min)
Allows
Multiple
Trauma
Corresponds
to DSM-IV
Criteria
Clinician administered
PTSD Scale (CAPS)
30
40-60
Up to 3
Yes
D Symptom ScaleInterview Version (PSS-I)
17
20-30
No
Yes
Structured Clinical
Interview for DSM-IV PTSD
Module (SCID)
21
20-30
No
Yes
Structured Interview for
PTSD (SI-PTSD)
27
20-30
No
Yes
Adult Interview
http://www.ncptsd.va.gov/ncmain/assessment/adult_interview.jsp
82
Measurement: Adult assessments
No. of
Items
Time to
Admin
(min)
Allows
Multiple
Trauma
Corresponds
to DSM-IV
Criteria
Davidson Trauma Scale (DTS)
17
10-15
No
Yes
Distressing Event Questionnaire (DEQ)
35
10-15
Yes
Yes
Impact of Events Scale-Revised (IES-R)
22
5-10
No
Yes
Los Angeles Symptom Checklist (LASC)
43
10-15
Yes
No
Mississippi Scale for Combat-Related PTSD
17
10-15
Yes
No
Modified PTSD Symptom Scale
17
10-15
Yes
Yes
Penn Inventory for PTSD
26
15-20
Yes
No
Posttraumatic Diagnostic Scale (PDS)
49
10-15
No
Yes
PTSD Checklist (PCL) - Civilian, Military, Specific Trauma
17
5-10
Yes
Yes
Purdue PTSD Scale (PPTSD-R)
17
5-10
No
Yes
Revised Civilian Mississippi Scale for PTSD (R-CMS)
30
5-10
No
Yes
Screen for Posttraumatic Stress Symptoms (SPTSS)
17
10-15
Yes
Yes
Trauma Symptom Inventory (TSI)
100
15-20
Yes
No
Trauma Symptom Checklist-40 (TSC-40)
40
15-15
Yes
No
Adult Self Reports
http://www.ncptsd.va.gov/ncmain/assessment/adult_selfreport.jsp
83
Measurement: Adult assessments
No. of
Items
Time to
Admin
(min)
Allows
Multiple
Trauma
Corresponds
to DSM-IV
Criteria
Primary Care PTSD Screen (PC-PTSD)
4
2
Yes
N/A
SPRINT
8
3
Yes
N/A
BAI-PC
7
3
Yes
N/A
Short Form of the PTSD Checklist
6
2
Yes
N/A
Short Screening Scale for PTSD
7
3
Yes
N/A
SPAN
4
2
Yes
N/A
Trauma Screening Questionnaire (TSQ)
10
4
Yes
N/A
Adult Self Reports
http://www.ncptsd.va.gov/ncmain/assessment/ptsd_screening.jsp
84
Measurement: Classification
Diagnostic categorical approach
Statistical methods to provide empirical
evidence on subgroups of individuals who
share similar symptoms
  Use observed measures and summarize them by one
quantity-a latent variable~class. The latent class represents a
hidden cluster or pattern in the response profiles that we do
not see.
  LCA is more of a model based approach that estimates the
probability of belonging to one class versus another class.
85
Measurement: Classification
86
Gender and trauma type
Breslau N, Reboussin BA, Anthony JC, Storr CL. Arch Gen Psychiatry. 2005 Dec;62(12):1343-51.
87
Consequences of Disturbance and Persistence of Symptoms
Percentage of each class seeking help
Members of class 3 were far more likely than members of class 2 to report each outcome.
Disturbance persisted significantly longer in members of class 3
than class 2 (log-rank chi-square= 27.1, p=0.0001).
The median time to remission: 60 months (C3) & 12 months (C2).
Breslau N, Reboussin BA, Anthony JC, Storr CL. Arch Gen Psychiatry. 2005 Dec;62(12):1343-51.
88
Measurement Issues
General population studies
 Types of traumatic events
(direct experiences vs witnessing)
  Selecting events for reporting about PTSD
  from multiple events: worse, first, or random event
  Age / developmental context
  Linking PTSD symptoms to specific event
89
Measurement Issues
Disaster studies
 Timing
 Proximity
 Role & Cultural aspects (country resources)
 Type of event
EX: Consequences of terrorism: a meta-analysis
90
Measurement Issues: Timing
Immediate and long term consequences
Prevalence of PTSD by time from event
2 months
15.9%
(6.0 – 35.9)
6 months
14.2%
(6.3 – 28.7)
12 months
12.3%
(5.8 – 24.0)
1-5 years
14.2%
(9.6 – 20.6)
Odds of PTSD associated with media images
1-3 months
2.4 (2.1, 2.8)
3-6 months
1.3 (1.1, 1.6)
DiMaggio C, Galea S. Acad Emerg Med. 2006;13(5):559-66.
91
Measurement Issues: Proximity
“Exposure Dose” (proximity to 9/11 crash site)
Probably PTSD % (SE)
NY City Metropolitan Area
11.2 (2.2)
DC Metropolitan Area
2.7 (1.2)
Other Major Metropolitan Area
3.6 (0.9)
Remainder of US
4.0 (1.0)
US Total
4.3 (0.8)
Schlenger WE, Caddell JM, Ebert L, et al. JAMA. 2002 Aug 7;288(5):581-8.
92
Measurement Issues: Role
Prevalence of PTSD by exposure category (meta analysis)
Survivors
18.0%
(12.7 – 24.9)
Rescuers
16.8%(11.4 – 24.2)
Employee cohorts
15.8% (9.9 – 24.2)
General population
10.9% (5.2 – 21.6)
Madrid 3/11/04: 10 bombs on 4 trains >1400 injured & 192 dead
interviewed at 5-12 weeks.
Injured
44.1%
(35.3 – 53.2)
Residents
12.2%
(9.6 – 15.6)
1.3%
(0.2 – 4.6)
Police
DiMaggio C, Galea S. Acad Emerg Med. 2006;13(5):559-66
Gabriel R, Ferrando L, Corton ES, Mingote C, Garcia-Camba E, Liria AF, Galea S. Eur Psychiatry. 2007 Jan 13; [Epub ahead of print]
.
93
Measurement Issues: Possible local & cultural aspects
Prevalence of PTSD
Western Europe 23.6% (19.6 - 28.1)
North America
12.7% (9.1 - 17.5)
Middle East
12.6% (8.8 - 17.9)
by event in the US
Oklahoma City
NYC Sept 11
DiMaggio C, Galea S. Acad Emerg Med. 2006;13(5):559-66.
17.3% (13.9 - 21.3)
13.0% (12.4 - 13.6)
94
Measurement Issues: Type of event
Rates of Acute Stress Disorder (timing held constant)





Typhoon
7%
Industrial accident 6%
MVA
14%
Violent assault
19%
Mass shooting
33%
Rates of Post- traumatic Disorder





Natural disaster
5%
Combat
8%
Bombing
34%
Plane crash into hotel
29%
Mass violence
67% Higher rates reported for
human-caused assaultive trauma.
Bryant RA, 2000
95
Section G
Summary
Stress Disorders
  requires exposure to a traumatic event
  unable to process the extreme emotions brought
about by the traumatic experience and one
graphically re-experiences the trauma
  symptoms are eventually so distressing that the
individual strives to avoid contact with everything
& everyone, even their own thoughts   a state of nervousness with the individual being
prepared for ‘fight or flight’
  significant distress and impairment
  duration: Short term (2 days-4 weeks) > ASD
but if persist longer than a month > PTSD
97
Who is most likely to develop a stress disorder?
  Those who experience greater stressor
magnitude and intensity, unpredictability,
uncontrollability, sexual (as opposed to
nonsexual) victimization, real or perceived
responsibility, and betrayal.
  Those who report greater perceived threat or
danger, suffering, upset, terror, and horror or
fear.
98
Who is most likely to develop PTSD?
99
Who is most likely to develop PTSD?
  Those with prior vulnerability factors such as
psychiatric history, low intelligence/poor
education, limited coping abilities, early age
of onset and longer-lasting childhood abuse,
lack of functional social support, and
concurrent stressful life events (dislocation).
  Lack of resources and follow-up support in the
weeks following exposure.
100
That which does not kill us
can only make us stronger.
Nietzsche
101