The PTSD Symptom Scale – Interview (PSS-I)

1. The PTSD Symptom Scale – Interview (PSS-I) Jennifer A. Schneider, Ph.D. National Center for Posttraumatic Stress Disorder, Department of Veterans Affairs, Pacific Islands Health Care System, Spark M. Matsunaga Medical Center, Honolulu, HI, USA

2. Objectives • Participants will demonstrate knowledge of the research basis for the PSSI • Participants will have an understanding of PSSI structure, administration, and scoring • Participants will be able to utilize the PSSI for clinical or research purposes

3. What is the PSS-I? • Semi-structured clinical interview used to: • Diagnose PTSD • Determine PTSD symptom severity

4. Development of the PSS-I • Established Internal Consistency, Reliability, Sensitivity • Shown to be reliable and valid in civilians • Overall, performs as well as the CAPS in diagnosis of PTSD • Research suggests that it has greater sensitivity to PTSD, whereas the CAPS has greater specificity (Foa et al, 1993; Foa & Tolin, 2000)

5. PSS-I versus CAPS Cons • Greater sensitivity to PTSDmay result in more false positives • Assessment of symptoms in the past 2 weeks, may result in capturing an abnormally asymptomatic or symptomatic window of time that does not reflect the individual’s true functioning Pros • Faster • Greater sensitivity may result in identification of individuals in need of treatment (Foa et al, 1993; Foa & Tolin, 2000)

6. Structured Clinical Interviews • “Clinical” means that the clinician’s judgment should come into play when making ratings • If the client has a clear response bias, the clinician should adjust ratings accordingly • Utilize observations of the client’s presentation during the assessment in scoring

7. DSM-IV-TR Criteria for PTSD • Criterion A: Stressor • The person has been exposed to a traumatic event in which both of the following were present: • The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others • The person's response involved intense fear, helplessness, or horror. Note: in children, this may be expressed instead by disorganized or agitated behavior. • Criterion B: Intrusive Recollections • The traumatic event is persistently reexperienced in one (or more) of the following ways: • Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: in young children, repetitive play may occur in which themes or aspects of the trauma are expressed. • Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognizable content • Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated). Note: in young children, trauma-specific reenactment may occur. • Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • Physiologic reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event (American Psychiatric Association, 2000)

8. DSM-IV-TR Criteria for PTSD • Criterion C: Avoidance/Numbing • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: • Efforts to avoid thoughts, feelings, or conversations associated with the trauma • Efforts to avoid activities, places, or people that arouse recollections of the trauma • Inability to recall an important aspect of the trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect (e.g., unable to have loving feelings) • Sense of foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) • Criterion D: Hyperarousal • Persistent symptoms of increased arousal (not present before the trauma), indicated by two (or more) of the following: • Difficulty falling or staying asleep • Irritability or outbursts of anger • Difficulty concentrating • Hypervigilance • Exaggerated startle response (American Psychiatric Association, 2000)

9. DSM-IV-TR Criteria for PTSD • Criterion E: Duration • Duration of the disturbance (symptoms in criteria B, C, and D) is more than one month. • Criterion F: Functional Significance • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning • Specify if: • Acute: if duration of symptoms is less than three months • Chronic: if duration of symptoms is three months or more • Specify if: • With Delayed Onset: if Onset of symptoms is at least six months after the stressor (American Psychiatric Association, 2000)

10. PSS-I Structure • PSS-I items correspond to DSM-IV criteria for PTSD DSM-IV Criterion B B1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions PSS-I Item 1. Have you had recurrent or intrusive distressing thoughts or recollections about the trauma?

11. PSS-I Structure • Ratings are made on a 4-Point Likert Scale that combines frequency and severity • 0 – Not at all • 1 – Once per week or less/a little • 2 – 2 to 4 times per week/somewhat • 3 - 5 or more times per week/very much • Frequency and severity are combined because some items lend themselves better to frequency ratings, while others lend themselves better to intensity ratings

12. PSS-I Structure • Frequency refers to the number of occurrences in the time-frame of reference • Severity refers to the subjective distress reported, the duration of the symptom, and its impact/interference

13. PSS-I Structure • Estimated Administration Time • 20 – 30 minutes in civilians • 20 – 40 minutes in veterans

15. PSS-I Administration

16. PSS-I Administration • Identify the Criterion A • Typically this is the event which is most distressing at present, however, any traumatic event may be chosen • Establish the presence of Criterion A2 • Fear, helplessness, or horror occurring during or after the traumatic event • Establish a Time Frame • Validated for last month & last two weeks • Longer or shorter time frames may be used

17. Establishing Criterion A • DSM-IV-TR Criterion A1 & A2 for PTSD • A1: The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others • A2: The person’s response involved intense fear, helplessness, or horror. Note: in children this may be expressed instead by disorganized or agitated behavior

18. Establishing Criterion A • Helpful Questions: • “In this interview, I will be focusing on one traumatic event. Which of the events that you mentioned to me bothers you the most at the present time?” • “Which of the traumatic experiences you mentioned currently gets in the way of your life the most? • “Which one of these events do you find yourself having the most upsetting and unwanted thoughts about lately?” (Feeny & Foa, 2002)

19. Criterion A Examples • Directly Experienced Trauma • Combat, life threatening accident (e.g., plane crash, motor vehicle accident), violent physical/sexual assault (in childhood or adulthood), torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disaster (e.g., earthquake, fire hurricane, flood), robbery, stabbing/shooting, being diagnosed with a life threatening illness • Witnessed Trauma • Observing death or injury of another person due to assault, war, or disaster, unexpectedly seeing a dead body or body parts • Confronted with/learned about Trauma • learning of family member’s (or friend’s) sudden, unexpected death, or learning that one’s child had a life threatening disease

20. Introduction “I want to get a really good picture of how things have been going for you in the past 2 weeks in terms of trauma related difficulties. So, today is (insert date)________, two weeks ago takes us back to (insert date)________, this is the period of time that I will focus on. Remember that throughout the interview I will be asking about difficulties related to the event that you identified as the most distressing, the (repeat event). Do you have any questions?” (Feeny & Foa, 2002)

21. PSS-I Administration: Rules of Thumb • Read all questions verbatim • Modification of questions is allowed when essential for the person’s understanding • Additional questions are allowed as necessary for clarification • Do not double-code • The same experience as reported by the person should not be used to score more than one item

22. PSS-I Administration: Rules of Thumb • Do not use PSS-I anchor pointsin questions • Translate them in to your own words • Use all information obtained during the interview when making ratings • Use information from later in the interview to modify earlier ratings • Use observations of the person’s behavior during the assessment

23. PSS-I Administration: Rules of Thumb • Make sure that symptoms which are not directly linked to the trauma (e.g. concentration, irritability/anger) represent a change from previous functioning • Repeatedly reiterate the time-frame within which you are assessing symptoms

24. PSS-I Item-By-ItemReexperiencing • Have you had recurrent or intrusive distressing thoughts or recollections about the trauma? • Only score if thoughts and images are related to the identified trauma • Frequency estimates are most useful for rating this symptom, however intensity ratings can help in scoring when the frequency rating falls between two scores • Have you been having recurrent bad dreams or nightmares about the trauma? • Only score if nightmares are related to the identified trauma • Frequency estimates are sufficient for rating this symptom, however, intensity may be used to bump up scores if its severity might not otherwise be reflected • Have you had the experience of suddenly reliving the trauma, flashbacks of it, acting or feeling as if it were re-occurring? • Use a combination of frequency and severity to score, gathering frequency information first • Differentiate between the experience “happening again” and having a memory, emotion, or physical feeling related to the trauma (this would be evidence of symptoms in question 4 and/or 5)

25. PSS-I Item-By-ItemReexperiencing • Have you been intensely EMOTIONALLY upset when reminded of the trauma (includes anniversary reactions)? • “Emotionally upset” refers to a range of emotions including but not limited to fear, sadness, anger, guilt or shame, and worry. • Elicit examples of trauma reminders or triggers that bring up this distress (e.g., for an assault victim: nighttime, TV shows, newspaper articles, people that look like the assailant, knives, etc) • Do not rate if the distress is appropriate to the situation (e.g. fear when walking down a dark alley in a bad neighborhood) • Intensity ratings should be utilized when the frequency rating is between two scores • Have you been having intense PHYSICAL reactions (e.g., sweaty, heart palpitations) when reminded of the trauma? • Frequency estimates are most useful for rating this symptom – Intensity ratings should be utilized when the frequency rating is between two scores • Consider the list of triggers elicited in question 4 and ask about physical reactions in addition to the emotional distress already queried (e.g., sweating, nausea, heart racing, increased respiratory rate)

26. PSS-I Item-By-ItemAvoidance • Have you persistently been making efforts to avoid thoughts or feelings associated with the trauma? • May include “pushing the thoughts away,” talking on the phone, “keeping busy,” playing music, or drug/alcohol use with the specific goal of avoiding or distracting from trauma-related thoughts and feelings • Frequency information is most useful when rating this item. Use distress ratings to push up or down a rating that falls between two scores. • Have you persistently been making efforts to avoid activities, situations, or places that remind you of the trauma? • Only score if the avoidance of people, places, and situations is specifically linked to not wanting to confront the identified criterion A. • Generate a list of situations, people, and places that are avoided and determine how much avoidance of each impairs functioning • Are there any important aspects about the trauma that you still cannot recall? • Score only if there are important/significant gaps or missing details in the trauma and if these clearly are not due to normal aging/memory decay or loss of consciousness during trauma

27. PSS-I Item-By-ItemAvoidance • Have you markedly lost interest in free time activities since the trauma? • Do not score if the person reports reduced activity related to avoidance of trauma reminders or to physical inability (e.g., injury, age) • Apathy, low energy/motivation, lack of interest (e.g., “I used to love doing X, but it just isn’t fun anymore”) should be coded here, even if it appears to be related to depression • Have you felt detached or cut off from others around you since the trauma? • For example, feeling cutoff, disconnected, alienated, different, keeping people at arms length, or being unable to feel close to or trust of others • Severity (e.g., “How strong is the feeling of disconnection?” “Do you have any one that you feel close to, even if it’s not all the time?”) is often more useful than frequency for rating this item • Have you felt that your ability to experience the whole range of emotions is impaired (e.g., unable to have loving feelings)? • Emotional numbness refers to emotional flatness or lack of responsivity despite stimuli, restricted range of affect for example feeling sad all the time, having difficulty experiencing love and happiness, or experiencing anger more easily than other emotions. • Severity (i.e., fluctuation versus continuous emotional numbing during the identified time frame) may assist in scoring

28. PSS-I Item-By-Item • Have you felt that any future plans or hopes have changed because of the assault (e.g., no career, marriage, children, or long life)? • Score if the individual reports having been permanently negatively impacted (e.g., “I will never have children”, “never achieve anything I wanted to do”, “my life will be short”, etc.) directly as a result of the traumatic experience • Frequency of thoughts and severity (level of “damage” or permanency of the “damage”) are both useful in scoring

29. PSS-I Item-By-ItemHyperarousal • Have you had persistent difficulty falling or staying asleep? • Combined frequency and intensity ratings are most helpful here (i.e., determine how often the individual is having difficulty falling or staying asleep, and then determine how many hours of sleep were lost) • Get specific when obtaining severity (ask “how long did it take to fall asleep?,” “how many times did you wake up during the night and how long did you stay up for?”) • Sleep disturbance should represent a change in functioning from prior to the trauma • Score based on the information provided by the individual, even if sleep medication is being used (i.e., do not speculate about how the person’s sleep would be without medication) • Use distress ratings to push up or down a rating that falls between two scores • Have you been continuously irritable or have outbursts of anger? • Irritability should represent a change in functioning from prior to the trauma, and if not should be scored 0 • Frequency of irritability or anger should be assessed first • Use distress ratings to push up or down a rating that falls between two scores

30. PSS-I Item-By-ItemHyperarousal • Have you had persistent difficulty concentrating? • Severity estimates are most useful for rating this symptom (e.g., “do you find you have to reread things you’ve just read,” “do you lose track or wander off during conversations,” “are you able to concentrate if there is something very compelling”) • Factor the individual’s ability to attend to the assessment into scoring • Are you overly alert (e.g., check to see who is around you, etc.) since the trauma? • For example, being wary, on guard, scanning or doing perimeter checks, listening for small sounds, sitting with one’s back to the wall, positioning oneself in direct line of sight to an exit, keeping weapons, double checking locks, etc. • Frequency (e.g., the amount of time spent engaging in the aforementioned behaviors) should be determined • Have you been jumpier, more easily startled, since the trauma? • Startle response should be scored only if it is unreasonable based on the stimulus (e.g., it is reasonable to react by jumping or ducking if a car is hurtling towards you) • Determine the frequency if exaggerated startle response and then utilize severity ratings (e.g., the amount of time it takes to calm down after being startled) to bump the score up or down if the rating falls between two scores

31. PSS-I Scoring

32. PSS-I Scoring • Severity • 0 – 10 Below Threshold • 11 – 15 Subclinical – Mild • 16 – 20 Mild • 21 – 25 Moderate • 26 – 30 Moderately Severe • 31 – 40 Severe • 41 – 51 Extremely Severe

33. PSS-I Scoring • Symptoms count as endorsed if they have a rating of: • ≥ 1 in civilians • ≥ 2 in veterans (unless underreporting is suspected) • PTSD Diagnosis • 1 Reexperiencing Symptom • 3 Avoidance Symptoms • 2 hyperarousal Symptoms • Symptoms must be present for > 1 month

34. Questions??

35. References American Psychiatric Association: Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. *Feeny, N.C., & Foa, E.B. (2002). Manual for the Administration and Scoring of the PTSD Symptom Scale – Interview (PSS-I) *Foa, E., Riggs, D., Dancu, C., & Rothbaum, B.(1993). Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. Journal of Traumatic Stress, 6, 459-474. Foa, E & Tolin, DF (2000). Comparison of the PTSD Symptom Scale-Interview Version and the Clinician Administered PTSD Scale. Journal of Traumatic Stress, 13, 181-191. * Indicates articles suggested for further reading