Assessment, Methodology, and Research Strategies

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Maurice York
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1 PARr II Assessment, Methodology, and Research Strategies As the field of traumatic stress studies has evolved, diversified, and increased in complexity, the development of an armamentarium of objective and projective psychometric techniques of assessing stress-response syndromes has shown a correspondence to theoretical and conceptual advances in our knowledge base. Similarly, the rapid accumulation of empirical studies of PTSD and associated characteristics has led to the development of more adequate and sophisticated research methodologies by which to test hypotheses and theoretical constructs. Part II of this volume contains eight chapters which specifically address the issues of assessment of PTSD by different research strategies, including epidemiological studies, objective and projective psychometric procedures, structured clinical interview techniques, and prospective and retrospective studies of traumatic events. In Chapter 10, Andrew Baum, Susan D. Solomon, Robert J. Ursano, and their colleagues present a concise review of critical issues in the field of disaster research and the study of psychic trauma. They begin by noting that investigators face a number of practical issues in the early stages of research. These critical issues include a proper and timely assessment of the population, a realistic estimate of the costs and time frame required to carry out the project, securing access to the victim population within legal and ethical limits, and conceptualizing the structure and dimensions of the trauma itself. Careful planning around these practical aspects of the research protocol can help to avoid mistakes that could result in an incomplete or inadequate data set. In the second half of this densely packed chapter, the authors review a number of methodological issues that have grown out of the empirical literature on disasters and trauma. This is an especially valuable task because it summarizes "lessons learned" and therefore aids in designing more rigorous scientific research designs in the future. Included in their analysis are such considerations as retrospective versus prospective design problems; the nature and adequacy of outcome measures; the types of psychological scales of measurement (e.g., diagnostic instruments, biological markers, behavioral measures, etc.); stressor measures; appropriate cohort and control groups; sampling designs and pitfalls; and statistical analyses. In Chapter 11, Bonnie L. Green, one of the principal investigators of the Buffalo Creek dam disaster, addresses the question of identifying survivors at risk, especially in regard to the nature of the trauma and the specific stressors to which they were exposed. In this regard, she states: 119

2 120 PART II ASSESSMENT, METHODOLOGY, AND RESEARCH STRATEGIES the most fruitful approach to examining aspects of events at this point in time, then, appears to be looking within a particular event, for individual differences in how the event unfolded and attempting to specify generic dimensions that might apply to a variety of events. But what is a traumatic event? It is clear that disasters and traumas often contain multiple stressors and are rarely unidimensional. Furthermore, although some stressors are objective and readily verifiable, others are not easily quantified, and there are large individual differences in subjective reactions to trauma which are qualitative in nature. The issue of stress vulnerability and threshold effects at which a person develops PTSD is a very important one. There is also the related question of chronic or ongoing stressors as well as the interaction between the original, primary stressors and a host of secondary stressors. All these considerations have, of course, direct implications for the proper measurement of stressors in order that their relationship to identifying individuals at risk can be assessed. Green concludes her lucid analysis by identifying five areas of investigation that would help to advance the field in terms of conceptualizing and differentiating the acute, chronic, and life-course impact of stressors on the onset of psychopathology and psychosocial adaptation. In the medical sciences, epidemiological studies are critical to understanding the prevalence and nature of disease processes. In Chapter 12, Richard A. Kulka and William E. Schlenger present a comprehensive analysis of survey research and field designs for the study of PTSD. In particular, they "focus on four specific problems that are common in such studies: (1) identification of target populations and selection of representative samples, (2) identification of relevant comparison groups, (3) case identification, and (4) collection of comprehensive data." Because the authors were part of a team that conducted the landmark National Vietnam Veteran Readjustment Study (NVVRS), one of the most heralded epidemiological studies ever undertaken, they bring a wealth of experience and knowledge regarding the potential limits to survey research in the study of stress-response syndromes. In addition, they are able to use the NWRS study as illustrative of how to design and carry out such an epidemiological study. This is quite important heuristically because the kinds of difficulties and successes they experienced can be of enormous value to other investigators throughout the world who would wish to study other disaster and trauma victims to identify the prevalence, severity, and comorbidity of PTSD and allied symptoms. In terms of the NWRS study, the authors state, relative to their objectives, that of particular interest were its antecedents, its course, its consequences, and its relationship to other physical and emotional disorders. Relationships between PTSD and other postwar psychological problems, on the one hand, and physical disabilities, substance abuse, minority group membership, and criminal justice involvement, on the other, were also to be examined, as was the impact of postwar psychological problems on veterans' families and on their use of VA [medical] facilities. In short, nothing less was required than perhaps the most far-reaching and ambitious national mental health epidemiological study ever attempted on any population. In their chapter, Kulka and Schlenger review the development of the NWRS study, its design, choice of measures, procedures, and problems of method. This process is most informative because it details the logic and rationale, step by step, for every major set of decisions made in the study. The result is a wealth of information and a ground plan of the necessary measures that researchers must follow to insure the reliability and validity of their findings, especially in terms of case identification (caseness). This remarkable chapter breaks new ground in the study of PTSD and demonstrates that scientific creativity is necessary to advance methods by which to obtain information that becomes the springboard for new directions of inquiry in the acquisition of knowledge. Although it is the case that epidemiological surveys study persons who have already experienced a traumatic event, there are few prospective studies that follow the

3 PART II ASSESSMENT, METHODOlDGY, AND RESEARCH STRATEGIES 121 progression and sequelae of a trauma from its beginning to a given point in time posttrauma. In Chapter 13, Anthony Feinstein presents research data in one of the first prospective studies of victims of physical trauma. In this regard, the prospective study method allows us to see the natural history of a disorder, such as PTSD, in a longitudinal way. Feinstein's study was conducted at Whittington Hospital in London, England. All the patients had been victims of physical injuries which resulted from motorbike accidents, motorcar collisions, sports injury, assault, domestic violence, falls, and pedestrian accidents, and had suffered fractures of the femur, tibia, or fibula without a loss of limb. The criteria also included being between 15 and 60 years of age, being admitted to an orthopedic ward for surgical correction, showing no evidence of head trauma, witnessing no fatalities in the accident, or self-inflicted injuries. The patients were initially assessed in the hospital orthopedic ward by standard medical procedures as well as objective measures of their injuries on two rating scales. The psychological measures included the General Health Questionnaire, the Clinical Interview Schedule, the Impact of Events Scale, and the Standardized Assessment of Personality instrument. The patients were followed-up 6 weeks and 6 months after accidental injury. PTSD symptoms were assessed using the DSM-III-R criteria by an experienced clinician familiar with the disorder and its diagnosis. Among the important results of this prospective study is that upon initial assessment in the hospital, about two thirds (67%) had symptoms sufficient to be classified as psychiatric cases. Among the "case"-identified individuals, 25% were suffering from PTSD as well as anxiety and depressive symptoms. Dissociative reactions were relatively rare, and the general pattern of recovery indicated a reduction of symptoms over time. As Feinstein stated: A consistent decline in all measures of symptoms was observed over time. At the group level, the maximum symptomatology was reported in the first week following the trauma when almost two thirds of the victims were classified as psychiatric cases. This had fallen to about 25% by 6 weeks and 6 months.... The fact that there was no significant change in the number of cases from 6 weeks to 6 months is not indicative of a stable situation having been reached by 6 weeks, since 5 patients deteriorated in their condition while a similar number had improved. Thus, among the many important findings reported in this study is the fact that for some patients, PTSD symptoms were immediately present whereas for others there was a delayed onset. Given the current DSM-III-R criteria for classifying PTSD after one month's duration, these results suggest that it may be necessary to reevaluate the idea of when to diagnose, a factor currently under consideration in DSM-IV. Finally, Feinstein's study illustrates the need for more prospective studies of different victim populations so that comparative analyses between populations can be made in order to deepen our knowledge of the natural history of PTSD (Le., the posttraumatic sequelae) in order to discern common pathways as well as areas of deviation specific to exposure to stressor events. As the quality of theoretical and conceptual paradigms of PTSD have become better defined in terms of psychobiological processes, the ability to develop and validate psychometric measures of the syndrome has increased accordingly. It is a truism that, to a large degree, the quality of psychometric assessment techniques is determined by the quality of the theoretical constructs which define stress-response syndromes. In Chapter 14, Jessica Wolfe and Terence M. Keane review the evolution of the assessment of PTSD, especially as it pertains to war stressors and combat exposure. They note that The publication in 1980 of the OSM-III, in conjunction with clinicians' growing awareness of the span of environmentally based trauma, thus provided an important catalyst for the development of assessment procedures specific to PTSD. The existence of a classification schema

4 122 PART II ASSESSMENT, METHODOWGY, AND RESEARCH STRATEGIES encouraged the development and application of psychological assessment tools in two specific ways: First, it provided preliminary scientific credibility for the disorder, stimulating the need to attempt further validation of the diagnostic category itself. Second, by proposing particular symptom patterns, the categorization stirred an interest in examining and detailing the various components of PTSD. From this point on, several new questions became pivotal in the assessment of PTSD. In their chapter, Wolfe and Keane review, largely in a historical chronology, various psychological scales which have been used to measure PTSD. These instruments include the MMPI, the Impact of Events Scale, the Vietnam Era Stress Inventory, the Mississippi Scale, structured clinical interview procedures such as the scm (which is discussed fully in Chapter 15), psychophysiological measures, and measures of personality and psychopathology. Each instrument is considered in terms of its psychometric qualities (e.g., reliability, validity, internal consistency, etc.) along with a discussion of the respective strengths and weaknesses of the scales. The result of this process is the identification of measures that can be of use to researchers in the field. In their conclusion, the authors state that "further research is needed to assess the effects of different typologies of stressors as well as their variations in frequency and duration on the development of PTSD." Clearly, this position is congruent with that of Green in Chapter 11 and points to the convergence in our understanding of where systematic research and programmatic efforts need to be made to discover new information about the interaction between the person, the trauma, and the specific stressors which impact on the self-structure and personality processes of the victim. In the psychometric tradition of objective personality assessment, the individual responds to a set of items structured by the questionnaire which are then scored, tabulated, and interpreted accordingly. Although this is a time-honored and tested procedure, it has its inherent limitations, as discussed by Wolfe and Keane. However, in recent years, efforts have been made to develop structured clinical interview techniques to diagnose all the DSM-III-R mental disorders on Axis I and Axis II. In Chapter 15, Daniel S. Weiss discusses the scm module for the diagnosis and assessment of PTSD. Weiss begins his chapter by placing the assessment of psychological distress into a historical context and states that The recognition of the basic uniformity of psychological and biological reactions following exposure to the range of traumatic stressors has been aided by the formalization of diagnostic criteria. The social... consequence of displaying a near universal pattern of reactions subsequent to surviving exposure to a traumatic stressor are weighty and need sodal attention. Thus, the specialist or researcher who seeks to make a differential diagnosis can benefit from the utilization of a standardized protocol which constitutes an algorithm for scientific decision-making. The advantages of such a protocol are numerous, of course, but perhaps the primary factor is that once the user is proficient with the procedure, it eliminates errors that are due to rater bias, lack of experience with the disorder, and inefficient or improper history taking. Thus, the scm PTSD module can be considered a "yardstick" by which to validly measure the symptoms which make up the A, B, C, and D criteria of PTSD in DSM-III-R, both in the present and during the lifetime. In his chapter, Weiss explains the logic and rationale for the questions which make up the SCID module for PTSD. Furthermore, examples are given for each of the DSM-III-R criteria, a strategy which results in "walking" the reader through the use of the protocol. In his conclusion, Weiss states that The roles of structured clinical interviews and the data made available by their use are crucial to the ongoing evolution of diagnostic criteria for PTSD or response to traumatic stress. What other psychological and/or physiological phenomena co-occur after exposure to traumatic stress continues to be an evolving and growing area of attention. For this reason alone, ignor-

5 PART II ASSESSMENT, METHODOWGY, AND RESEARCH STRATEGIES 123 ing the increase in precision and the possibility for comparability of results, the regular use of standard structured clinical interviews ought to be a regular activity for those who work with survivors of trauma. The development of objective psychometric measures of PTSD has clearly demonstrated the need for assessment procedures that are sensitive to the dimensions of the disorder. As noted by van der Kolk and Saporta in Chapter 2, PTSD is a disorder of arousal in which the ability to modulate affect is adversely altered. The disruption of the steady state (stasis) causes a disequilibrium in the psyche which has, of course, manifestations in affect, cognition, and behavior. In Chapter 16, Patti Levin presents an analysis of PTSD by the Rorschach projective technique. The Rorschach is a simple test in which an individual is asked to view 10 inkblot cards, five of which contain color, and explain the nature of his or her perceptions of the parts of the inkblots. Developed in 1921 by Hermann Rorschach, the test was further codified as a clinical assessment tool by psychologists in the United States-Beck, Klopfer, Piatrowski, and Rappaport among them-who created complex and detailed scoring systems. In 1974, John E. Exner further modified the Rorschach into the Comprehensive Scoring System, an objective procedure which generated norms for pathological and normal subjects. Levin summarizes the results of her study of 27 adults who had a positive PTSD diagnosis. The subjects all had experienced trauma in adulthood (e.g., rape, major accidents) and none of them had a premorbid history on Axis I or Axis II diagnosis. The individuals were each administered the Rorschach and their results were compared to Exner's normative data. Over 200 variables were compared to the normative national sample, and about one half were found to be significantly different for the PTSD sample. In her chapter, Levin discusses her six major hypotheses, all of which were supported by the data which reveal a detailed portrait of PTSD symptoms that are operating on an unconscious level. As predicted, the PTSD sample showed high degrees of unmodulated affect, impaired reality testing, interpersonal detachment, emotional constriction, and hypervigilance. In her conclusion, Levin notes that the Rorschach was able to tap unconscious mental processes in a manner which highlighted and underscored reports of PTSD throughout the literature. Yet the Rorschach was able to go beyond the "ballpark" snapshots of other psychometric instruments, which may be less sensitive to the specific process of PTSD. Rather, the Rorschach demonstrated a finely tuned calibration of the discrete and subtle levels of the syndrome, suggesting its applicability as a sensitive and exquisite measure of PTSD. This finding appears to be a very important one because the procedure is a projective one in which the person generates his or her own percepts onto the stimulus field. Without prompting by a cue contained in an item on an objective measure of PTSD, the individual's pathology is expressed quite readily without conscious awareness. Thus, Levin's work appears to have identified a PTSD profile (Rorschach codes using the Exner system) which is sensitive to all the major DSM-III-R dimensions of the disorder. Clearly, this discovery adds yet another assessment technique to the domain of reliable measures of PTSD and will stimulate many further studies to discern commonalities and differences among objective and projective techniques of personality assessment. In Chapter 17, Mark Creamer and his colleagues present a retrospective study of a multiple shooting which took place in Melbourne, Australia, in December, Nine people were killed and five were wounded by a berserk gunman who wielded a semiautomatic rifle and fired randomly at employees on two floors of an 18-story office building. In addition to the individuals who directly witnessed the shootings on the 5th and 12th floors, many others in the building were aware that a serious crisis was at hand. To study the effects of the shooting on the workers in the building, Creamer and

6 124 PART II ASSESSMENT, METHODOLOGY, AND RESEARCH STRATEGIES his colleagues mailed surveys to all people employed in the building with data collection occurring at 4, 8, and 14 months. The researchers found a contrast (control) group of nontraumatized office workers in a similar-sized office building in downtown Melbourne. The subjects were administered the Impact of Event Scale, the SCL-90-R, and the General Health Questionnaire. Sociodemographic and social support network data were also obtained from the participants. The response rate to the survey groups was relatively high (55%) and consistent across the time intervals sampled. The result produced a rich set of findings concerning psychological symptoms after the shooting. As expected, the traumatized groups had PTSD symptoms and more depression, anxiety, poor concentration, and relationship problems than did the contrast group. The general level of psychological distress experienced by the traumatized group diminished very little between the 4- and 14-months posttrauma followup, a finding that is in accord with Feinstein's prospective study of victims of physical injury reported in Chapter 13. Perhaps among the most important aspect of Creamer's study is the quality of the research design as a retrospective study of trauma. As the authors state: The current study also has implications for future research in the area. In particular, the results highlight the importance of utilizing a longitudinal methodology to adequately chart the course of posttrauma reactions. With the current subject group, there is also a need for longer term follow-up, given the relatively high level of psychological problems reported at 14- months posttrauma.

CONCEPTUAL ISSUES 13

CONCEPTUAL ISSUES 13 1 Conceptual Issues Trauma has become a very popular concept in psychology, psychiatry, and the social sciences, and its popularity is stil! growing rapidly. The starting point of this exceptional development