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MEASURES OF ASD
ClinicianeAdministered Measures
59
validated against DSM-IV criteria. The ASDI is reproduced in Appendix
A. It contains 19 dichotomously scored items that relate to the dissociative
(Cluster B, 5 items), reexperiencing (Cluster C, 4 items), avoidance (Clus-
ter D, 4 items), and arousal (Cluster E, 6 items) symptoms of ASD. Sum-
ming the affirmative responses to each symptom provides a total score
indicative of acute stress severity (ranging from 1 to 19). In addition, ques-
tions assessing the stressor (Cluster A), the impairment arising from the
symptoms (Cluster F), the trauma-assessment interval (Cluster G), and the
use of drugs or medication (Cluster H) are included.
Determining the clinical utility of the ASDI was hampered by the
absence of any established tools to measure ASD. Accordingly, we tested
the concurrent validity of the ASDI by comparing it with independent
diagnostic decisions made by clinicians who were experienced in assessing
FTSD and ASD. Sixty-five trauma survivors were administered the ASDI
by one of three clinical psychologists between 2 and 21 days posttrauma.
A clinical interview, based on DSM-IV criteria, was then administered by
a different clinical psychologist, who was unaware of the responses on the
ASDI, between 1 and 5 days later. The sensitivity of the ASDI, defined as
the percentage of participants diagnosed with ASD by the clinical inter-
view who also were diagnosed by the ASDI, was 91%. The rate of false-
positive diagnoses was 7%. Specificiry of the ASDI, defined as the percent-
age of participants not diagnosed with ASD by the clinical interview who
also were not diagnosed by the ASDI, was 93%. The rate of false-negative
diagnoses was 9%. Table 5.1 presents the sensitivity and specificity of each
cluster of ASD symptoms. Although dissociation possessed the weakest
sensitivity (79%), all symptom clusters had strong sensitivity. The arousal
cluster possessed markedly weaker specificity (69%) than did the other
clusters. That is, whereas the ASDI items on dissociation had the lowest
power in identifying those participants who satisfied this cluster in the
clinical interview, the ASDI arousal items had the lowest power in iden-
tifying those participants who did not satisfy this cluster in the clinical
interview. The internal consistency of the 19 items was high ( r = .90).
TABLE 5.1
Sensitivity and Specificity for Acute Stress Disorder
interview (ASDI) Clusters
ASDI cluster Sensitivity Specificity
A: Stressor 100 100
B: Dissociation 79 90
C: Reexperiencing 100 82
D: Avoidance 96 80
E: Arousal 94 69
Note. For sensitivity, values represent the percentage of participants diagnosed with acute stress
disorder (ASD) by the clinical interview and by the ASDI. For specificity, values represent the
percentage of participants not diagnosed with ASD by the clinical interview or by the ASDI.
TABLE 5.2
Test-Retest Agreement for Acute Stress Disorder Interview Clusters
Presence Absence of Cluster severity
ASDI cluster of cluster cluster correlation
A: Stressor 100 100
B: Dissociation 81 94 .85
C: Reexperiencing 87 100 .86
D: Avoidance 80 100 .80
E: Arousal 96 80 .87
Note. Items in Columns 1 and 2 are percentages of agreement. No correlation is given for Cluster
A because the three items are not scored.
ASSESSMENT TOOLS 61
Self-Report Measures
that the optimal formula for scoring the ASDS relative to the ASD di-
agnosis was to consider the dissociative and other clusters separately. By
using a cutoff for the dissociative cluster of I9 combined with a cutoff of
2 28 for the cumulative scores on the reexperiencing, avoidance, and
arousal clusters, we achieved sensitivity of .95, specificity of 3 3 , positive
predictive power (of the ASDS cutoff identifying ASD) of 30, negative
predictive power (of the ASDS cutoff identifying no ASD) of .96, and
efficiency (the percentage correctly identified as meeting or not meeting
ASD criteria) of 3 7 .
In terms of test-retest reliability, we administered the ASDS to 107
survivors of bushfires within 3 weeks of the trauma. All participants were
recontacted between 2 and 7 days after initial completion of the ASDS
and were asked to complete the ASDS a second time. The internal con-
sistency of the ASDS was strong, with alpha coefficients being .96 for the
ASDS total score, .84 for dissociation, .87 for reexperiencing, .92 for avoid-
ance, and .93 for arousal. Adopting the cutoff criteria described above, 30
participants (28%) received a diagnosis of ASD on the initial ASDS ad-
ministration. A t the second administration, 28 (26%) received a diagnosis.
In terms of reliability, 83% of participants who received a diagnosis at the
first administration also received a diagnosis at the second administration.
Furthermore, 100% of participants who did not receive a diagnosis at the
first assessment also did not receive a diagnosis at the second assessment.
The ASDS total scores correlated .94 between the two assessments.
To index the utility of the ASDS in predicting subsequent PTSD, we
reassessed 82 of the 107 bushfire survivors who initially completed the
ASDS. At follow-up, 11 (13%) met criteria for PTSD according to assess-
ASSESSMENT TOOLS 63
ments based on the Clinician Administered PTSD Scale (CAPS; Blake et
al., 1990). We calculated the optimal predictive formula for predicting
PTSD on the basis of ASDS scores. Consistent with evidence that acute
dissociation is not necessary for subsequent development of PTSD (Harvey
& Bryant, 1998d), we found that better predictive ability was obtained by
a total severity score on the ASDS rather than by requiring a minimum
score on the dissociation cluster. Specifically, a cutoff of 2 56 on the ASDS
resulted in 91% of those who later met criteria for PTSD being identified
(sensitivity) and 93% of those who did not develop PTSD being correctly
identified (specificity). The main flaw with this cutoff was that 33% of
individuals who scored above this score did not subsequently develop
PTSD. This result is consistent with evidence that many people who have
high levels of acute stress will remit in the following months. Accordingly,
we caution that the ASDS requires further validation in a variety of trauma
populations. Nonetheless, at the current time, it possesses the strongest
psychometric properties among those self-report instruments that attempt
to screen acute stress reactions that may subsequently develop into PTSD.
MEASURES OF PTSD
CliniciamAdministered Measures
ASSESSMENT TOOLS 65
chometric support. Several studies have indicated that the DIS has less-
than-adequate specificity and sensitivity in making diagnostic decisions
(e.g., Anthony et al., 1985; Keane & Penk, 1988).
Self-Report Measures
ASSESSMENT TOOLS 67
ative symptoms because it provides the clinician with a structured inter-
view to assess both the individual’s subjective experience of dissociation
and the observer’s perceptions of behavior that is indicative of dissociation.
It is a 27-item scale; Items 1 to 23 are subjective items read out by the
interviewer, and Items 24 to 27 are objective items that measure the in-
terviewers’ observations of the client.
Impact of Event Scuk (IES). The IES (Horowitz et al., 1979) has been
used to index intrusive and avoidance symptoms in the acute posttraumatic
phase (Bryant & Harvey, 1995b, 1996a; Dancu et al., 1996; Shalev, 1992).
The IES is a 15-item inventory that comprises intrusion and avoidance
scales, has been shown to correlate with PTSD, and possesses sound psy-
chometric properties (Zilberg, Weiss, & Horowitz, 1982). The IES is prob-
ably the most popular index of the intrusive and avoidance symptoms of
PTSD. Caution is required in using it for diagnostic purposes, however,
because Blanchard and Hickling ( 1997) have demonstrated the inadequacy
of the IES as a diagnostic instrument. To address the omission of arousal
symptoms, Weiss and Marmor (1997) developed the IES-Revised (IES-
R), which added seven items pertaining to hyperarousal. Studies to date
indicate that the IES-R possesses sound internal consistency and test-
retest reliability.
Beck Depression Inventory-2 (BDI-2). The second edition of the BDI
(BDI-2; Beck, Steer, & Brown, 1996) is a 21-item self-report measure of
depressive symptoms. Its items are based on DSM-IV descriptions of de-
pressive disorders, and each item is scored on a 4-point scale. The BDI-2
possesses very strong psychometric properties. Its scoring criteria permit
respondents to be classified as reporting minimal, mild, moderate, or severe
depression.
Spielberger State-Trait Anxiety Inventory (STAI). The STAI (Spielber-
ger, Gorsuch, Lushene, Vagg, &Jacobs, 1983) indexes both state and trait
anxiety. This instrument contains 40 items and measures levels of anxiety
experienced “at the moment” (state) and “generally” (trait). It possesses
good internal consistency and test-retest reliability (Anastasi, 1988).
COPING STYLE
ASSESSMENT TOOLS 69
she or he ascribes to trauma-related cognitive beliefs. This scale indexes
negative cognitions about oneself and the world and self-blame. It possesses
sound psychometric properties, discriminates between people with and
without PTSD, and correlates strongly with PTSD severity. This new mea-
sure is a very promising tool to index the typical cognitions that trauma-
tized clients report and in this sense represents a useful measure for assess-
ing ASD clients.
Personal Beliefs and Reactions Scale (PBRS). The PBRS (Resick, Schni-
cke, & Markway, 1991) is a 60-item scale that requires respondents to
indicate on a 7-point scale the extent to which they hold cognitions about
safety, trust, power, esteem, intimacy, self-blame, undoing, and rape. This
scale has good test-retest reliability and internal consistency; it is used
primarily with rape victims (Resick & Schnicke, 1993).
World Assumption Scale (WAS). The WAS (Janoff-Bulman, 1992) is
a 33-item measure that respondents answer on 6-point scales. The WAS
indexes the extent to which respondents believe cognitions about benev-
olence of the world, self-worth, benevolence of other people, justice, con-
trollability, randomness, self-controllability, and luck. It possesses sound
psychometric properties.
PSYCHOPHYSIOLOGICAL ASSESSMENT
ASSESSMENT TOOLS 71