How Do I Perform a Trauma Patient Assessment?

Traumatic events refer to serious events that threaten the integrity of the individual's life, body or mental world, including war, violent crime, sexual assault, serious traffic accidents, natural disasters and long prison sentences. Epidemiological evidence suggests that approximately 5-12% of people may develop posttraumatic stress disorder (PTSD) after a traumatic event. ^[1] PTSD is a common type of mental disorder characterized by the three main symptoms of re-experience, high arousal, and avoidance response. PTSD usually appears three months after the trauma event, but it may also delay the onset from months to years after the event. How to accurately assess the population who experienced the trauma event can help the early identification and treatment of PTSD. Beneficial to the patient's prognosis and recovery of social function. At present, the international assessment tools for PTSD are mainly divided into two categories, namely screening scales and diagnostic scales. The two types of scales are now described in detail ^[2] .

The PTSD screening questionnaire mainly includes four, namely:

1. Trauma Screening Questionnaire (TSQ)

The TSQ is based on the PTSD Symptom Scale-Self-Report Version. It includes 10 questions that require participants to have more than two symptoms in the past week after a traumatic event. For self-evaluation, the project adopts a two-point scoring method of "yes, no". The demarcation score is at least 6 re-experiences or highly arousal symptoms. Studies have found that TSQ has a sensitivity of 0.85, a specificity of 0.89, a negative predictive value of 0.98, and a positive predictive value of 0.48. ^[3]

There are many types of PTSD diagnosis questionnaires, which mainly include structured interviews and self-assessment scales. Among them, structured interviews are regarded as the gold standard for diagnosis of PTSD, mainly including DSM-III-R Structured Clinical Interview for DSM-III-R, Structured Interview PTSD measure (SIP), and PTSD clinical Scale (ClinicianAdministered PTSD Scale, CAPS). However, due to the long time required for structured interviews and high requirements for the main test operation, many self-assessment scales have shown great potential advantages and clinical application values. These self-assessment scales mainly include the Impact of Events IES), the Mississippi Scales for Combat and Non-combat, the Short Form of the MississippiScale, the Penn Inventory, the PTSD list (the PTSD Checklist (PCL), the Post-traumatic Stress Diagnostic Scale (PDS), and the Davidson Trauma Scale (DTS). The main scales are described below.

( ) Traumatic stress assessment form (a) self-assessment scale

1. Davidson Trauma Scale (DTS)

The DTS is a self-assessment scale that includes 17 questions that score the frequency and severity of each symptom, covering the three symptom groups of PTSD. Questions 1-4 and 17 reflect the symptoms of PTSD Standard B (Re-Experience), Questions 5-11 reflect the symptoms of Standard C (Avoidance and Numbness), and Questions 12-16 reflect Standard D (Highly Awakened). ). Each item is graded 5 (0-4) with a total score of 136 points. The diagnostic criteria were that a subject had at least one flashback symptom, three avoidance / numbness symptoms, and two arousal symptoms more than two times in the past week to be diagnosed as PTSD. The scale has good reliability and validity, retest reliability of 0.86, internal consistency reliability of 0.99, demarcation score of 40 points, positive predictive value of 0.92, negative predictive value of 0.79, and diagnostic efficiency of 0.83. The Chinese version of the DTS (DTS-C) has an internal consistency coefficient of 0.97, a split-half reliability of 0.96, and a diagnostic accuracy of 85% when the demarcation score is 44 ^[6] .

2. PTSD Checklist (PTSD Checklist, PCL)

PCL is a self-assessment scale, which mainly evaluates the PTSD standards B, C, and D. There are 17 questions, each of which is a 5-point scale (1 point represents "never", 5 points is "almost always"), and the total score is The range is 17-85 points. There are three versions of PCL, namely the military version (PCL-M, military version), which is mainly used for stress military experience; the non-military version (PCL-S, specific), which can be used for any special traumatic event; civilian version (PCL-C, civilian) for routine non-military stress events. The scoring criteria are the same for all three versions. Studies have confirmed that PCL has good reliability and validity, including retest reliability of 0.96, internal consistency reliability of 0.94, prediction validity of 0.64, and a recommended demarcation score of 50 points. Some studies have found that using 50 points as the demarcation score, the sensitivity is 0.778, the specificity is 0.864, and the diagnostic efficiency is 0.825. However, if 44 points are used as the demarcation score, the diagnostic efficiency is 0.900, the sensitivity is 0.944, the specificity is 0.864, and PCL-C and The correlation of CAPS was 0.929, and the diagnostic efficiency was 0.900 ^[7] . Xiaoyun Yang's research on PCL-C among Chinese medical students found that the retesting reliability was 0.708, the Cronbach coefficient was 0.823, and the semi-uniformity coefficient was 0.649. The correlation with SCL-90 and EPQ was also high. Has good reliability and validity.

3. Post-traumatic Diagnostic Scale (PDS)

The PDS is a self-assessment scale that includes 49 questions, and diagnostic criteria A to F for evaluating PTSD. The total score ranges from 0 to 51 points. The study found that the internal consistency coefficients of the PDS total scale and subscale were 0.93 and 0.82-0.91, specificity 0.93, sensitivity 0.57, diagnostic consistency of PDS and SCID was 83%, and a demarcation score of 8 was recommended. ^[8] .

4. Impact of Events Scale-Revised (IES-R)

IES-R is a self-assessment scale that evaluates an individual's suffering from the stress of a particular life event. IES-R includes 22 questions, 6 questions evaluating highly arousal symptoms, 8 questions evaluating intrusive thinking symptoms, 8 questions evaluating avoidance symptoms, each question is graded on a scale of 0-4, 0 points means "never ", 4 points for" extreme ". The total test time is about 5-10 minutes. The test results include the scores and total scores of the three subtests of the intrusive subscale, the avoidance subscale, and the height arousal subscale. The internal consistency coefficients of the three subscales are 0.87- 0.92, 0.84-0.86, and 0.79-0.90, and the retest reliability is 0.57, 0.51, and 0.59, respectively ^[9] . The Chinese version of Impact of Event Scale-Revised (CIES-R) has 22 entries, which are divided into three factors: increased alertness, avoidance, and intrusive recall. There are also good Reliability and validity.

5. Harvard Trauma Questionnaire (HTQ)

HTQ is a self-rating scale. It includes five parts: the first part, the scale lists a series of traumatic events, and the participants answer "yes" or "no" based on their actual experience; the second part includes two open-ended questions, which require the subjects to describe the trauma Sexual events; part three, assessing the risk of traumatic events that may cause neurological syndrome; part four, including 40 questions, assessing the psychological impact, each of which is a 4-level Likert score, 1 for "never", 4 Represents "almost always", the first 16 questions assess the diagnostic symptoms of PTSD, also known as Part 4-PTSD, and the last 24 questions assess the impact of traumatic events on the social function of the subject, called Part 4-Functioning; Out of 29 tortures. Some studies have found that the internal consistency reliability of HTQ is 0.90 in the first part, 0.96 in the fourth part, and the first part of the question-scale correlation is 0.56, and the fourth part is 0.65. The HTQ manual recommends a demarcation score of 2.5. Studies have confirmed that when the demarcation score is set to 2.5, the sensitivity of HTQ is 0.78 and the specificity is 0.65. In the diagnosis of PTSD, the fourth part of HTQ is mainly used. HTQ has been translated into many languages and is widely used in different languages and cultures. A large number of studies have found that the internal consistency reliability of HTQ is between 0.86 and 0.94, and it has high predictability ^[10] . The study found that the French version of HTQ Part IV had an internal consistency coefficient of 0.95, an accuracy of 0.83, a sensitivity of 0.87, and a specificity of 0.73 for PTSD.

6. Other self-assessment scales

The Mississippi Scale for Combat-Related PTSD (M-PTSD) includes 35 questions, and each item uses a 5-point scale (1 point means "not at all", 5 points means "extremely serious"), the full scale Scores range from 35 to 175. There is currently no uniform demarcation score. The study found that the scale had a sensitivity of 0.93, a specificity of 0.89, and a hit rate of 0.90. The Penn Inventory questionnaire includes 26 questions, each of which is graded on a scale of 0-3. Penn Inventory does not evaluate all 17 symptoms of PTSD in DSM-IV. It also includes those unrelated to DSM diagnostic criteria. Questions, the total scale of the scale is 0-78 points.

( ) Traumatic Stress Assessment Form (2) Structured Interview Form

1. PTSD Structured Interview for PTSD (SI-PTSD)

SI-PTSD is a structured table, including 13 questions, each of which uses a 5-point scale (0 points for "no" and 4 points for "extremely serious"). The interview form has good reliability and validity, and a retest reliability of 0.71. The internal consistency coefficient was 0.94, the scorer coefficient was 0.97-0.99, the sensitivity was 0.96, the specificity was 0.80, and the Kappa coefficient was 0.79 ^[11] .

2. Short PTSD Rating Interview (SPRINT)

The SPRINT interview form includes 8 items, of which 4 questions correspond to the four core symptoms of PTSD, namely intrusive recall, avoidance, numbness and high arousal; the other 4 questions involve physical discomfort, susceptibility to stress and impaired social functioning . Each question is graded on a 5-point scale, with 0 being "almost", 4 being "extreme", and a maximum score of 32. The entire interview process takes about 5-10 minutes. The study found that the retest reliability of SPRINT was 0.78, the internal consistency coefficient was 0.77, and the correlation with DTS was 0.73. The diagnostic accuracy was 96% when the score was 14-17 ^[12] .

( ) Traumatic Stress Assessment Form (III) Semi-structured Interview Form

1. Post Traumatic Stress Disorder Interview Form (Post- traumaticStress Disorder Interview, PTSD-I)

PTSD-I is a semi-structured interview form. Patients were asked to assign a 7-point score to the 17 symptoms of PTSD, with 1 being "never" and 7 being "severe / always". There are also two follow-up questions, one is whether the symptoms still exist at least one month after the traumatic event, and the other is whether the symptoms still exist. Among them, 4 questions evaluated traumatic reexperience, 7 questions evaluated evasion symptoms related to traumatic stimulation, and 6 questions evaluated symptoms of excessive arousal. The entire interview takes 20-30 minutes to complete. The internal consistency coefficient of PTSD-I is 0.92, the retest reliability is 0.95, and the DIS is used as the standard. The sensitivity of PTSD-I is 0.89, the specificity is 0.94, and the Kappa value is 0.82 ^[13] .

2. Clinical PTSD Scale (Clinician-AdministeredPTSD Scale, CAPS)

CAPS is a comprehensive diagnostic tool based on DSM-IV. It belongs to a semi-structured interview form, which includes 30 items, involving 17 core symptoms and 8 related symptoms. It is divided into repeated experience, avoidance and increased alertness. Table, in which repeated experience symptoms are independent groups, while avoidance and increased alertness belong to the same group. CAPS mainly evaluates the symptoms of patients in the past week, and scores from two aspects: frequency and severity. The score ranges from 0 to 136 points. It is divided into 5 levels according to different scores: 0-19 is sub-clinical status, 20-39 is mild, 40-59 is moderate, 60-79 is severe, and 80 or more is extremely severe. The demarcation score of CAPS is 65, and a diagnosis higher than 65 can be diagnosed as PTSD. The study found that CAPS has a sensitivity of 0.84, a specificity of 0.95, and an internal consistency coefficient of 0.78. The scores of the CAPS three subscales are between 0.77 and 0.96, the internal consistency coefficient is between 0.8 and 0.9, and the convergent validity is between 0.8 and 0.9. The entire CAPS test was completed in 33 ± 16 minutes [14]. CAPS is currently recognized as one of the gold standards for PTSD diagnosis and has become the most widely used standardized diagnostic measurement tool in the trauma field. CAPS also has a children and adolescent version of CAPS-CA (child and adolescents).

3. PTSD Symptom Scale-Interview Version (PTSD SymptomScale-Interview, PSS-I)

PSS-I is a semi-structured interview form that includes 17 questions corresponding to the 17 symptoms of PTSD. Unlike CAPS, which assesses both the frequency and severity of symptoms, PSS-I combines the severity and frequency of symptoms. Each question is a short question. The interviewer assigns a 4-point scale based on the respondent's answer. A score of 0 indicates "never" and a score of 3 indicates "5 or more times per week / very serious", which is higher than A score of 1 (ie, "once a week or less / a little bit") is considered to have PTSD symptoms, and the PSS-I score ranges from 0 to 51 points. The internal consistency coefficient is 0.65 to 0.71, the retest reliability is 0.66 to 0.77, and the scorer reliability is 0.93 to 0.95. PSS-I took an average of 22 ± 11 minutes ^[14] .

4. PTSD Diagnostic Interview Form-PTSD Module (Diagnostic Interview Schedule PTSD module, DIS PTSD module)

DIS is a composite mental interview form developed in collaboration with the University of Washington and the National Institute of Mental Health (NIMH). Includes a series of questions to assess mental disorders. This includes the PTSD module, referred to as the DIS PTSD module. Participants answered "yes, no" based on the questions. The study found that the sensitivity of the DIS was 0.87, the specificity was 0.73, and the clinical diagnosis efficiency was 0.64.

Most of the PTSD sufferers are survivors (victims), witnesses and rescuers who are directly or exposed to traumatic events. At present, their clinical research mainly focuses on drug intervention ^[15] , and they are accurately and quickly evaluated. It is helpful for the timely diagnosis and early intervention of PTSD, which is beneficial to the prognosis of the disease and has important clinical significance. There are many internationally available PTSD screening and diagnostic scales, which mainly include self-assessment scales, semi-structured, and structured interview forms. A large number of studies in recent years have confirmed that most of the scales have good information, Validity, accuracy of screening and diagnosis are also ideal, and the actual use effect is better. Among them, most of the PTSD screening scales are relatively short and easy to operate, such as TSQ, PC-PTSD, etc., which are convenient for rapid and large-scale testing in specific populations. Among them, TSQ and SPAN are currently widely used, and SPAN is already available. The revised Chinese version has good reliability and validity and can be used after traumatic events. Relatively speaking, there are many types of PTSD diagnostic scale and the operation is more complicated, but due to its high accuracy, it is currently used in clinical diagnosis. According to the different testing methods, the PTSD diagnostic scale includes three types: self-assessment, semi-structured interview form, and structured interview form. Among the self-assessment scales, the DTS and PCL are currently the most effective and widely used internationally. Both are 17 questions and the testing time is short; CAPS and PTSD-I are widely used in the semi-structured interview form, and the structured interview is widely recognized as the gold standard for PTSD diagnosis, mainly including SI-PTSD and SPRINT, with strict operating procedures. Standards are more complex to implement and inspectors need to be professionally trained. However, the shortcoming is that most of these scales lack Chinese translations or revised versions. At present, the most widely used domestic version is the translated and revised CAPS Chinese version of the Second Xiangya Hospital of Central South University. Due to the lack of existing mature Chinese scales, the effectiveness of the PTSD screening and diagnosis questionnaires in the domestic clinical evaluation and popularization have been seriously affected, and it is unknown whether most of the scales have cultural differences. Therefore, the next step These excellent scales should be translated and revised as much as possible, analyze possible cultural differences, and conduct clinical practical tests to promote the in-depth development of early screening and diagnosis of PTSD in China ^[2] .