Background: Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated lifetime prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode. Methods: Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey. Results: The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years. Conclusions: Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas. (Arch Gen Psychiatry. 1995;52:1048-1060)

Posttraumatic stress disorder in the National Comorbidity Survey.

Resilience may be viewed as a measure of stress coping ability and, as such, could be an important target of treatment in anxiety, depression, and stress reactions. We describe a new rating scale to assess resilience. The Connor-Davidson Resilience scale (CD-RISC) comprises of 25 items, each rated on a 5-point scale (0–4), with higher scores reflecting greater resilience. The scale was administered to subjects in the following groups: community sample, primary care outpatients, general psychiatric outpatients, clinical trial of generalized anxiety disorder, and two clinical trials of PTSD. The reliability, validity, and factor analytic structure of the scale were evaluated, and reference scores for study samples were calculated. Sensitivity to treatment effects was examined in subjects from the PTSD clinical trials. The scale demonstrated good psychometric properties and factor analysis yielded five factors. A repeated measures ANOVA showed that an increase in CD-RISC score was associated with greater improvement during treatment. Improvement in CD-RISC score was noted in proportion to overall clinical global improvement, with greatest increase noted in subjects with the highest global improvement and deterioration in CD-RISC score in those with minimal or no global improvement. The CDRISC has sound psychometric properties and distinguishes between those with greater and lesser resilience. The scale demonstrates that resilience is modifiable and can improve with treatment, with greater improvement corresponding to higher levels of global improvement. Depression and Anxiety 18:76–82, 2003. & 2003 Wiley-Liss, Inc.

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Development of a new resilience scale: The Connor‐Davidson Resilience Scale (CD‐RISC)

A primary goal of scale development is to create a valid measure of an underlying construct. We discuss theoretical principles, practical issues, and pragmatic decisions to help developers maximize the construct validity of scales and subscales. First, it is essential to begin with a clear conceptualization of the target construct. Moreover, the content of the initial item pool should be overinclusive and item wording needs careful attention. Next, the item pool should be tested, along with variables that assess closely related constructs, on a heterogeneous sample representing the entire range of the target population. Finally, in selecting scale items, the goal is unidimensionality rather than internal consistency ; this means that virtually all interitem correlations should be moderate in magnitude. Factor analysis can play a crucial role in ensuring the unidimensionality and discriminant validity of scales.

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Constructing validity: Basic issues in objective scale development

Many people are exposed to loss or potentially traumatic events at some point in their lives, and yet they continue to have positive emotional experiences and show only minor and transient disruptions in their ability to function. Unfortunately, because much of psychology’s knowledge about how adults cope with loss or trauma has come from individuals who sought treatment or exhibited great distress, loss and trauma theorists have often viewed this type of resilience as either rare or pathological. The author challenges these assumptions by reviewing evidence that resilience represents a distinct trajectory from the process of recovery, that resilience in the face of loss or potential trauma is more common than is often believed, and that there are multiple and sometimes unexpected pathways to resilience. M ost people are exposed to at least one violent or life-threatening situation during the course of their lives (Ozer, Best, Lipsey, & Weiss, 2003). As people progress through the life cycle, they are also increasingly confronted with the deaths of close friends and relatives. Not everyone copes with these potentially disturbing events in the same way. Some people experience acute distress from which they are unable to recover. Others suffer less intensely and for a much shorter period of time. Some people seem to recover quickly but then begin to experience unexpected health problems or difficulties concentrating or enjoying life the way they used to. However, large numbers of people manage to endure the temporary upheaval of loss or potentially traumatic events remarkably well, with no apparent disruption in their ability to function at work or in close relationships, and seem to move on to new challenges with apparent ease. This article is devoted to the latter group and to the question of resilience in the face of loss or potentially traumatic events. The importance of protective psychological factors in the prevention of illness is now well established (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000). Moreover, developmental psychologists have shown that resilience is common among children growing up in disadvantaged conditions (e.g., Masten, 2001). Unfortunately, because most of the psychological knowledge base regarding the ways adults cope with loss or potential trauma has been derived from individuals who have experienced significant psychological problems or sought treatment, theorists working in this area have often underestimated and misunderstood resilience, viewing it either as a pathological state or as something seen only in rare and exceptionally healthy individuals. In this article, I challenge this view by reviewing evidence that resilience in the face of loss or potential trauma represents a distinct trajectory from that of recovery, that resilience is more common than often believed, and that there are multiple and sometimes unexpected pathways to resilience.

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Loss, Trauma, and Human Resilience Have We Underestimated the Human Capacity to Thrive After Extremely Aversive Events?

Several interviews are available for assessing PTSD. These interviews vary in merit when compared on stringent psychometric and utility standards. Of all the interviews, the Clinician-Administered PTSD Scale (CAPS-1) appears to satisfy these standards most uniformly. The CAPS-1 is a structured interview for assessing core and associated symptoms of PTSD. It assesses the frequency and intensity of each symptom using standard prompt questions and explicit, behaviorally-anchored rating scales. The CAPS-1 yields both continuous and dichotomous scores for current and lifetime PTSD symptoms. Intended for use by experienced clinicians, it also can be administered by appropriately trained paraprofessionals. Data from a large scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD interview.

The development of a Clinician-Administered PTSD Scale.

CONTEXT: Initial treatment of major depressive disorder in adolescents may include cognitive-behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI). However, little is known about their relative or combined effectiveness. OBJECTIVE: To evaluate the effectiveness of 4 treatments among adolescents with major depressive disorder. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial of a volunteer sample of 439 patients between the ages of 12 to 17 years with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnosis of major depressive disorder. The trial was conducted at 13 US academic and community clinics between spring 2000 and summer 2003. INTERVENTIONS: Twelve weeks of (1) fluoxetine alone (10 to 40 mg/d), (2) CBT alone, (3) CBT with fluoxetine (10 to 40 mg/d), or (4) placebo (equivalent to 10 to 40 mg/d). Placebo and fluoxetine alone were administered double-blind; CBT alone and CBT with fluoxetine were administered unblinded. MAIN OUTCOME MEASURES: Children's Depression Rating Scale-Revised total score and, for responder analysis, a (dichotomized) Clinical Global Impressions improvement score. RESULTS: Compared with placebo, the combination of fluoxetine with CBT was statistically significant (P =.001) on the Children's Depression Rating Scale-Revised. Compared with fluoxetine alone (P =.02) and CBT alone (P =.01), treatment of fluoxetine with CBT was superior. Fluoxetine alone is a superior treatment to CBT alone (P =.01). Rates of response for fluoxetine with CBT were 71.0% (95% confidence interval [CI], 62%-80%); fluoxetine alone, 60.6% (95% CI, 51%-70%); CBT alone, 43.2% (95% CI, 34%-52%); and placebo, 34.8% (95% CI, 26%-44%). On the Clinical Global Impressions improvement responder analysis, the 2 fluoxetine-containing conditions were statistically superior to CBT and to placebo. Clinically significant suicidal thinking, which was present in 29% of the sample at baseline, improved significantly in all 4 treatment groups. Fluoxetine with CBT showed the greatest reduction (P =.02). Seven (1.6%) of 439 patients attempted suicide; there were no completed suicides. CONCLUSION: The combination of fluoxetine with CBT offered the most favorable tradeoff between benefit and risk for adolescents with major depressive disorder. Language: en

Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.

Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study.

ContextThe terrorist attacks of September 11, 2001, represent an unprecedented
exposure to trauma in the United States.ObjectivesTo assess psychological symptom levels in the United States following
the events of September 11 and to examine the association between postattack
symptoms and a variety of indices of exposure to the events.DesignWeb-based epidemiological survey of a nationally representative cross-sectional
sample using the Posttraumatic Stress Disorder (PTSD) Checklist and the Brief
Symptom Inventory, administered 1 to 2 months following the attacks.Setting and ParticipantsSample of 2273 adults, including oversamples of the New York, NY, and
Washington, DC, metropolitan areas.Main Outcome MeasuresSelf-reports of the symptoms of PTSD and of clinically significant nonspecific
psychological distress; adult reports of symptoms of distress among children
living in their households.ResultsThe prevalence of probable PTSD was significantly higher in the New
York City metropolitan area (11.2%) than in Washington, DC (2.7%), other major
metropolitan areas (3.6%), and the rest of the country (4.0%). A broader measure
of clinically significant psychological distress suggests that overall distress
levels across the country, however, were within expected ranges for a general
community sample. In multivariate models, sex, age, direct exposure to the
attacks, and the amount of time spent viewing TV coverage of the attacks on
September 11 and the few days afterward were associated with PTSD symptom
levels; sex, the number of hours of television coverage viewed, and an index
of the content of that coverage were associated with the broader distress
measure. More than 60% of adults in New York City households with children
reported that 1 or more children were upset by the attacks.ConclusionsOne to 2 months following the events of September 11, probable PTSD
was associated with direct exposure to the terrorist attacks among adults,
and the prevalence in the New York City metropolitan area was substantially
higher than elsewhere in the country. However, overall distress levels in
the country were within normal ranges. Further research should document the
course of symptoms and recovery among adults following exposure to the events
of September 11 and further specify the types and severity of distress in
children.

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Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11.

The Combat Exposure Scale (CES) was constructed as an attempt to measure the subjective report of wartime stressors experienced by combatants

Clinical evaluation of a measure to assess combat exposure

Interviews were conducted with a nationally representative sample of 1,200 male Vietnam veterans and the spouses or co-resident partners of 376 of these veterans. The veteran interview contained questions to determine the presence of posttraumatic stress disorder (PTSD) and items tapping family and marital adjustment, parenting problems, and violence. The spouse or partner (S/P) interview assessed the S/P's view of these items, as well as her view of her own mental health, drug, and alcohol problems and behavioral problems of school-aged children living at home. Compared with families of male veterans without current PTSD, families of male veterans with current PTSD showed markedly elevated levels of severe and diffuse problems in marital and family adjustment, in parenting skills, and in violent behavior. Clinical implications of these findings are discussed.

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John A. Fairbank

Papers

Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial.

Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study.

Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11.

Clinical evaluation of a measure to assess combat exposure

Problems in families of male Vietnam veterans with posttraumatic stress disorder.