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7007 ترجمة
UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 1 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 1
UCLA PTSD
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 2 ©1998 Pynoos, Rodriguez,
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727
UCLA PTSD (7-12 years)
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SCORING WORKSHEET FOR UCLA PTSD INDEX FOR DSM-IV, Revision 1:
CHILD VERSION©
Subject ID#__________ Age_____ Sex (circle): M F # of days since traumatic event
_____
CRITERION A-TRAUMATIC EVENT PTSD SEVERITY: OVERALL SCORE
Exposure to Traumatic Event
Questions 1-13: at least 1 “Yes” answer YES NO
Type of Traumatic Event rated as most
distressing (Question 14: write trauma
type in the blank) _________________
Criterion A1 met
Questions 15-21: at least 1 “Yes” answer YES NO
Criterion A2 met
Questions 22-26: at least 1 “Yes” answer YES NO
Criterion A met YES NO
Peritraumatic Dissociation YES NO
Question 27: answer "Yes"
Question # /Score Question # /Score
1._____ 12._____
2._____ 13._____
3._____ [Omit 14].
4. _____ 15._____
5._____ 16._____
6._____ 17._____
7. _____ 18._____
8. _____ 19._____
9. _____ [Omit 20].
* 10. or
11._____
(Sum the items from the above 2 columns, write sum below)
(Sum total PTSD SEVERITY
of scores) = ______ SCORE
*Place the highest Score from either Question 10 or 11 in the
blank above: Score Question 10.____/Score Question 11.____
CRITERION B (REEXPERIENCING) SX. CRITERION C (AVOIDANCE) SX.
Question #/DSM-IV Symptom Score
3. (B1) Intrusive recollections _____
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 4 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 4
5. (B2) Trauma/bad dreams _____
6. (B3) Flashbacks _____ # of Criterion B
2. (B4) Cues: Psychological Questions with
reactivity _____ Score > Symptom
18. (B5) Cues: Physiological Cutoff: _____
reactivity _____
CRITERION B SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION B MET:
(Diagnosis requires at least 1 “B” Symptom): YES NO
Question #/DSM-IV Symptom Score
9. (C1) Avoiding thoughts/feelings _____
17. (C2) Avoiding activities/people _____
15. (C3) Forgetting _____ # of Criterion C
7. (C4) Diminished interest etc. _____ Questions with
8. (C5) Detachment/estrangement _____ Scores > Symptom
*10. or 11. (C6) Affect restricted _____ Cutoff: _____
19. (C7) Foreshort. future _____
[*Place the highest Score from either Question 10 or 11 in the
blank above.]
CRITERION C SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION C MET:
(Diagnosis requires at least 3 “C” Symptoms): YES NO
CRITERION D (INCREASED AROUSAL) SX. DSM-IV PTSD DIAGNOSTIC
INFO.
Question #/DSM-IV Symptom Score
13. (D1) Sleep problems _____
4. (D2) Irritability/anger _____
16. (D3) Concentration problems _____ # of Criterion D
1. (D4) Hypervigilance _____ Questions with
12. (D5) Exaggerated startle _____ Score > Symptom
Cutoff: _____
[+Place the highest Score from either Question 4 or 20 in the
blank above.]
CRITERION D SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION D MET:
(Diagnosis requires at least 2 “D” Symptoms): YES NO
DSM-IV FULL PTSD DIAGNOSIS LIKELY
(Criteria A, B, C, D all met) YES NO
PARTIAL PTSD LIKELY
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 5 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 5
[Criterion A met and:
Criteria (B + C) or (B + D) or (C + D)] YES NO
©1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D., Alan Steinberg, Ph.D., Margaret
Stuber, M.D., Calvin Frederick, M.D. All Rights Reserved
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 6 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 6
b) Question #/DSM-IV Symptom Score
3. (B1) Intrusive recollections _____
5. (B2) Trauma/bad dreams _____
6. (B3) Flashbacks _____ # of Criterion B
2. (B4) Cues: Psychological Questions with
reactivity _____ Score > Symptom
18. (B5) Cues: Physiological Cutoff: _____
reactivity _____
CRITERION B SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION B MET:
(Diagnosis requires at least 1 “B” Symptom): YES NO
31
52
63
24
185
c) Question #/DSM-IV Symptom Score
9. (C1) Avoiding thoughts/feelings _____
17. (C2) Avoiding activities/people _____
15. (C3) Forgetting _____ # of Criterion C
7. (C4) Diminished interest etc. _____ Questions with
8. (C5) Detachment/estrangement _____ Scores >
Symptom
*10. or 11. (C6) Affect restricted _____ Cutoff: _____
=19. or 21. (C7) Foreshort. future _____
[*Place the highest Score from either Question 10 or 11 in
the blank above; = Place the highest Score from either
Question 19 or 21 in the blank above.]
CRITERION C SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION C MET:
(Diagnosis requires at least 3 “C” Symptoms): YES NO
91
172
153
74
85
11116
19217
1111
1921
3
d) Question #/DSM-IV Symptom Score
13. (D1) Sleep problems _____
+4. or 20. (D2) Irritability/anger _____
16. (D3) Concentration problems _____ # of Criterion D
1. (D4) Hypervigilance _____ Questions with
12. (D5) Exaggerated startle _____ Score > Symptom
Cutoff: _____
131
4212
163
14
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Steinberg, Stuber, & Frederick. 7
[+Place the highest Score from either Question 4 or 20 in
the blank above.]
CRITERION D SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION D MET:
(Diagnosis requires at least 2 “D” Symptoms): YES NO
125
421
DSM-IV FULL PTSD DIAGNOSIS LIKELY (Criteria A, B, C, D all met) YES NO PARTIAL PTSD LIKELY (Criterion A met and: Criteria B + C or B + D or C + D) YES NO
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 8 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 8
UCLA PTSD for adolescents (13 and above)
21
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 9 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 9
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SCORING WORKSHEET FOR UCLA PTSD INDEX FOR DSM-IV, Revision
1: ADOLESCENT VERSION©
Subject ID#__________ Age_____ Sex (circle): M F # of days since traumatic
event _____
CRITERION A-TRAUMATIC EVENT PTSD SEVERITY: OVERALL
SCORE
Exposure to Traumatic Event
Questions 1-13: at least 1 “Yes” answer YES NO
Type of Traumatic Event rated as most
distressing (Question 14: write trauma
type in the blank) _________________
Criterion A1 met
Questions 15-21: at least 1 “Yes” answer YES NO
Criterion A2 met
Questions 22-26: at least 1 “Yes” answer YES NO
Criterion A met YES NO
Peritraumatic Dissociation YES NO
Question 27: answer "Yes"
Question # /Score Question # /Score
1. _____ 12._____
2. _____ 13._____
3. _____ [Omit 14].
+4. or 15._____
20. _____ 16._____
5. _____ 17._____
6. _____ 18._____
7. _____ =19. or
8. _____ 21._____
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 10 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 10
9. _____ [Omit 22].
* 10. or (Sum total PTSD SEVERITY
11._____ of scores) = ______ SCORE
+Place the highest Score from either Question 4 or 20 in the
blank above: Score Question 4.____/Score Question 20.____
*Place the highest Score from either Question 10 or 11 in the
blank above: Score Question 10.____/Score Question 11.____
= Place the highest Score from either Question 19 or 21 in the
blank above: Score Question 19.____/Score Question 21.____
CRITERION B (REEXPERIENCING) SX. CRITERION C (AVOIDANCE)
SX.
Question #/DSM-IV Symptom Score
1. (B1) Intrusive recollections _____
5. (B2) Trauma/bad dreams _____
6. (B3) Flashbacks _____ # of Criterion B
7. (B4) Cues: Psychological Questions with
reactivity _____ Score > Symptom
28. (B5) Cues: Physiological Cutoff: _____
reactivity _____
CRITERION B SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION B MET:
(Diagnosis requires at least 1 “B” Symptom): YES NO
Question #/DSM-IV Symptom Score
9. (C1) Avoiding thoughts/feelings _____
27. (C2) Avoiding activities/people _____
25. (C3) Forgetting _____ # of Criterion C
7. (C4) Diminished interest etc. _____ Questions with
8. (C5) Detachment/estrangement _____ Scores > Symptom
*10. or 11. (C6) Affect restricted _____ Cutoff: _____
=19. or 21. (C7) Foreshort. future _____
[*Place the highest Score from either Question 10 or 11 in the
blank above; = Place the highest Score from either Question 19
or 21 in the blank above.]
CRITERION C SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION C MET:
(Diagnosis requires at least 3 “C” Symptoms): YES NO
CRITERION D (INCREASED AROUSAL) SX. DSM-IV PTSD DIAGNOSTIC
INFO.
Question #/DSM-IV Symptom Score
21. (D1) Sleep problems _____
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 11 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 11
+4. or 20. (D2) Irritability/anger _____
26. (D3) Concentration problems _____ # of Criterion D
2. (D4) Hypervigilance _____ Questions with
27. (D5) Exaggerated startle _____ Score > Symptom
Cutoff: _____
[+Place the highest Score from either Question 4 or 20 in the
blank above.]
CRITERION D SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION D MET:
(Diagnosis requires at least 2 “D” Symptoms): YES NO
DSM-IV FULL PTSD DIAGNOSIS LIKELY
(Criteria A, B, C, D all met) YES NO
PARTIAL PTSD LIKELY
(Criterion A met and:
Criteria B + C or B + D or C + D) YES NO
2998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D., Alan Steinberg, Ph.D.,
Margaret Stuber, M.D., Calvin Frederick, M.D. All Rights Reserved.
7007 ترجمة
UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 12 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 12
727
UCLA PTSD (7-12 years-mothers form)
101234
201234
301234
401234
501234
601234
701234
801234
901234
1001234
1101234
1201234
1301234
1401234
1501234
1601234
1701234
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 13 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 13
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3-6 UCLA PTSD INDEX FOR DSM IV
(3-6 years-mothers form)
1
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2
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4
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5
01234
6 01234
7 01234
8 01234
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 14 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 14
9 01234
10 01234
11 01234
12 01234
13 01234
14 01234
15
01234
16 01234
17 01234
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 15 ©1998 Pynoos, Rodriguez,
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SCORING WORKSHEET FOR UCLA PTSD INDEX FOR DSM-IV, Revision 1:
PARENT VERSION©
Subject ID#__________ Age_____ Sex (circle): M F # of days since traumatic event
_____
CRITERION A-TRAUMATIC EVENT PTSD SEVERITY: OVERALL SCORE
Exposure to Traumatic Event
Questions 1-13: at least 1 “Yes” answer YES NO
Type of Traumatic Event rated as most
distressing (Question 14: write trauma
type in the blank) _________________
Criterion A1 met
Questions 15-26: at least 1 “Yes” answer YES NO
Criterion A2 met
Questions 22-26: at least 1 “Yes” answer YES NO
Criterion A met YES NO
Question # /Score Question # /Score
1. _____ =10 or
2. _____ 11._____
* 3 or 12._____
21. _____ 13._____
4. _____ [Omit 14].
5. _____ 15._____
6. _____ 16._____
7. _____ 17._____
8. _____ 18._____
9. _____ 19._____ [Omit 20].
(Sum the items from the above 2 columns, write sum below)
(Sum total PTSD SEVERITY
of scores) = ______ SCORE
*Place the highest Score from either Question 3 or 21 in the
blank above: Score Question 3. ____/Score Question 21._____
=Place the highest Score from either Question 10 or 11 in the
blank above: Score Question 10.____/Score Question 11.____
CRITERION B (REEXPERIENCING) SX. CRITERION C (AVOIDANCE) SX.
Question #/DSM-IV Symptom Score
3. (B1) Intrusive recollections
or ____*
21. (B2)Repetitive Traumatic Play
5. (B2) Trauma/bad dreams _____
6. (B3) Flashbacks _____ # of Criterion B
2. (B4) Cues: Psychological Questions with
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 16 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 16
reactivity _____ Score > Symptom
18. (B5) Cues: Physiological Cutoff: _____
reactivity _____
*Place the highest Score from either Question 3 or 21 in the
blank above: Score Question 3 (Intrusive recollections) _____
Score Question 21(Repetitive play) _____
CRITERION B SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION B MET:
(Diagnosis requires at least 1 “B” Symptom): YES NO
Question #/DSM-IV Symptom Score
9. (C1) Avoiding thoughts/feelings_____
17. (C2) Avoiding activities/people_____
15. (C3) Forgetting _____ # of Criterion C
7. (C4) Diminished interest etc. _____ Questions with
8. (C5) Detachment/estrangement _____ Scores > Symptom
=10. or 11. (C6) Affect restricted _____ Cutoff: _____
19. (C7) Foreshortened future _____
CRITERION C SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION C MET:
(Diagnosis requires at least 3 “C” Symptoms): YES NO
=Place the highest Score from either Question 10 or 11 in the
blank above: Score Question 10.____/Score Question 11.____
CRITERION D (INCREASED AROUSAL) SX. DSM-IV PTSD DIAGNOSTIC
INFO.
Question #/DSM-IV Symptom Score
13. (D1) Sleep problems _____
4. (D2) Irritability/anger _____
16. (D3) Concentration problems_____ # of Criterion D
1. (D4) Hypervigilance _____ Questions with
12. (D5) Exaggerated startle _____ Score > Symptom
Cutoff: _____
CRITERION D SEVERITY
SCORE (Sum of above scores): = _____
DSM-IV CRITERION D MET:
(Diagnosis requires at least 2 “D” Symptoms): YES NO
DSM-IV FULL PTSD DIAGNOSIS LIKELY
(Criteria A, B, C, D all met) YES NO
PARTIAL PTSD LIKELY
(Criterion A met and:
Criteria B + C or B + D or C + D) YES NO
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Steinberg, Stuber, & Frederick. 17
©1998 Robert Pynoos, M.D., Ned Rodriguez, Ph.D., Alan Steinberg, Ph.D., Margaret
Stuber, M.D., Calvin Frederick, M.D. All Rights Reserved.
b) Question #/DSM-IV Symptom Score
3. (B1) Intrusive recollections _____
5. (B2) Trauma/bad dreams _____
6. (B3) Flashbacks _____ # of Criterion B
2. (B4) Cues: Psychological Questions with
reactivity _____ Score > Symptom
18. (B5) Cues: Physiological Cutoff: _____
reactivity _____
CRITERION B SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION B MET:
(Diagnosis requires at least 1 “B” Symptom): YES NO
31
52
63
24
185
c) Question #/DSM-IV Symptom Score
9. (C1) Avoiding thoughts/feelings _____
17. (C2) Avoiding activities/people _____
15. (C3) Forgetting _____ # of Criterion C
7. (C4) Diminished interest etc. _____ Questions with
8. (C5) Detachment/estrangement _____ Scores >
Symptom
*10. or 11. (C6) Affect restricted _____ Cutoff: _____
=19. or 21. (C7) Foreshort. future _____
[*Place the highest Score from either Question 10 or 11 in
the blank above; = Place the highest Score from either
Question 19 or 21 in the blank above.]
CRITERION C SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION C MET:
(Diagnosis requires at least 3 “C” Symptoms): YES NO
91
172
153
74
85
11116
19217
1111
1921
3
d) Question #/DSM-IV Symptom Score
13. (D1) Sleep problems _____
+4. or 20. (D2) Irritability/anger _____
16. (D3) Concentration problems _____ # of Criterion D
131
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 18 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 18
1. (D4) Hypervigilance _____ Questions with
12. (D5) Exaggerated startle _____ Score > Symptom
Cutoff: _____
[+Place the highest Score from either Question 4 or 20 in
the blank above.]
CRITERION D SEVERITY SCORE (Sum of above scores): = _____
DSM-IV CRITERION D MET:
(Diagnosis requires at least 2 “D” Symptoms): YES NO
163
14
125
421
DSM-IV FULL PTSD DIAGNOSIS LIKELY (Criteria A, B, C, D all met) YES NO PARTIAL PTSD LIKELY (Criterion A met and: Criteria B + C or B + D or C + D) YES NO
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 19 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 19
UCLA PTSD-V
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12D7 . 01234
13C1 . 01234 14B5
.
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17D6 . 01234 01234
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18B1
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20E2 . 01234
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23D1 . 01234 24E4
.
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 21 ©1998 Pynoos, Rodriguez,
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Item # DSM-5 Symptom
Score 5
(0-4)
18 B1 18
10 B2 10
5 B3 5
11 B4 11
14 B5 14
SYMPTOM CATEGORY
B SUMMATIVE SCORE:
______ 2
13 C1 13
3 C2 3
SYMPTOM CATEGORY
C SUMMATIVE SCORE:
______
Item # DSM-5 Symptom
Score
(0-4) 7
23 D1 23
2* D2 2916
9* D2 ____
16* D2 1519
15* D3
19* D3 ____
6* D4 622,25
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 22 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 22
22* D4 ____
25* D4
27* D4
7 D5 7
17 D6 17
12 D7 12 SYMPTOM CATEGORY D SUMMATIVE SCORE:
______
Item # DSM-5 Symptom 6
Score (0-4)
4 4
20* E2 2126
26* E2 ____
1 E3 1
24 E4 24
8 E5 8
21 E6 21 SYMPTOM CATEGORY E SUMMATIVE SCORE
______
Dissociative Symptoms
28. A1 ____ 2829
29. A1 ____ (Indicate highest score for A1) ___
30. A2 ____ 3131
31. A2 ____
(Indicate highest score for A2) __
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 23 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 23
DSM-5 PTSD DIAGNOSIS
B: One or more Category B symptoms present:
C: One or more Category C symptoms present:
D: Two or more Category D symptoms present:
E: Two or more Category E symptoms present:
F: Symptom duration greater than one month:
G: Symptoms cause clinically significant distress or impairment:
Specify Dissociative Subtype:
One or more dissociative symptoms present: □