UCLA PTSD...UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1) Page 1 ©1998 Pynoos, Rodriguez,...
Transcript of UCLA PTSD...UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1) Page 1 ©1998 Pynoos, Rodriguez,...
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 1 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 1
UCLA PTSD
0024069877900002406987799000249622807700
email: [email protected] , [email protected]
email: [email protected]
mailto:[email protected]:[email protected]:[email protected]://www.amthabet/
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 2 ©1998 Pynoos, Rodriguez,
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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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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,
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[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,
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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
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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
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1921
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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: _____
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[+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
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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)
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 9 ©1998 Pynoos, Rodriguez,
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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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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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+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.
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UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 12 ©1998 Pynoos, Rodriguez,
Steinberg, Stuber, & Frederick. 12
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UCLA PTSD (7-12 years-mothers form)
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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)
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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,
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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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©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
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63
24
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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
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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
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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-V
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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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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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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: □