UCLA PTSD...UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1) Page 1 ©1998 Pynoos, Rodriguez,...

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ترجمة7007 UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 1 ©1998 Pynoos, Rodriguez, Steinberg, Stuber, & Frederick. 1 UCLA PTSD 0024069877900 0024069877990 00249622807700 email: [email protected] , [email protected] www.amthabet.net email: [email protected]

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,

    Steinberg, Stuber, & Frederick. 2

    727

    UCLA PTSD (7-12 years)

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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 3 ©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,

    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

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    52

    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

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    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: _____

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    14

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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 7 ©1998 Pynoos, Rodriguez,

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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,

    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,

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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

    727

    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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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 14 ©1998 Pynoos, Rodriguez,

    Steinberg, Stuber, & Frederick. 14

    9 01234

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    13 01234

    14 01234

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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 15 ©1998 Pynoos, Rodriguez,

    Steinberg, Stuber, & Frederick. 15

    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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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 17 ©1998 Pynoos, Rodriguez,

    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

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    52

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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

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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

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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 INDEX FOR DSM IV (Child Version, Revision 1 ) Page 19 ©1998 Pynoos, Rodriguez,

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    UCLA PTSD-V

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    7D5

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    UCLA PTSD INDEX FOR DSM IV (Child Version, Revision 1 ) Page 20 ©1998 Pynoos, Rodriguez,

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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,

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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: □