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Predicting Postraumatic Stress Disorder in Single-Incident Trauma Survivors with an Acute Injury" (2015)

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Predicting Postraumatic Stress Disorder in Single-Incident Trauma Survivors with an Acute Injury University of Wisconsin Milwaukee UWM Digital Commons Theses and Dissertations May 2015 Predicting Postraumatic Stress Disorder in Single- Incident Trauma Survivors with an Acute Injury Joshua C. Hunt University of Wisconsin-Milwaukee Follow this and additional works at: https://dc.uwm.edu/etd Part of the Clinical Psychology Commons, and the Medicine and Health Sciences Commons Recommended Citation Hunt, Joshua C., "Predicting Postraumatic Stress Disorder in Single-Incident Trauma Survivors with an Acute Injury" (2015). Theses and Dissertations. 881. https://dc.uwm.edu/etd/881 This Dissertation is brought to you for free and open access by UWM Digital Commons. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of UWM Digital Commons. For more information, please contact [email protected]. PREDICTING POSTRAUMATIC STRESS DISORDER IN SINGLE-INCIDENT TRAUMA SURVIVORS WITH AN ACUTE INJURY by Joshua C. Hunt, M.A. A Dissertation Submitted in Partial Fulfillment of the Requirements of the Degree of Doctor of Philosophy in Educational Psychology at The University of Wisconsin-Milwaukee May 2015 ABSTRACT PREDICTING POSTRAUMATIC STRESS DISORDER IN SINGLE-INCIDENT TRAUMA SURVIVORS WITH AN ACUTE INJURY by Joshua C. Hunt, M.A. The University of Wisconsin-Milwaukee, 2015 Under the Supervision of Professor Marty Sapp, Ed.D. The objective of this study was to create a brief and easily administered screen that can be used by hospital staff to identify those at risk for the later development of PTSD. Utilizing previous research examining pretrauma, peritrauma, and posttrauma risk factors for the development of PTSD among single-incident trauma survivors with an acute injury, an item pool was created and reviewed by experts in the field. This item pool along with a previously created screen were given to patients admitted to two level 1 trauma centers in the U.S. A follow-up was conducted at one month in which participants were administered two psychometrically valid PTSD diagnostic tools. A stepwise bivariate logistic regression was used to determine the items from the item pool that were most strongly associated with PTSD diagnosis at approximately one month post injury. The logistic regression yielded a five item model which outperformed a previously created screen. ROC curve analysis was used to determine sensitivity (100%), specificity (81.33%), negative predictive value (100%), positive predictive value (66.7%), and to yield an optimal cutoff score (≥ 1). The clinical implications of this tool along with a rationale for item retention is provided. ii © Copyright by Joshua C. Hunt, 2015 All Rights Reserved iii TABLE OF CONTENTS Page CHAPTER ONE: INTRODUCTION……………………………………………………………..1 Definition of terms………………………………………………………………………………...2 Statement of the problem………………………………………………………………………….4 Rationale…………………………………………………………………………………………..5 Risk factors, comorbidity and early intervention………………………………………………….6 Purpose of the study…………………………………………………..…………………………...9 CHAPTER TWO: LITERATURE REVIEW………………………………...………………….11 PTSD: History and Definition…………………………………………………………………...11 Cultural Specificity in the DSM…………………………………………………………………17 Early Intervention………………………………………………………………………………..19 Evidence Based Assessment……………………………………………………………………..21 Evidence Based Measures for PTSD Diagnosis………………………………………....23 Evidence Based Measures for Predicting PTSD in Injured Trauma Survivors.…....……26 Risk Factors………………………………………………………………………………….......28 Pretrauma Risk Factors – Sociodemographics…………………………………………..29 Pretrauma Risk Factors – Psychosocial…………………………………………….……35 Peritrauma Risk Factors………………………………………………………………….39 Posttrauma Risk Factors………………………………………………………………....42 Summary Review………………………………………………………………………...46 The Present Study………………………………………………………………………………..47 Hypotheses…………………………………………………………………………………...…..47 CHAPTER THREE: METHODS………………………………………………..………………48 Participants……………………………………………………………………...………………..48 Creation of Screen Items for the Injured Trauma Survivor Screen (ITSS)…….………………..50 Procedures………………………………………………………………………………………..52 Funding and Collaboration………………………………………………………………………53 Measures………………………………………………………………………...……………….53 Description of Variables and Research Design……..……...……………………………………56 Statistical Analyses……………………...……………………………………………………….57 Comparison of the ITSS and Richmond et al. Measure…...……………………………..57 Assumptions of Logistic Regression……………….………………………………..58 Entry Method……..…..……………………………………………………………...60 Predictive Accuracy of the Measures in the Sample…..…...……………………………61 iv CHAPTER FOUR: RESULTS…………………………………………………………………..63 Agreement and Reliability……………………………………………………………………….63 Hypothesis Testing……………………………………………………………………………….64 Hypothesis One…………………………………………………………………………..64 Multicollinearity……………………………………………………………………..65 Model fit for ITSS items and Richmond et al. measure in the sample………………66 Goodness-of-fit……………………........................…………………………………68 Odds Ratios...………………….……………………………….………….…………68 Cross Validation…………………………………………………………………...…69 Hypothesis Two………………………………………………………………………….70 Sensitivity and Specificity…………..……………………………………………….72 NPV and PPV………..………………………………………………………………73 CHAPTER FIVE: DISCUSSION………………………………………………………………..74 Rationale…………………………………………………………………………………………74 Hypothesis One…………………………………………………………………………………..75 Injured Trauma Survivor Screen (ITSS)…………………………………………………………75 Premorbid Psychopathology…..…...…………………………………………………….75 Perceived Threat to Life…...…………………….……………………………………….77 Posttraumatic Negative Alteration in Mood..………………….…………………….......79 Posttraumatic Rumination and Trait Worry...……………………………………….…...81 Posttraumatic Negative Alterations in Cognition………………………………...……...82 Risk Factors Not Included in the Model……………………………...………………………….84 Biological Risk Factors…………………………………………………………………..84 Sociocultural Risk Factors……………………………………………………………….86 Resilience and Meaning Making……………..……………………………………...90 Hypothesis Two………………………………………………………………………….………92 Comparing the ITSS and the Richmond et al. Measure.………………………………....92 Limitations……………………………………………………………………………………….94 Future Directions………………………………………………………………………………...96 Conclusion……………………………………………………………………………………….97 REFERENCES………………….………………………….……………………………………98 Appendix A, Predictive Screening Tool for Depression and PTSD after Injury...…………..…119 Appendix B, ITSS Items Administered to Participants……………………………………...…120 Appendix C, Demographic Questions Asked of Participants…………………………………..122 v LIST OF FIGURES Page Figure 1 – DSM-5 309.81 Posttraumatic Stress Disorder………………..………………………15 Figure 2 – Study Flowchart……………………………………………………………………....62 Figure 3 – Cumulative Distribution Function of the ITSS………………………………………67 Figure 4 – ROC Curve Analysis…………………………….……………………………….......70 vi LIST OF TABLES Page Table 1 – Injury type by PTSD diagnosis at one month follow-up………………………….......50 Table 2 – Results of the Regression Analysis…………..………………………………………..65 Table 3 – Injured Trauma Survivor Screen ...……………………………………………………66 Table 4 – Goodness-of-Fit tests………………………………………………..………………...68 Table 5 – Odds Ratios for Individual ITSS items…..……………………………………………69 Table 6 – Comparison of Area Under the Curve and Cutoff Scores…..………………………...71 Table 7 – Pairwise Comparison of ROC Curves.………………………………………………..72 Table 8 – Youden’s J index, Optimal Cutoff Scores, Sensitivity, Specificity, NPV and PPV…..72 Table 9 – PTSD Diagnosis by Sex and Race…………………………………………………….87 vii 1 Chapter 1 Introduction In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, ([DSM-5] American Psychiatric Association [APA], 2013), a person is considered to have experienced a traumatic event if the person has been exposed “to actual or threatened death, serious injury, or sexual violence” either directly, witnessed, through learning that the event happened to a friend or family member, or through the experience of repeated exposure to details of the event (APA, 2013, p.271). Epidemiological studies utilizing various methodologies have demonstrated the lifetime prevalence of exposure to such an event ranges from 51% to 89.6% (Breslau et al, 1998; Flett, Kazantzis, Long, MacDonald, & Miller, 2002). Once exposed to such an event, estimated lifetime prevalence rates of the development of a posttraumatic stress disorder (PTSD) in the general population have varied from 6.8% to 9.2% across various demographics and types of events (Breslau et al., 1998; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Kessler et al., 2005). One unique subset of trauma survivors that is subsumed in these numbers are single- incident injured trauma survivors. According to the 2009 national hospital ambulatory medical care survey, 22% of primary diagnoses at emergency department visits were due to injury and poisoning (Center for Disease Control and Prevention, 2011). Concordantly, each year approximately 2.5 million people in the U.S. are involved in a single-incident traumatic experience (e.g., motor vehicle crash, industrial accidents, falls, gunshot wounds, stabbings and blunt assaults) resulting in severe injuries requiring care at a level 1 trauma center (Bonnie, Fulco, & Liverman, 1999). Of these individuals, research indicates that 10-42% will develop symptoms consistent with PTSD within one year of injury (Blanchard, Hickling, Taylor, & Loos, 1996; Holbrook, Anderson, Sieber, 2 Browner, & Hoyt, 1999; Michaels et al., 1999a; Ursano et al., 1999; Zatzick et al., 2002; Zatzick et al., 2007). Despite this variability, serious injury
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