USE OF THE MISSISSIPPI SCALE FOR COMBAT-RELATED PTSD IN DETECTING WAR-RELATED, NON-COMBAT STRESS SYMPTOMATOLOGY

PATRICK SLOAN AND LINDA ARSENAULT

Veterans Aflairs Medical Center, Mountain Home, Tennessee

MARK HILSENROTH

University of Tennessee

LEO HARVILL

James H. Quillen College of Medicine East Tennessee State University

This study investigated the effectiveness of the Mississippi Scale for Desert Storm War Zone Personnel (M-PTSD-DS), developed from the Mississippi Scale for Combat Related PTSD (M-PTSD; Keane, Caddell, &Taylor, 1988), in the measurement of varying degrees of war-related post-traumatic stress (PTS) symptomatology of non-combat Persian Gulf War veterans. Thirty Marines were administered the M-PTSD-DS after 3 months of active duty in Operation Desert Storm. The M-PTSD-DS scores of the Marines were related significantly to the number of PTS symptoms reported by the Marines. This scale appears to be quite effective in detecting varying degrees of war-related stress in non-combatants.

The desire to assess accurately post-traumatic stress (PTS) and the related psychiatric syndrome, post-traumatic stress disorder (PTSD), has led to the development of a number of diagnostic methods designed to make such classifications. One objective measure that has been shown to enhance the efficacy of a multiaxial, multimethod approach in the clinical descision-making process to diagnose PTSD has been the Mississippi Scale for Combat Related PTSD (M-PTSD; Keane et al., 1988). The M-PTSD was developed to assess the domain of PTSD symptoms in Vietnam-combat veterans using the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM- 111; American Psychiatric Association, 1980) as a guideline.

Subsequent research has replicated the utility of this measure as a useful screening measure of PTSD (Blake, Cook, & Keane, 1992; Kulka et al., 1991; McFall, Smith, Mackay, & Tarver, 1990) in Vietnam combat veterans. However, a number of authors have identified the need to ascertain the sensitivity of the M-PTSD in the assessment of varying degrees of PTS as well as in the identification of war-zone stress in non- combatants (Berk et al., 1989; Fontana, Rosenheck, & Brett, 1992; Kulka et al., 1991; Litz, Penk, et al., 1991; McFall et al., 1990).

Research with Persian Gulf War returnees provides a rare opportunity to study the acute psychological sequelae of exposure to war stressors in contrast to the available literature on war-related stress reactions, particularly combat-related PTSD, which is based largely on research with Vietnam veterans at least 5 or more years after their return home (Sutker, Uddo-Crane, &Allah, 1991). Given the need for further research on the acute psychological impact of exposure to war stress, this study attempted to determine

This research was supported by a grant from Department of Veterans Affairs, Mental Health & Behavioral

Correspondence should be addressed to Patrick Sloan, Ph.D., Chief, Psychology Service (1 16B-2), VA Science Services, Washington, DC.

Medical Center, Mountain Home, TN 37684.

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800 Journal of Clinical Psychology, November 1995, Vol. 51, No. 6

the effectiveness of the M-PTSD in detecting less pathological degrees of war-related, post-traumatic stress in Persian Gulf War non-combat veterans. It was predicted that the amount of PTS symptomatology would be related to M-PTSD in a conceptually valid manner. We defined acute PTS in an individual when he reported the presence of one or more symptoms of PTSD listed in the Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. rev. (DSM-111-R; American Psychiatric Association, 1987) without meeting the full criteria for PTSD.

METHOD

Subjects Sixty-six U.S. Marine Reservists took part in a post-war debriefing interview 3

months after their return from Operation Desert Storm (ODs). These interviews were conducted by VA clinical psychology staff trained and experienced in evaluating the PTSD criteria of the DSM-111-R. During this interview, 47 (71%) of these subjects reported experiencing one or more symptoms of PTSD from the DSM-111-R criteria B, C, and D (American Psychiatric Association, 1987). Individual appointments were solicited for these 47 Marines at the VA Medical Center for further evaluation and services. Of this group, 30 Marines participated in these follow-up services. All of the respondents were White males, typically single, who averaged 22 years of age and were enlisted personnel with 12 or more years of education (M = 13.5 years).

Measure Mississippi Scale for Desert Storm War Zone Personnel (M-PTSD-DS) is derived

from the M-PTSD, which originally was a 35-item scale that assesses a wide range of symptoms of combat related PTSD and associated psychosocial disturbances. The M-PTSD-DS was distributed to VA clinical outreach teams as part of the Operation Desert Storm Clinician Packet (Abueg et al., 1991) written and compiled by the Na- tional Center for PTSD. The M-PTSD-DS is a slightly modified version of the M-PTSD designed to make it more applicable and, thus, more useful for ODS personnel. First, the wording of the items reflects Persian Gulf War content; second, items 3 and 5 were changed to accommodate the experiences of women veterans; and third, 3 new items (36-38) were added so as to include questions about memory difficulties and hyperarousal symptoms (Litz, Knight, et al., 1991). The clinical cut-off recommended for the M-PTSD, and M-PTSD-DS as well, is 107, which has been shown to identify accurately PTSD patients 90% of the time (Keane et al., 1988). Each Marine was administered the M-PTSD individually as part of an evaluation assessment.

These Marines had spent 3 months of active duty in Saudi Arabia, where they pro- vided security for military positions and guarded Iraqi prisoners, but experienced no direct combat. However, the respondents did report a number of stressful experiences that occurred during their tour of duty, such as coming under heavy artillery fire and frequent missile alerts. They experienced equipment failures and lost radio communica- tions while in the open desert, all within close proximity to enemy lines. They provided security for Iraqi prisoners and reported being assaulted by prisoners who were threaten- ing to riot. Although they did not actually kill or wound anyone, these reservists did report seeing dead and wounded people, which they described anecdotally as their most stressful war experience. None of the subjects had a premorbid history of PTSD or a psychiatric condition, and none of the subjects has applied for disability.

RESULTS AND DISCUSSION

Of 17 possible DSM-111-R symptoms that define PTSD, subjects reported an average of 3.33 symptoms (range 1-13). Four Marines initially met the DSM-111-R criteria for

Detection of Noncombat PTSD 801

a diagnosis of PTSD. (A minimum of 6 symptoms is required by DSM-111-R, for a dura- tion of at least 1 month). Of the 30 subjects, none scored above 107, and only 3 veterans in our group, all of whom met the initial criteria for PTSD, exceeded the cut-off score of 89 used to detect PTSD in community veteran samples (Kulka et al., 1991). Scores on the M-PTSD-DS were moderate to low (M = 63.6, SD = 14.7) and fell within nor- mal parameters (Keane et al., 1988; Kulka et al., 1991; McFall et al., 1990). Although the Marines’ scores did not reach pathological levels, M-PTSD-DS was related to PTS symptomatology in a manner that supports its construct validity. The M-PTSD-DS score was correlated significantly and positively with the number of PTS symptoms reported by the Marines ( r = 232, p < .0001). This correlation indicates that as the number of PTS symptoms experienced by the veterans increased, their resultant score on the M-PTSD increased as well.

This finding supports the construct validity (sensitivity) of this scale in the measure- ment of relatively non-pathological degrees of war-related, non-combat stress. Also, this strong relationship supports the primary intent of the M-PTSD and M-PTSD-DS to assess the spectrum of DSM-111-R symptoms of PTSD. In addition, the robust associa- tion between the M-PTSD-DS and degree of PTS symptomatology further substantiates the use of this measure in the screening, identification, and treatment planning of ODS veterans, combat or non-combat, who are experiencing war-related stress and are at high risk for PTSD.

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