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Davidson Trauma Scale (DTS)
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Practical Information
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Instrument Name:
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Davidson Trauma Scale (DTS)
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Instrument Description:
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The Davidson Trauma Scale (DTS) is a 17-item self-rating instrument that assesses post-traumatic stress disorder (PTSD) symptoms in individuals with a trauma history. The objectives are to measure symptom frequency and severity as well as to evaluate treatment over a period of time, which may include different types of therapy. The DTS items correspond to the 17 DSM-IV symptoms: items 1-4, and 17 match criteria B (intrusive re-experiencing); items 5-11 match criteria C (avoidance and numbness); and items 12-16 match criteria D (hyperarousal). (Ref: 2)
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Price:
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The cost per administration/copy is approx. $1.00, via a copyright license agreement.
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Administration Time:
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Less than 10 minutes. (Ref: 3)
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Publication Year:
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1997
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Item Readability:
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According to Flesch-Kincaid, the DTS items have a 6.0 reading level. A subject with a 6th grade reading level should be able read and understand the scale.
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Scale Format:
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5-point Likert-type scale. (Ref: 2) Frequency: not at all; once only; 2-3 times; 4-6 times; every day. Severity: not at all distressing; minimally distressing; moderately distressing; markedly distressing; extremely distressing. (Ref: 5)
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Administration Technique:
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Self-report and telephone clinician-administered. (Ref: 2,5)
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Scoring and Interpretation:
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Items are rated from 0 to 4, which can yield a total possible score up to 136 points. Also, subscores may be calculated separately for frequency and severity. (Ref: 2) One study reported using a cut-score of 40 to confirm a DSM-IV diagnosis of PTSD and a cut-score of 27 to identify those with high levels of post-trauma psychopathology who might/might not meet DSM-IV criteria for PTSD. (Ref: 5)
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Forms:
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There is a short version of the DTS, known as the SPAN (Startled, Physiological arousal, Anger, and Numbness). (Ref: Meltzer-Brody S, Churchill E, Davidson JR. Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder.Psychiatry Res. 1999 Oct 18;88(1):63-70. PMID: 10641587) Other language translations include: French, Serbo-Croatian, Bosnian, Hebrew. (Ref: Martenyi F, Brown EB, Zhang H, Prakash A, Koke SC. Fluoxetine Versus Placebo in Posttraumatic Stress Disorder. J Clin Psychiatry. 2002 Mar; 63(3):199-206.)
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Research Contacts
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Instrument Developers:
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Jonathan R.T. Davidson, MD
Researchers requesting to use the DTS in studies must contact either the MultiHealth Systems Inc., Research and Development Department at R&D@mhs.com (for use of original materials) or the MHS Legal Department at legaldept@mhs.com to obtain a copyright license agreement for permission to copy. For contacts inquiring or requesting further information regarding the DTS should email: customerservice@mhs.com.
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Instrument Development Location:
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Department of Psychiatry and Behavioral Sciences
Duke University Medical Center
PO Box 3812
Durham, NC 27710
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Instrument Developer Email:
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jonathan.davidson@duke.edu
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Instrument Developer Website:
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www.mhs.com
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Annotated Bibliography
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1. Hertzberg MA, Feldman ME, Beckham JC, Davidson JRT. Trial of Trazodone for Posttraumatic Stress Disorder Using a Multiple Baseline Group Design. J of Clin Psychopharm. 1995 Dec 15;16(4):294-98. [PMID: 8835704]
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Purpose:
To evaluate possible benefits for Posttraumatic Stress Disorder (PTSD) and related symptomology in patients with chronic PTSD.
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Sample:
N = 6 male veteran patients with combat-related PTSD. Demographic characteristics: mean age was 46 years (range 43-48 years), all patients had a comorbid history of major depression, two had alcohol dependence, two were employed full time whereas the other four were unemployed, the mean self-reported beginning of PTSD symptoms was 25 years (range 22 to 27 years), the mean of reported side effects between pre-and posttreatment reduced slightly from 42 to 38 (10%).
The total DTS scores in Group 2 (pretreatment) at baseline 1, baseline 2 (1 month), and baseline 3 (2 months) were 109, 113, and 112 respectively.
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Methods:
The subjects were recruited from the outpatient treatment program at the Durham Veterans Administration Medical Center in May 1994; informed consent was obtained after the procedures and possible side effects were explained to them. The research study was conducted from May 1994 to February 1995. The patients’ current PTSD diagnosis was confirmed by meeting the DSM-III-R criteria that was determined by the Clinician-Administered PTSD Scale-diagnostic version (CAPS-1). Other assessments included: the Davidson Trauma Scale (DTS), the Pittsburgh Sleep Quality Index (PSQI), the Beck Depression Inventory (BDI), the State-Trait Anxiety Scale, and the CAPS at baseline and week 16. The Clinical Global Impression (CGI) was used to assess global improvement at pre- and posttreatment.
The subjects were divided into two groups, three subjects per group. Group 1 received trazadone at the baseline assessment and completed a posttreatment evaluation at 4 months. Group 2 subjects were evaluated monthly and trazadone treatment began after 2 months of baseline assessments; posttreatment evaluations were completed 4 months later. The treatment dosages were administered by one of the authors at 50 mg/day for the first 2 weeks, 100 mg/day at 2 weeks, and 200 mg/day at 4 weeks. The patients were fully aware of the name of the medication and they did not receive any new additional treatments.
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Implications:
The results suggest that trazadone was well tolerated possibly due to the increased dosages over several months and taking one full dose at bedtime. Within 2 to 3 months, sleep was improved; other PTSD symptoms had decreased after 4 months. As related to the DTS, the "anger intensity and frequency" mean ratings decreased over the treatment phase.
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2. Davidson JR, Book SW, Colket JT, Tupler LA, Roth S, David D, Hertzberg M, Mellman T, Beckham JC, Smith RD, Davison RM, Katz R, Feldman ME. Assessment of a new self-rating scale for post-traumatic stress disorder. Psychol Med. 1997 Jan;27(1):153-60. [PMID: 9122295]
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Purpose:
To assess a newly developed self-rating scale of post-traumatic stress disorder (PTSD), the Davidson Trauma Scale (DTS).
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Sample:
N = 350. The sample included four different study groups: 1) female rape victims (n=78), 2) male war veterans (n=110), 3) Hurricane Andrew victims (n=53), and 4) survivors of miscellaneous traumas (n=102). Group 1 demographics: 78 females; 0 male; mean age (SD), 26.4 (6.9) years; 20 married; 58 not married; 66 Caucasian; 12 Other ethnicity. Group 2 demographics: 0 female; 110 male; mean age (SD), 46.7 (12.7) years; 73 married; 37 not married; 66 Caucasian; 44 Other ethnicity. Group 3 demographics: 11 male; 42 female; mean age (SD), 40.8 (12.7) years; 33 married; 20 not married; 36 Caucasian; 17 Other. Group 4 demographics: 84 male; 18 female; mean age (SD), 44.7 (7.4) years; marital status and race characteristics were not available.
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Methods:
The DTS was administered along with several other scales: global ratings, Symptom Check List (SCL-90-R), Eysenck Scale, Impact of Event Scale and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID).
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Implications:
The DTS was found to have good test-retest reliability, internal consistency, convergent and divergent validity, predictive validity, and responsiveness evidence.
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3. Davidson JR, Tharwani HM, Connor KM. Davidson Trauma Scale (DTS): normative scores in the general population and effect sizes in placebo-controlled SSRI trials. Depress Anxiety. 2002;15(2):75-8. [PMID: 11891997]
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Purpose:
To evaluate the Davidson Trauma Scale (DTS) in a general and clinical trial population to detect treatment differences.
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Sample:
N = 438 (general population sample) and N = 449 (clinical trial populations). The general population included four subsamples: 1) DSM-IV threshold post-traumatic stress disorder (PTSD), subthreshold PTSD (n=13), 2) with impairment (n=26), 3) without impairment (n=78), and 4) no PTSD (n=321). The clinical trial population had three subsamples: 1) 12-week placebo-controlled trial of fluoxetine (n=54), 2) two identical 12-week studies of sertraline and placebo (sertraline-I and sertraline-II) with 187 and 208 subjects, respectively. Demographic characteristics for the general population included: mean (SD) age, 44.9 (15.7) years; 62% female; 79% Caucasian. Demographic characteristics for the clinical trial samples included: a) mean (SD) age, 40.2 (9.6) years for sertraline and 39.5 (10.6) years for placebo, and b) mean (SD) age, 37.6 (11.1) years for sertraline, 36.6 (10.1) for placebo; 84% and 76% were female, and 83% and 81% were Caucasian, respectively.
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Methods:
The general population was recruited by Random Digit Dialing (RDD) and interviews were conducted by a professional survey organization. To assess trauma, diagnosis, and symptoms of PTSD the subjects were given the Trauma Questionnaire (TQ), the Mini International Neuropsychiatric Interview (MINI), and the DTS, respectively. The subjects in placebo-controlled trial of fluoxetine sample were administered the DTS and Impact of Event Scale (IES) for self-ratings, and interviewer-based Structured Interview for PTSD scale to assess "subjective impact of intrusive and avoidant symptoms." Those subjects in the sertraline and placed controlled studies were administered the DTS and IES as well, however, the interviewer-based scale included the Clinician Administered PTSD Scale (CAPS).
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Implications:
No significant differences were found in DTS scores between men and women, in neither the general nor subgroup samples. Also, no statistically significant differences were reported between subthreshold PTSD with impairment compared to those with full PTSD. The DTS was related with effect sizes in three studies, which was shown to be slightly greater than IES, and comparable to the CAPS and SIP. The individuals with full PTSD in the general population had a DTS score at the lower end of the range than those in the clinical trials.
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4. Wells JE, Williams TH, Macleod AD, Carroll GJ. Posttraumatic stress disorder: do electrical startle responses and thyroid function usefully supplement self-report? A study of Vietnam War veterans. Aust N Z J Psychiatry. 2003 Jun;37(3):334-9. [PMID: 12780473]
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Purpose:
To study the effectiveness of electrical startle responses and thyroid function as supplements to self-report measures of post-traumatic stress disorder (PTSD).
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Sample:
N = 35 male Vietnam War veterans. The veterans had a range of PTSD symptoms from none to many to severe. The mean (SD, range) age was 53.4 (5.1, 46-69) years, the service range in Vietnam was 5 months to 48 months with a mean of 12.6 months (SD=7.7), greater than 90% completed their time in Vietnam between 1968-1971, 15 reported a diagnosis of PTSD. In test-retest sample, N=33 (one week interval), and at a 6-month follow-up N=32.
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Methods:
Vietnam War veterans in North Canterbury were mailed invitations to participate in the research study. The measures included: the Davidson Trauma Scale (DTS), the PTSD scale of the Symptom Check List (SCL-90R), and the Alcohol Use Disorder Identification Test (AUDIT). The assessments took place between April and May 1998, where an interviewer met with each participant and administered all the questionnaires and set up a time for the startle test and blood tests within two to three working days, sometimes on the same day. The DTS was also given one week later to measure short-term test-retest reliability; the mean (SD) time was 9.4 days (SD = 4.6 days). About six months after the initial assessment, a follow-up was conducted; the AUDIT and SCL-90R were only administered at the initial assessment. The thyroid function was measured as a ratio of T3 to T4, startle response was measured from below the obicularis oculi muscle by surface electrodes, and the stimulation intensities in ascending order (10, 20, 30, 40 and 50 mA) were performed on the trigeminal nerve.
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Implications:
As related to the DTS, it was found to be reliable and correlated significantly with the SCL-90R PTSD scale. In addition, the thyroid function and electrical eye startle did not correlate with each other or with self-report; the electrical startle did not have good reliability and was disliked by veterans.
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5. Cuthbertson BH, Hull A, Strachan M, Scott J. Post-traumatic stress disorder after critical illness requiring general intensive care. Intensive Care Med. 2004 Mar;30(3):450-5. Epub 2003 Sep 05. [PMID:12961065]
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Purpose:
To establish the frequency and severity of post-traumatic stress disorder (PTSD) symptoms in a group of general intensive care (ICU) patients requiring ICU care 3 months after discharge.
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Sample:
N = 78 ICU survivors. The mean (range) for baseline characteristics were: age, 58 (18-87) years; ICU length of stay, 5.6 (1-51) days; APACHE II score, 18 (4-38); ventilatory days, 2 (0-44); and 56% male, 44% female. The mean DTS score was 8 (range 0-87), with 17 patients having a 27 or higher DTS score and 9 having a 40 or higher DTS score.
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Methods:
Patients were approached at the time of ICU discharge where they agree to participate in the study, three months later a research nurse contacted patients by telephone and they were asked to complete a brief interview and a telephone assessment of the Davidson Trauma Scale (DTS).
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Implications:
The total DTS score or its subscores were not correlated with sex, severity of illness, or ICU length of stay, however, the total DTS score was correlated with length of time on mechanical ventilation.
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Factors and Norms
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Factor Analysis Work:
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A principal-components factor analysis of data from 3 clinical studies (N = 241) identified two main factors: one factor, identified as the severity factor, accounted for over 20% of the total variance (eigenvalue =24.19) and the second factor (eigenvalue = 1.34) accounted for a small percentage of variance. The loadings for the second factor were positive on ‘intrusive’ items and negative on ‘avoidance and numbness’ items. (Ref: 2)
Factor analysis was also performed only on subjects with a current PTSD diagnosis where six factors were revealed with eigenvalues of 18.88, 2.44, 1.98, 1.45, 1.14, and 1.02. Factor I loaded on ‘general severity’; Factor II loaded on ‘reduced enjoyment’, ‘estrangement’, ‘lack of loving feelings’, and ‘foreshortened future’, Factor III had positive loadings on ‘avoiding doing things and insomnia’; Factor IV loaded on ‘insomnia, frequency of avoiding thoughts, feelings, and situations reminiscent of the event’; Factor V loaded negatively on hyperarousal symptoms of ‘irritability, hypervigilance and exaggerated startle response;’ and Factor VI loaded positively on ‘frequency of amnesia for important aspects of event’ and negatively loaded on ‘distressing dreams and frequency of foreshortened future.’ (Ref: 2)
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Normative Information Availability:
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One study reports that DTS scores can distinguish PTSD patients and partial PTSD patients from patients with no PTSD in the general population and provides normative population data for such samples. (Ref: 3)
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Reliability Evidence
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Test-retest:
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The baseline total DTS score was compared with a DTS assessment two weeks later in subjects from the multicentre clinical trial who had been scored with ‘no change’ on the Clinical Global Impressions (CGI) Improvement scale. The test-retest reliability coefficient was 0.86 (P<0.0001). (Ref: 2)
repeat of the DTS one to two weeks later. The test-retest coefficient was 0.93 at one to two weeks and 0.73 at six months. (Ref: 4)
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Inter-rater:
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No information found.
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Internal Consistency:
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The overall Cronbach alpha was 0.99 for the 17 frequency and severity items; it was 0.97 and 0.98 for the frequency and severity scales alone, respectively. (Ref: 2)
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Alternate Forms:
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No information found.
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Validity Evidence
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Construct/ Convergent/ Discriminant:
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The DTS was compared with the Clinician Administered PTSD Scales (CAPS) and the Impact of Event Scale (IES) which tested for both convergent and discriminant validity. The correlations found were 0.78 (P<0.0001) for the CAPS and 0.64 (P<0.0001) for the IES. (Ref: 2) The DTS also had high correlations with the SCL-90-R PTSD (0.89 initial, 0.85 repeat) and the AUDIT (0.29 initial, 0.31 repeat) in a sample of Vietnam war veterans. Other correlations included: a ratio measure of thyroid function, total T3/free T4 (0.27 initial, 0.20 repeat) and startle response (0.18 initial, 0.26 repeat). (Ref: 4)
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Criterion-related/ Concurrent/ Predictive:
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Concurrent validity of the DTS was examined by its association with the Structured Clinical Interview for DSM-III-R (SCID) scores among rape victims, war veterans, and Hurricane Andrew victims. The highest efficiency (0.83) was found at a cut-score of 40, where the area under the curve was 0.88. At this cut-score, sensitivity was 0.69, `specificity was 0.95, positive predictive value was 0.92, and negative predictive value was 0.79.
The range of values of different cut-scores (17, 27, 36, 40, 48) is as follows: positive (low, 0.65; high, 0.97) and negative (low, 0.74, high, 0.88), sensitivity (low, 0.57; high, 0.90) specificity (low, 0.60; high, 0.99) and efficiency (low, 0.73; high, 0.81). (Ref: 2)
Predictive validity of the DTS was tested by evaluating baseline DTS total scores with respect to endpoint CGI scores to investigate whether severity at first on the DTS predicted reactions to double-blind treatment. Regression analysis with DTS scores as the predictor and CGI scores as the outcome was significant (p<0.005), but R2 was low (0.10). (Ref: 2)
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Content:
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No information found.
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Responsiveness Evidence:
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DTS total scores for responders vs. non-responders were evaluated in the double-blind medical clinical trial group using Trazodone as the treatment. The definition of ‘response’ was an endpoint CGI score of 1 or 2 and non-response was defined as a CGI score of 3 or greater. A significant correlation was found between responder status and DTS totals at baseline and endpoint (F {1,95} = 31.75, P < 0.0001). The mean DTS total scores for 50 CGI responders were 73.6 (SD, 29.1) and 40.3 (SD, 32.9) at baseline and endpoint, respectively, while the mean scores for 47 CGI non-responders were 87.2 (SD, 26.5) and 85.8 (SD, 32.1), respectively. (Ref:1)
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Scale Application in VA Populations:
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Yes. (Ref: 1,5)
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Scale Application in non-VA Populations:
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Yes. (Ref: 2-4)
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Comments
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The DTS is a self-report assessment of PTSD symptoms, including severity and frequency. It includes 17 items that correspond to DSM-IV criteria for PTSD diagnosis.
Overall Usefulness for a Certain Population: The DTS has been used in adult populations, both veteran and non-veteran, general and clinical, and across different ethnic groups. Generalizability of the scale’s use among children and adolescents is unknown.
Advantages: The DTS is relatively brief and is available in several language translations. Test-retest and internal consistency reliability evidence is good, and norms are available. The DTS appears to have a good association with other measures of trauma (CAPS, IES, SCL-90-R).
Disadvantages: Scoring guidelines are not provided, although one study has provided information on cut-scores and corresponding sensitivity, specificity, positive and negative predictive values (Ref: 2). The DTS total score was a significant predictor of reaction to treatment as assessed by the CGI, although the model accounted for a small proportion of the variance in scores.
Recommendations: The DTS appears to be an effective tool for the self-report of PTSD symptoms, with items corresponding to DSM-IV criteria. It can be used among varied populations, though its utility with non-adults is unknown. It should be further evaluated for its responsiveness to treatment to guide its use an outcome assessment.
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