Journal of Traumatic Stress, Vol. 18, No. 5, October 2005, pp. 401–412 (C ?2005)
Phenomenology and Psychological Assessment
of Complex Posttraumatic States
John Briere1,3and Joseph Spinazzola2
to early onset, multiple, or extended traumatic stressors. Six prominent and overlapping symptoms
clusters are described: altered self-capacities, cognitive symptoms, mood disturbance, overdeveloped
avoidance responses, somatoform distress, and posttraumatic stress. A strategy for the structured,
psychometrically valid assessment of these outcomes is introduced, and specific recommendations
for use of various generic and trauma-specific child and adult measures are provided. Implications of
trauma assessment for treatment planning are discussed.
Reactions to overwhelming psychological stressors
can be viewed as residing on a complexity continuum.
At one end are responses to adult-onset, single-incident,
traumatic events (e.g., a motor vehicle accident, a mug-
ging) that occur in individuals with adequate childhood
morbid psychological disorders. At the opposite end are
responses to early onset, multiple, extended, and some-
times highly invasive traumatic events, frequently of an
interpersonal nature, often involving a significant amount
of stigma or shame, that occur in individuals who, for
a variety of reasons, may be more vulnerable to stress
uum are the subject of this article. These individuals are
likely to experience a variety of posttraumatic symptoms
and negative mood states, and often present with chronic
affect regulation and interpersonal difficulties (Herman,
1Department of Psychiatry and the Behavioral Sciences, Keck Schoolof
Medicine, University of Southern California, Los Angeles, California.
2The Trauma Center, Division of Psychiatry, Boston University School
of Medicine & National Child Traumatic Stress Network, Boston,
3To whom correspondence should be addressed at Psychological
Trauma Program, LAC+USC Medical Center, 2020 Zonal Avenue,
Los Angeles, California 90033; e-mail: firstname.lastname@example.org.
1992). The implications of this heterogeneity for the pro-
cess and content of psychological assessment are signif-
icant. For example, it is unlikely that a single, overar-
ching diagnostic label or construct will encompass the
complexity of posttraumatic outcomes for the majority of
a phenomenologically based framework to guide psycho-
logical assessment of the many psychological responses
associated with exposure to more extreme or sustained
The modern literature on posttraumatic stress sug-
among a number of factors, of which the specific trau-
matic experience is only one. For example, more severe
and complex posttraumatic outcomes frequently are asso-
ciated with a life history of multiple interpersonal victim-
ization experiences, often beginning with extended child-
hood abuse and neglect, and associated disruption of the
parent-child attachment system (e.g., Ford & Kidd, 1998;
Zlotnick et al., 1996). Such maltreatment not only may
produce lasting sequelae itself, but also is a risk factor for
C ?2005 International Society for Traumatic Stress Studies • Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jts.20048
402 Briere and Spinazzola
being revictimized in the future (Neumann, Houskamp,
Pollock, & Briere, 1996) and for responding to later trau-
matic events with more severe and complex symptoms
(e.g., Bremner, Southwick, Johnson, Yehuda, & Charney,
1993). Also associated with more extreme posttraumatic
responses are a range of person-level variables, includ-
ing nervous system hyperreactivity (Yehuda, 1997), the
presence of other anxiety, depressive, or personality-level
disorders (Breslau, Davis, & Andreski, 1991), and exces-
Saunders, & Best, 1999) — all of which both moder-
ate the effects of trauma exposure and may arise them-
selves, from previous traumatic events (McCauley et al.,
1997). Finally, response complexity is often affected by
(Steketee & Foa, 1987), lower socioeconomic status (e.g.,
zation associated with certain traumatic experiences (e.g.,
Lebowitz & Roth, 1994), and may vary according to
whatever idioms of distress are most acceptable within
a given culture (Marsella, Friedman, Gerrity, & Scurfield,
Given the complexity of some posttraumatic out-
comes, psychological assessment in this area must poten-
tially address a wide range of symptom clusters in addi-
tion to classic posttraumatic stress disorder (PTSD). Most
broadly, these can be subsumed under the intrinsically
overlapping headings presented below.
The literature on the effects of severe or extended
childhood abuse and neglect, especially when such mal-
treatment involves disruption of early parent–child at-
tachment, often emphasizes dysfunctions in the areas
of identity, affect regulation, and interpersonal related-
ness (Cole & Putnam, 1992; Herman, Perry, & van der
Kolk, 1989). These domains have been subsumed un-
der the general notion of "self-capacities" (Briere, 2000a;
McCann & Pearlman, 1990; Pearlman, 1998) because
such disturbance involves dysfunction in one’s abili-
ties to regulate one’s internal experience and one’s in-
teraction with others. Problems in the self domain, in
turn, have been implicated in the development of dys-
functional behaviors often seen in complex posttrau-
matic outcomes, including suicidality (e.g., Zlotnick,
Donaldson, Spirito, & Pearlstein, 1997), impulse control
problems (e.g., Herpertz et al., 1997), substance abuse
(e.g., Grilo et al., 1997), and the “tension reduction” be-
haviors (e.g., self-mutilation) described in a separate sec-
assault) has been associated with subsequent low self-
esteem, self-blame, helplessness, hopelessness, expec-
tations of rejection and loss, and an overestimation of
the amount of danger in the world (Foa, Ehlers, Clark,
Tolin, & Orsillo, 1999; Janoff-Bulman, 1989; McCann &
Pearlman, 1990). When these cognitions are developed
early in life in the context of sustained abuse or neglect,
they may form complex relational schemata (Baldwin,
Fehr, Keedian, Seidel, & Thompson, 1993) or internal
working models (Bowlby, 1988) involving negative self-
by later stimuli that are somehow reminiscent of the orig-
inal abusive experience (e.g., perceived or real rejection
or criticism),leading to reactivated experiences of, for ex-
ample, self-hatred, anger, or abandonment fears (Baldwin
et al., 1993; Briere, 2002a).
A number of studies indicate that exposure to inter-
personal traumas can result in symptoms or disorders in-
Heim & Nemeroff, 2001; Pollock et al., 1990). Anxiety
and depressive disorders are commonly comorbid with
posttraumatic stress (Kessler, Sonnega, Bromet, Hughes,
& Nelson, 1995), and may be associated with traumatic
events irrespective of PTSD (Heim & Nemeroff, 2001;
Prigerson, Maciejewski, & Rosenheck, 2002). Such out-
comes may arise from the enduring physiological effects
of some traumatic experiences and trauma-related cog-
nitive distortions, as described above, or in some cases,
may reflect conditioned emotional responses to activated
trauma memories (Eckhardt, Barbour, & Davison, 1998;
Foa et al., 1999; Heim & Nemeroff, 2001).
Overdeveloped Avoidance Responses
curs early in life and is sustained over time—can lead to
ples of such responses are dissociation, substance abuse,
and tension reduction activities.
Assessment of Complex Trauma403
as alterations in conscious awareness that arise, in part,
from defensive changes in otherwise integrated thoughts,
feelings, memories, and behavior. Examples of this group
of responses are depersonalization, derealization, fugue
states, and dissociative identity disorder (American Psy-
chiatric Association [APA], 2000). Although dissociative
symptoms may function as a way to reduce the emotional
distress associated with traumatic events, they also may
be invoked long after the traumatic event in an attempt to
reduce the emotional responses associated with triggered
traumatic memories (Briere, 2002a; Chu, Frey, Ganzel, &
A number of studies indicate that individuals with
complex and chronic trauma histories are more likely to
use drugs and alcohol (e.g., Grilo et al., 1997). Such use
may constitute a form of emotional avoidance, whereby
substances are taken to anesthetize negative affect asso-
ciated with traumatic experiences or subsequent trauma
perience suggests that substance use can also serve to
alleviate affective numbness in some trauma survivors
by inducing transient and predictable pleasurable bodily
sensations or emotions. Unfortunately, substance abuse,
in turn, can be related to further victimization (Acierno
more complex) posttraumatic symptomatology.
individuals often rely on external ways of avoiding or re-
ducing activated abuse-related distress. These include not
only substance abuse, but also what are referred to as ten-
sion reduction behaviors (Briere, 2002a), such as com-
pulsive sexual behavior (Briere & Elliott, 2003), binging
and purging (Webster & Palmer, 2000), self-mutilation
(Briere & Gil, 1998), and suicidality (Zlotnick et al.,
1997). Along with substance abuse, tension reduction
activities are thought to work by providing temporary
distraction or by inducing distress-incompatible affective
distress or dysfunction that arises from (or is significantly
intensified by) psychological phenomena (American Psy-
abuse (Walker et al., 1988) and ongoing adult victimiza-
tion (Kimerling & Calhoun, 1994). In addition, somatic
symptoms may serve as an idiom of posttraumatic dis-
tress for cultures or subcultures that deny or reinterpret
psychological dysfunction (Marsella et al., 1996).
Although exposure to traumatic events does not al-
ways lead to posttraumatic stress disorder (e.g., Kessler
ten present with some degree of intrusive re-experiencing
(e.g., flashbacks or nightmares), avoidance (e.g., emo-
tional numbing or efforts to avoid traumatic reminders),
or autonomic hyperarousal (e.g., heightened startle re-
sponses or insomnia). In this regard, posttraumatic stress
may be viewed as a multidimensional, spectrum-level
phenomenon—involving some combination of three sep-
arate but moderately correlated symptom clusters—that
(somewhat arbitrarily) reaches disorder status when cer-
tain numbers of symptoms per cluster are reported at
specified levels. Although a dichotomous diagnosis of
PTSD has obvious clinical utility, a dimensional per-
spective may allow more precision in understanding the
posttraumatic symptoms of a given trauma survivor.
comes, it is unlikely that the psychological assessment of
traumatized individuals can be accomplished through the
mere administration of a single measure, for example a
test for PTSD. Instead, once it has been determined that
exposure to a potentially traumatic event is part of the
proliferate. In the remainder of this article we address the
technical aspects of this expanded assessment process.
As is true of psychological tests in general, those
used to evaluate the effects of complex trauma-related
outcomes should have adequate reliability and validity,
and should be standardized on demographically represen-
tative samples of the general population. Such tests also
should have good sensitivity and specificity if they are of-
fered as diagnostic instruments. For example, a measure
404 Briere and Spinazzola
of PTSD (sensitivity) and those cases where no PTSD is
Unfortunately, because of the relative recency of
our understanding of posttraumatic conditions, some cur-
rently available trauma-specific instruments do not meet
existing standards for clinical psychological tests. Al-
though such tests may be internally consistent, and may
correlate with relevant trauma variables, their actual clin-
ical utility (i.e., sensitivity and specificity) in clinical con-
texts is often unknown or less than encouraging. At least
as problematic, many trauma measures have not been
normed on the general population. Without normative
data, the clinician is unable to compare a given client’s
score on a measure with the average individual’s score
on that measure, and thus cannot determine the extent to
which said score represents dysfunction or disorder. In
the case of solely diagnostic screening instruments, the
absence of normative data is generally not a problem, be-
are—or are not—present.
For these reasons, the clinician is advised to avoid,
when possible, the use of nonstandardized self-report
measures in the assessment of trauma effects, complex
or otherwise. In this regard, most of the measures recom-
mended in this article have been fully standardized and
normed or, in the case of diagnostic measures, have been
shown to have adequate sensitivity and specificity. As a
result, several measures with good psychometric proper-
ties but lacking normative or standardization data are not
Approach to Assessing Complex
Posttraumatic outcomes vary widely; hence, the ini-
tial approach to assessment is critically important. In a
sense, the clinician must make an educated guess as to
what are likely to be the relevant areas of distress or dys-
function for a given client, even though he or she has
yet to determine them psychometrically. In most cases,
this determination is made during the initial interview,
when a traumatic event history and presenting complaints
are elicited and the client’s overall clinical presentation
is considered. This process may be assisted by a struc-
tured review of potentially traumatic events and the ad-
evaluate a number of different areas of symptomatology
Assessing Exposure to Traumatic Events
Although we devote much of this article to the eval-
uation of symptomatology, a complete trauma assessment
also must consider the client’s specific history of expo-
sure to traumatic events. Various studies indicate that
psychotherapy clients and other individuals often fail to
reveal significant traumatic experiences if not specifically
in a sensitive manner, using behavioral descriptions of
the events (as opposed to merely asking about “rape” or
“abuse”), and employing some sort of structured measure
or interview that assesses exposure to the major types of
Especially relevant to the issue of complex posttrau-
symptomatology have undergone a significant number
of adverse experiences, often beginning with childhood
abuse. Because both childhood and adult traumatic events
tology in such individuals may represent (a) the effects of
relatively recent (i.e., adult) traumatic experiences, (b)
the chronic effects of childhood abuse, (c) the additive ef-
fects of childhood abuse and adult traumatic experiences
(e.g., flashbacks to both childhood and adult victimiza-
tion), or (d) the exacerbating interaction of child abuse
and adult traumatic experiences (e.g., especially severe,
regressed, dissociated, or even transiently psychotic re-
sponses; Briere, 2004). Beyond the interaction between
different traumatic events, a general finding in the trauma
that have occurred in an individual’s life, the more post-
traumatic symptomatology is likely to be present (e.g.,
son, the client’s recent and remote trauma history should
be taken into account before his or her symptoms can be
attributed solely to a given event—especially when the
symptomatology is complex or pervasive.
There are a range of trauma exposure interviews
and inventories available to the clinician, in most cases
applicable to adolescents and adults. Among these are
the Potential Stressful Events Interview (PSEI; Falsetti,
Resnick, Kilpatrick, & Freedy, 1994; Kilpatrick, Resnick,
& Freedy, 1991), Stressful Life Events Screening Ques-
tionnaire (SLESQ; Goodman, Corcoran, Turner, Yuan, &
Green (1998), and Traumatic Events Scale (TES; Elliott,
1992). In addition, there are trauma exposure sections in
two frequently used trauma symptom measures: the Post-
traumatic Stress Diagnostic Scale (PDS; Foa, 1995) and
the Detailed Assessment of Posttraumatic Stress (DAPS;
Assessment of Complex Trauma405
Symptom Measures for Children and Adolescents
As opposed to the assessment of adults, there are
relatively few approaches to complex posttraumatic out-
comes available for use with children and adolescents.
The three most popular of these—one generic and two
trauma-specific—are reviewed below. A number of other
symptoms in children, but, by virtue of their less frequent
use with this population, are not reviewed here.
Child Behavior Checklist. The Child Behavior
Checklist (CBCL; Achenbach, 2002) is one of the most
widely used clinical instruments for the assessment of
general psychological distress in children, and often is
used to evaluate those who have experienced childhood
abuse (Friedrich, 2002). The current version appears to be
an improvement over the previous one, with new norms,
more items and scales, and specific reference to the dis-
orders detailed in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association, 1994). Unfortunately, the age
ranges for each normative group remain quite broad. The
most popular form of the CBCL is completed by a care-
taker or teacher, although there also is a self-administered
"Youth Self-Report" version for children from ages 11 to
18, and a new Young Adult Self-Report for individuals
ages 18 to 30. The CBCL measures a range of problems
that may arise from abuse or other traumatic events, such
delinquent behavior, as well as examining competencies
that may modify or reduce these problems.
Trauma Symptom Checklist for Children. The
Trauma Symptom Checklist for Children (TSCC; Briere,
1996) evaluates self-reported trauma symptoms in chil-
and Hyperresponse) and six clinical scales: Anxiety, De-
pression, Anger, Posttraumatic Stress, Sexual Concerns
(with two subscales),and Dissociation (with two sub-
scales). An alternate version of this measure (the TSCC-
A) does not evaluate sexual symptomatology. The TSCC
and inner city environments, and demonstrates good reli-
ability and validity in a number of studies (Briere, 1996;
it examines both trauma symptoms and common comor-
bidities, this instrument can evaluate complex posttrau-
matic outcomes. There is now a parent report version of
the TSCC for children 3 years of age or older, the Trauma
Symptom Checklist for Young Children (TSCYC; Briere,
2005; Briere et al., 2001), that approximates TSCC item
content, but examines PTSD symptom clusters in greater
Child Sexual Behavior Inventory. The Child Sexual
Behavior Inventory (CSBI; Friedrich, 1998) is a reliable
and valid measure that evaluates the sexual behaviors ob-
served in children, ages 2 to 12, during the prior 6 months
(Friedrich, 1998). Nine domains frequently associated
Boundary Problems, Exhibitionism, Gender Role Behav-
ior, Self-Stimulation, Sexual Anxiety, Sexual Interest,
Sexual Intrusiveness, Sexual Knowledge, and Voyeuris-
tic Behavior. The CSBI yields a total score and two scale
scores:Developmentally RelatedSexual Behavior, which
reflects the level of age and gender-appropriate sexual be-
havior; and Sexual Abuse Specific Items, which consists
of items that have been empirically related to a history of
sexual abuse. Normative data for the CSBI were collected
on over 1,000 children.
Because the number of standardized tests available
to evaluate complex posttraumatic symptoms in children
and adolescents is small, the options for the evaluator are
limited. Generally, the recommendation is to administer
both the Youth Self-Report form (if the child is age 11
or older) and the parent report versions of the CBCL, as
well as the TSCC and the TSCYC. If there is a possibil-
ity of sexual victimization, the CSBI also should be ad-
ministered. Additional, more generic tests may be added
to this battery as needed. Unfortunately, there are few
standardized tests available to assess children’s impaired
self-capacities. The situation is only slightly better for
older adolescents, whose self-disturbance also may be as-
sessed, to some extent, with the Minnesota Multiphasic
Personality Inventory–Adolescents (MMPI-A; Butcher et
al., 1992). As a result, the evaluator is forced to rely to
a greater extent on subjective interview data for children
than for adults.
Adult Self-Report Measures
Psychological tests of complex trauma effects in
adults can be divided into two groups: instruments that
tap a wide range of generic (i.e., nontrauma-specific) psy-
forms of posttraumatic disturbance.
A variety of psychological tests are available for the
assessment of nontrauma-specific symptoms in those ex-
posed to traumatic events. Several evaluate syndromes
relevant to Axis I of the DSM-IV (e.g., the Millon Clinical
406 Briere and Spinazzola
Multiaxial Inventory, 3rd Edition [MCMI-III], Millon,
1994; Minnesota Multiphasic Personality Inventory, 2nd
Edition [MMPI-2], Butcher, Dahlstrom, Graham, Telle-
gen, & Kaemmer, 1989; and the Psychological Assess-
ment Inventory [PAI], Morey, 1991). Each of the above-
mentioned tests also yield detailed information on those
sensitivity and specificity. Some generic instruments also
reporting of symptoms. Although validity scales can be
helpful, research indicates that traumatized individuals—
perhaps by virtue of the unusual quality of some post-
traumatic symptoms—tend to score higher than others
on negative impression scales, even when not attempting
to malinger (e.g., Elhai, et al., 2002; Jordan, Nunley, &
Posttraumatic Stress Measures
that tap symptoms without reference to a specific trauma,
and thus yield scores representing the overall "amount"
of posttraumatic symptoms currently experienced by an
individual in a variety of different areas, and those that
examine responses to a specific traumatic event and typ-
ically provide a provisional diagnosis of PTSD. Among
standardized tests, only one is available for the evaluation
of which are reviewed below) can be used to determine a
possible diagnosis of trauma-specific PTSD.
Trauma Symptom Inventory. The Trauma Symptom
Inventory (TSI; Briere, 1995) taps the overall level of
acute and chronic posttraumatic symptomatology experi-
enced by an individual without any specific reference to
any given traumatic event. It has been shown to have
good reliability and to demonstrate various indices of
validity (Briere, 1995). Each symptom item is rated ac-
cording to its frequency over the prior 6 months. The
TSI has three validity scales (Response Level, Atypi-
cal Response, and Inconsistent Response) and 10 clinical
scales (Anxious Arousal, Depression, Anger/Irritability,
Intrusive Experiences, Defensive Avoidance, Dissocia-
tion, Sexual Concerns, Dysfunctional Sexual Behavior,
Impaired Self-Reference, and Tension Reduction Behav-
ior), the latter of which appear sensitive to the effects of
a variety of different traumatic events (e.g., Green et al.,
2000; Runtz & Roche, 1999). The variety of symptoms
assessed by the TSI has resulted in the use of this measure
as a broad spectrum measure of complex posttraumatic
outcomes (e.g., Resick, Nishith, & Griffin, 2003).
matic Stress Diagnostic Scale (PDS; Foa, 1995) evaluates
four domains: exposure to potentially traumatic events,
characteristics of the most traumatic event, 17 symptoms
corresponding to DSM-IV PTSD criteria, and extent of
symptom interference in the individual’s daily life. The
spect to a PTSD diagnosis (.82 and .77, respectively) and
reasonable diagnostic efficiency (κ = .59). The PDS has
not been normed on the general population and thus does
not yield standardized T-scores. Instead, PTSD symptom
severity estimates are based on extrapolation from a clin-
ical sample of 248 traumatized women.
Detailed Assessment of Posttraumatic Stress. The
Detailed Assessment of Posttraumatic Stress (DAPS;
Briere, 2001) provides information on an adult client’s
history of exposure to various types of traumatic events
(Trauma Specification and Relative Trauma Exposure),
as well as containing scales that tap his or her immedi-
ate cognitive, emotional, and dissociative reactions (Per-
itraumatic Distress and Peritraumatic Dissociation), sub-
sequent posttraumatic stress symptoms (Reexperiencing,
Avoidance, and Hyperarousal), and level of experienced
disability (Posttraumatic Impairment) in the context of a
a potential DSM-IV diagnosis of PTSD. This measure has
of symptoms (Positive Bias and Negative Bias, respec-
tively), and three scales that measure common trauma
and PTSD-related comorbidities (Trauma-specific Disso-
ciation, Substance Abuse, and Suicidality). The DAPS is
normed on over 400 general population men and women
A traumatic event. The scales of this measure are inter-
nally consistent and demonstrate various forms of valid-
ity. The posttraumatic stress scales have good sensitivity
(.88) and specificity (.86) with respect to a CAPS PTSD
diagnosis, with an associated κ of .73 (Briere, 2001).
Complex posttraumatic outcomes often include dif-
ficulties in identity and boundary awareness, affect reg-
ulation, and interpersonal relationships. As a result, an
accurate evaluation of complex trauma usually includes
tests of the self domain.
Several tests have scales or subscales that tap one
or more aspects of impaired self-capacities, including the
Borderline Features subscales of the PAI, the Impaired
Self-reference scale of the TSI, and various personality
scales of the MCMI-III. In addition to the Rorschach
(Rorschach, 1981; described later), there are also two
Assessment of Complex Trauma 407
stand-alone standardized tests available to assess psycho-
logical functioning in this area.
Bell Object Relations and Reality Testing Inventory.
The only standardized test of what is generally referred to
as object relations, the Bell Object Relations and Reality
Testing Inventory (BORRTI; Bell, 1995) has scales that
ment, Egocentricity, and Social Incompetence. The BOR-
RTI item content also reflects identity issues and affect
regulation difficulties, although there are no scales specif-
ically tapping those domains. A very small literature in
uating self-capacity and attachment issues in traumatized
populations (e.g., Santina, 1998). Because this measure
reflects a specific underlying theoretical perspective (i.e.,
object relations), its use may be somewhat limited in gen-
eral trauma practice.
Inventory of Altered Self Capacities. The Inventory
of Altered Self Capacities (IASC; Briere, 2000a) is a
standardized test of difficulties in the areas of related-
ness, identity, and affect regulation. The scales of the
IASC assess the following domains: Interpersonal Con-
flicts, Idealization-Disillusionment, Abandonment Con-
cerns, Identity Impairment, Susceptibility to Influence,
Affect Dysregulation, and Tension Reduction Activities.
The IASCscaleshave been showntopredictself-reported
child abuse history (especially sexual and emotional mal-
treatment),adultattachment style,“borderline” and “anti-
social” personality features, relationship problems, suici-
(Briere, 2000a; Briere & Runtz, 2002). It is also designed
to predict certain issues (e.g., abandonment fears, ideal-
ization/devaluation, and hypersusceptibility to influence)
that otherwise might disrupt or derail the client–therapist
relationship during treatment. The IASC is standardized
on the general population and various clinical and univer-
convergent and discriminant validity.
Cognitive Disturbance Measures
As noted in the introduction, complex or sustained
traumatic events often produce relatively chronic cog-
nitive symptoms. Fortunately, there are available mea-
sures that tap cognitive distortions and negative relational
schemata. Two of these scales, especially helpful in the
assessment of complex posttraumatic outcomes, are pre-
Cognitive Distortions Scale (CDS). The Cognitive
Distortions Scale (CDS; Briere, 2000b) is a 40-item test
that measures five types of cognitive symptoms or dis-
tortions found among those who have experienced inter-
personal victimization: Self-Criticism, Self-Blame, Help-
lessness, Hopelessness, and Preoccupation with Danger.
gent validity with other cognitive distortion measures in
various clinical and nonclinical samples. The CDS scales
are predictive of childhood and adult interpersonal vic-
timization history, as well as suicidality, depression, and
posttraumatic stress (Briere, 2000b).
Trauma and Attachment Belief Scale. The Trauma
and Attachment Belief Scale (TABS; Pearlman, 2003)
measures disrupted cognitive schemata and need states
associated with exposure to traumatic events. This in-
strument taps five related content areas: Safety, Trust,
Esteem, Intimacy, and Control. There are reliable sub-
scales for each of these domains, rated both for "self"
and "other." Earlier versions of the TABS have been
shown to predict vicarious traumatization in therapists
and to vary as a function of trauma exposure on college
students, outpatients, battered women, and the homeless
(Pearlman, 2003). In contrast to more symptom-based
tests, the TABS measures the self-reported needs and ex-
pectations of trauma survivors as they predict self in rela-
tion to others. As a result, the TABS is likely to be helpful
in understanding important assumptions that the client
carries in his or her relationships to others, including the
Despite the potential importance of dissociation in
complex posttraumatic disturbance, until recently clin-
icians have had to rely on unstandardized measures
when assessing this domain. The most popular of such
instruments, the Dissociative Experiences Scale (DES;
Bernstein & Putnam, 1986) has good psychometric char-
acteristics, including predictive validity for dissociative
identity disorder when a cut-off score of 30 is used
(Carlson et al., 1993). However, as noted earlier, the ab-
cut-off) is not easily interpreted in terms of its extremity
from "normal" dissociative responses (Armstrong, 1995).
Further, like most other dissociation measures, the DES
and thus does not discriminate between those who experi-
those with dissociative identity disorder. Because dissoci-
ationappears tobeamultidimensionalphenomenon (e.g.,
Briere, Weathers, & Runtz, 2005), single-score measures
in this area sometimes are problematic.
408 Briere and Spinazzola
Currently, there are three scales within larger stan-
dardized tests that tap dissociative symptoms (the Dis-
sociation scale within the TSI, and the Trauma-Specific
Dissociation and Peritraumatic Dissociation scales of the
DAPS), as well as one freestanding standardized test of
dissociative responses, the 30-item Multiscale Dissocia-
tion Inventory (MDI; Briere, 2002b). In contrast to the
TSI, DAPS, or DES, which yield a single score, and
thus overlook dimensionality, the MDI consists of six
internally consistent scales (Disengagement, Depersonal-
ization, Derealization, Memory Disturbance, Emotional
Constriction, and Identity Dissociation) that, together,
as expected with victimization history, PTSD, and other
measures of dissociation. Analyses in a sample of over a
thousand clinical and nonclinical individuals indicate that
the MDI has substantial factorial validity (Briere et al.,
2005). In another study, the Identity Dissociation scale
had a specificity of .92 and a sensitivity of .93 with re-
spect to a dissociative identity disorder diagnosis (Briere,
Measures of Dysfunctional Behavior
As noted earlier, many individuals who suffer com-
plex posttraumatic symptoms (perhaps especially those
with affect regulation problems) engage in externaliza-
with trauma-related memories and affects. In addition to
the Tension Reduction Behavior (TRB) scale of the TSI,
and the Tension Reduction Activities (TRA) of the IASC,
various measures can be used to assess specific dysfunc-
tional behaviors common to complex posttraumatic dis-
tress. These include the Dysfunctional Sexual Behavior
(DSB) scale of the TSI, the Suicidality scale of the DAPS
(as well freestanding suicide measures, such as the Adult
the Eating Disorders Inventory [EDI-2], Garner, 1990),
and the Substance Abuse scale of the DAPS.
The Rorschach differs from the other instruments
described in that it is a projective test, rather than a
self-report or interview measure. Although there is some
controversy regarding the general clinical utility of the
Rorschach (e.g., Hunsley & Bailey, 2001), a review of
the extant literature indicates a significant empirical rela-
tionship between various Rorschach indicators and both
trauma exposure and posttraumatic stress (Luxenberg &
Levin, 2004). Unfortunately, when interpreted by those
without specific trauma training, some complex posttrau-
testing or personality disorder on this test (e.g., Van der
Kolk & Ducey, 1989).
Adult Interview-Based Measures
Posttraumatic Stress Disorder Interviews
There are several structured clinical interviews for
the diagnosis of PTSD. In several cases, these instru-
ments were developed and validated for DSM-III (APA,
1980) or DSM-III-R (APA, 1987), and have less psycho-
metric data available for their DSM-IV (APA, 1994) ver-
sions. Two interviews, however, demonstrate good psy-
in research and clinical applications. See Briere (2004),
Carlson (1997), and Wilson and Keane (2004) for more
detailed reviews of trauma-relevant interviews.
The Clinician-Administered Posttraumatic Stress
Disorder Scale. The Clinician-Administered Posttrau-
matic Stress Disorder Scale (CAPS; Blake et al., 1995)
is a structured diagnostic interview that generates both di-
chotomous and continuous scores for current and lifetime
PTSD diagnosis, the CAPS demonstrates good reliability
and validity in a variety of contexts (Weathers, Keane,
& Davidson, 2001). In addition to diagnostic items, this
interview also examines trauma exposure, posttraumatic
impacts on social and occupational functioning, response
validity, and overall PTSD severity, as well as guilt and
acute dissociative symptoms. One potential limitation of
the CAPS is that its detail and length can extend adminis-
tration time to an hour or longer in some instances.
The PTSD Module of the Structured Clinical Inter-
Spitzer, Gibbon, & Williams, 1997) includes a PTSD
module, a component that was optional in the DSM-III-R
version of this interview. The SCID has the advantage of
screening for a variety of disorders in addition to PTSD,
although, as with previous versions, it does not assess for
the dissociative disorders. Its broad diagnostic range pro-
vides a more comprehensive clinical picture than is avail-
able with most trauma-specific measures, thereby making
it potentially appropriate for the assessment of more com-
plex posttraumatic outcomes.
Interviews for Other Disorders or Constructs
The Structured Clinical Interview for DSM-IV Dis-
sociative Disorders. The Structured Clinical Interview
Assessment of Complex Trauma409
for DSM-IV Dissociative Disorders (SCID-D; Steinberg,
identity confusion, and identity alteration. This interview
disorders, along with acute stress disorder. Also evaluated
by the SCID-D are "intra-interview dissociative cues,"
such as alterations in demeanor, spontaneous age regres-
The Structured Interview for Disorders of Extreme
Stress.The Structured Interviewfor Disordersof Extreme
Stress (SIDES; Pelcovitz et al., 1997) was developed as
a companion to existing interview-based rating scales for
lifetime presence of the proposed diagnosis, disorders of
extreme stress—not otherwise specified (DESNOS; Van
der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005).
The SIDES evaluates the presence of the total DESNOS
construct and each of six symptom clusters: Affect Dys-
regulation, Somatization, and Alterations in Attention or
Consciousness, Self-Perception, Relationships with Oth-
ers, and Systems of Meaning. Item descriptors contain
concrete behavioral anchors to facilitate clinician ratings.
The SIDES interview has good interrater reliability (κ =
(Pelcovitz et al., 1997; Zlotnick & Pearlstein, 1997).
ment of adult complex posttraumatic symptoms. First, in
most cases, at least two broadband screening instruments
should be administered: one for general psychological
symptomatology (e.g., the PAI or MMPI) and at least one
for general trauma-related disturbance (e.g., the TSI or
SIDES). If, based on these tests or the general clinical in-
terview, PTSD is suspected, a diagnostic test or interview
additional trauma outcomes are possible, the interviewer
should administer whatever tests or interviews seem most
relevant, including those tapping dissociation (e.g., the
SCID-D or MDI), cognitive issues (e.g., the CDI), self-
other schema (e.g., the TABS), suicidality (e.g., the ASIQ
or DAPS), or disturbed self-capacities (e.g., the IASC,
BORRTI, or Rorschach).
Complex posttraumatic responses reflect the wide
variety of potential adverse experiences in the world and
the many biological, social, cultural, and psychological
variables that moderate the impact of these experiences.
In this context, the notion of a “one-size-fits-all” diagno-
sis (e.g., PTSD or DESNOS) often is untenable. Instead,
the clinician should consider the entire range of posttrau-
matic responses potentially attributable to a given client’s
history and risk factors. In many cases, this may require
rent with, other tests relevant to the individual’s specific
Evaluation of complex posttraumatic outcomes not
only informs diagnosis, but can assist in treatment. As-
sessment approaches that examine the full range of po-
tential trauma responses may highlight treatment targets
tifying trauma symptoms within more generic syndromes
(e.g., dissociative symptomatology in the context of a ma-
jor depressive disorder) or generic symptoms within a
stress disorder (e.g., significantly distorted cognitions in
an instance of PTSD). In addition, because most tests of
complex posttraumatic outcomes measure symptoms as
continuous variables (as opposed to dichotomous diag-
noses), assessment may help determine the relative extent
of posttraumatic symptomatology, rather than solely the
presence or absence of a DSM-IV disorder. Further, such
continuous measures can be administered periodically to
evaluate increments of treatment-related improvement or
exacerbation over time.
Measures of complex posttraumatic symptomatol-
has a significant drug abuse history or suffers from affect
regulation difficulties may lead the clinician to eschew a
stress symptoms and, instead, use an empirically sup-
on cognitive phenomena (e.g., Resick & Schnicke, 1993),
or more directly addresses substance abuse issues (e.g.,
The last decade has witnessed the development of
a growing number of psychometrically valid tests and
icians become more aware of the range and potential
complexity of at least some posttraumatic psychological
disturbance, the importance of such psychological assess-
ment becomes clear. With greater quantitative focus and
clinical specificity, the full range of trauma outcomes can
be more clearly delineated and, as a result, more directly
addressed in treatment.
410 Briere and Spinazzola
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