Attachment B36-7 DISC PTSD

0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

START NEW CARD
DUP COL 1 - 10
MOD.

A

9

[11 - 12]

CARD NO. 0

1
b

[13 - 14]
[15]

PTSD
Now I’m going to ask you about upsetting things that sometimes happen to children or
teenagers.
1.

Has ________ ever been in a flood … or a tornado … or an earthquake … or
hurricane … or some other natural disaster where [he/she] thought [he/she] was
going to die or be seriously injured?

0

2*

7

9

[16]

2.

Has [he/she] ever been in a situation where [he/she] or someone close to [him/her]
could have been killed … or could have been hurt very badly?

0

2*

7

9

[17]

3.

Has [he/she] ever been attacked by somebody … or badly beaten?

0

2*

7

9

[18]

4.

Has [he/she] ever been very upset by someone forcing [him/her] to do something
sexual that [he/she] really didn’t want to do?

0

2*

7

9

[19]

IF YES, A. Has [he/she] ever been attacked sexually or raped?

0

2*

7

9

[20]

5.

Has [he/she] ever been threatened with a weapon?

0

2*

7

9

[21]

6.

Has [he/she] ever been in a bad accident?

0

2*

7

9

[22]

7.

Other than on television or at the movies, has ________ ever seen or heard
somebody get killed … or get hurt very badly … or die?

0

2*

7

9

[23]

8.

Has [he/she] ever been very upset by seeing a dead body … or by seeing pictures
of the dead body of somebody [he/she] knew well?

0

2*

7

9

[24]

a:

IF ANY * RESPONSES WERE CODED IN Q 1 - 8, GO TO
INSTRUCTION BOX “b”
ALL OTHERS, GO TO MODULE B

b:

IF ONLY ONE * RESPONSE WAS CODED IN Q 1 - 8, CONTINUE
ALL OTHERS, GO TO Q 10

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 77

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0=NO

9.

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

You said that [he/she] [NAME * SITUATION IN Q 1 - 8]. Has something like this
happened to [him/her] more than once?

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

0

2

7

9

[25]

0

2

7

9

[26]

10. You said that [he/she] [NAME * SITUATION(S) IN Q 1 - 8]. Did these things all
happen at the same time?

0

2

7

9

[27]

IF NO, A. Has [he/she] talked about any of those things in the last year?

0

2

7

9

[28]

IF NO, GO TO Q 10C
IF YES, A. Has [he/she] talked about any of those things in the last year?
IF NO, GO TO MODULE B
IF YES, B. Which did [he/she] talk about most? (GET FULL
DESCRIPTION)

GO TO INSTRUCTION BOX “c”

IF NO, GO TO MODULE B
IF YES, B. Which did [he/she] talk about most? (GET FULL
DESCRIPTION)

GO TO INSTRUCTION BOX “c”
IF YES, C. What happened to [him/her]?

CODE TRAUMATIC EVENT HERE ----------------------------->

c:

|____ ____ ____|

[29-31]

For the rest of the section: TRAUMATIC EVENT refers to the
traumatic situation described in Q 9B, 10B, or 10C.

11. In the last year, has it seemed to you by the way [he/she] talked or acted that [he/
she] was often thinking about what [happened/[he/she] saw] ?

0

2

7

9

[32]

IF NO, GO TO MODULE B
Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 78

[5/20/98]

0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

12. Did ________ say that [he/she] felt very afraid when [he/she] [was/saw/heard]
[TRAUMATIC EVENT]?

0

2

7

9

[33]

13. Did [he/she] say that when [he/she] [was/saw/heard] [TRAUMATIC EVENT],
[he/she] felt helpless … or felt bad that [he/she] couldn’t do anything to stop it?

0

2

7

9

[34]

14. When [he/she] [was/saw/heard] [TRAUMATIC EVENT], did [he/she] act like
[he/she] was going crazy … like [he/she] didn’t know what to do or say next?

0

2

7

9

[35]

15. Did [TRAUMATIC EVENT] happen in the last year – that is, since [[NAME
EVENT]/[NAME CURRENT MONTH] of last year]?

0

2

7

9

[36]

16. [In the last year – that is, since [NAME EVENT]/[NAME CURRENT MONTH]
of last year//Since [TRAUMATIC EVENT]] – has ________ said that [he/she]
often thought about [[TRAUMATIC EVENT]/what happened] even though [he/
she] didn’t want to think about it?

0

2

7

9

[37]

IF YES, A. Did [he/she] say that [he/she] thought about it a lot even when
[he/she] was (at [school/work] or when [he/she] was) doing things
with other people?

0

1

2

7

9

[38]

B. Did thinking about [TRAUMATIC EVENT] seem to upset [him/her]
a lot?

0

1*

2*

7

9

[39]

C. Now, what about the last four weeks?
Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]], has [he/she] said that [he/she] often thinks about
[TRAUMATIC EVENT]?

0

2

7

9

[40]

d:

e:

IF SUBJECT 12 YRS. OR OLDER, CODE “8” IN Q 14,
THEN GO TO Q 15

8

READ INTRODUCTORY STATEMENT BELOW ONLY IF
EVENT OCCURRED MORE THAN ONE YEAR AGO.
The next set of questions are about things [he/she] may have done in the
last year.

f:

IF EVENT OCCURRED MORE THAN ONE YEAR AGO, READ
“IN THE LAST YEAR” IN QUESTIONS 16 - 33. IF EVENT OCCURRED IN LAST YEAR, READ “SINCE [TRAUMATIC EVENT]”
IN QUESTIONS 16 - 33?

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 79

[5/20/98]

0=NO

g:

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

IF SUBJECT 12 YRS. OR OLDER, CODE “8” IN Q 17,
THEN GO TO NOTE 1

17. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] often played games
where something or someone gets hurt or scared in the same way that happened in
[TRAUMATIC EVENT]?

0

2*

7

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] played these games?

0

2

7

NOTE 1:

0

[2]

WAS A * RESPONSE CODED IN Q 16 OR Q 17?

18. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] had problems falling
asleep or staying asleep?

0

IF YES, A. Does [he/she] have more trouble sleeping than [he/she] used to …
before [TRAUMATIC EVENT]?

9

[41]

9

[42]

[43]

2

7

9

[44]

0

[2]

7

9

[45]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] had
trouble sleeping?

0

2

7

9

[46]

19. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] had a lot of
nightmares?

0

[2]

7

9

[47]

2

7

9

[48]

IF YES, A. Were these nightmares about [TRAUMATIC EVENT]?

0

1

8

1

B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] had a lot of nightmares?

0

2

7

9

[49]

20. [In the last year/Since [TRAUMATIC EVENT]], has ________ ever said that [he/
she] felt like [he/she] was reliving what happened … that [he/she] felt like
[[TRAUMATIC EVENT]/it] was happening all over again?

0

[2]

7

9

[50]

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] said that it felt like [TRAUMATIC
EVENT] was happening all over again?

0

2

7

9

[51]

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 80

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0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

21. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] said that there
have been certain things that usually made [him/her] remember [[TRAUMATIC
EVENT]/it]?

0

2

7

9

[52]

IF YES, A. [In the last year/Since [TRAUMATIC EVENT]], when [he/she] was
reminded of [[TRAUMATIC EVENT]/it] would [he/she] seem very
nervous or upset?

0

[2]

7

9

[53]

IF YES, B. Has this happened in the last four weeks?

0

2

7

9

[54]

0

[2]

7

9

[55]

0

2

7

9

[56]

22. [In the last year/Since [TRAUMATIC EVENT]], has it seemed like [he/she] tried
very hard not to think about [[TRAUMATIC EVENT]/it] and not to hear about it
or talk about it?

0

[2]

7

9

[57]

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] tried very hard not to think or hear
or talk about [TRAUMATIC EVENT]?

0

2

7

9

[58]

23. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] stopped going places
or doing things that might make [him/her] think about it?

0

2*

7

9

[59]

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] not gone places or done things that
might make [him/her] think about TRAUMATIC EVENT]?

0

2

7

9

[60]

24. [In the last year/Since [TRAUMATIC EVENT]], has ________ tried to keep away
from people who might remind [him/her] of [[TRAUMATIC EVENT]/what
happened]?

0

2*

7

9

[61]

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] tried to keep away from people who
might remind [him/her] of [TRAUMATIC EVENT]?

0

2

7

9

[62]

NOTE 2:

0

[2]

25. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] said that no matter
how hard [he/she] tried to remember [TRAUMATIC EVENT/it] there are parts of
what happened that [he/she] couldn’t remember?

0

[2]

7

9

[64]

IF YES, A. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle of/the end of
[LAST MONTH]]), has [he/she] said that there are parts of what
happened that [he/she] can’t remember even when [he/she] tries?

0

2

7

9

[65]

C. [In the last year/Since [TRAUMATIC EVENT]], when these things
reminded [him/her] of [[TRAUMATIC EVENT]/what happened],
would [he/she] start to sweat or feel like [he/she] was going to faint?
IF YES, D. Has this happened in the last four weeks?

WAS A * RESPONSE CODED FOR Q 23 - 24?

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 81

[63]

[5/20/98]

0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

26. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] seemed less interested in things [he/she] used to enjoy?

0

2

7

9

[66]

IF YES, A. Was that a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[67]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] seemed
less interested in things that [he/she] used to enjoy?

0

2

7

9

[68]

27. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] said that [he/she] felt
separate or far away from other people as if [he/she] didn’t fit in with them?

0

2

7

9

[69]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[70]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] said [he/
she] felt separate or far away from other people?

0

2

7

9

[71]

28. [In the last year/Since [TRAUMATIC EVENT]], has it seemed like ________
stopped feeling strongly about other people so that [he/she] didn’t show any
affection towards anyone or didn’t show anger or any other feelings?

0

2

7

9

[72]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[73]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has it seemed like [he/
she] had no strong feelings one way or the other
towards other people?

0

2

7

9

[74]

29. [In the last year/Since [TRAUMATIC EVENT]], did [he/she] stop talking about
the future or about things [he/she] might do when [he/she] [grows up/is older]?

0

2

7

9

[75]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[76]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] talked
less about the future?

0

2

7

9

[77]

30. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] lost [his/her] temper
a lot or been more irritable or grouchy?

0

2

7

9

[78]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[79]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] lost [his/
her] temper or been very irritable or grouchy?

0

2

7

9

[80]

START NEW CARD
DUP COL 1 - 12
CARD NO. 0
Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 82

2
b

[13 - 14]
[15]

[5/20/98]

0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

31. [In the last year/Since [TRAUMATIC EVENT]], has it been very hard for [him/
her] to keep [his/her] mind on things or to concentrate?

0

2

7

9

[16]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[17]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has it seemed very
hard for [him/her] to keep [his/her] mind on things?

0

2

7

9

[18]

32. [In the last year/Since [TRAUMATIC EVENT]], has ________ been very jumpy
or nervous when [he/she] heard noises or when people were moving around [him/
her] or touched [him/her]?

0

2

7

9

[19]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[20]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] been very
jumpy or nervous like this?

0

2

7

9

[21]

33. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] jumped at sudden
noises or when someone spoke to [him/her]?

0

2

7

9

[22]

IF YES, A. Was this a change from how [he/she] was before [TRAUMATIC
EVENT]?

0

[2]

7

9

[23]

IF YES, B. Now, what about the last four weeks?
(Since [[NAME EVENT]//the beginning of/the middle
of/the end of [LAST MONTH]]), has [he/she] often
jumped at sudden noises?

0

2

7

9

[24]

34. You said that [he/she] [NAME ALL * ITEMS AND [ ] SYMPTOMS IN Q 16 - 33
AND NOTES 1 - 2]. Was [he/she] bothered by most of these things for as long as
a month?

0

2*

7

9

[25]

IF NO, A. Was [he/she] bothered by these things for two days or longer?

0

2*

7

9

[26]

IF YES, B. Was [he/she] bothered by most of these things for three months or
longer?

0

2

7

9

[27]

h:

IF 3 OR MORE [ ] RESPONSES WERE CODED IN Q 16 - 33,
AND NOTES 1 - 2 (see tally sheet), CONTINUE
ALL OTHERS, GO TO MODULE B

i:

IF * RESPONSE TO Q 34 OR Q 34A, CONTINUE
ALL OTHERS, GO TO MODULE B

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 83

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0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

35. How soon after [TRAUMATIC EVENT] did [he/she] start feeling bothered by
these things? Was it (INTERVIEWER: stop at first yes) … right away … or did they
start less than a month after [TRAUMATIC EVENT] … or was it less than six
months … or did it start after that?
Right away ......................................................................................
Within one month ...........................................................................
One month to less than six months .................................................
Six months or longer .......................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................

4
3
2
1
7
9

[28]

36. You said that in the last year [he/she] [NAME ALL * ITEMS AND [ ] SYMPTOMS
IN Q 16 - 33 AND NOTES 1 - 2].
Now, I’d like you to think back to the time in the last year when the way [he/she]
felt or acted caused the most problems.
At that time, did [you (or [his/her] [CARETAKERS])/[his/her] [CARETAKERS]]
get annoyed or upset with ________ because of the way [he/she] felt or acted
because of [TRAUMATIC EVENT]?

0

1

2

7

9

[29]

IF YES, A. How often did [you (or [his/her] [CARETAKERS])/[his/her] [CARETAKERS]] get annoyed or upset with [him/her] because [he/she] was
like that? Would you say: a lot of the time, some of the time, or hardly
ever?
A lot of the time ..............................................................................
Some of the time .............................................................................
Hardly ever .....................................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................
37. At that time, did the way ________ felt or acted after [TRAUMATIC EVENT]
seem to keep [him/her] from doing things or going places with [you or [his/her]
family/[his/her] family]?

3
2
1
7
9
0

[30]

1

2

7

9

[31]

IF YES, A. How often did being like that keep [him/her] from doing things or
going places with [you or [his/her] family/[his/her] family? Would
you say: a lot of the time, some of the time, or hardly ever?
A lot of the time ..............................................................................
Some of the time .............................................................................
Hardly ever .....................................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................
38. At that time, did the way [he/she] felt or acted seem to keep [him/her] from doing
things or going places with other [children/people [his/her] age]?

3
2
1
7
9
0

[32]

1

2

7

9

[33]

IF YES, A. How often did being like that keep [him/her] from doing things or
going places with other [children/people [his/her] age]? Would you
say: a lot of the time, some of the time, or hardly ever?
A lot of the time ..............................................................................
Some of the time .............................................................................
Hardly ever .....................................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................
Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 84

3
2
1
7
9

[34]

[5/20/98]

0=NO

j:

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

IF CHILD DID NOT ATTEND SCHOOL OR WORK IN LAST
YEAR, CODE “8” IN Q 39 AND Q 40, THEN GO TO Q 41

39. When the problems were worst, did the way [he/she] felt or acted seem to [make
it difficult for [him/her] to do [his/her] schoolwork or cause problems with [his/her]
grades/make it difficult for [him/her] to do [his/her] work]?

0

1

2

7

8

9

[35]

IF YES, A. How bad were the problems [he/she] had with [his/her] [schoolwork/
work] because [he/she] was like that? Would you say: very bad, bad,
or not too bad?
Very bad ..........................................................................................
Bad ..................................................................................................
Not too bad ......................................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................
40. At that time, did the way [he/she] felt or acted cause ___________’s [teachers/boss]
to be annoyed or upset with [him/her]?

3
2
1
7
9
0

[36]

1

2

7

8

9

[37]

IF YES, A. How often [were/was] [his/her] [teachers/boss] annoyed or upset
with [him/her] because [he/she] was like that? Would you say: a lot
of the time, some of the time, or hardly ever?
A lot of the time ..............................................................................
Some of the time .............................................................................
Hardly ever .....................................................................................
Refuse to answer .............................................................................
Don’t know .....................................................................................
41. When the problems were worst, did it seem like the way ________ felt or acted after
[TRAUMATIC EVENT] made [him/her] feel bad or made [him/her] feel upset?

3
2
1
7
9
0

[38]

1

2

7

9

[39]

IF YES, A. How bad did being like that seem to make [him/her] feel? Would you
say: very bad, bad, or not too bad?
Very bad ..........................................................................................
Bad ..................................................................................................
Not too bad ......................................................................................
Refused to answer ...........................................................................
Don’t know .....................................................................................

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

Page 85

3
2
1
7
9

[40]

[5/20/98]

0=NO

1=SOMETIMES/SOMEWHAT

2=YES

7, 77=REFUSE TO ANSWER

42. [In the last year/Since [TRAUMATIC EVENT]], has [he/she] been to see someone
at a hospital or a clinic or at their office because of the way [he/she] felt or acted
after [[TRAUMATIC EVENT]/it happened]?

8, 88=NOT APPLICABLE

9, 99=DON’T KNOW

0

2

7

9

[41]

0

2

7

9

[42]

IF YES, GO TO OPTIONAL DETAILS
IF NO, A. Does [he/she] have an appointment set up to see someone because of
the way [he/she] has felt or acted?
IF YES, GO TO OPTIONAL DETAILS

OPTIONAL DETAILS:
43.

Who [did _________ see/is _________ going to see]? (WRITE IN:)
Name:

|____ ____|

[43-44]

|____ ____|

[45-46]

Profession:
Address:
A. IF SOMEONE WAS SEEN, ASK:
What did the person [he/she] saw say was the matter?

Module A:
Post-Traumatic Stress Disorder
DISC IV-P, past year

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