A Longitudinal Evaluation of the Mississippi Scale

for Combat-Related PTSD in Detecting War-Related

Stress Symptomatology
Ä

Patrick Sloan and Linda Arsenault

Veterans Affairs Medical Center, Mountain Home, Tennessee
Ä

Mark J. Hilsenroth
University of Arkansas

The long-term psychological effects of war-related stress were assessed 3

years after the Persian Gulf War with 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).
The M-PTSD-DS scores of 30 Marine reservists were compared with the
number of DSM-III-R PTSD criteria each met at two points in time, initially
at 3 months after the Gulf War and again 3 years later. Findings support
the construct validity (sensitivity) of this scale in the immediate and lon-
gitudinal measurement of relatively nonpathological degrees of war-
related stress in reservists not involved in direct fighting. Initial level of
PTSD symptomatology upon returning from a war zone was predictive of
M-PTSD-DS scores 3 years later. This scale was effective in detecting
varying degrees of war-related stress in this self-selected group of reserv-
ists and warrants further study. © 1998 John Wiley & Sons, Inc. J Clin
Psychol 54: 1085–1090, 1998.

The psychological effects of war on soldiers have received a considerable amount of

attention (Berk et al., 1989; Gerardi, Keane, & Penk, 1989; Glover, 1988; Kulka et al.,
1991; Sutker, Uddo-Crane, & Allain, 1991; Watson, Juba, & Anderson, 1989), culminat-
ing in the belief that war-related stress reactions have potentially lasting effects that can
leave soldiers emotionally vulnerable for extended periods of time (Green, Lindy, Grace,

Correspondence concerning this article should be addressed to Patrick Sloan, Ph.D., Chief, Psychology Service
(116B-2), VA Medical Center, Mountain Home, Tennessee 37684.

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 54(8), 1085–1090 (1998)

© 1998 John Wiley & Sons, Inc. CCC 0021-9762/98/081085-06
1086 Journal of Clinical Psychology, December 1998

& Gleser, 1989; Kulka et al., 1991; Solomon, 1989; Wheatley & Ursano, 1982). How-
ever, a limited amount of research has addressed the longitudinal course of posttraumatic
stress (PTS) symptomatology (Solomon, 1987; Solomon & Mikulincer, 1987, 1988; Sol-
omon, Oppenheimer, & Noy, 1986; Ursano, Wheatley, Sledge, Rahe & Carlson, 1986;
Wheatley & Ursano, 1982). Typically, this research has focused on war zone combatants
or former prisoners of war. A number of authors, however, have identified the need to
ascertain the sensitivity of various instruments in the assessment of varying degrees of
PTS, the identification of war zone stress on noncombatants (i.e., those not involved in
direct fighting), and the assessment of long-term psychological functioning in the after-
math of war-related stressors (Berk et al., 1989; Fontana, Rosenheck, & Brett, 1992;
Kulka et al., 1991; Litz et al., 1991b; McFall, Smith, Mackay, & Tarver, 1990).
The Mississippi Scale for Combat-related PTSD (M-PTSD; Keane et al., 1988) has
been found useful as a screening measure of PTSD in Vietnam combat veterans (Blake,
Cook, & Keane, 1992; Kulka et al., 1991; McFall et al., 1990), and more recently, the
Desert Storm version M-PTSD-DS was useful in detecting PTS in Persian Gulf War
veterans (Sloan, Arsenault, Hilsenroth, & Harvill, 1995). The M-PTSD was developed to
assess the domain of PTSD symptoms using the diagnostic criteria of the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric
Association, 1980) as a guideline.
Although research has been conducted on the utility of this measure in assessing
Posttraumatic Stress Disorder (PTSD), the sensitivity in assessing the longitudinal course
of subclinical levels of PTS is relatively unexplored. One identified area of interest is the
longitudinal effects of war zone stress on noncombatants and the link between these
objective scores and stress symptomatology (Berk et al., 1989; Litz et al., 1991b; Lyons
& Keane, 1992). Additional longitudinal research is needed to better understand the psy-
chological impact of acute PTS symptomatology and long-term effects of exposure to
war stressors.
The present study examines the utility of the M-PTSD-DS in the evaluation of war-
related PTS and PTSD symptoms. This study compares the M-PTSD-DS scores and
number of PTSD criteria met by 30 Marine reservists who were not involved in direct
fighting at an initial evaluation shortly after returning home from the Gulf War and again
3 years later. This study is distinctive for several reasons. First, this is the first study using
the M-PTSD-DS that attempts to investigate this issue. Second, participants were tested
initially 3–5 ½ months after their war zone experience, the briefest period between expo-
sure to war and testing in any study to date with the Mississippi scales or other self-report
measures (i.e., MMPI-2, IES). Third, most of the published studies of war-related stress
were done more than 5 years after soldiers returned home, which increased the potential
influence of other comorbidities, such as substance abuse or psychiatric disorders (Kulka
et al., 1991; Sutker et al., 1991). Fourth, data obtained within 6 months of exposure to
trauma reduces the likelihood that the individual may minimize, distort, or exaggerate
experiences or symptoms (Henderson, Byrne, & Duncan-Jones, 1981; McFarlane, 1988;
Paykel, 1983). Finally, none of our participants had sought psychological treatment or
disability benefits, which distinguished them from veterans in previous studies with chronic
stress syndromes or PTSD.

METHOD
Participants
Participants were 30 Marine reservists who volunteered for further evaluation in the
Mountain Home Veterans Affairs Medical Center, Operation Desert Storm (ODS) out-
 Longitudinal Evaluation of PTS 1087

reach project. All participants were white men, typically young (M 5 22 years), single,
enlisted personnel with 12 or more years of education (M 5 13.5 years). None were
involved in direct fighting, but all were exposed to war zone stressors. Additional demo-
graphics of the sample, enumeration of war zone experiences, and procedures of initial
testing are detailed in Sloan et al. (1995). None of these Marines had a premorbid history
of PTSD, psychiatric condition, or psychiatric hospitalization prior to ODS. After the
Gulf War, all 30 participants had been identified as experiencing acute, war-related PTS
during postwar debriefing interviews at a Reserve Training Center, 90 days after their
return from ODS.
Acute PTS was defined as the presence for at least 1 month of one or more symptoms
of PTSD listed in the Diagnostic and Statistical Manual of Mental Disorders, Third
Edition, Revised (DSM-III-R; American Psychiatric Association, 1987) without meeting
the full diagnostic criteria for PTSD. Of 17 possible DSM-III-R symptoms defining PTSD,
participants reported an average of 3.33 symptoms (range 5 1–13) with four Marines
initially meeting the criteria for a diagnosis of PTSD (a minimum of 6 symptoms in
respective domains for a duration of at least one month is required by DSM-III-R). At the
3-year follow-up, participants reported an average of 1.03 symptoms of PTSD (range 5
0–5), which was significantly lower than the mean symptom average obtained during the
initial evaluation ( p , .001), and none of the participants met criteria for PTSD.

Measure
The Mississippi Scale for Desert Storm War Zone Personnel (M-PTSD-DS) is derived
from the M-PTSD, which was originally a 35-item scale to assess a wide range of symp-
toms of combat-related PTSD and associated psychosocial disturbances. The M-PTSD-DS
was distributed to Veterans Affairs (VA) clinical outreach teams as part of the Operation
Desert Storm Clinician Packet (Abueg et al., 1991) developed by the VA National Center
for PTSD. The M-PTSD-DS is a slightly modified version of the M-PTSD that is more
applicable for ODS personnel. Modifications were as follows: (a) The wording of the
items reflect Persian Gulf War content, (b) items 3 and 5 were changed to better accom-
modate the experiences of women veterans, and (c) three new items (36–38) were added
regarding memory difficulties and hyperarousal symptoms (Litz et al., 1991a). The clin-
ical cutoff score of 107 used for the M-PTSD was also recommended for M-PTSD-DS. A
score of 107 on the M-PTSD has been shown to accurately identify veternas with PTSD
90% of the time (Keane et al., 1988).
At initial testing, none of the 30 participants scored above the M-PTSD criterion of
107 (Keane et al., 1988). Only three veterans, all of whom met criteria for PTSD, exceeded
the M-PTSD cutoff 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 5 63.6, SD 5
14.7) and fell within normal parameters (Keane et al., 1988; Kulka et al., 1991; McFall
et al., 1990). At 3-year follow-up, participants’ scores were again well within the normal
range based upon M-PTSD criteria; (M 5 62.0, SD 5 14.0; Kulka et al., 1991). Only one
of the three veterans continued to exceed the cutoff score of 89; however, this individual
no longer met criteria for PTSD at the 3-year follow-up. A comparison of the M-PTSD-DS
scores at initial testing and at 3-year follow-up were not significant (t 5 .72, p 5 ns).

Procedure
Approximately 3 years (i.e., 36–37 months) after initial testing, we contacted 30 Marines
for further individual evaluation at the VA Medical Center. All 30 Marines in the group
1088 Journal of Clinical Psychology, December 1998

participated in the 3-year follow-up assessment. Each Marine was administered individ-
ually the M-PTSD-DS at both evaluations. All the participants received financial remu-
neration for their time. Data were analyzed to determine if there were significant
relationships among the variables of interest and the relationship of these variables over
time.

RESULTS
Comparison of the number of PTSD symptoms and total M-PTSD-DS scores at the initial
time of testing and 3-year follow-up are presented in Table 1. As noted previously, the
M-PTSD-DS scores at the initial testing were significantly and positively correlated with
the number of PTSD symptoms reported by the Marines at that time (r 5 .82, p , .0001;
Sloan et al., 1995). In the current study, there was an equally strong relationship exhibited
between veterans’ M-PTSD-DS scores and number of PTSD symptoms reported at the
3-year follow-up assessment (r 5 .82, p , .0001). Although the relationship between the
number of PTSD symptoms reported at the initial evaluation and 3 years later was not
significant (r 5 .33, p 5 .08), M-PTSD-DS scores at these two separate points in time
were significantly related to one another (r 5 .62, p 5 .0002).
Regarding the question of whether M-PTSD-DS scores and number of PTSD symp-
toms at 3-year follow-up can be predicted from the same variables at the initial evalua-
tion, an individual’s initial score on the M-PTSD-DS was significantly related to the
number of PTSD symptoms he reported 3 years later (r 5 .48, p 5 .006). Also, a strong
relationship existed between the initial number of PTSD symptoms reported by these
veterans and their subsequent M-PTSD-DS scores 3 years later (r 5 .55, p 5 .001).

DISCUSSION
Although the veterans’ scores did not reach pathological levels at either time of testing,
M-PTSD-DS scores were related to PTSD symptomatology in a manner that supports the
construct validity of the scale. These correlations indicate that at the initial testing and
3-year follow-up, as the number of PTSD symptoms experienced by the veterans increased,
their resultant scores on the M-PTSD-DS increased as well. This finding supports the

Table 1. Relationships Among the MS-PTSD-DS Scores and PTSD Symptoms at Initial Evaluation and 3-year
Follow-up (N = 30)

PTSD-1 MS-PTSD-DS-1 PTSD-3 MS-PTSD-DS-3

PTSD-1 — r = .82 r = .33 r = .55

p = <.0001 p = .08 p = .001
MS-PTSD-DS-1 — — r = .48 r = .62
p = .006 p = .0002
PTSD-3 — — — r = .82
p = <.0001
MS-PTSD-DS-3 — — — —

PTSD-1 = Posttraumatic Stress Disorder (Initial Evaluation).

PTSD-3 = Posttraumatic Stress Disorder (3-year Follow-up).
MS-PTSD-DS-1 = Mississippi Scale for Desert Storm War Zone Personnel (Initial evaluation).
MS-PTSD-DS-3 = Mississippi Scale for Desert Storm War Zone Personnel (3-year follow-up).
 Longitudinal Evaluation of PTS 1089

construct validity (sensitivity) of this scale in the immediate and longitudinal measure-
ment of relatively nonpathological degrees of war-related stress in noncombatants.
Initial level of PTSD symptomatology upon returning from a war zone was predic-
tive of not only initial scores on the M-PTSD-DS but also of M-PTSD-DS scores 3 years
later. This strong relationship supports the primary intent of the M-PTSD-DS to assess
the spectrum of DSM-III-R symptoms of PTSD. Limitations of this study include that
this was a small, self-selected group of young, reservist men who were not involved in
direct fighting and were not actively seeking treatment or compensation initially or 3
years after the war. The results may not be generalized to all Gulf War veterans, women
veterans of that war, or those seeking treatment or compensation for Gulf War–related
physical or emotional problems. However, the robust association between the M-PTSD-DS
and degree of PTS symptomatology found in this study encourages the clinical use of this
measure, as well as further longitudinal and cross-validational research in the screening,
identification, and treatment planning of Gulf War veterans who are experiencing war-
related stress and may be at risk for development of chronic PTS or PTSD.

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