There are no known studies to date examining the risk of posttraumatic stress disorder (PTSD) associated with sudden and dramatic personal financial loss. A Web-based, online, nonprobability convenience survey of 172 Madoff victims (56 percent female; mean age, 60.9 years) using the Posttraumatic Stress List Checklist, civilian version was conducted eight to 10 months following the focal event. Sociodemographic information and data concerning anxiety/depression and health-related concerns were gathered by self-report questionnaire. A five-point Likert-type scale was used to assess victim response to government regulatory systems. Results demonstrated that a majority of respondents (55.7 percent) met criteria for a presumptive Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) diagnosis of PTSD, and as a group, respondents acknowledged high levels of anxiety (60.7 percent), depression (58 percent), and health-related problems (34 percent). Victims overwhelmingly affirmed a substantial loss of confidence in financial institutions (90 percent). This raises a public health concern as to governmental response and counseling needs during times of severe economic trauma.
KEY WORDS: financial loss; Madoff; Ponzi scheme; PTSD; trauma
The news of the arrest of Bernard Madoff on December 11, 2008, heralded the largest financial Ponzi scandal in global history. As much as $61 billion dollars in assets disappeared along with former investors' lifelong savings and legacies. Most of these victims were socially networked; therefore entire families, communities, and charitable institutions were adversely affected (Arvedlund, 2010; Henriques, 2011). In a literature review of the epidemiology of post-traumatic stress disorder (PTSD) following disaster, Galea, Nandi, and Vlahov (2005) noted that the definition of "disaster" in many studies does not necessarily connote a loss of human life. In their view, disasters could result from "mass traumatic events that involve multiple persons and are frequently accompanied by loss of property and economic hardship on a large scale" (p. 79). For Madoff victims en masse, this sudden and devastating financial event meets criterion A qualifications of a trauma as required for the Diagnostic and Statistic Manual of Mental Disorders (4th ed., text rev.) (DSM--IV-TR) diagnosis of PTSD (American Psychiatric Association [APA], 2000).
To date, research has not specifically examined the risk factor for PTSD associated with sudden and dramatic personal financial loss. Since the introduction of the formal diagnosis in 1980, a series of epidemiologic studies using community samples has found that the relatively high incidence of traumatic experiences in the normal civilian population does not necessarily translate to correspondingly high lifetime PTSD prevalence rates (6 percent to 12 percent) (Breslau, Davis, Andreski, Peterson, & Schultz, 1997; Kessler et al., 2005; Kessler, Sonnega, Bromet, Hughs, & Nelson, 1995).
LEVELS OF PTSD
Several factors are believed to influence the likelihood of developing PTSD following a traumatic event. The nature of the trauma has been closely examined in PTSD occurrence (Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999). In the simplest of terms, the Madoff trauma could be considered a criminal robbery. It has long been established that higher risk of PTSD is associated with stressors such as sexual assault, robbery, and multiple trauma (Breslau, 2002; Kessler et al., 1995), although assaultive violence may be a strong underlying factor (Breslau et al., 1999). Profdes of victims of criminal events show heightened levels of distress and fear coupled with suspiciousness/ guardedness that are believed to contribute to elevations of PTSD in comparison with victims of industrial accidents (Shercliffe & Colotla, 2009).
PTSD can be especially severe or long lasting when the stressor is of human design rather than that of natural disaster (APA, 2000). The criminality involved in the Madoff trauma was exacerbated by feelings of betrayal at the hands of a man several victims knew personally. Many victims who made direct investments were encouraged to do so within the context of their own social networking. Indirect investors were often guided through their financial advisors (Arvedlund, 2010). A majority of the victims of this trauma were Jewish. These qualities are in keeping with the type of financial crime known as affinity fraud. According to the U.S. Securities and Exchange Commision (SEC, 2006), affinity frauds focus on members of identifiable groups, such as religious organizations, ethnic communities, professional groups, and charitable organizations. As in the case of Bernard Madoff, the duplicitous financial advisor is oftentimes a member of the group, which, in turn, inspires greater trust and less scrutiny on the part of the investor.
Mass casualty events are also associated with increased rates of PTSD (Pandya, 2009), as is the case with terrorist attacks (Galea et al., 2002; Schlenger et al., 2002) and natural disasters such as hurricanes (Mills, Edmondson, & Park, 2007; Weems et al., 2007) or earthquakes (Priebe et al., 2009). Of course, these events involve untold physical devastation and loss of life. Perhaps this explains the vacuum within the research community in consideration of severe financial disaster on a similar spectrum and accounts for the fact that there have been no studies correlating PTSD to dramatic changes in socioeconomic status (SES) in such populations as those suddenly unemployed or facing imminent foreclosures or entire communities such as Detroit, Michigan, facing loss of industries. Galea et al. (2005) noted that low SES is considered a risk factor for PTSD; however, there are no known studies examining the direct impact of financial loss as a trauma in and of itself.
Nonetheless, research has begun to demonstrate the influence of the contextual response to trauma. The perception of governmental responsiveness or lack thereof from a public policy perspective during and in the immediate aftermath of traumatic events may trigger risk or protective factors for PTSD (Hobfoll et al., 2009; Weems et al., 2007). Thus, attentive community response and social support has been deemed to play a protective role in postdisaster research on PTSD and related mental health concerns (Adams, Boscarino, & Galea, 2006; Galea et al., 2005; Satcher, Friel, & Bell, 2007). Conversely, lack of social support and depression following disaster has been tied to poorer self-rated health status and increases in health risk behaviors (Ruggiero et al., 2009). To this end, the trauma of the Madoff event was further compounded by the publicly acknowledged lapses in oversight on the part of government regulatory agencies such as the SEC, which failed to uncover the fraud in spite of investigations and multiple warnings dating back to 1992 (Markopolos, Casey, Cheolo, Kashroo, & Ocrant, 2010). The Securities Investor Protection Act of 1970 established the Securities Investor Protection Corporation (SIPC), a private, nonprofit corporation similar to the Federal Deposit Insurance Corporation with oversight by the SEC, to offer protection to the securities investor in the event of loss or failure of the firm (Woolley & Peters, 1999-2010). With respect to the Madoff event, SIPC was severely underfunded and could, therefore, not respond in a timely manner to compensate investors for their losses, which further attenuated the nature of their trauma (Network for Investor Action and Protection, 2010). Future research is indicated to explore the degree to which expectation of governmental support, perception of actual assistance, and timing of response in the wake of disaster affect resilience in the surviving community of disaster victims. These factors may play a role in either exacerbating the traumatic response and promoting chronicity of symptoms or fostering resilience by promoting a sense of responsive support.
INTERNET SURVEY AS AN ASSESSMENT OF PTSD
The use of the Internet survey to assess trauma and PTSD is a relatively recent phenomenon. Ideal for the unpredictable nature of traumatic events and the desire for rapid, real-time assessment of exposure and post-exposure responses in victim populations, Web-based surveys are an alternative to traditional in-person or phone methods for data collection. Web-based surveys are private, economically feasible, and particularly well suited to the study of trauma and its aftermath (Read, Farrow, Jaanimagi, & Ouimette, 2009; Schlenger & Silver, 2006). Web-based surveys reduce social desirability bias and increase the revelation and accuracy of sensitive material, such as psychiatric symptoms, substance abuse, and sexual behavior, in comparison with interaction directly with the interviewer (Read et al., 2009). The Posttraumatic Stress List Checklist, civilian version (PCL-C) (Weathers, Litz, Herman, Huska, & Keane, 1993) has been used for Web-based epidemiological surveys of PTSD in response to terrorism (Blanchard, Rowell, Kuhn, Rogers, & Wittrock, 2005; Schlenger et al., 2002) and adapted to a computerized binary version to assess stress in firefighters post--September 11, 2011 (Corrigan et al., 2009). The PCL-C has been found to be a reliable instrument when used on the Interuet to assess trauma and PTSD in a population of college students (Read et al., 2009).
In sum, the nature of the Madoff event and its aftermath intersects several aspects of trauma in such a way as to predict a high level of PTSD and negative mental health and physical health sequellae. This study was designed to learn four things: (1) the current level of PTSD reported by victims in response to the Madoff trauma; (2) how this level of PTSD compared with the literature on epidemiology on PTSD rates postdisaster; (3) whether there would be a reported increase in health risk behaviors, mental health, and physical health symptoms, as reported in the trauma literature; and (4) whether the perceived level of contextual governmental support affected PTSD levels.
A Web-based design research study using the PCL-C would provide a more immediate gauge of levels of PTSD within this population and offer an opportunity for early intervention. Additional information concerning the impact on mental health, health, and governmental response could offer an opportunity to highlight public policy responses that can mitigate the effects of economic disaster.
Participants and Data Collection
This convenience, nonprobability sample was solicited via direct link to the study placed in online Madoff survivor support groups and comment sections of newspapers and blogs dealing with the event. The study announcement encouraged victims to forward the link to other former investors who might be interested in responding to the survey, thereby creating a snowball effect. The link led directly to a study description and enabled respondents to give informed consent prior to study participation. Participants were assured of anonymity of their responses and were instructed how to proceed in the event of increased feelings of distress as a result of study material. The survey was presumed to take approximately five to 10 minutes to complete. Online responses were collected from August 13, 2009, to October 27, 2009 (eight to 10 months following the event on December 11, 2008). The survey data were housed online at http://www.surveymonkey.com and downloaded to SPSS version 16 for statistical analysis. Of the 206 respondents who gave informed consent to participate in this anonymous study, a total of 172 completed the survey. There were no other exclusion criteria.
Measurement of PTSD. For purposes of this study, the level of current PTSD (past month) was measured using the PCL-C. The PCL-C is a 17-item standardized, self-report rating scale for assessing PTSD symptoms according to DSM--IV criteria. Respondents are asked to indicate how much they are bothered by each symptom using a five-point Likert-type scale ranging from 1 = not at all to 5 = extremely. The psychometric properties of the PCL-C were determined against the gold-standard Clinician Administered PTSD Scale (CAPS) in a predominantly female population (n = 40) of victims of sexual assault and motor vehicle accidents (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). For the PCL-C as a whole, the correlation with CAPS is .929 and its diagnostic efficiency is .900. Developed at the National Center for PTSD, the civilian version of the PCL is the most frequently used instrument for the exploration of PTSD (Schinka, Brown, Borenstein, & Mortimer, 2007). The psychometric properties of the PCL were originally evaluated in two separate studies of 123 Vietnam veterans and 1,006 Persian Gulf combat veterans, respectively. In both studies, convergent validity was demonstrated between the PCL and the Mississippi Scale (.93). Test--retest reliability over two to three days was reported as .96, and internal consistency ranged in both studies from .89 to .96 for symptom clusters A, B, and C and .96 to .97 for all 17 items (Weathers et al., 1993).
The PCL-C can be used as a continuous measure of PTSD symptom severity by summing scores across the 17 items for a total severity score that ranges from 17 to 85, with higher scores indicating more severe symptoms. A recommended total PCL--C score cut-off of 50 yields a sensitivity of .778, a specificity of .864, and a diagnostic efficiency of.825 against the CAPS (Blanchard et al., 1996).
The PCL-C can also be used as a categorical variable for a presumptive diagnosis of PTSD using DSM--IV criteria. Diagnosis is scored by positively endorsing one symptom of reexperiencing (criterion B, questions 1 through 5), three symptoms of numbing and avoidance (criterion C, questions 6 through 12), and two symptoms of hyperarousal (criterion D, questions 13 through 17).
Measures of Mental Health/Health. Data were obtained from a personal demographic screening questionnaire and a self-rated questionnaire designed by the researcher to gather information regarding "yes" or "no" responses to increases in anxiety, depression, obsessional thinking, alcohol use, prescription medication use, and health-related concerns for respondents and their relatives after the Madoff event.
Information was also gathered using a five-point Likert-type scale to assess trauma-related consequences specific to the Madoff event. On a scale ranging from 1 = not at all to 5 = extremely, participants were asked to rate their responses to questions concerning their confidence in SIPC, financial institutions, and the SEC and their fear of clawbacks, a process in which victims would be asked to reimburse past withdrawals they made believing that the assets belonged to their own account. Finally, participants were given an opportunity to respond to the open-ended question, "What do you consider to be the biggest personal life change as a result of the Madoff event?"
Demographic Description of the Sample A total of 172 individuals participated in this anonymous online survey of the clients of Bernard L. Madoff Investment Securites, LLC (BLMIS). Demographic details are provided in Table 1. The mean age of participants was 60.86 (SD = 12.05). As former Madoff clients, most participants (79 percent) reported that they were direct investors. Nineteen percent reported that they were indirect investors (that is, they were clients of BLMIS by virtue of their participation in feeder funds, individual retirement accounts, and other types of pension investments). Fifteen percent of the study sample reported that they were relatives of other direct investors. Less than 2 percent endorsed association with charitable foundations with holdings in BLMIS. Finally, these former investors participated as clients of BLMIS for nearly 15 years (that is, they first invested with Madoff in 1993 on average [M= 1992.86, SD = 8.11]).
There are two standardized measures that are used to characterize the level of PTSD in the study sample. As outlined earlier, the PCL-C is a continuous measure of which the mean in this population was 49.02 (SD= 18.62). As reported by Blanchard et al. (1996), a cut-offscore of 50 maximizes the diagnostic efficiency of this measure. The mean PCL-C score suggests that the typical Madoff investor in this sample would approach the clinical cutoff for PTSD based on this measure. The second standardized measure uses the same PCL-C data to arrive at a presumptive DSM--IV--TR diagnosis of PTSD based on the number of questions endorsed in each of three clinical clusters (that is, re-experiencing, avoidance, and hyperarousal). On the basis of the responses to the items that operationalize each of these clusters, 56 percent of the sample qualifies for a presumptive diagnosis of PTSD.
A cross-tabulation of these two standardized measures is presented in Table 2. The continuous version of the PCL-C has been dichotomized at 50, the clinical cutoff recommended for diagnosis of PTSD as a continuous measure. The DSM-IV--TR diagnostic measure is intrinsically dichotomous. As displayed in Table 2, there are 128 cases that lie on the main diagonal (that is, the agreement diagonal) of this table. In percentage terms, these two measures agree on 86 percent (128 of 149) of the respondents included in the table as to whether they do, or do not, meet clinical criteria for PTSD. In more formal statistical terms, kappa, a chance-corrected measure of agreement, is .72, which indicates substantial agreement according to Landis and Koch (1977).
Given that these data provide a reasonable basis for identifying likely cases of PTSD, the next set of analyses uses the DSM--IV--TR diagnostic measure as a basis for clinically interpreting the subjective experiences of these Madoff investors as indicated by a series of self-reports regarding their personal experiences in the aftermath of the collapse of BLMIS.
As displayed in Table 3, of Madoff investors who reported anxiety, depression, obsessing, increased consumption of alcohol, increased use of prescription medications, and health-related problems, a majority qualifies for a diagnosis of PTSD. A formal statistical comparison of each pair of percentages using chi-square tests finds that all are statistically significant (p < .001).
A second set of comparisons between those who do and do not qualify for a clinical diagnosis of PTSD is presented in Table 4, but now with the focus on structured semi-reports specific to the circumstances surrounding the Madoff event. Of the nine comparisons that make up Table 4, six items are statistically significant, "Life choices altered" (p = .049); "Immediate family negatively affected" (p = .035); "Worried about the well-being of other relatives" (p = .007); "Had to move locations" (p = .005); "Had to return to work" (p = .000); and "Felt betrayed by SEC" (p = .011). These items are generally related to personal consequences of the Madoff experience and do differentiate those who did and did not qualify for a diagnosis of PTSD. Three items in Table 4 were not statistically significant: "Worried about clawbacks" (p = .172); "No confidence in SIPC" (p = .604); and "No confidence in financial institutions" (p = .205). Each of these items received very strong levels of endorsement (>64 percent) from Madoff investors who both did and did not meet DSM--IV--TR criteria for PTSD. Because relatively large percentages of both groups endorsed these items, they are not clinically informative.
PTSD is the most common psychological and mentally debilitating outcome in 74 percent of studies of disasters (natural, mass violence, and technologic disasters such as industrial and nuclear incidents, fires, and explosions) that include other mental health variables, such as depression, anxiety, and nonspecific distress (Satcher et al., 2007). In this cross-sectional study of Madoff victims, the 55.7 percent prevalence rate of presumptive PTSD could be seen as high even by standards of special victim populations, such as firefighter, victims of sexual assault, and returning veteran populations (Galea et al., 2005). These findings support the possibility that sudden financial disaster could be considered a risk factor for PTSD.
This observation is in keeping with research that found that levels of psychological symptoms and probable PTSD are highest for victims in human-made disasters (Corrigan et al., 2009). In a review of 192 studies from 1980 to 2003, Galea et al. (2005) noted a range of 25 percent to 75 percent prevalence of PTSD in investigations of direct victims usually carried out within the first year of a human-made/technological disaster. This is followed by PTSD ranges of 5 percent to 40 percent reported for those involved in rescue efforts following a disaster and a range of 1 percent to 11 percent for those affected in the general population. The probable PTSD findings for the victims of Madoff are in the mid to upper prevalence range of human-made trauma and demonstrate a trend toward a prolonged and chronic response to PTSD in the face of sudden and severe financial disaster. Perhaps the explanation for these high rates lies in the nature of affinity fraud, which involves massive communal and personal betrayal by a trusted perpetrator.
Alternatively, Walter and Hobfoll (2009) suggested one way to conceptualize the onset and maintenance of PTSD is to observe that the disorder is accompanied by a rapid loss of material and psychosocial resources. Hobfoll and Lilly (1993) proposed the conservation of resources theory, in which stress results from a loss of psychological and material resources, which, in turn, leads to a downward spiral as the resources needed to cope with the trauma are also depleted. This rapid decline in resources further undermines the recovery process. Similarly, the rapid loss of financial resources experienced in the wake of the Madoff trauma may account for the high levels of PTSD noted in this study and the diminished capacity to rebound from the trauma.
Health/Mental Health Concerns
The present study confirms the toll of the Madoff trauma on physical and mental indicators of health. A positive relationship between increased physical health problems, obsessively thinking about the Madoff trauma, depression, anxiety, and use of prescription medications such as tranquilizers, sedatives, and pain medications was endorsed by a vast majority of the victims, although the endorsement was significantly higher across the indices by those who met DSM--IV--TR criteria than those who did not. These clinical findings are consistent with previous research that supports increased health risk behaviors, such as smoking, drinking, and drug use, described after the September 11, 2001, terrorist attacks in New York City (Adams et al., 2006). Self-rated negative changes in health status after the 2004 Florida hurricanes were also reported in a representative sample of 1,452 survivors and were attributed to PTSD, depression, and fear that may alter neurological and immune responses (Ruggiero et al., 2009). These authors suggested that postdisaster health status was strongly associated with two modifiable variables, social support and depression (Ruggiero et al., 2009).
There is evidence that stressful life events generating feelings of loss (real or imagined and including people, material positions, and respect in the community) and humiliation (feeling devalued in relation to others or to one's core sense of self or a sense of role failure) are specifically predictive of depression (Kendler, Hettema, Butera, Gardner, & Prescott, 2003). Past research also suggests that older adults are at higher risk of psychological distress in response to trauma if they experience ongoing family, financial, or neighborhood stress, relocation, and social isolation (Brown, 2007). In this study, the need to return to work was a significant factor distinguishing Madoff victims who suffer from PTSD from those who do not. It suggests that at its core the nature of financial trauma resulting in sudden economic deficit and the concomitant need to generate replacement income by fostering immediate life transition (from retirement to work) is significantly related to PTSD.
Ruggiero et al. (2009) noted that screening for depression, poor social supports, and non-modifiable factors such as older age, low income, and extreme fear could point to risk factors that require community intervention to offset long-term direct and indirect economic burden on a macro level. This study would support the fact that the Madoff victims, by virtue of age (mean age of 60.86), decline in economic and social supports, depression, and self-identified concern for health-related problems, represent a prototypical community in which early efforts at intervention aimed at decreasing the long-term consequences of this traumatic event on morbidity and mortality rates can be further explored.
Prevention efforts need to be assessed from an individual and a social level. To this end, the perception of the role of government in disasters needs to be questioned from a public policy standpoint. In this study, it is clear that the vast majority of Madoff victims surveyed felt betrayed by the governmental agencies (SEC) and financial supports (SIPC) presumably designed to protect them. The contextual role of the entitlement to governmental support and deliverance is critical to psychological functioning. Weems et al. (2007) found a correlation between regional difference and psychological outcomes among groups of postdisaster survivors of Hurricane Katrina. The lack of government responsiveness and the belief that the government may have been to blame for the outcome in New Orleans was offered as a possible contributing factor accounting for the more negative psychological outcomes of New Orleans residents compared with those from the Mississippi Gulf Coast.
In the Madoff event, victims falsely believed that their investments were insured under SIPC and regulated by the SEC. It is surprising that it was a sense of betrayal in response to the failure of the SEC to provide protection that significantly correlated with PTSD in this survey, although the vast majority of victims also lost confidence in the SIPC and financial institutions and feared clawbacks.
In sum, the impact of the Madoff trauma is best portrayed by the responses to the open-ended question, "What do you consider to be the biggest personal life change as a result of the Madoff event?" The following response captures the issues discussed:
Loss of my security to be able to pay for myself in my old age. Loss of my life style and freedom because I work full time. Loss of my sense of well-being. Loss of my faith in America because of gaining the knowledge of how corrupt our government is. Anxiety and depression are my constant companions now.
Limitations and Future Research
The current study is limited by the fact that Madoff victims were self-selected and responded to an anonymous, self-assessment, online survey. The use of an Internet survey provided opportunities to conduct research more efficiently and effectively by virtue of instant distribution, reduced costs, environmental benefit, and the capacity to draw from a large geographical domain. Responses to electronic mail may, however, be different from the responses generated in-person or through regular mail due to the digital divide among age groups and income levels (Couper, 2000; Pealer, 2001). Given that victims of Madoff skewed toward the elderly, the use of the Internet survey might not sufficiently capture the true magnitude of this event within the older population who are less sophisticated with computer technology. Overall, generalizations from this study are limited by the small portion of investors relative to the magnitude of the event. As with most cross-sectional studies on disaster research, no previous information on victim's psychological coping prior to the trauma was available, so causal conclusions are not possible.
The use of retrospective self-report measures to assess health risk behaviors, self-rated health, and mental health consequences of the Madoff trauma cannot preclude recall or social desirability biases. Here, too, the ability to generalize to other studies with regard to the constructs of anxiety and depression is hampered by the lack of valid and rehable instrumentation. A longitudinal study would more accurately demonstrate the impact of increased health risk behaviors of alcohol and prescription drug use over time. The use of more nuanced assessments of health-related measures would begin to direct future research toward specific physical health concerns most affected by traumatic stress.
Nonetheless, sudden and severe financial loss such as that incurred in the Madoff event has not previously been considered a traumatic risk factor for PTSD. Failure to view severe economic trauma as a risk factor precludes identification and early intervention strategies to enhance coping. The elevated rates of PTSD, coupled with the significant self-reported consequences to health found in this study, suggest that populations affected by sudden and severe financial hardship are in need of social services on a micro and macro level. The Madoff victims provide insight into the adverse toll of economic trauma. This group can serve as a prototypical population on which the longitudinal effects of economic disaster can be further studied.
Original manuscript received March 13, 2011
Final revision received August 29, 2011
Accepted September 7, 2011
Advance Access Publication July 4, 2012
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Audrey Freshman, PhD, MSW, is director of Continuing Education and Professional Development, School of Social Work, Adelphi University, Garden City, NY 11530; e-mail: email@example.com.
Table 1: Demographic Description of the Description of the Study Sample Variable Frequency Valid Gender Female 84 56.0 Male 66 44.0 Religion Catholic 24 17.1 Jewish 94 67.1 Protestant 4 2.9 Unaffiliated 18 12.9 Marital status Single, never married 15 10.3 Married, living with partner 97 66.4 Separated, divorced 21 14.4 Widowed 13 8.9 Educational status Some high school 2 1.3 High school diploma or GED 5 3.3 Some college or associates degree 26 17.3 Bachelors degree 44 29.3 Grad school or more 73 48.7 Employment Full-time 44 25.6 Part-time 23 15.4 Unemployed/job seeking 21 14.1 Retired 61 40.9 Total 172 Table 2: Intrameasure Agreement PTSD DX Based on OSM-IV-TR Criteria No, DSM-IV--TR PTSD DX Dichotomized <50 Count % within PTSD 61 PCL-C DX based on DSM-IV 7R criteria 92.4 >50 Count % within PTSD 5 DX based on DSM-IV-TR criteria 7.6 Total Count % within PTSD 66 DX based on DSM-IV-TR criteria 100 PTSD DX Based on OSM-IV-TR Criteria Yes,-DSM-IV-TR PTSD DX Total Dichotomized 16 77 PCL-C 19.3 51.7 67 72 80.7 48.3 Total 83 149 100 100 Note: PTSD=posttraumatic stress disorder; DX=diagnosis; D5M-IV-TR=Diagnostic and Statistic Manual of Mental Disorders (4th ed., text rev.); PCL-C=Posttraumatic Stress List Checklist, civilian version. Table 3: Clinical Self-Reports, by Posttraumatic Stress Disorder (PTSD) Diagnosis PTSD DX Based Do You Believe Do You Believe You on DSM-IV-TR You Are Are Experiencing a Criteria Experiencing a Current Problem (PCL-C) Current Problem with Depression? with Anxiety? No, DSM-IV TR PTSD DX n 66 65 M .30 .20 Yes, DSM-IV TR PTSD DX n 82 82 M .85 .88 Total n 148 147 M .61 .58 PTSD DX Based Do You Find Do You Believe You on DSM-IV-TR Yourself Obsessing Have Increased Your Criteria Thinking about the Consumption of (PCL-C) Madoff Event? Alcohol? No, DSM-IV TR PTSD DX 65 65 .45 .11 Yes, DSM-IV TR PTSD DX 83 80 .78 .39 Total 148 145 .64 .26 Have You Increased Your' Use of Are You PTSD DX Based Prescription Experiencing on DSM-IV-TR Medications Such as an Increase in Criteria Sleeping Pills, Health-Related (PCL-C) Tranquilizers, or Problems? Painkillers? No, DSM-IV TR PTSD DX 66 66 15 .14 Yes, DSM-IV TR PTSD DX 83 83 .48 .51 Total 149 149 .34 .34 Note: DX=diagnosis; PCL-C= Posttraumatic Stress List Checklist, civilian version. Table 4: Madoff-specific Consequences, by Posttraumatic Stress Disorder (PTSD) Diagnosis Worried about PTSD DX Life Immediate the Well-being of Based on Choices Family Other Relatives DSM-IV-TR Altered by Negatively Tha Were Criteria Madoff Affected by Affected by the (PCL-C) Event? Madoff Event? Madoff Event? No, DSM-IV-TR PTSD DX n 66 65 65 M .92 .89 .75 Yes, DSM-IV-TR PTSD DX n 83 83 83 M .99 .98 .92 Total n 149 148 148 M .96 94 .84 PTSD DX Had to Move Had to Return to Based on Locations as a Work frorn DSM-IV-TR Result of the Retirelnent as a Criteria Madoff Result of the (PCL-C) Event? nveat off Event No, DSM-IV-TR PTSD DX 65 64 .17 .11 Yes, DSM-IV-TR PTSD DX 82 77 .38 .52 Total 147 141 .29 33 PTSD DX Based on Worried about Felt Betrayed No Confidence DSM-IV-TR Criteria Clavvbacks? by the SEC7 in SIPC? (PCL-C) PTSD DX n 66 66 65 M .64 .92 .88 Yes, DSM-IV-TR PTSD DX n 81 83 83 M .74 1.00 .90 Total n 147 149 148 M .69 .97 .89 PTSD DX Based on No Confidence in DSM-IV-TR Criteria Financial (PCL-C) Institutions? PTSD DX n 66 M .86 Yes, DSM-IV-TR PTSD DX n 82 M .93 Total n 148 M .90 Note: DX = diagnosis; DSM-IV-TR=Diagnostic and Statistic Manual of Mental Disorders (4th ed., text rev.); PCL-C=Posttraumatic Stress List Checklist, civilian version; SEC= Securities and Exchange Commission; SIPC=Securities Investor Protection Act.