Journal of Traumntic Stress, VoL 13, No.

I , 2cxK)

Psychometric Evaluation of Horowitz's Impact

of Event Scale: A Review
Stephen Joseph'

Despite being developed before theformal introduction of posttraumatic stress disorder (PTSD)within the diagnostic literature, the Impact of Event Scale (Horowitz,
Wilner;& Alvarez, 1979) remains one of the most widely used self report measures
of posttraumatic stress. This paper presents an overview of research using the IES
in an attempt to assess its psychometric status. It is concluded that the psychometric properties of the IES are satisfactory (although not as a PTSD diagnostic
measure) and that continued use of the IES as a measure of intrusive and avoidant
processes is warranted.
KEY WORDS: assessment; Impact of Event Scale; PTSD; diagnosis; factor analysis.

The Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a selfreport scale that is used to assess the frequency of intrusive and avoidantphenomena
associated with the experience of a particular event. Although the IES was not
designed to assess PTSD, which was formally introduced within the diagnostic
literature a year later [American Psychiatric Association(APA), 19801,the IES was
quickly adopted by those working in the then new area of traumatic stress research.
The IES subsequently became one of the most widely used global self-report
instruments for the assessment of posttraumatic stress reactions. However, many
alternative instruments have since been designed to assess the specific symptoms
associated with the diagnostic criteria of PTSD (see Wilson & Keane, 1996).
In light of the developments in the assessment of trauma-related reactions,
the aim of the present paper was to evaluate whether continued use of the IES is
warranted. The present paper provides an overview of research that has examined
the psychometric properties of the IES and its status as a diagnostic measure
of PTSD. The paper also discusses issues relevant to assessment arising from a
consideration of Horowitz's two factor model. It is concluded that although the
'Department of Psychology, University of Warwick, Coventry CV4 7AL,England.

101
08949867/00101oM)101$18.00/1 8 Zoo0 International Society for Traumatic Stress Studies

Joseph

102

IES possesses considerable shortcomings as a measure of PTSD, there remain

compelling reasons for researchers to continue using the IES, at least in the short
term. In the longer term, it is argued that future instrument development needs to
be guided by data on the architecture of posttraumatic stress symptoms.

Development of the IES

The IES was developed to reflect Horowitzs ( I 976) information processing formulation of stress response as consisting of alternating phases of intrusion
and avoidance. The items on the IES were developed from statements most frequently used to describe episodes of distress by people who had experienced recent life events. Each of the 15 IES items were administeredby Horowitz, Wilner,
and Alvarez (1 979) using 4-point frequency scales (i.e., 0 = not at all, 1 = rarely,
3 = sometimes, and 5 = often) in relation to the past week so that total scores on
the IES have a possible range of 0 to 75, with higher scores indicting a greater
frequency of intrusive thoughts and attempts at avoidance (subscale scores can
also be computed for the 7 intrusion items, with a possible range of 0-35, and
the 8 avoidance items, with a possible range of 0-40).Horowitz (1982) identified
thresholds for low, medium, and high symptom levels corresponding to levels of
clinical concern using the IES total score: low, ~ 8 . 5 medium,
;
8.6 to 19.0; and
high, =- 19). However, this categorization is not indicative of any specific clinical
diagnoses and these cutoff points are arbitrary.
The IES has been used in numerous studies with a variety of adult populations,
for example,combat veterans (e.g., Green, Grace, Lindy, &Leonard, 1990),victims
of assault (e.g., Elliott & Briere, 1995), survivors of motor vehicle accidents (e.g.,
Bryant & Harvey, 1996a), survivors of disasters at sea (e.g., Dalgleish, Joseph,
Thrasher, Tranah, & Yule, 1996), firefighters (e.g., Bryant & Harvey, 1996b), and
survivors of natural disaster (e.g., Johnsen, Eid, Lovstad, & Michelsen, 1997).
The IES has also been used in clinical outcome work to assess the effectiveness
of drug trials (e.g., Davidson, Roth, & Newman, 1991), relaxation training (e.g.,
Hossack 8i Bentall, 1996), treatment programs (e.g., Richards, Lovell, & Marks,
1994), time-limited psychotherapy (e.g., Ford et al., 1997), and Eye Movement
Desensitization and Reprocessing (e.g., Grainger, Levin, Allen-Byrd, Doctor, &
Lee, 1997) and has proved valuable in documenting the course of posttraumatic
phenomena over time (e.g., Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992).
In addition, the IES has also been used with children and adolescents (e.g.,
Green et al., 1994) and has been described as probably the best questionnaire
available for evaluating childhood PTSD (McNally, 1991). Furthermore, the IES
has also been translated into several languages, for example, Hebrew (e.g.,
Schwarzwald, Solomon,Weisenberg,& Mikulincer, 1987),and Dutch (e.g., Brom,
Kleber, & Defares, 1986). Some difficulty in translation for use with asylum seekers to the United Kingdom, mainly from the Middle East and Turkey, has, however,

Impact of Event Scale

103

been reported (Velsen, Gorst-Unsworth, & Turner, 1996). Velsen et al. (1996) say
that there was some difficulty in translating colloquialisms,but the main difficulty
was in pinpointing a single trauma when the refugees had been subject to so many
over their lives. A similar point is made by Newman and Lee (1997), who also
argue that the IES is not effective or meaningful when used with people who have
been exposed to multiple traumas. However, these criticisms are not unique to the
IES and might also be leveled at other PTSD-related scales.

PsychometricProperties of the IES

Reliability

In the evaluation of trauma-related measures, the two most commonly reported forms of reliability are internal consistency and test-retest reliability (see
Weathers, Keane, King, & King, 1996). Horowitz et al. (1979) reported satisfactory internal reliability (Cronbachs a! = .86 for the total IES, .78 for intrusion, and
.82 for avoidance). Zilberg, Weiss, and Horowitz (1982) also report satisfactory
internal reliability (Cronbachs a! = .86 for the total IES). However, few studies
have subsequently reported further data on the internal reliability of the IES, although where such data are available, they confirm that the internal reliability of
the IES is satisfactory. For example, Shalev (1992), using the Hebrew translation
(Schwarzwald et al., 1987),administeredthe IES to survivorsof terrorist attack at 2
and 6 days after admission to hospital and again at 14 months. Internal reliabilities
of the total IES at each time point were found to be .78, .73, and .88, respectively.
Reliability data were, however, not reported for the IES subscales. Robbins and
Hunt (1996) found that the intrusion and avoidance subscales had internal reliabilities of .86 and .73, respectively, with Second World War veterans, and Kopel and
Friedman (1997) report internal reliabilities of .79 and .69, respectively (.79 for
the total IES), with South African Police. These data would seem to confirm that
the internal consistency of the IES is satisfactory, although not consistently high.
Horowitz et al. (1979) report a test-retest reliability of r = .89 for intrusion
and r = .79 for avoidance, over 1 week. However, no studies have subsequently
reported further data on the test-retest reliability of the IES. Given that so few
studies have reported on internal consistency and test-retest reliability, there is
concern that the available data might overestimate the reliability of the IES.
Validity

However,it has been suggestedthat validity is of greater concern (see Weathers

et al., 1996). Horowitz et al. (1979) describe the IES as a measure of current subjective distress. Although some items have face validity as measures of subjective

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Joseph

distress, other items do not and may even be perceived as neutral by the respondent (e.g., item 6, I had dreams about it), questioning the extent to which the
IES is an index of distress (see Lees-Haley, 1990). Furthermore, in the context of
bereavement, Raphael (1997) notes that the IES does not clearly specify the nature
of intrusive thoughts, which she argues, can be either highly affectively charged or
associated with fond and nostalgic memories. Thus, in terms of face validity the
IES is not clearly a measure of distress, limiting its content validity (see Haynes,
Richard, & Kubany, 1995).
Furthermore, the fact that the IES measures intrusion and avoidance [experiences which are central to the construct of PTSD ( M A , 1994)l has led many
researchers to use the IES as though it were a measure of PTSD, and for others
to criticize the content validity on the grounds that the IES is limited in its assessment of PTSD phenomena as it does not contain items tapping hyperarousal
(criterionD). Furthermore,the IES does not cover some avoidant symptomsfrom
criterion C (i.e., amnesia, detachment, diminished interest in important activities,
sense of foreshortenedfuture) or some intrusivesymptomsfrom criterion B (Lee,
flashbacks, physiological reactivity). The content validity of the IES as a measure
of PTSD is limited; although it is not clear to what extent the omitted symptoms
cooccur with assessed symptoms.
However, in response to the omission of DSM symptoms, a revised version of the IES has been proposed by Weiss and Marmar (1997), the IES-R,
which includes several items based on criterion D, to test for symptoms of hyperarousal. The content validity of the Weiss and Marmar scale as a measure
of PTSD would seem to be less of a problem, although further psychometric
data are required, and the use of the IES-R as a diagnostic tool remains to be
tested.
Despite poor content validity as a measure of PTSD, the IES has been shown
to differentiate between those who receive a diagnosis of PTSD and those who
do not (e.g., Bryant & Harvey, 1996c) and to be sensitive to PTSD (e.g., McFall,
Smith, Roszell, Tarver, & Malas, 1990), but it is not clear to what extent the IES
is specific to PTSD.
In one study which has investigated the specificity of the IES, Neal et al. (1994)
found that an optimum cutoff score for the total IES of 35 produced the highest
positive predictive value (.88) and the lowest apparent total misclassification error
rate (1 1.4%). Furthermore, Neal et al. (1994) found the IES to be the most useful
dichotomous measure, compared to the CAPS-1 (Weathers & Litz, 1994) and
the MMPI-PTSD (Keane et al., 1984). Other work has shown that scores on the
IES are associated with scores on measures of PTSD (e.g., Foa, Riggs, Dancu, &
Rothbaum, 1993).
Although this evidence shows that the IES is tapping posttraumatic stressrelated phenomena, the IES was not developed to assess PTSD per se. Horowitz
and colleagues introduced the IES as a measure of subjective distress and the

Impact of Event Scale

105

strength of correlation between scores on the IES and various PTSD measures
would support this, as would the correlation between the IES and various measures
of psychological distress (e.g., BDI, STAI, GHQ, and SCL-90) (e.g., Bryant &
Harvey, 1996a; Creamer, Burgess, & Pattison, 1992; Foa et al., 1993; Joseph
et al., 1996). Additionally, IES scores have also been found to be associated with
increased physiological responsivity (e.g., Orr, 1993).
Although there is evidence for convergent validity of the IES as a measure
of subjective distress, other evidence shows that respondents can easily fake psychopathology on the IES questioning its validity. Lees-Haley (1990) asked 52
college students to respond to the IES as they would if they were involved in
a lawsuit for damages associated with an experience which was genuinely, but
briefly, disturbing. Their goal was to fake psychological disturbance. The mean
intrusion score was 24 and the mean avoidance score was 22. Lees-Haley (1990)
concludes that an untrained person can simulate psychopathology on the IES and,
when asked to malinger in a plausible manner, produce scores similar to those of
genuinely injured patients. Future revisions of the IES might include items to help
detect exaggerators and researchers and clinicians should be cautious in interpreting data where there may be strong motivations to fake bad. As well as problems
of faking, self-report measures are subject to problems of accurate recall. Low
correspondence has been reported between laboratory time-based sleep schedule records and endorsement of sleep-related items on the IES as well as other
self-report measures (Dagan & Lavie, 1991): However, these criticisms are not
necessarily confined to the IES and also apply to other self-report PTSD measures
(e.g., Fairbank, McCaffrey, & Keane, 1985).
Thus, as a measure of PTSD per se, the IES is severely limited in its content
validity. The items contained in the IES do not reflect DSM criteria and many
newer instruments have been developed which do assess PTSD. Consequently, a
researcher setting out to investigate PTSD would not be recommended to use the
IES. However, the IES would seem to have satisfactory psychometric properties
as a measure of subjective distress, although in common with other self-report
measures, it can be easily faked. A researcher wanting to assess subjectivedistress
might be recommended to use the IES.
Within Horowitz's model of adjustmentthe IES can also be viewed as an index
of ongoing cognitive and behavioral processes and it is perhaps for this use that
the IES might still be recommended (i.e., as an independent variable rather than as
a dependent variable). Research has shown that higher scores on the IES are able
to predict greater subsequent distress (Joseph, Yule, & Williams, 1994; Joseph,
Yule, & Williams, 1995; Joseph et al., 1996; McFarlane, 1992a). With regard
to PTSD, Perry, Difede, Musngi, Frances, and Jacobsberg (1992) found that IES
intrusion scores at 2 months predicted PTSD at 6 months and IES avoidance scores
at 6 months predicted PTSD at 12 months. These data suggest that scores on the
IES can usefully predict later distress and F'TSD.

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Joseph

However, the ability of the IES to predict later psychiatric status has not
consistently been shown. Other data with survivors of a terrorist attack do not show
scores on the IES, assessed within days of the attack, able to predict psychiatric
morbidity 14 months later (Shalev, 1992). McFarlane (1992b) argues that in the
immediate aftermath of an event, high levels of intrusion and avoidance are normal
and do not signal an inability to emotionally process the event (a conclusion in
accord with the DSM one month criteria for PTSD symptoms). Consequently, it
is only later that high scores on the IES become predictive of later outcome.
Alternatively, Creamer et al. (1992) have proposed that the IES can be used
to measure the cognitive processes that mediate between the traumatic event and
subsequent emotional responses. Creamer et al. suggest that higher scores on the
IES are indicativeof active cognitiveprocessing and therefore higher scores should
be predictive of less rather than more subsequent psychological distress. Data
presented by Creamer et al. (1992) support this hypothesis. Thus, research findings
on the role of the IES in predicting subsequent distress is mixed. These mixed
findings may reflect the uncertain content validity of the IES. For example, some
facets of intrusive or avoidant experience may be predictive of poorer subsequent
adjustment, whereas other facets are predictive of better subsequent adjustment.
Several factor-analytic studies have been carried out on the IES items which help
to shed some light on the possible multifactorial content of the IES. These studies
are discussed below.

Dimensionality

Horowitz et al. (1979) reported a positive correlation between the intrusion

and the avoidance subscales, a finding which has subsequently been replicated in
other studies. However, the degree to which intrusion and avoidance are associated
would also seem to depend on the timing of measurement. Zilberg et al. (1982)
conducted repeated measures of a group of patients undergoing therapy, finding
correlations between intrusion and avoidance ranging from .15 to .78, the lowest
associationsbeing obtained within the first pretherapy session. These data suggest
that in the immediate aftermath of trauma, intrusion and avoidance may be dissociated (see also Williams, Joseph, & Yule, 1994)but, over time, become increasingly
associated. However, the evidence for this suggestion is weak. Overall, correlations between intrusion and avoidance have generally been found to be moderate
to strong (e.g., Creamer et al., 1992; Kopel & Friedman, 1997; Robbins & Hunt,
1996; Schwarzwald et al., 1987; Williams et al., 1994; Zilberg et al., 1982) and
Solomon and her colleagues concluded that these scales reflected a single dimension of general distress (Solomon, Mikulincer, & Arad, 1991, p. 215). However,
such a view is inconsistent with the theoretical two-factor development of the
IES. Also, some factor analytic work assessing all PTSD symptoms suggests that

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107

reexperiencing and avoidant phenomena load on the same first factor with numbing symptoms loading on a separate factor (Foa, Riggs, & Gershuny, 1995; Taylor,
Kuch, Koch, Crockett, & Passey, 1998).
Several studies have been conducted which have attempted to validate the
two factor structure of the IES. In the first study, subsequent to the original paper
by Horowitz et al. (1979), to report on the psychometric properties of the IES,
Zilberg et al. (1982) conducted a principal-components analysis of the IES with
a combined pool of 35 outpatients who sought treatment after the death of their
parent and 37 respondents obtained from a list of death records naming next of kin.
Three factors with eigenvalues greater than 1.00 were obtained. The third factor
was dropped in a two-factor forced solution, as it barely met the standard inclusion
criteria, yielding an eight-item avoidance factor (items 2,3,7,8,9, 12, 13, and 15)
and a seven-item intrusion factor (items 1,4,5,6, 10, 11, and 14), confirming the
scoring procedure outlined by Horowitz et al. (1979). Although this has become
the most cited study supporting the two factor scoring procedure, it is not without
criticism. Although the analysis by Zilberg et al. (1982) was close to meeting the
criteria of five respondents per variable proposed by Gorsuch (1983), structural
analyses of psychological tests ideally requires a minimum of 200 respondents
(see Comrey, 1988).
Consequently, Schwarzwaldet al. (1987) investigated the IES factor structure
with 382 male combat veterans. Again, a principal-components analysis yielded
three factors, of which the third factor was again dropped in a two-factor forced
solution, yielding a nine-item intrusion factor (items 1,2,4,5,6, 10, 11, 12, and
14) and a four-item avoidance factor (items 3, 7, 9, and 13). Schwarzwald et al.
(1987) noted that their item clusters were similar to those of Zilberg et al. (1982)
but that several discrepancies existed. First, two avoidance items (items 8 and 15)
loaded together as a third factor, which they characterized as emotional avoidance.
Second, two other avoidance items (items 2 and 12) loaded on the intrusion factor.
Schwarzwald et al. noted that these items appeared more ambiguous, as they
contained aspects of both intrusion and avoidance and might therefore not be
expected to load consistently on one factor.
Further principal-component analyses with various populations, such as adult
survivors of shipping disasters (Joseph, Williams, Yule, & Walker, 1992; Joseph,
Yule, Williams, & Hodgkinson, 1993), adolescent survivors of shipping disaster
(Yule, Ten Bruggencate, & Joseph, 1994),female bank staff caught up in an armed
raid (Hodgkinson & Joseph, 1995), and Korean and Second World War veterans (Robbins & Hunt, 1996),have generally confirmed the two-factor theoretical
structure. However, minor inconsistencieshave been noted throughout these studies, namely, that items 2 and 12 do not always load on their proposed factor, that
items 8 and 15 sometimesload together as a second avoidance factor (characterized
as emotional numbing), and items 4 and 6 sometimes load together as a second
intrusion factor (characterized as sleep disturbances and dreams). Despite the fact

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Joseph

that confirmatory factor analysis would have been the more appropriate technique
with which to evaluate the hypothesized structure (see Weathers et al., 1996),
these various inconsistencies have drawn attention to the possible multifactorial
nature of intrusion and avoidance and the limited content validity of the IES as a
measure of intrusive and avoidant experiences.

Assessment Issues
Although the evidence suggests that the IES has adequate properties of reliability and validity, the fact that it lacks clear criteria and norms for diagnostic
use has been noted as a shortcoming of the IES. Paradoxically, it is also probably
one reason for the popularity and longevity of the IES. While diagnostic criteria
have changed, and new instruments have been introduced to replace those which
have been made redundant, the IES has provided an unchanging standard measure of posttraumatic stress for almost 20 years. It has commonly been used to
validate new measures against and has provided, at least historically, what might
be described as the gold standard self-report measure in trauma research. A compelling argument in favour of the continued use of the IES is therefore the fact that
the IES allows for comparative conclusions to be made regarding similarities and
differences between new and old trauma samples.
For those who do choose to continue using the IES, three recommendations
are made. First, it was noted that some researchers have used different weightings
to score the IES and others have amended the time frame making comparability
between some studies difficult. It is recommended that in the future researchers
make such amendments explicit in their reports. Second, it was noted that data on
the reliability of the IES is sparse and it is recommended that reliability data be
routinely reported. Third, it was noted that the IES can be easily faked and so it
is recommended that researchers include some measure of the tendency toward
faking.
It has been suggested,however, that researchers and clinicians should now use
measures based on DSM criteria which provide a separate score for hyperarousal
in addition to scores for intrusion and avoidance. The IES-R was designed for this
purpose (Weiss & Marmar, 1997). The IES-R contains the original IES item pool
and so can be used to yield scores comparable to previous research using the IES
as well as providing measurement of hyperarousal for those who wish to base their
assessment on the DSM structure.
However, the question is raised what it is that we should be trying to assess. It is possible that the current DSM structure will be modified in the future
and instruments based on the DSM three-factor structure will themselves become
redundant. There is considerabledebate on the architecture of posttraumatic symptoms. The IES was based on Horowitzs higher-order two-factor model of trauma

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response and it might be that a higher-order two-factor model does in fact provide
the best fit structure to trauma-related reactions. Symptoms contained in the DSM
D section for hyperarousal were considered by Horowitz within the two-factor
system, i.e., sleep disturbances, hypervigalence, and exaggerated startle response
were considered within the intrusion factor, whereas memory loss and difficulties
in concentration were considered within the avoidance factor. Section D has been
described as a miscellaneous section, and in accordance with Horowitzs twofactor theory, it might be that section D symptoms should be divided between the
two dimensions of repetitive phenomena and defense phenomena. Laufer, Brett,
and Gallops (1985) suggest that symptoms may be grouped into two patterns:
(a) a reexperiencing symptom pattern divided into (1) intrusion symptoms and
(2) hyperarousal symptoms; and (b) a denial symptom pattern, divided into
(1) numbing and (2) cognitive difficulties. Indeed, recent factor-analytic data using the Clinician Administered PTSD scale reported that a four-factor solution
produced the best fit (King, Leskin, King, & Weathers, 1998), with Category C
symptoms loading on two separate factors, effortful avoidance and emotional
numbing. The question of the underlying symptom structure to trauma-related
reactions remains unresolved and there is a need for further conceptually based
psychometric studies on the architecture of reactions (Joseph, Williams, & Yule,
1997). Such data would provide the foundation stone for future instrument
development.
However, even if supporting data were provided for Horowitzs higher-order
two-factor structure, it is recognized that the phenomenology of posttraumatic
stress reactions is wider than that contained in the pool of items that constitute the IES and that its content validity as a two-factor measure might be limited. For example, it is clear from the principal-component data discussed above
that sleep disturbances and emotional numbing, insofar as they are measured by
the IES, are potentially separable features of intrusion and avoidance, respectively. This is consistent with other evidence using a wider pool of items (Hovens
et al., 1994). Drawing on this literature, Joseph et al. (1997) suggest that there
might be two distinct forms of intrusion-the first characterized as deliberate
ruminative activity which is under conscious control and the second characterized by nightmares and flashbacks and other experiences which are automatic
and outside conscious control-and two distinct forms of avoidance-the first
characterized as conscious efforts at coping which are under conscious control
and the second characterized as emotional numbing and other experiences which
are automatic and outside conscious control. The distinction between automatic
and controllable processes has also been pointed to in recent theoretical work
on the cognitive processes underlying PTSD (see, e.g., Brewin, Dalgleish, &
Joseph, 1996; Power & Dalgleish, 1997) and it would seem that this distinction provides a powerful theoretical architecture for future psychometric scale
development.

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Joseph

Concluding Comments
Further conceptually based work containing a wider pool of items reflecting
the theoretical distinction between automatic and controlled processes is called
for. However, at present the IES remains the only measure based on the two-factor
structure. In this respect, continued use of the IES would seem to be warranted,
at least until newer rationally developed and psychometrically valid measures of
trauma-related processes are developed which either refute the two-factor structure
or provide an alternative higher-order two-factor measure with improved psychometric properties and the ability to distinguish between different facets of intrusion
and avoidance.
In conclusion,there is evidence supportingthe validity of the IES as a measure
of trauma-related distress (although not PTSD per se). However, the main usefulness of the IES is, perhaps, as a measure of the intrusive and avoidant processes
that mediate between the experience of trauma and subsequent adjustment. In this
respect, continued use of the IES would seem to be warranted, at least in the short
term. In the longer term,however, there is a need for psychometric investigation
into the potential multifactorial nature of intrusive and avoidant processes.

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