Evidence-based assessment/Posttraumatic stress disorder (disorder portfolio)/extended version

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Evidence-based assessment/Posttraumatic stress disorder (disorder portfolio)/Sidebar

What is a "portfolio"?

• For background information on what assessment portfolios are, click the link in the heading above.
• Does this page feel like too much information? Click here for the condensed version.

Preparation phase

Diagnostic criteria for post traumatic stress disorder

ICD-11 Diagnostic Criteria

ICD-11 Criteria

• Post-traumatic stress disorder (PTSD) is a syndrome that develops following exposure to an extremely threatening or horrific event or series of events that is characterized by all of the following:
  • 1) re-experiencing the traumatic event or events in the present in the form of vivid intrusive memories, flashbacks, or nightmares, which are typically accompanied by strong and overwhelming emotions such as fear or horror and strong physical sensations, or feelings of being overwhelmed or immersed in the same intense emotions that were experienced during the traumatic event;
  • 2) avoidance of thoughts and memories of the event or events, or avoidance of activities, situations, or people reminiscent of the event or events
  • 3) persistent perceptions of heightened current threat, for example as indicated by hypervigilance or an enhanced startle reaction to stimuli such as unexpected noises.
• The symptoms must persist for at least several weeks and cause significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Additionally, ICD 11 includes a category called "Complex post-traumatic stress disorder," which is described as:

• A disorder that may develop following exposure to an event or series of events of an extremely threatening or horrific nature, most commonly prolonged or repetitive events from which escape is difficult or impossible (e.g., torture, slavery, genocide campaigns, prolonged domestic violence, repeated childhood sexual or physical abuse).
• The disorder is characterized by the core symptoms of PTSD; that is, all diagnostic requirements for PTSD have been met at some point during the course of the disorder.
• In addition, Complex PTSD is characterized by:
  • 1) severe and pervasive problems in affect regulation;
  • 2) persistent beliefs about oneself as diminished, defeated or worthless, accompanied by deep and pervasive feelings of shame, guilt or failure related to the traumatic event
  • 3) persistent difficulties in sustaining relationships and in feeling close to others. The disturbance causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.

Changes in DSM-5

• The diagnostic criteria for post-traumatic stress disorder changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

Developmental sensitivities

Click for more information

Diagnostic thresholds have been lowered for children and adolescents to account for development. Separate and additional criteria have been added for children age 6 or younger. Child sexual abuse has been found to have a substantial effect on the development of PTSD. Children with higher exposure to trauma, less social support, and other major life events are more likely to have continued PTSD symptoms 7 months after a trauma. 10 months after a trauma, however, only experience of a major life event remained predictive of continuing PTSD symptoms. Lack of social support, specifically lack of support by a teacher, was predictive of higher PTSD symptoms among children who had gone through an environmental trauma. Children who reported using blame and anger as strategies for coping had higher levels of PTSD symptoms 10 months after a trauma. Negative affect in children before a traumatic event was predictive of development of PTSD symptoms after a traumatic event. Posttraumatic stress disorder is now more sensitive to development in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate and additional criteria have been added for children age 6 years of age or younger.

Base rates of PTSD in different clinical settings and populations

This section describes the demographic settings of the populations sampled, base rates of PTSD diagnoses, country/region sampled, and the diagnostic methods that were used. Using this information, clinicians will be able to anchor the most appropriate rate of PTSD that they are likely to see in their clinical practice.

• To see prevalence rates across multiple disorders, click here.

Setting	Base Rate	Demography	Diagnostic Method	Best Recommended For
Non-clinical: Population based	6.8%	United States, nationally representative, age 18 and older	National Comorbidity Survey - Replication
Non-clinical: Population based	7.4%	Netherlands, nationally representative, age 18-80	Composite International Diagnostic Interview (CIDI)
Non-clinical: Population based	6.4%	United States, nationally representative, age 18 and older	Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions
Non-clinical: Population based	8.8%	Northern Ireland, representative sample, age 18 and older	Northern Ireland Study of Health and Stress
Non-clinical: Population based	2.3%	South Africa, nationally representative sample, age 18 and older	South African Stress and Health Study, using the Composite International Diagnostic Interview (CIDI)
U.S. Service Members	11.5% - 19.5% ♦	U.S. Army and Marine Soldiers Deployed to Iraq and Afghanistan	PTSD Checklist
Non-clinical: Population based	5.0%	United States, nationally representative, ages 13-18	National Comorbidity Survey Replication—Adolescent Supplement (NCS-A)

♦ Note: These rates were using broad PTSD Checklist scoring criteria of being scored positive if subjects reported at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptom that were categorized as at the moderate level. The 11.5% is for soldiers returning from deployment in Iraq, 19.5% is for soldiers returning from Afghanistan. Another common practice is to use a strict cutoff of 50 on the PCL, above which someone screens positive for PTSD. With this cutoff, rates are 6.2% and 12.9% for Service Members returned from Afghanistan and Iraqi, respectively.

Prediction phase

Psychometric properties of screening for PTSD

The following section contains a list of screening and diagnostic instruments for PTSD. The section includes administration information, psychometric data, and PDFs or links to the screenings.

• Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.

• For a list of more broadly reaching screening instruments, click here.

Measure	Format (Reporter)	Age Range	Administration/ Completion Time	Inter-rater reliability	Test-retest reliability	Construct validity	Content validity	Highly recommended
PCL (PTSD Checklist for DSM-5)	Self-Report	adult	5-10 minutes	N/A	G	E	G	X
CAPS (Clinician Administered PTSD Scale)	Clinician Administered Interview	adult and child versions available	40-60 minutes	E	E	E	E	X
SCID-IV (Structured Clinical Interview for DSM-IV)	Clinician Administered Interview	adult	1-2 hours	A	A	G	G	X
PSS-I (PTSD Symptom Scale Interview)	Clinician Administered Interview	adult	20 minutes	E	G	G	G
SI-PTSD (Structured Interview for PTSD)	Clinician Administered Interview	adult	20-30 minutes	E	A	G	G
ADIS (Anxiety Disorder Interview Schedule)	Clinician Administered Interview	adult	2-4 hours	G	A	G	G
UCLA PTSD Reaction Index for DSM-5	Clinician Administered	child, school age, adolescents		G		G	G	Yes
CPSS (Children's PTSD Symptom Scale)	Self-Report	child	10-20 minutes					XX (new rec)
IES-R (Impact of Event Scale-Revised)	Self-Report	adult	10-15 minutes	N/A	A	G	G
M-PTSD (Mississippi Scale for Combat Related PTSD)	Self-Report	adult, specific versions for veterans and civilians	10-15 minutes	N/A	G	E	E
PK Scale (Keane PTSD Scale of the MMPI-2)	Self-report	adult	60-90 minutes (entire MMPI-2)	N/A	G	E	G
PDS (Post-traumatic Diagnosis Scale)	Self-Report	adult	10-20 minutes	N/A	G	E	G	X
LASC (Los Angeles Symptoms Checklist)	Self-Report	adult	5-10 minutes	N/A	G	G	G
Child’s Reaction to Traumatic Events Scale-Revised	Self-Report	7-16	5-10 Minutes			G	G
Child Trauma Screening Questionnaire (CTSQ)	Self-Report	child	5-10 minutes			G	G
Children’s Revised Impact of Events Scale (CRIES-8)	Self-Report	8+ (must be able to read)	5-10 minutes
Trauma Symptoms Checklist for Young Children (TSCYC)	Parent Report on Child	3-12 years old	15-20 minutes	For validities, norms vary based on gender and age group, since each has different scales.
Young Child PTSD Checklist (YCPC)	Parent Report	child	13 items	G		G	G	Yes
Child Behavior Checklist-Posttraumatic Stress Disorder Scale (CBCL-PTSD)	Parent Report	6-18 years old	10-15 minutes			G
International Trauma Questionnaire (ITQ) – Youth Version	Self-Report	child	10 minutes

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Likelihood ratios and AUCs of screening measures for PTSD

• For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

Screening Measure (Primary Reference)	AUC (sample size)	DLR+ (score)	DLR- (score)	Clinical Generalizability	Download

Interpreting PTSD screening measure scores

• For information on interpreting screening measure scores, click here.
• Also see the page on likelihood ratios in diagnostic testing for more information

Prescription phase

Gold standard diagnostic interviews

• For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for PTSD

Diagnostic instruments for PTSD
Measure	Format (Reporter)	Age Range	Administration/ Completion Time	Interrater Reliability	Test-Retest Reliability	Construct Validity	Content Validity	Highly Recommended	Free and Accessible Measures
CAPS-5 (Clinician Administered PTSD Scale)	Clinician Administered Interview	adult	40-60 minutes
PTSD Symptom Scale Interview (PSS-I-5)	Clinician Administered Interview	adult and child version available	24 items
For Children and Adolescents Specifically
CAPS-CA-5 (Clinician-Administered PTSD Scale for DSM-5 - Child/Adolescent Version)	Clinician Administered Interview	child	30 items
Children’s PTSD Inventory (CPTSD-I)	Diagnostic Interview	6-18 years	50 items	G		G

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Severity interviews for PTSD

Measure	Format (Reporter)	Age Range	Administration/ Completion Time	Interrater Reliability	Test-Retest Reliability	Construct Validity	Content Validity	Highly Recommended	Free and Accessible Measures
Schedule for Affective Disorders and Schizophrenia for School Age Children (K-SADS)	Diagnostic Interview	6-18 years	18 PTSD items	G		G
Anxiety Disorders Interview Schedule, Child Version (ADIS-C)	Diagnostic Interview	7-17 years	26 PTSD items	G		G
Children’s Interview for Psychiatric Symptoms (ChIPS)	Diagnostic Interview	6 – 18 years	31 PTSD items	G		G
Diagnostic Infant and Preschool Assessment (DIPA)	Diagnostic Interview	Age 6 and younger	46 PTSD items	G		G

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase

The following section contains a brief overview of treatment options for PTSD and list of process and outcome measures for PTSD. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Process measures

• Information coming soon

Outcome and severity measures

This table includes clinically significant benchmarks for PTSD specific outcome measures

• Information on how to interpret this table can be found here.
• Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
• For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.

Clinically significant change benchmarks with common instruments for PTSD
Benchmarks Based on Published Norms
Measure	Cut-off scores			Critical Change (unstandardized scores)
	A	B	C	95%	90%	SEdifference
Primary Care PTSD Screen	1.0	3.1	2.0	1.0	.8	.5
PTSD Checklist Scores	28.8	40.8	34.9	4.6	3.8	2.3
Clinician Administered PTSD Scale	28.8	40.8	34.9	8.3	7.0	4.2

Treatment

• Please refer to the Wikipedia page on PTSD for more information on available treatment for PTSD or go to the Effective Child Therapy page for for a curated resource on effective treatments for PTSD.

Click here for more information

Behavioral interventions Recommended (have significant benefit) : Brief Cognitive Behavioral Therapy (CBT; 4-5 sessions) This includes stress inoculation training, trauma-focused therapy including components of cognitive restructuring, Cognitive Processing Therapy (CPT), imaginal, virtual, and in-vivo exposure as in Prolonged Exposure psychotherapy (PE)2 Patient education is recommended as part of psychotherapy for patients and family members EMDR may help both acute and chronic PTSD, especially individuals who have trouble with prolonged exposure or have trouble verbalizing their trauma. Long term gains require further study. Treatments with weaker evidence (have some benefit) : Patient education, Imagery rehearsal therapy, Psychodynamic therapy, Hypnosis, Relaxation techniques, and Group therapy. Treatment with unknown benefit : Web-based CBT, Acceptance and commitment therapy, and Dialectical Behavioral Therapy. Medication SSRIs are more effective than placebo in treating PTSD. There is no evidence to support a medication to prevent the development of PTSD. Imipramine, propranolol, prazosin, other antidepressants, anticonvulsants, and atypical antipsychotics have unknown benefit. Strongly recommend against the use of benzodiazepines2 and typical antipsychotics since they have no benefit and potential harm.

External resources

For professionals

• Post Traumatic Stress Disorder Information Resource from The University of Queensland School of Medicine
• APA practice parameters for assessment and treatment for PTSD (Updated 2017)
• Resources for professionals from VA National PTSD Center
• SAMHSA's Trauma-Informed Care Resources and Training
• SAMHSA's Resources on Intimate Partner Violence (IPV) for Clinicians, Patients, Families, and Organizations

For caregivers

• Tips for parents on shooting media coverage
• Parent guidelines to helping youths after a shooting
• Caregiver tips for helping teens with traumatic grief
• Caregiver tips for helping school-age children with traumatic grief
• EffectiveChildTherapy.Org information on PTSD
• Society of Clinical Child and Adolescent Psychology

For educators

• Teacher tips for providing psychological first aid
• Educator tips for helping youths after a community trauma

For public

• Resources for grief and loss
• Psychological impacts of recent shootings
• Tips to talking to youths about a shooting
• Tips to talking to children about a shooting
• Helping young children heal after a crisis
• Psychological first aid for schools
• Resources and manuals on psychological first aid
• Resources for the public from VA National PTSD Center
• Posttraumatic stress disorder at Curlie (based on DMOZ)

References

Click here for references