Evidence based assessment/Posttraumatic stress disorder (disorder portfolio)

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Medical disclaimer: This page is for educational and informational purposes only and may not be construed as medical advice. The information is not intended to replace medical advice offered by physicians. Please refer to the full text of the Wikiversity medical disclaimer.

What is a "portfolio"?[edit]

  • For background information on what assessment portfolios are, click the link in the heading above.

Preparation phase[edit]

Diagnostic criteria for post traumatic stress disorder[edit]

ICD-10 Diagnostic Criteria and ICD-11 Description (criteria coming soon)

ICD-10 Diagnostic Criteria[edit]

  • A. The patient must have been exposed to a stressful event or situation (either short- or long-lasting) of exceptionally threatening or catastrophic nature, which would be likely to cause pervasive stress in almost anyone.
  • B. There must be persistent remembering or "reliving" of the stressor in intrusive "flashbacks", vivid memories, or recurring dreams, or in experiencing distress when exposed to circumstances resembling or associated with the stressor.
  • C. The patient must exhibit an actual or preferred avoidance of circumstances resembling or associated with the stressor, which was not present before exposure to the stressor.
  • D. Either of the following must be present:
    • 1. inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor;
    • 2. persistent symptoms of increased psychological sensitivity and arousal (not present before exposure to the stressor), shown by any two of the following:
      • (a) difficulty in falling or staying asleep;
      • (b) irritability or outbursts of anger;
      • (c) difficulty in concentrating;
      • (d) hypervigilance;
      • (e) exaggerated startle response
  • E. Criteria B, C, and D must all be met within 6 months of the stressful event or of the end of the period of stress. (For some purposes, onset delayed more than 6 months may be included, but this should be clearly specified.)


  • The ICD 11 describes PTSD in this way-
    • 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[edit]

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.[1]
  • 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.[2] 10 months after a trauma, however, only experience of a major life event remained predictive of continuing PTSD symptoms.[2]
  • 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.[2]
  • Children who reported using blame and anger as strategies for coping had higher levels of PTSD symptoms 10 months after a trauma.[2]
  • Negative affect in children before a traumatic event was predictive of development of PTSD symptoms after a traumatic event.[3]

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[edit]

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[4] 6.8% United States, nationally representative, age 18 and older National Comorbidity Survey - Replication
Non-clinical: Population based[5] 7.4% Netherlands, nationally representative, age 18-80 Composite International Diagnostic Interview (CIDI)
Non-clinical: Population based[6] 6.4% United States, nationally representative, age 18 and older Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions
Non-clinical: Population based[7] 8.8% Northern Ireland, representative sample, age 18 and older Northern Ireland Study of Health and Stress
Non-clinical: Population based[8] 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[9] 11.5% - 19.5% ♦ U.S. Army and Marine Soldiers Deployed to Iraq and Afghanistan PTSD Checklist
Non-clinical: Population based[10] 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[edit]

Psychometric properties of screening for PTSD[edit]

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 Self-Report, Caregiver Report child
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

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[edit]

  • 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[edit]

Prescription phase[edit]

Gold standard diagnostic interviews[edit]

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

Recommended diagnostic interviews for PTSD[edit]

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

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

Severity interviews for PTSD[edit]

Measure Format (Reporter) Age Range Administration/

Completion Time

Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures

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

Process phase[edit]

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[edit]

  • Information coming soon

Outcome and severity measures[edit]

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[edit]

  • 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) [11]:

  1. 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
  2. EMDR may help both acute and chronic PTSD, especially individuals who have trouble with prolonged exposure or have trouble verbalizing their trauma.[12]
    1. Long term gains require further study.

Treatments with weaker evidence (have some benefit) [11]:

  1. Patient education,
  2. Imagery rehearsal therapy,
  3. Psychodynamic therapy,
  4. Hypnosis,
  5. Relaxation techniques,
  6. and Group therapy.

Treatment with unknown benefit [11]:

  1. Web-based CBT,
  2. Acceptance and commitment therapy,
  3. and Dialectical Behavioral Therapy.

Medication

  • SSRIs are more effective than placebo in treating PTSD.[12]
  • There is no evidence to support a medication to prevent the development of PTSD.[11]
    • 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[edit]

For professionals[edit]

For caregivers[edit]

For educators[edit]

For public[edit]

References[edit]

Click here for references
  1. Paolucci, Elizabeth ODDONE; Genuis, Mark L.; Violato, Claudio (January 2001). "A Meta-Analysis of the Published Research on the Effects of Child Sexual Abuse". The Journal of Psychology 135 (1): 17–36. doi:10.1080/00223980109603677. 
  2. 2.0 2.1 2.2 2.3 La Greca, A; Silverman, WK; Vernberg, EM; Prinstein, MJ (August 1996). "Symptoms of posttraumatic stress in children after Hurricane Andrew: a prospective study.". Journal of consulting and clinical psychology 64 (4): 712-23. PMID 8803361. 
  3. Weems, CF; Pina, AA; Costa, NM; Watts, SE; Taylor, LK; Cannon, MF (February 2007). "Predisaster trait anxiety and negative affect predict posttraumatic stress in youths after hurricane Katrina.". Journal of consulting and clinical psychology 75 (1): 154-9. doi:10.1037/0022-006X.75.1.154. PMID 17295574. 
  4. Kessler, Ronald C.; Berglund, Patricia; Demler, Olga; Jin, Robert; Merikangas, Kathleen R.; Walters, Ellen E. (2005-06-01). "Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication" (in en). Archives of General Psychiatry 62 (6). doi:10.1001/archpsyc.62.6.593. ISSN 0003-990X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archpsyc.62.6.593. 
  5. de Vries, Giel-Jan; Olff, Miranda (2009-08-01). "The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands" (in en). Journal of Traumatic Stress 22 (4): 259–267. doi:10.1002/jts.20429. ISSN 1573-6598. http://onlinelibrary.wiley.com/doi/10.1002/jts.20429/abstract. 
  6. Pietrzak, Robert H.; Goldstein, Risë B.; Southwick, Steven M.; Grant, Bridget F.. "Prevalence and Axis I comorbidity of full and partial posttraumatic stress disorder in the United States: Results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions". Journal of Anxiety Disorders 25 (3): 456–465. doi:10.1016/j.janxdis.2010.11.010. http://linkinghub.elsevier.com/retrieve/pii/S0887618510002288. 
  7. Bunting, Brendan P.; Ferry, Finola R.; Murphy, Samuel D.; O'Neill, Siobhan M.; Bolton, David (2013-02-01). "Trauma Associated With Civil Conflict and Posttraumatic Stress Disorder: Evidence From the Northern Ireland Study of Health and Stress" (in en). Journal of Traumatic Stress 26 (1): 134–141. doi:10.1002/jts.21766. ISSN 1573-6598. http://onlinelibrary.wiley.com/doi/10.1002/jts.21766/abstract. 
  8. Atwoli, Lukoye; Stein, Dan J.; Williams, David R.; Mclaughlin, Katie A.; Petukhova, Maria; Kessler, Ronald C.; Koenen, Karestan C. (2013-07-03). "Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study". BMC Psychiatry 13: 182. doi:10.1186/1471-244x-13-182. ISSN 1471-244X. https://doi.org/10.1186/1471-244X-13-182. 
  9. Hoge, Charles W.; Castro, Carl A.; Messer, Stephen C.; McGurk, Dennis; Cotting, Dave I.; Koffman, Robert L. (2004-07-01). "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care". New England Journal of Medicine 351 (1): 13–22. doi:10.1056/nejmoa040603. ISSN 0028-4793. PMID 15229303. http://dx.doi.org/10.1056/NEJMoa040603. 
  10. Merikangas, Kathleen Ries; He, Jian-ping; Burstein, Marcy; Swanson, Sonja A.; Avenevoli, Shelli; Cui, Lihong; Benjet, Corina; Georgiades, Katholiki et al.. "Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A)". Journal of the American Academy of Child & Adolescent Psychiatry 49 (10): 980–989. doi:10.1016/j.jaac.2010.05.017. https://doi.org/10.1016/j.jaac.2010.05.017. 
  11. 11.0 11.1 11.2 11.3 Department of Veterans Affairs and Department of Defense. . (2010). VA/DoD clinical practice guidelines: management of post-traumatic stress. Washington, D.C.: Veterans Health Administration, Department of Defense.
  12. 12.0 12.1 Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., . . . McIntyre, J. S. (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder: American Psychiatric Publ