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Evidence-based assessment/Traumatic brain injury (assessment portfolio)/extended version

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What is an assessment "portfolio"?

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

Preparation Phase

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Demographic information

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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.

Base rates of PTSD in different clinical settings and populations

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Setting Reference Base Rate Demography Diagnostic Method Best Recommended For
Non-clinical: Population based Kessler et al., 2005[1] 6.8% United States, nationally representative, age 18 and older National Comorbidity Survey - Replication
Non-clinical: Population based de Vries & Olff, 2009[2] 7.4% Netherlands, nationally representative, age 18-80 Composite International Diagnostic Interview (CIDI)
Non-clinical: Population based Pietrzak et al., 2011[3] 6.4% United States, nationally representative, age 18 and older Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions
Non-clinical: Population based Bunting et al., 2013[4] 8.8% Northern Ireland, representative sample, age 18 and older Northern Ireland Study of Health and Stress
Non-clinical: Population based 23819543 Atwoli et al., 2013[5] 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 Hoge et al., 2004[6] 11.5% - 19.5% ♦ U.S. Army and Marine Soldiers Deployed to Iraq and Afghanistan PTSD Checklist
Non-clinical: Population based Merikangas et al., 2010[7] 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

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Diagnosis

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DSM-5 criteria

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The DSM-5 criteria are copyrighted by the American Psychiatric Association, which restricts access. We are working on getting permission to reproduce or link to them here.

Diagnostic changes

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The DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV and also are different from the current definition in the International Classification of Diseases (ICD). Changes between DSM-IV and -5 and are as follows:

  • Stressor criterion (Criterion A) is more specific regarding the individual experience of "traumatic events";
  • Criterion A2 (subjective reaction) no longer exists;
  • The three major symptoms clusters in DSM-IV (re-experiencing, avoidance/numbing, and arousal) are now four symptom clusters in DSM-5.
    • The avoidance/numbing cluster is now divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood;
    • The persistent negative alterations in cognitions and mood cluster contains most of the DSM-IV arousal symptoms and includes irritable or aggressive behavior and reckless or self-destructive behavior;
  • Diagnostic thresholds have been lowered for children and adolescents to be more sensitive to development;
  • There are additional separate criteria for children 6 years of age or younger.

Developmental sensitivities

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  • 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.

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.

Screening and diagnostic instruments for PTSD

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Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended
Glasgow Coma Scale Clinician Administered adult and pediatric versions available 5 minutes N/A G E G X
CAPS (Clinician Administered PTSD Scale) Clinician Administered Self-Report adult and child versions available 40-60 minutes E E E E X
SCID-IV (Structured Clinical Interview for DSM-IV) Interview

(Patient)

adult 1-2 hours A A G G X
PSS-I (PTSD Symptom Scale Interview) Interview

(Patient)

adult 20 minutes E G G G
SI-PTSD (Structured Interview for PTSD) Interview

(Patient)

adult 20-30 minutes E A G G
ADIS (Anxiety Disorder Interview Schedule) Interview

(Patient)

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
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

Prescription Phase

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Process Phase

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Treatment

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Behavioral interventions

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  • Recommended:
    • Brief Cognitive Behavioral Therapy (CBT; 4-5 sessions) has significant benefit.[8]
      • 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.[9] Long term gains require further study.
  • Treatments with weaker evidence:
    • Patient education, imagery rehearsal therapy, psychodynamic therapy, hypnosis, relaxation techniques, and group[8]

therapy may have some benefit. Web-based CBT, Acceptance and commitment therapy, and Dialectical Behavioral Therapy have unknown benefit.[8]

Medication

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  • SSRIs are more effective than placebo in treating PTSD.[9]
  • There is no evidence to support a medication to prevent the development of PTSD.[8]
    • 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.

Process and outcome measures

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Severity and outcome

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Clinically significant change benchmarks with common instruments for PTSD

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Measure Cut-off scores Critical Change
(unstandardized scores)
Benchmarks Based on Published Norms
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
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For professionals

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For caregivers

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For educators

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For public

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References

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Click here for references
  1. ↑ Kessler, RC; Berglund P, Demler O, Jin R, Merikangas KR, Walters EE (July 2005). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.". Archives of General Psychiatry 62 (6): 593. PMID 15939837. http://www.ncbi.nlm.nih.gov/pubmed/15939837. Retrieved 7 October 2014. 
  2. ↑ de Vries, GJ; Olff M (August 2009). "The lifetime prevalence of traumatic events and posttraumatic stress disorder in the Netherlands.". Journal of Traumatic Stress 22 (4): 259-67. PMID 19645050. http://www.ncbi.nlm.nih.gov/pubmed/19645050. Retrieved 7 October 2014. 
  3. ↑ Pietrzak, RH; Goldstein RB, Southwick SM, Grant BF (April 2011). "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): 456-65. PMID 21168991. http://www.ncbi.nlm.nih.gov/pubmed/21168991. Retrieved 7 October 2014. 
  4. ↑ Bunting, BP; Ferry FR, Murphy SD, O'Neill SM, Bolton D (February 2013). "Trauma associated with civil conflict and posttraumatic stress disorder: Evidence from the Northern Ireland study of Health and Stress". Journal of Traumatic Stress 26 (1): 134-41. PMID 23417880. http://www.ncbi.nlm.nih.gov/pubmed/23417880. Retrieved 7 October 2014. 
  5. ↑ Atwoli, L; Stein DJ, Williams DR, Mclaughlin KA, Petukhova M, Kessler RC, Koenen KC (July 2013). 23819543 "Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study.". BMC Psychiatry 13 (1): 182. PMID 23819543. http://www.ncbi.nlm.nih.gov/pubmed/ 23819543. Retrieved 7 October 2014. 
  6. ↑ Hoge, CW; Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL (July 2004). "Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.". New England Journal of Medicine 351 (1): 13-22. PMID 15229303. http://www.ncbi.nlm.nih.gov/pubmed/15229303. Retrieved 7 October 2014. 
  7. ↑ Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., . . . Swendsen, J. (2010). 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.
  8. ↑ 8.0 8.1 8.2 8.3 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.
  9. ↑ 9.0 9.1 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
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