Assessment and Diagnosis of PTSD with the DSM-V

1. Assessment and Diagnosis of PTSD with the DSM-V Kimberly D. Kalish, Ph.D. Consulting Psychologist: Warrior Salute Clinical Assistant Professor of Psychiatry, School of Medicine & Dentistry, University of Rochester

2. Learning Objectives • Understand the importance of PTSD Assessment • Be Familiar with the New Diagnostic Criteria • Select and Use Appropriate Measures • Promote Accurate Diagnosis: Best Practices/Challenges • Next Steps

3. Why Assess for PTSD in Primary Practice?

4. Trauma Prevalence • 8.7% of Americans experience PTSD in their lives • 50-60% of adults in US experience a trauma • Military Specific • Theater Veterans • Military Sexual Trauma • Tends to be unrecognized/underdiagnosed

5. Comorbidity: PTSD and Mental Health • Panic • Phobias • Anxiety disorders • Depression • Anger/hostility • Insomnia • mTBI • Substance Abuse Disorders • Bipolar Disorder • Conduct Disorder

6. Comorbidity: PTSD and Health • PTSD impacts health • Cancer • Cardiovascular illness • Chronic lung disease • Gastrointestinal distress • Chronic pain • PTSD = increased high risk behaviors • Impaired cognitive functioning • PTSD = increased medical service utilization

7. Diagnostic Criteria: DSM-V American Psychiatric Association (APA). Released May 2013

8. Changes in Criteria DSM-IV DSM-V • Same criteria for young children • Classified as an Anxiety Disorder • 17 Symtpoms • Specific Criteria for young children • Classified as a Trauma and Stressor-Related disorders • 20 Symptoms

9. Trauma- and Stressor-Related Disorders • Reactive Attachment Disorder • Disinhibited Social Engagement Disorder • Posttraumatic Stress Disorder • Acute Stress Disorder • Adjustment Disorder • Other Specified Trauma- and Stressor-Related Disorder • Unspecified Trauma- and Stressor-Related Disorder

10. Changes in Criteria (continued) DSM-IV DSM-V • Divided into 3 clusters Re-experiencing Avoidance & Numbing Increased arousal • Divided into 4 clusters Intrusion Avoidance Negative alterations in cognitions & mood Alterations in Arousal & Reactivity

11. Changes in Criteria (continued) Removed from DSM-IV Added to DSM-V • trauma “requiring intense fear, helplessness or horror happen right after the trauma “ • unexpected death of family or close friend due to natural causes • Acute/Chronic Specifiers • Sense of “foreshortened” future • Sexual Assault/Recurring Exposure • Persistent distorted blame of self or others • Persistent negative emotional state • Aggression • Reckless/Self-Destructive Behavior • Dissociative Subtype • 6 or Younger Subtype

12. Significance of Changes • New assessment measures • Similar prevalence rates, higher in women, increased prevalence with increased exposure • Estimated drop in PTSD rates • Possible Reasons for changes • unexpected death of family or close friend due to natural causes: no longer allowed for diagnosis • At least one avoidance symptom now required

13. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10)

14. Exposure

15. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) • Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: • Directly experiencing the traumatic event(s) • Witnessing, in person, the event(s) as it occurred to others • Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental. • Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless the exposure is work related.

16. Intrusive Thoughts

17. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) continued • Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s) • Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surrounding). • Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s) • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

18. Avoidance

19. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) • Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one of both of the following: • Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s) • Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories thoughts, or feelings about or closely associated with the traumatic event(s).

20. Cognitions/Mood

21. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) continued • Negative alternations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs). • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”). • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others. • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame). • Markedly diminished interest or participation in significant activities. • Feelings of detachment or estrangement from others. • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

22. Arousal/Reactivity

23. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) continued • Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects • Reckless or self-destructive behavior • Hypervigilance • Exaggerated startle response • Problems with concentration • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

24. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10) continued • Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month. • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The disturbance is not attributable to physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

25. DSM-V Criteria: PTSD 309.81 (ICD-10: F43.10): Specifiers Specify whether: With dissociative symptoms: symptoms meet PTSD criteria and, in response to the stressor, experiences persistent or recurrent symptoms of either of the following: • Depersonalization: Persistent or recurrent experience of feeling detached from and as if one were an outside observer of, one’s mental processes or body (e.g., feeling though one were in a dream; feeling a sense of unreality of self or body or time moving slowly) • Derealizaton: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociate symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures). Specify if: With delayed expression: if the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of symptoms may be immediate).

26. Acute Stress Disorder • Exposure to trauma (SAME) • Intrusive Symptoms • Negative Mood • Dissociative Symptoms • Avoidance Symptoms • Arousal Symptoms • Duration is 3 days to 1 month following trauma exposure

27. Risk Factors • Nature of Trauma • Demographics • Prior Traumatic Exposure • Aftermath • Supports • Mental Health • Physical Health • Coping • Recreation/Self-Care • Physiological/Neurological

28. Physiological/Neurological:Risk Factors/Assessment Possibilities • Stathmin: protein needed to form fear memories • GRP (Gastrin-releasing peptide): chemical in the brain that helps control fear • Amygdala: part of the brain that stores memories of emotional events

29. Protective Factors • Demographics • Supports • Spirituality • Mental Health • Physical Health • Coping/Resilience • Recreation/Self-Care • Physiological/Neurological

30. Diagnosing PTSD

31. Multimethod Assessment • Hx of Trauma • PTSD Symptoms • Co-Morbid Conditions • Response Bias • Supporting Documentation • Denotation of medals or honors • DD214 • Discharge papers • Medical/Neurological/Neuropsychological Records • Occupational Records • Family Reports, other

32. Measures

33. Measures 1 • Aftermath of Battle Scale (DRRI-2 Section: E) • Beck Anxiety Inventory - Primary Care (BAI-PC) • Child Posttraumatic Stress Reaction Index (CPTS-RI) • Child PTSD Symptom Scale (CPSS) • Childhood Family Functioning Scale (DRRI-2 Section: B) • Childhood PTSD Interview • Children's Impact of Traumatic Events Scale-Revised (CITES-2) • Children's PTSD Inventory (CPTSDI) • Clinician-Administered PTSD Scale (CAPS) • Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) • Combat Experiences Scale (DRRI-2 Section: D) • Combat Exposure Scale (CES)

34. Measures 2 • Concerns about Life and Family Disruption Scale (DRRI-2 Section: L) • Davidson Trauma Scale (DTS) • Deployment Measures • Deployment Risk and Resiliency Inventory (DRRI) • Difficult Living and Working Environment Scale (DRRI-2 Section: C) • Dimensions of Stressful Events Rating Scale (DOSE) • Distressing Events Questionnaire (DEQ) • Evaluation of Lifetime Stressors (ELS) • Family Stressors Scale (DRRI-2 Section: M) • General Harassment Scale (DRRI-2 Section: K-1) • Impact of Event Scale - Revised (IES-R) • Life Event Checklist (LEC)

35. Measures 3 • Life Stressor Checklist - Revised (LSC-R) • Los Angeles Symptom Checklist (LASC) • Mississippi Scale for Combat-Related PTSD (M-PTSD) • Modified PTSD Symptom Scale (MPSS-SR) • My Worst Experiences Survey • Parent Report of Child's Reaction to Stress • Penn Inventory for Posttraumatic Stress Disorder (Penn Inventory) • Perceived Threat Scale (DRRI-2 Section: G) • Postdeployment Family Functioning Scale (DRRI-2 Section: P) • Postdeployment Social Support Scale (DRRI-2 Section: O) • Postdeployment Stressors Scale (DRRI-2 Section: N) • Posttraumatic Diagnostic Scale (PDS)

36. Measures 4 • Potential Stressful Events Interview (PSEI) • The Primary Care PTSD Screen (PC-PTSD) • Prior Stressors Scale (DRRI-2 Section: A) • PTSD Checklist (PCL) • PTSD Symptom Scale - Interview (PSS-I) • Screen for Posttraumatic Stress Symptoms (SPTSS) • Nuclear, Biological, and Chemical Exposures Scale • Preparedness Scale (DRRI-2 Section: H) • Sexual Harassment Scale (DRRI-2 Section: K-2) • Short Form of the PTSD Checklist - Civilian Version • Short Screening Scale for PTSD • SPAN

37. Measures 5 • SPRINT • Stressful Life Events Screening Questionnaire (SLESQ) • Structured Clinical Interview for the DSM-IV Axis I Disorders (SCID PTSD Module) • Structured Interview for PTSD (SI-PTSD) • Trauma Assessment for Adults--Self-report (TAA) • Trauma History Questionnaire (THQ) • Trauma History Screen (THS) • Trauma Screening Questionnaire (TSQ) • Trauma Symptom Checklist - 40 (TSC-40) • Trauma Symptom Checklist for Children (TSCC) • Trauma Symptom Checklist for Young Children (TSCYC)

38. Measures 6 • Trauma Symptom Inventory (TSI) • Traumatic Events Questionnaire (TEQ) • Traumatic Events Screening Inventory (TESI-C) • Traumatic Life Events Questionnaire (TLEQ) • Traumatic Stress Schedule (TSS) • The UCLA PTSD Index for DSM-IV • Unit Social Support Scale (DRRI-2 Section: J) • When Bad Things Happen Scale (WBTH)

39. Choosing the “Right” Measure • Goals • Level of Training • Time • Cost • Patient Characteristics • Psychometric Properties of the Measure

40. Samples • Primary Care PTSD Screen (PC-PTSD) • Self-administered: PTSD Checklist (PCL) • Interview: Clinician Administered PTSD Scale (CAPS)

41. Recommendation for Medical Practice: Primary Care PTSD Screen (PC-PTSD) • In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: • Have had nightmares about it or thought about it when you did not want to? YES NO • Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO • Were constantly on guard, watchful, or easily startled?YES NO • Felt numb or detached from others, activities, or your surroundings? YES NO • ¾ “yes” responses = positive screen. • Positive screen warrants further investigation • Positive screen warrants suicidal ideation screen

42. PCL • 17-item self-report measure • Likert Scale: 1-5 from “Not at All” to “Extremely” • Follows DSM diagnostic Criteria • 5-10 minutes to complete • May assist with Diagnosis • May be used to measure change over time • Three versions: military, civilian, specific

43. PCL-M: Sample INSTRUCTIONS: Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Not at all A little bit Moderately Quite a bit Extremely 1. Repeated, disturbing memories, thoughts, or images of a stressful military experience? 2. Repeated, disturbing dreams of a stressful military experience? 3. Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

44. PTSD Coach • Smart phone application • Education • Coping/Support • Self-tracking of PTSD using the PCL • Not to be used as a stand alone treatment

45. Clinician Administered PTSD Scale (CAPS) • Gold Standard • 45-60 minutes • 30-item structured clinician-administered interview • Follows DSM criteria • In conjunction with Life Events Checklist • Severity, Frequency, Intensity on ≤ 3 traumatic events • Impact on social, occupational functioning • Requires Significant Training • In public domain, available from VA

46. Challenges to Accurate Diagnosis

47. Symptom Similarity • Sleep • Appetite • Energy • Concentration • Headaches • Pain • Tinnitus

48. More Challenges to Accurate Dx • Estimated underreports • Unwillingness to endorse symptoms • Internal • External • Patients not presenting at clinics • Malingering

49. Now What?

50. Next Steps • Provide patients with results • Ensure privacy • Acknowledge distress/show concern • Explain that PC-PTSD responses suggest follow-up is in order • Assess immediate risks • Normalize and Incentivize • i.e., many people experience trauma in their lives • trauma can impact a person’s health, relationships, concentration, and sleep • Recommend evaluation, not therapy • Acknowledge barriers • Provide Education/offer to speak with family members • Make Referral