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

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.

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

 * 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.

♦ 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.

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.

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.

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

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

Severity interviews for PTSD
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.

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.

 Behavioral interventions 

Recommended (have significant benefit) :


 * 1) Brief Cognitive Behavioral Therapy (CBT; 4-5 sessions)
 * 2) * 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
 * 3) * Patient education is recommended as part of psychotherapy for patients and family members
 * 4) EMDR may help both acute and chronic PTSD, especially individuals who have trouble with prolonged exposure or have trouble verbalizing their trauma.
 * 5) Long term gains require further study.

Treatments with weaker evidence (have some benefit) :


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

Treatment with unknown benefit :


 * 1) Web-based CBT,
 * 2) Acceptance and commitment therapy,
 * 3) 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.

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)