Approach

Many people who come into contact with health or social care services soon after having experienced a traumatic event do not report or seek help for psychological problems. Staff working in these services should be aware of traumas associated with the development of PTSD and take the opportunity to assess the person's psychological state. This should include an awareness that PTSD can arise as a result of ongoing situations (e.g., domestic violence, sexual abuse, being a refugee) previously not reported by the person. Initial assessment should be carried out by competent individuals and a decision made as to the need for referral for psychiatric assessment.

History

Key risk factors include combat exposure, terrorist attack, rape, torture, serious accident, sudden death of a loved one, witnessing violence or domestic abuse, natural disaster, molestation, victimization by attacker, previous trauma, multiple major life stressors, or a history of mental disorder or substance misuse.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), PTSD is characterized by the following 4 types of symptom groups. These symptoms must persist for more than 1 month and cause functional impairment for a diagnosis to be made.[1]

Intrusion symptoms[1]

  • Refers to involuntary re-experiencing of aspects of the traumatic event in a vivid and distressing way (e.g., flashbacks, intrusive images and sensory impressions, dreams/nightmares, emotional and physiologic reactivity to internal and external cues).

  • Such re-experiencing arouses intense distress and/or physiologic reactions.

Avoidance[1]

  • Refers to avoidance of reminders of the trauma.

  • Patients typically avoid people, situations, or circumstances resembling or associated with the event. This may extend to more general avoidance of potential reminders, such as newspapers, television programs, or films.

  • Patients often try to push memories of the event out of their mind, and avoid thinking or talking about it in detail, particularly about its worst moments. However, many ruminate excessively about questions that prevent them from coming to terms with the event .

Negative alterations in cognition and mood[1]

  • These changes include amnesia for significant parts of the event, persistent negative beliefs about oneself or the world, distorted ideas of blame related to the traumatic event or its consequences, and negative trauma-related emotions such as fear, horror, anger, guilt, or shame.

  • Patients may experience an inability to experience positive feelings, a disinterest in significant pre-trauma activities, or feelings of detachment and alienation from others.

Alterations in arousal and reactivity[1]

  • Changes in arousal and reactivity include hypervigilance for threat, exaggerated startle response, irritability, angry outbursts, self-destructive or reckless behavior, difficulty concentrating, and sleep problems.

Initial presentation

Difficulty of disclosure may lead to a delay in patients presenting with PTSD, particularly in circumstances of rape and sexual abuse. Also, in a small proportion of cases, the actual onset of symptoms may be delayed.[48][49][50] When presentation is delayed, for whatever reason, people may be less likely to relate their current psychological problems to the traumatic event.

While re-experiencing symptoms is usually the most common initial presentation, this is not always the case. Patients may present with a wide variety of problems, such as depression, anxiety, fear of leaving home, somatic complaints, irritability, sleep difficulties, and an inability to work. In particular, it is likely that older adults will be reluctant to report traumatic events or emotional or psychological problems, and are more likely to present with somatic and physical complaints.[51][52]

Recognition of PTSD

Studies have shown that PTSD is underdetected, even among high-risk groups, and strongly recommend that directly asking about exposure to trauma may significantly improve the recognition rate.[53][54] Health professionals should consider asking people who repeatedly present with unexplained physical symptoms whether they have experienced a traumatic event. Examples of traumatic events should be given, and it may be helpful to use a checklist of common traumatic experiences and symptoms (some screening instruments contain checklists), particularly for people who find it difficult to vocalize these.

Patients will usually have distressing re-experiencing symptoms, report avoidance of reminders of the trauma, and have symptoms of hyperarousal and/or emotional numbing. Health professionals should recognize that many people with these symptoms will be anxious about engaging in assessment and treatment, and may be reluctant to discuss their trauma history and symptoms. Nevertheless, health professionals should ask specifically about each group of symptoms.

Screening

A number of well-validated screening instruments are available. These include the Post-traumatic Diagnostic Scale (PDS-5), the PTSD Checklist for DSM-5, and the Trauma Screening Questionnaire (TSQ).[55][56][57][58] Screening measures based on ICD-11 criteria are also available, e.g. the International Trauma Questionnaire (ITQ).[59]

One systematic review concluded that instruments with fewer items, simpler response scales, and simpler scoring methods perform as well if not better than longer and more complex measures.[60] 

Diagnostic interview

A number of well-validated, structured and semi-structured interview schedules, based on the DSM-IV criteria for the diagnosis of PTSD, are available to assist with the assessment of people presenting with symptoms of PTSD. These include the PTSD Symptom Scale-Interview Version for DSM-5 (PSS-I-5), and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5).[57][58][61] Clinician-administered diagnostic assessments based on ICD-11 criteria are also available, e.g., the International Trauma Interview (ITI).[62]

There may be a variety of presenting complaints, including symptoms that are not specific to PTSD, such as depression, sleep disturbance, and alcohol or drug misuse. The person may focus on these, rather than on the more specific symptoms of PTSD, such as re-experiencing phenomena, avoidance, and hyperarousal. It is important, therefore, to seek to establish whether people presenting with such difficulties have had a traumatic experience, either recently or in the past. This needs to be done sensitively but explicitly, and examples of traumatic events should be given.

The assessment of people presenting with PTSD symptoms should be conducted by individuals who are competent to do so, and should cover the person's physical, psychological, and social needs, as well as an assessment of risks to self and others. It should also cover the impact of the traumatic experience(s) on members of the person's family or the person's close social network.

It is important to be aware that people are likely to find it difficult and distressing to discuss their traumatic experience(s). They may find it difficult to disclose precise details of the experience(s) and/or the symptoms and emotions that they are currently experiencing. It may be impossible for them, especially at first, to describe or discuss the most distressing parts of their experience(s). This may be particularly so when the traumatic experience occurred a long time ago or when the onset of symptoms is delayed. US Department of Veterans Affairs (PTSD): Assessment overview Opens in new window 

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