The proposed posttraumatic stress disorder (PTSD) criteria for the International Classification of Diseases (ICD) 11th revision are simpler than the criteria in ICD-10, DSM-IV or DSM-5. The aim of this study was to evaluate the ICD-11 PTSD factor structure in samples of young people, and to compare PTSD prevalence rates and diagnostic agreement between the different diagnostic systems.
« Previous: Front MatterSuggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
In response to growing national concern about the number of veterans who might be at risk for posttraumatic stress disorder (PTSD) as a result of their military service, the Department of Veterans Affairs (VA) asked the Institute of Medicine (IOM) to conduct a study on the diagnosis and assessment of, and treatment and compensation for PTSD. An existing IOM committee, the Committee on Gulf War and Health: Physiologic, Psychologic and Psychosocial Effects of Deployment-Related Stress, was asked to conduct the diagnosis, assessment, and treatment aspects of the study because its expertise was well-suited to the task. The committee was specifically tasked to “review the scientific and medical literature related to the diagnosis and assessment of PTSD, and to review PTSD treatments (including psychotherapy and pharmacotherapy) and their efficacy.” In addition, the committee was given a series of specific questions from VA regarding diagnosis, assessment, treatment, and compensation. The questions pertaining to diagnosis and assessment and the committee’s responses are provided in Appendix A. This report is a brief elaboration of the committee’s responses to VA’s questions, not a detailed discussion of the procedures and tools that might be used in the diagnosis and assessment of PTSD.
The committee decided to approach its task by separating diagnosis and assessment from treatment and preparing two reports. This first report focuses on diagnosis and assessment of PTSD. Given VA’s request for the report to be completed within 6 months, the committee elected to rely primarily on reviews and other well-documented sources. A second report of this committee will focus on treatment for PTSD; it will be issued in December 2006. A separate committee, the Committee on Veterans’ Compensation for Post Traumatic Stress Disorder, has been established to conduct the compensation study; its report is expected to be issued in December 2006.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
PTSD is a psychiatric disorder that can develop after the direct, personal experiencing or witnessing of a traumatic event, often life-threatening. The essential characteristic of PTSD is a cluster of symptoms that include:
- Re-experiencing—intrusive recollections of a traumatic event, often through flashbacks or nightmares,
- Avoidance or numbing—efforts to avoid anything associated with the trauma and numbing of emotions,
- Hyperarousal—often manifested by difficulty in sleeping and concentrating and by irritability.
If those symptoms last for a month or less, they might be indicative of acute stress disorder; however, for a diagnosis of PTSD to be made, the symptoms must be present for at least a month and must cause “clinically significant distress and/or impairment in social, occupational, and/or other important areas of functioning.”
CURRENT DIAGNOSTIC CRITERIA
Although there is a long history of descriptions of posttraumatic syndromes, the modern era of diagnosing PTSD began in 1980 with the introduction of PTSD in the third edition of APA Diagnostic andStatistical Manual of Mental Disorders (DSM-III). Formal recognition of PTSD led to a large body of systematic research on its features and research findings led to modification and refinement of the diagnostic criteria. But many of the diagnostic criteria from DMS-III are largely unchanged in the latest revision of the fourth edition of the diagnostic manual, DSM-IV-TR (hereafter referred to as the DSM-IV).
The evidence-based diagnosis of PTSD, according to DSM-IV (see Box 2.1) has several components: exposure to a traumatic event, intrusive re-experiencing of the event, avoidance and numbing,
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
hyperarousal, duration of symptoms for at least a month, and clinically significant distress or impairment that was not present before the trauma.
Numerous traumatic events or stressors are known to influence the onset of PTSD; however, not everyone who experiences a traumatic event or stressor will develop PTSD. Its development depends on the intensity of the traumatic event or stressor and on a host of risk and protective factors occurring before, during, and after the trauma.
After a traumatic event, there is substantial variation among patients with regard to both the timing of the onset of symptoms and the types of symptoms. Furthermore, there might be a delay between the onset of symptoms and when the patient seeks help. Patients also vary in how they present to a health professional. For example, a patient might present at a health facility with a physical or psychiatric complaint unrelated to PTSD, and it is only during the course of evaluating or treating the patient for the presenting complaint that symptoms of PTSD can be identified and a diagnosis made. In other cases, a patient might present to a mental health professional who is conversant with the diagnosis of PTSD and is better able to elicit a narrative of exposure and symptoms; or a family member or other person familiar with the veteran might seek advice from a health professional about coping with a veteran who might be suffering from PTSD. The presenting symptoms and initial diagnostic process are variable and might necessitate a brief or long assessment.
Optimally, a patient is evaluated in a confidential setting with a face-to-face interview by a health professional experienced in the diagnosis of psychiatric disorders, such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse. The interview should elicit the patient’s symptoms, assess the history of potentially traumatic events, determine whether the patient meets the DSM-IV criteria for PTSD, determine the frequency and severity of symptoms and the associated disability, and determine whether there are comorbid psychiatric and
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
medical conditions. It is critical that adequate time be allocated for this assessment. Depending on the mental and physical health of the veteran, the veteran’s willingness and capacity to work with the health professional, and the presence of comorbid disorders, the process of diagnosis and assessment will likely take at least an hour and could take many hours to complete.
Unfortunately, many health professionals do not have the time or experience to assess psychiatric disorders adequately or are reluctant to attribute symptoms to a psychiatric disorder. Furthermore, veterans with PTSD might not present to a mental health professional, because they do not attribute their symptoms to a psychiatric disorder, they feel that a stigma is associated with psychiatric illness, they have limited access to such professionals, or for other reasons, such as cost. Therefore, health professionals should be aware that veterans, especially those who have served in war theaters, are at risk for the development of PTSD, but might present with physical or psychiatric complaints that are symptomatic of substance use disorder or other psychiatric conditions. Health professionals should ask all veterans about possible exposure to potentially traumatic events.
A basic component in diagnosing PTSD is determining whether a person has experienced a traumatic event that has led to symptoms indicative of PTSD (see criterion A in Box 2.1). A war environment is rife with opportunities for exposure to traumatic events of many types. Types of traumatic stressors related to war include serving in dangerous military roles, such as driving a truck at risk for encountering roadside bombs, patrolling the streets, and searching homes for enemy combatants, suicide attacks, sexual assaults or severe sexual harassment, physical assault, duties involving graves registration, accidents causing serious injuries or death, friendly fire, serving in medical units, killing or injuring someone, seeing someone being killed, injured, or tortured, and being taken hostage.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
The most important consideration in diagnosing PTSD is a systematic, comprehensive approach to obtaining a patient’s clinical history in a face-to-face, confidential diagnostic interview. Structured and semi-structured approaches to diagnosing PTSD are also useful, especially in epidemiologic and treatment-outcomes research. Some of the most widely used interview instruments for diagnosing PTSD are the Clinician-Administered PTSD Scale (CAPS), the Structured Clinical Interview for DSM-IV, the PTSD Symptom Scale-Interview Version, the Structured Interview for PTSD, the Diagnostic Interview Schedule IV, and the Composite International Diagnostic Interview.
Structured interviews such as the CAPS, which were developed specifically for diagnosis of PTSD, might take an hour or more to administer, although others, such as the PSS-I, can take less time. There are also several self-report instruments that can be used to help document symptoms and traumatic exposures. These include the Posttraumatic Diagnostic Scale, the Davidson Trauma Scale, and the Detailed Assessment of Posttraumatic Stress (DAPS). Each of the instruments determines what symptoms of PTSD are present, as well as their frequency and intensity.
Although numerous instruments have been developed for the diagnosis and assessment of PTSD, the committee strongly concludes that the best way to determine whether a person is suffering irom PTSD is with a thorough, face-to-face clinical interview by a health professional trained in diagnosing psychiatric disorders. Such a health professional will be familiar with the DSM-IV criteria for PTSD (which the committee finds are appropriate for diagnosing PTSD) and will use those criteria when diagnosing patients.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
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Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Suggested Citation:'Summary.' Institute of Medicine. 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. doi: 10.17226/11674.
Next: 1 Introduction »diagnostic criteria for Posttraumatic Stress Disorder(PTSD)
diagnostic criteria
Structured Clinical Interviews
There is no definitive diagnostic tool available for making any psychiatric diagnosis, but the clinical interview currently stands as the linchpin of a multiaxial, multimodal assessment protocol. With a goal of improving diagnostic validity and reliability, a number of structured and semistructured clinical interviews have been developed to assess psychological and psychiatric problems. The Structured Clinical Interview for DSM-IV was designed for use by trained clinicians to assess signs and symptoms of both Axis I and Axis II disorders. The interview is divided into modules that assess the presence of major categories of disorders and also assess specific diagnoses within each category. The format of the interview is such that the diagnostic criteria are presented concurrently with the stem questions to assess the presence of each DSM diagnostic criterion.
However, the stem questions are not intended to be used in the absence of further probing by the clinician. The original PTSD module of the SCID was developed for use in the National Vietnam Veterans Readjustment Study; consequently, considerable data have been collected regarding the reliability and the validity of the PTSD module in a veteran population. In the NVVRS, interrater reliability for the DSM-III version of the PTSD module was .933 (kappa coefficient). Additionally, the correspondence in PTSD diagnosis between the SCID and other measures of PTSD (e.g., Mississippi Scale for CombatRelated PTSD, the Keane et al. MMPI-PTSD subscale) was high. As the diagnostic criteria for PTSD (and other psychiatric disorders) have been revised, subsequent versions of the SCID have been revised to correspond to current nosological specifications. As researchers and clinicians have gained a better understanding of the complexities of PTSD and its co-occurrence with other psychiatric disorders, recognition of the importance of the capacity to assess comorbid disorders has been commensurate. Instruments such as the SCID that assess the full spectrum of Axis I and Axis II diagnoses offer a decided advantage in this regard. However, the same concerns about ensuring reliable and valid diagnosis apply to assessing these comorbid conditions. Fortunately, the SCID has been fairly rigorously tested across the diagnostic spectrum. For example, the SCID has been shown reliable when distinguishing major depressive disorder from generalized anxiety disorder. In child and adolescent assessment, the Diagnostic Interview for Children and Adolescents— Revised offers an approach similar to that of the SCID; that is, the instrument assesses several DSM-IV disorders, including PTSD. A four-point rating scale of symptom frequency is part of this assessment. Examination of the reliability of the PTSD module has indicated good interrater reliability; however, validity studies of the PTSD module of the DICAR revealed variable sensitivity and specificity. Several interviews have been designed that are narrower in focus; that is, they were developed for assessing PTSD exclusively. One notable example of this type of interview is the Clinician Administered PTSD Scale. The CAPS was designed to address the shortcomings of previously developed structured interviews for diagnosing PTSD.
The CAPS is a comprehensive interview that (1) uses behavioral referents for symptoms when feasible; (2) assesses all DSM-IV criteria, as well as a selected sample of relevant associated features; (3) provides separate intensity and frequency ratings of symptoms; (4) specifically establishes that the time frame for symptom occurrence is consistent with diagnostic criteria; and (5) determines both current and lifetime symptoms. Additionally, the CAPS provides ratings of global functioning and of the impact of PTSD symptoms on relevant areas of life functioning. Evaluations of reliability and validity indicate strong psychometric performance. Initial examinations of interrater reliability were quite good (at the symptom level, r ranges from .92 to .99, and there is perfect agreement at the diagnostic level), and subsequent examinations of test–retest reliability for PTSD were .89. Weathers, Blake et al. also found a coefficient alpha of .89, and compared to a SCID PTSD diagnosis, they obtained a sensitivity of .91, a specificity of .86, and a kappa of .77. Additionally, the CAPS has shown strong correlation with other psychometric measures of PTSD, including the Mississippi Scale and the PK Scale of the MMPI. Recent additions to the CAPS include changes to accommodate DSM-IV symptom revisions, as well as additional questions to assess trauma exposure in more detail. A version of the CAPS for use with children has also been developed—the CAPS-C. This instrument is based on DSM-IV diagnostic criteria but also includes the assessment of additional symptoms/features that have been documented in children.
Assessment of academic and social functioning are also included in the CAPSC. This relatively new instrument has not yet reached full psychometric maturity but shows promise, particularly given the full range of symptoms and functional variables that are assessed. There is some indication, however, that the length and the demand of completing the rating scales may be problematic for younger children. In this section, we have provided only a brief introduction to the types of clinical interviews and approaches now available for assessing PTSD, as well as examples of some of the more notable of these interviews. Other choices of clinical interviews that are currently available are delineated and reviewed more extensively in other sources.
Structured Clinical Interviews
There is no definitive diagnostic tool available for making any psychiatric diagnosis, but the clinical interview currently stands as the linchpin of a multiaxial, multimodal assessment protocol. With a goal of improving diagnostic validity and reliability, a number of structured and semistructured clinical interviews have been developed to assess psychological and psychiatric problems. The Structured Clinical Interview for DSM-IV was designed for use by trained clinicians to assess signs and symptoms of both Axis I and Axis II disorders. The interview is divided into modules that assess the presence of major categories of disorders and also assess specific diagnoses within each category. The format of the interview is such that the diagnostic criteria are presented concurrently with the stem questions to assess the presence of each DSM diagnostic criterion.
However, the stem questions are not intended to be used in the absence of further probing by the clinician. The original PTSD module of the SCID was developed for use in the National Vietnam Veterans Readjustment Study; consequently, considerable data have been collected regarding the reliability and the validity of the PTSD module in a veteran population. In the NVVRS, interrater reliability for the DSM-III version of the PTSD module was .933 (kappa coefficient). Additionally, the correspondence in PTSD diagnosis between the SCID and other measures of PTSD (e.g., Mississippi Scale for CombatRelated PTSD, the Keane et al. MMPI-PTSD subscale) was high. As the diagnostic criteria for PTSD (and other psychiatric disorders) have been revised, subsequent versions of the SCID have been revised to correspond to current nosological specifications. As researchers and clinicians have gained a better understanding of the complexities of PTSD and its co-occurrence with other psychiatric disorders, recognition of the importance of the capacity to assess comorbid disorders has been commensurate. Instruments such as the SCID that assess the full spectrum of Axis I and Axis II diagnoses offer a decided advantage in this regard. However, the same concerns about ensuring reliable and valid diagnosis apply to assessing these comorbid conditions. Fortunately, the SCID has been fairly rigorously tested across the diagnostic spectrum. For example, the SCID has been shown reliable when distinguishing major depressive disorder from generalized anxiety disorder. In child and adolescent assessment, the Diagnostic Interview for Children and Adolescents— Revised offers an approach similar to that of the SCID; that is, the instrument assesses several DSM-IV disorders, including PTSD. A four-point rating scale of symptom frequency is part of this assessment. Examination of the reliability of the PTSD module has indicated good interrater reliability; however, validity studies of the PTSD module of the DICAR revealed variable sensitivity and specificity. Several interviews have been designed that are narrower in focus; that is, they were developed for assessing PTSD exclusively. One notable example of this type of interview is the Clinician Administered PTSD Scale. The CAPS was designed to address the shortcomings of previously developed structured interviews for diagnosing PTSD.
The CAPS is a comprehensive interview that (1) uses behavioral referents for symptoms when feasible; (2) assesses all DSM-IV criteria, as well as a selected sample of relevant associated features; (3) provides separate intensity and frequency ratings of symptoms; (4) specifically establishes that the time frame for symptom occurrence is consistent with diagnostic criteria; and (5) determines both current and lifetime symptoms. Additionally, the CAPS provides ratings of global functioning and of the impact of PTSD symptoms on relevant areas of life functioning. Evaluations of reliability and validity indicate strong psychometric performance. Initial examinations of interrater reliability were quite good (at the symptom level, r ranges from .92 to .99, and there is perfect agreement at the diagnostic level), and subsequent examinations of test–retest reliability for PTSD were .89. Weathers, Blake et al. also found a coefficient alpha of .89, and compared to a SCID PTSD diagnosis, they obtained a sensitivity of .91, a specificity of .86, and a kappa of .77. Additionally, the CAPS has shown strong correlation with other psychometric measures of PTSD, including the Mississippi Scale and the PK Scale of the MMPI. Recent additions to the CAPS include changes to accommodate DSM-IV symptom revisions, as well as additional questions to assess trauma exposure in more detail. A version of the CAPS for use with children has also been developed—the CAPS-C. This instrument is based on DSM-IV diagnostic criteria but also includes the assessment of additional symptoms/features that have been documented in children.
Assessment of academic and social functioning are also included in the CAPSC. This relatively new instrument has not yet reached full psychometric maturity but shows promise, particularly given the full range of symptoms and functional variables that are assessed. There is some indication, however, that the length and the demand of completing the rating scales may be problematic for younger children. In this section, we have provided only a brief introduction to the types of clinical interviews and approaches now available for assessing PTSD, as well as examples of some of the more notable of these interviews. Other choices of clinical interviews that are currently available are delineated and reviewed more extensively in other sources.
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