The
comprehensive evaluation of PTSD should include information from the
individual, collaterals, psychometric indices (such as self-reported
questionnaires) and a clinical interview. The standard for diagnosis in
clinical research studies is always to use a structured clinical interview. The
use of self-report instruments can be used to corroborate information obtained
in the clinical interview, or can be used as a screening assessment for a
clinical interview. All information would then be integrated on the basis of
clinical judg-ment, especially if discrepancies existed. A number of structured
interviews exist, along with other self-rating scales. The “gold standard” of
clinical interviewing is the Clinician-Administered PTSD scale (Blake et al., 1990).
Other instruments that have been used to evaluate PTSD are the Structured
Clinical Interview for DSM-IV, the Diagnostic Interview Schedule and the
Structured Interview for PTSD. Self-rated measures that can be used in-clude
self-rating psychometric assessments, such as the Davidson Trauma Scale, the
Short PTSD Rating Instrument (SPRINT), the PTSD Checklist, the PK scale on the
Minnesota Multiphasic Personality Inventory, the Mississippi Scale for
Combat-Related PTSD, the Impact of Events Scale and the PTSD Scale.
Structured interview and psychometric measures are also available for
children with PTSD but are less well developed with regard to validity and
reliability. A version of the Clinician-Administered PTSD Scale for children
and adolescents allowsfor current and lifetime diagnoses as well as the
dimensional assessment of PTSD symptoms and related psychopathology. It has
also been suggested that the use of additional measures (such as the Conners
Parent Rating Scale and Conners Teacher Rating Scale) are important adjuncts to
assess externalizing collateral symptoms, whereas the Children’s Depression
Inventory can be used to assess internalizing symptoms found in PTSD.
Immediately following traumatic exposure, a high percentage of
individuals develop a mixed symptom picture, which includes disorganized
behavior, dissociative symptoms, psychomotor change and, sometimes, paranoia.
The diagnosis of ASD (de-scribed later) accounts for many of these reactions.
These reac-tions are generally short-lived, although by 1 month the symptom
picture often settles into a more classic PTSD presentation, such that after
rape, for example, as many as 90% of individuals may qualify for the diagnosis
of PTSD. Approximately 50% of people with PTSD recover, and approximately 50%
develop a persist-ent, chronic form of the illness still present 1 year
following the traumatic event.
The longitudinal course of PTSD is variable and perma-nent recovery
occurs in some people, whereas others show a relatively unchanging course with
only mild fluctuation. Still others show a more obvious fluctuation with
intermittent periods of well-being and recurrences of major symptoms. In a
limited number of cases, the passage of time does not bring a resolu-tion of
symptoms, and the patient’s condition tends to deteriorate with age. Particular
symptoms that have been noted to increase with time in many people include
startle response, nightmares, irritability and depression. Clinicians during
World War II also observed that the existence of marked startle response and
hy-pervigilance in the acute aftermath of exposure to combat often represented
a comparatively poor prognostic sign. In children, PTSD can be, and often is,
chronic and debilitating.
General medical conditions may occur as a direct con-sequence of the
trauma (e.g., head injury, burns). In addition, chronic PTSD may be associated
with increased rates of adverse physical outcomes, including musculoskeletal
problems and car-diovascular morbidity.
General principles of treating PTSD involve explanation and
destigmatization, which can be provided both to the patient and to family
members. This often includes a description of the symptoms of PTSD and the way
in which it can affect behaviors and relation-ships. Information can be given
about general treatment principles, pointing out that sometimes cure is
attainable but that at other times symptom containment is a more realistic
treatment goal, par-ticularly in chronic and severe PTSD. Regaining self-esteem
and attaining greater control over impulses and affect are also desired in many
instances. Information can be provided as to appropriate literature, local
support groups and resources, and names and ad-dresses of national advocacy
organizations. If the therapist attends to these important issues early in
treatment, the patient is able more readily to build trust and also to
appreciate that the therapist shows a good understanding both of the condition
and of the patient.
PTSD is
sometimes comparatively straightforward to treat and at other times it is more
complicated. However, treatment by a mental health provider (rather than a
primary care provider) is almost always indicated. The initial history taking
can evoke strong affect to a greater degree than is customarily found in otherdisorders. In fact, it may take several interviews for the details to
emerge. A sensitive yet persistent approach is needed on the part of the
interviewer. During treatment, although the mental health care provider will
clearly want to impart a sense of optimism to the patient, it is also a
reflection of reality to point out early that recovery may be a slow process
and that some symptoms (e.g., phobic avoidance, startle response) may persist.
It is important for the mental health care provider to be comfortable in
hearing and tolerating unpleasant affect and often horrifying stories. All
these must take place in a noncritical and accepting manner.
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