ASSESSING AND DIAGNOSING PATIENTS WITH KNOWN OR SUSPECTED PTSD

Soldiers, veterans, and civilians injured by trauma should be screened systematically for PTSD and connected to high-quality mental health services. Primary care patients with new anxiety, fear, or insomnia should be asked about a history of trauma and also screened for PTSD. Others in which PTSD may be a factor are those with anxiety symptoms, social isolation, and increased substance use.

Clinical Interview

Individuals who screen positive for PTSD are referred for additional evaluation, which is typically a face-to-face interview by a health professional trained in diagnosing psychiatric disorders. A face-to-face interview is the optimal method of assessment to determine a PTSD diagnosis. Clinical interviews can be structured, semi-structured, or unstructured.

Formal Assessment Tools

Structured and semi-structured interviews are most often conducted utilizing a formal assessment tool. The following are used in the assessment of PTSD in adults:

• Primary Care for PTSD Screen (PC-PTSD). A 4-item, self-administered screening tool for use in primary care settings.
• Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). A 30-item, structured interview administered by clinicians and appropriately trained paraprofessionals to make a current or lifetime diagnosis of PTSD and to assess PTSD symptoms over the previous week. The full interview takes 45 to 60 minutes to administer (Sareen, 2020).
• PTSD Checklist for DSM-5 (PCL-5). A 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. It is used to monitor symptom change during and after treatment, screen for PTSD, and make a provisional PTSD diagnosis. This tool takes 5 to 10 minutes to complete and can be completed by patients in a waiting room (Sareen, 2020).
• Life Events Checklist for DSM-5 (LEC-5). A self-report measure that screens for potentially traumatic events in a patient’s lifetime. It is often used in combination with other tools. There are three formats for LEC-5, including the standard self-report that establishes whether an event has occurred, the extended self-report that establishes the worst event if more than one, and the interview to establish if Criterion A stressor has been met (NCPTSD, 2018b).

ASSESSING THE OLDER ADULT

Assessment of trauma and related symptoms should be routine. Older adults may not readily report traumatic experience or they may minimize their importance, especially if the event(s) occurred a long time in the past.

The recommendations for assessment of an older adult include a full mental status examination, including a cognitive screening. The same “gold standard” assessment tool, CAPS-5, is recommended for the older adult. If dementia is suspected, the patient should be referred for a comprehensive diagnostic evaluation. If delirium or possible medication interaction is suspected, the patient should be referred for medical evaluation.

When interviewing older adults, it should be understood that older patients may talk about problems or respond to questions differently than younger people. They may be less likely to identify problems from a psychological point of view and be more likely to report physical concerns or pain, sleep difficulties, cognitive problems, or gastrointestinal issues. In addition, the older adult is likely to have more medical problems, co-occurring psychiatric problems, and cognitive problems that can complicate the assessment and treatment of PTSD.

Suicide assessment is particularly important in older patients. Older veterans are at greater risk for completed suicide than are middle-aged veterans (Hermann, 2019).

Physical Examination

Any patient presenting with symptoms of PTSD should have a complete history and physical examination to rule out any other causes for symptomatology, such as endocrine, cardiovascular, and neurological disorders. A review of systems and social history should also address the use of over-the-counter medications and mood-altering substances such as prescribed medications, alcohol, marijuana, or other substances of abuse.

Medical Diagnosis

A medical diagnosis is the naming of a disorder based on an assessment of physical signs and symptoms, medical history, and results of diagnostic tests and procedures. The DSM-5 establishes the criteria required in order to make the medical diagnosis of PTSD, as described in the table below.

MEDICAL DIAGNOSIS OF PTSD

Criterion	Requirement
(APA, 2013)
A. Stressor	Must be exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Must have one of the following: Direct exposure Witnessing, in person Indirect exposure, by learning that someone close was exposed to trauma, and if involved, actual or threatened death must be violent or accidental Repeated or extreme indirect exposure to details of traumatic event(s) such as experienced in the course of occupation (e.g., EMS personnel, police, firefighters); does not include indirect nonprofessional exposure through electronic media, television, movies, or pictures
B. Intrusion	Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)
C. Avoidance	Must have one of the symptoms in this symptom cluster (see “Symptoms” earlier in this course)
D. Negative alterations in cognitions and mood that worsened after the traumatic event	Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)
E. Alterations in arousal and reactivity that began or worsened after the traumatic event	Must have two of the symptoms in this cluster (see “Symptoms” earlier in this course)
F. Duration	Symptoms having persisted for more than one month
G. Functional	Must be significant symptom-related distress or functional impairment in activities of daily living such as socialization and occupation
H. Exclusion	Disturbance not due to medication, substance use, or other illness
Specify whether the person experiences dissociative symptoms	Depersonalization: Recurrent experiences of feeling detached from one’s mental processes or body Derealization: Persistent or recurrent experiences of unreality of surroundings
Specify if with delayed expression	Diagnostic criteria not met until at least 6 months after the event

Nursing Diagnosis

NANDA International (2018) defines a nursing diagnosis as “a clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response, by an individual, family, group, or community.”

PTSD is classified as an anxiety disorder, and nursing diagnoses that are appropriate to the patient suffering from PTSD include, but are not limited to:

• Hopelessness/powerlessness
• Fear
• Deficit knowledge
• Ineffective coping
• Sleep pattern disturbance
• Dysfunctional grieving
• Impaired social interaction
• Ineffective relationships
• Social isolation
• Impaired individual resilience
• Risk for suicide and/or self-destructive behavior
  (Vera, 2019)