ASSESSING AND DIAGNOSING PATIENTS WITH KNOWN OR SUSPECTED PTSD

Individuals exposed to a traumatic event 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.

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) is considered the gold standard in PTSD assessment. It is 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 45–60 minutes to administer. A version of CAPS for children and adolescents ages 7 and above is also available.

The Life Events Checklist for DSM-5 (LEC-5) is often used in combination with CAPS-5 for the purpose of establishing exposure to a PTSD criterion, which is essential for making a PTSD diagnosis. The LEC-5 assesses exposure to 16 events known to potentially result in PTSD or distress and includes one additional item assessing any other extraordinarily stressful event not captured in the first 16 items. There is no formal scoring protocol or interpretation other than identifying whether the person has experienced any of the events (Comorbidity Guidelines, 2023; NCPTSD, 2022a).

ASSESSING THE OLDER ADULT

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

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

When interviewing older adults, it is 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. (Hermann, 2022).

Physical Examination

Any patient presenting with symptoms of PTSD should have a complete history and physical examination to rule out any medical or neurological disorder. Routine laboratory testing such as complete blood count, urine toxicology, thyroid-stimulating hormone, vitamin B₁₂, and folate levels are checked. Individuals may present with physical injuries in regards to the trauma, and accordingly, neuroimaging studies such as computed tomography (CT) and magnetic resonance imaging (MRI) scans of the brain is indicated as per the history and presentation (Mann & Marwaha, 2023).

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