32
I P T F O R P T S D
arousal symptoms (for example, panic attacks), thus meeting
DSM-5
Criteria
B through D for PTSD. Yet if these patients report qualifying symptoms but
no
plausible trauma, they should be treated for a different diagnosis, not for
PTSD.
Differential diagnosis of PTSD requires deciding whether the patient better
qualifies for an adjustment disorder, acute stress disorder (duration: three days
to one month), or other trauma- or stressor- related disorder. In addition, the
diagnosis of PTSD should be contextualized by psychiatric and medical co-
morbidity. Major depressive disorder is a particular concern,
as it presents
in roughly half of patients diagnosed with PTSD (Shalev et al., 1998). Other
anxiety disorders, substance use disorders, personality disorders, and phys-
ical trauma (that is, traumatic brain injury [TBI]; Stein et al., 2015) also may
inform clinical decision making.
Our study, which began in 2008, used the then- current
DSM- IV
(1994)
criteria for PTSD. These have been altered somewhat for
DSM-5
, which ar-
rived in 2013 (see Table 2. 1), although the two sets of diagnostic criteria appear
roughly comparable (Hoge et al., 2014). Research trials
do not simply rely upon
DSM criteria, but also typically measure the severity of PTSD symptoms using
rating instruments. I strongly recommend this procedure, even for clinicians
in non- research settings. Assessing PTSD severity at the start of treatment
helps to clarify the diagnosis. Furthermore, it provides initial psychoeduca-
tion for patients who may have difficulty in distinguishing between who they
are and the disorder they have. Thus, using a clinical rating instrument helps
patients recognize PTSD symptoms as such and begin to regard them as sepa-
rable from themselves, and ego- dystonic.
Nor should rating end with diagnosis. Serial assessment, another regular
feature
of outcome research studies, involves repeating the rating scale at reg-
ular intervals over the course of treatment. For a 14- week treatment like IPT,
the therapist might want to administer the scale, not only at the start of treat-
ment, but at week 4, week 8, week 12, and after completing week 14. Or at least
at weeks 7 and 14. Repeating the measure reinforces patients’ understanding
of the symptoms of PTSD. Beyond that, it keeps both therapist and patient at-
tuned to progress (or lack thereof) in the treatment.
Patients may not always
recognize how much they are improving. A score on an established PTSD
scale may help them do so and encourage them to proceed.
For screening purposes or as a patient self- report instrument, clinicians
might want to use a measure such as the PTSD Checklist (PCL- 5; Weathers
et al., 2013). This is a 20- item scale, with each item rated 0– 4. It takes just a
few minutes to complete; a score of 38 appears to demarcate clinical severity.
Clinicians can obtain the measure at no cost from the scale available from the
National Center for PTSD at www.ptsd.va.gov.
The
Target Diagnosis
33
The best- established observer- rated instrument for PTSD is probably the
Clinician- Administered PTSD Scale (CAPS; Blake et al., 1995; Weathers et al.,
2001; Weathers et al., 2013a). The 30- item CAPS- 5, released in 2013, asks the
rater to assess the 20
DSM-5
symptom criteria for PTSD (Table 2. 1, criteria B– E),
gauging their frequency and intensity on a scale of 0 (absent) to 4 (extreme/
incapacitating) (Weathers et al., 2013a). It can take almost an hour to admin-
ister, but this may be worth it, as the CAPS-5 delves into the type of trauma
and the nature of symptoms in detail. Like reviewing the
DSM-5
criteria with
a patient, this may help reify the diagnosis as something the patient may not
always have had, and in any case as a disorder,
something distinct from the
patient as a human being.
The PCL- 5 and CAPS- 5 each have different versions for the interval of recent
symptoms (e.g., past week, versus past month, versus worst month). Numerous
alternative PTSD scales exist. Which scale you use in treating patients may
matter less than that you use one. Because patients with PTSD suffer from
numbness, emotional detachment, and alexithymia, as well as mistrust of
others (including therapists), some may initially under- report symptoms,
then “wake up” in the course of treatment to an increased
recognition of their
(hopefully receding) suffering.
Serial rating of patients over the course of a time- limited therapy has always
been a feature of IPT, which arose in a research setting where such assessment
was standard conduct (Markowitz & Weissman, 2012). An initial evaluation
should of course include more than a PTSD measure: a history of present ill-
ness, psychiatric and family psychiatric histories, medical and social history,
and mental status examination (American Psychiatric Association, 2015).
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