A. Assessment of Trauma Exposure Related Symptoms

BACKGROUND

Posttraumatic stress disorder (PTSD) is the development of characteristic and persistent symptoms along with difficulty functioning after exposure to a life-threatening experience or to an event that either involves a threat to life or serious injury. In some cases the symptoms of PTSD disappear with time, whereas in other cases they persist for many years. PTSD often occurs with or precedes other psychiatric illnesses.

The symptoms required for the diagnosis of PTSD may be divided into 3 clusters and should be present for at least 1 month.

• Intrusion or re-experiencing - memories of the trauma or "flashbacks" that occur unexpectedly; these may include nightmares, intrusive mental images or extreme emotional distress and/or physiological reactivity on exposure to reminders of the traumatic event
• Avoidance - avoiding people, places, thoughts, or activities that bring back memories of the trauma; this may involve feeling numb or emotionless, withdrawing from family and friends, or "self-medicating" by abusing alcohol or other drugs
• Hyperarousal - feeling "on guard" or irritable, having sleep problems, having difficulty concentrating, feeling overly alert and being easily startled, having sudden outbursts of anger.

Diagnostic criteria for acute stress disorder (ASD) require a presentation of dissociative symptoms - numbing, reduction in awareness, derealization, depersonalization or dissociative amnesia

Patients are most likely to present to primary care with unexplained somatic and/or psychological symptoms (e.g., sleep disturbance, night sweats, fatigue, difficulty with memory or concentration). In some cases, providers may consider PTSD early and use this guideline first, whereas in others it may be useful to follow the algorithms and recommendation of the DoD/VA guideline for Post Deployment, the VA/DoD guideline for medical unexplained symptoms or the VA/DoD guideline for management of depression in primary care. All these guidelines provide a link to this module when appropriate.

RECOMMENDATIONS

Assessment in Primary Care

1. Patients who are presumed to have symptoms of PTSD or who are positive for PTSD on the initial screening should receive specific assessment of their symptoms.
2. A thorough assessment of the symptoms is necessary for accurate diagnosis, rating the severity of the disorder, and making correct clinical decisions.
3. Consider self-administered checklists to ensure systematic, standardized, and efficient review of the patient’s symptoms.
4. Useful information may include details such as time of onset, frequency, course, severity, level of distress, functional impairment, and other relevant information.

DISCUSSION

Initial screening is discussed in the CORE module (See Core Module annotation C; For Screening Tools see Appendix C ).

The DSM-IV (1994) describes three-symptom clusters characteristic of PTSD (reexperiencing, avoidance, and arousal).

The traumatic event is persistently reexperienced in one (or more) of the following ways:

1. Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions
2. Recurrent distressing dreams of the event
3. Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur upon awakening or when intoxicated)
4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid activities, places, or people that arouse recollections of the trauma
3. Inability to recall an important aspect of the trauma
4. Markedly diminished interest or participation in significant activities
5. Feeling of detachment or estrangement from others
6. Restricted range of affect (e.g., unable to have loving feelings)
7. Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).

Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance
5. Exaggerated startle response.

Diagnostic criteria for ASD require a presentation of dissociative symptoms in addition to one symptom of each of the three PTSD symptom clusters. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

1. Subjective sense of numbing, detachment, or absence of emotional responsiveness
2. Reduction in awareness of his or her surroundings (e.g., "being in a daze")
3. Derealization
4. Depersonalization
5. Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).

Dissociative symptoms are not considered an essential feature of PTSD, as they are for ASD. Dissociative symptoms included among the diagnostic criteria for PTSD are categorized as reexperiencing (e.g., dissociative flashbacks) or avoidance. A number of symptoms of avoidance could be characterized as dissociative. For example, the dissociative symptom of numbing could be considered an expression of a restricted range of affect and, hence, an avoidance symptom in the PTSD diagnosis. Feeling detached or estranged from others (another avoidance symptom in PTSD) might also be an example of the dissociative symptom of detachment. Similarly, the inability to remember an important aspect of the trauma describes the dissociative symptom of amnesia. Stupor, another dissociative symptom, is characterized as a decrease in activity that is both spontaneous and responsive. Symptoms of stupor could be interpreted as a decreased interest or participation in significant activities, thereby qualifying as another avoidance symptom of PTSD. Thus, while dissociation has not been identified as a central feature of PTSD, dissociative symptoms can contribute to a diagnosis of PTSD, making the comparison of ASD and PTSD less inconsistent than it might seem.