Post Traumatic Stress Disorder

• Post-Traumatic Stress Disorder (PTSD) is “…a delayed or protracted response to a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone” (World Health Organization, 2010).
• PTSD is characterized by intrusive recollections (e.g., flashbacks, nightmares), avoidance/numbing (e.g., loss of interest, detachment), and hyperarousal symptoms (e.g., irritability, difficulty concentrating, sleep disturbance), and causes significant stress and/or functional impairment in important areas of functioning (e.g., social, occupational).
• High rates of PTSD are associated with rape, combat exposure, torture, childhood neglect and abuse, and sexual molestation. Lower rates are associated with accidents, witnessing death or injury, and fire or natural disasters (Kessler, Chiu, Demler, & Walters, 2005).

Resources:

• American Counseling Association: Disaster Mental Health: https://www.counseling.org/knowledge-center/trauma-disaster
• National Center for PTSD: http://www.ptsd.va.gov/.
• NICE Guidelines: Post-traumatic stress disorder (PTSD) (CG26): http://www.nice.org.uk/cg26.
• Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care: https://www.nice.org.uk/guidance/cg26/evidence/full-guideline-including-appendices-113-193442221
• Webber, J. M., & Mascari, J. B. (2010). Terrorism, trauma, and tragedies: A counselor’s guide to preparing and responding (3rd ed.). Alexandria, VA: American Counseling Association.

Prevalence

• About 3.6 percent of U.S. adults ages 18 to 54 (5.2 million people) present PTSD during the course of a given year. Prevalence is higher among women (5.2%) and deployed U.S. military personnel (14–16%; Gates et al., 2012; Kessler et al., 2005; Tang & Freyd, 2012).

Resources:
National Institute of Mental Health (NIMH): Post-Traumatic Stress Disorder Among Adults: http://www.nimh.nih.gov/health/statistics/prevalence/post-traumatic-stress-disorder-among-adults.shtml

National Center for PTSD-Epidemiology of PTSD: http://www.ptsd.va.gov/professional/newsletters/research-quarterly/V24n2-3.pdf 

Identification/Assessment Strategies

A wide variety of instruments exist to identify and assess PTSD. Examples of commonly used structured interviews and self-report measures or inventories are provided below.

Structured Interviews

Clinician Administered PTSD Scale (CAPS; Blake, Weathers, Nagy, Kaloupek, Charney, & Keane, 1995)
The Clinician Administered PTSD Scale is a 30-item structured interview that corresponds to the DSM-IV criteria for PTSD. The CAPS can be used to assess symptoms over the past week, or make a current (past month) or lifetime diagnosis of PTSD. The CAPS identifies traumatic stressors experienced by means of The Life Events Checklist (LEC). The CAPS can be administered by clinicians, researchers, and paraprofessionals trained to administer the instrument. Administration takes 25-45 minutes.

Resources:
http://www.ptsd.va.gov/professional/assessment/overview/index.asp

The PTSD Symptom Scale–Interview (PSS-I; Foa, Riggs, Dancu, & Rothbaum, 1993)
The PTSD Symptom Scale–Interview is a 17 questions interview developed to assess DSM-IV criteria for PTSD. The PSS-I yields a severity/frequency score for each of the 3 PTSD symptom clusters as well as a severity score. Administration takes about 20 minutes and can be administered by interviewers trained to recognize PTSD.

Resources:
International Society for Traumatic Stress Studies (ISTSS): Assessing Trauma Posttraumatic Symptom Scale - Interview Version (PSS-I): http://www.istss.org/assessing-trauma/posttraumatic-symptom-scale-interview-version.aspx

National Center for PTSD: http://www.ptsd.va.gov/professional/assessment/overview/index.asp

The Structured Interview for PTSD (SIP; Davidson, Kudler, & Smith, 1990)
The Structured Interview for PTSD assesses DSM-IV criteria for PTSD. The SIP consists of 19 items, including 2 items that measure trauma-related guilt and 17 items that correspond to DSM-IV diagnosis. The interview takes 20-30 minutes to administer and can be administered by mental health professionals, or trained paraprofessionals. 

Resources: National Center for PTSD: http://www.ptsd.va.gov/professional/assessment/adult-int/si-ptsd.asp

Self-Report Measures
The Posttraumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997)
The Posttraumatic Stress Diagnostic Scale is a 49-item self-report measure designed to assess all the DSM-IV diagnostic criteria for PTSD in adults 18 to 65 years old. Completion time is 15 minutes.

Resources:
National Center for PTSD: http://www.ptsd.va.gov/professional/assessment/adult-sr/pds.asp 

The PTSD Checklist (PCL; Weathers, Litz, Herman, Huska & Keane, 1993)
The PTSD Checklist is a 17-item self-report measure of PTSD developed at the National Center for PTSD in 1990. The items measure the corresponding 17 DSM-IV symptoms of PTSD. Completion time is 5 to 10 minutes.

Resources:
National Center for PTSD: http://www.ptsd.va.gov/professional/pages/assessments/ptsd-checklist.asp;

http://www.ptsd.va.gov/professional/pages/assessments/assessment-pdf/PCL-handout.pdf

Information About Additional Assessments
Adult assessments: http://www.ptsd.va.gov/professional/assessment/overview/index.asp

Child assessment: National Child Traumatic Stress Network Measures Review

Foa, E. B., & Yadin, E. (2011). Assessment and diagnosis of Posttraumatic Stress Disorder: An overview of measures. Psychiatric Times, 28, 1-8. 

Intervention Strategies

Effective Psychotherapies for PTSD
Categorizing interventions found to be effective for PTSD is difficult given the diversity of treatments available, lack of a common terminology to describe same treatment components, variations in the manualization of such components, and low consensus among advocates for specific treatments (Department of Veteran Affairs, Department of Defense [DV/DoD], 2010). Evidence-based psychotherapeutic interventions for PTSD strongly supported by randomized control trials and other sources of evidence are presented below: 

The following resources serve as the basis for best practice determination:

Counseling Today: Treating Trauma: http://ct.counseling.org/2010/04/treating-trauma/.

NICE Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care.

National Center for PTSD: Treatment: http://www.ptsd.va.gov/professional/treatment/overview/index.asp. USDHHS, SAMHSA’s National Registry of Evidence-Based Programs and Practices: http://www.samhsa.gov/nrepp

Exposure-Based Therapies (ET)
Exposure-based therapies emphasize in-vivo, imaginal, and narrative (oral and/or written) exposure. ET includes elements of cognitive restructuring (e.g., evaluating the accuracy of beliefs about danger) as well as relaxation techniques and self-monitoring. Examples of ET therapies include Prolonged Exposure Therapy, Brief Eclectic Psychotherapy, and Narrative Therapy with written or narrative (Borntrager, Chorpita, Higa-McMillan, Daleidend, & Starace, 2013). exposure. 

Cognitive-Based Therapies (CT)
Cognitive-based therapies emphasize cognitive restructuring (i.e., challenging automatic negative beliefs connected to the traumatic event) of beliefs about safety or trust. CT also includes relaxation techniques and discussion of the traumatic event orally, through writing, or both. Examples include Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Trauma Cognitive Processing Therapy and various cognitive therapies tested in randomized control trials (Galovski, Blain, Mott, Elwood, & Houle, 2012).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for children/families
TF-CBT (Cohen, Mannarino, & Deblinger, 2006) is a conjoint child and caregiver therapy approach used with children and adolescents who are experiencing significant difficulties secondary to traumatic life events. Through TF-CBT, children and caregivers learn new skills to help them process thoughts and feelings related to traumatic life events; manage and resolve distressing feelings, thoughts, and behaviors that are related to the traumatic life events; and develop an enhanced sense of safety, personal growth, parenting skills, and improved communication within the family unit. A free 10 hour certificate training program on TF-CBT can be completed through TF-CBTWeb. This training program can be completed by professionals and counseling interns (Mannarino, Cohen, Deblinger, Runyon, & Steer, 2012). Resources: https://tfcbt.musc.edu/

Stress Inoculation Training (SIT)
Stress Inoculation Training combines cognitive and behavioral techniques to treat PTSD. SIT places emphasis on breathing retraining, muscle relaxation, self-dialogue, thought stopping, role playing, and, often, exposure techniques (in-vivo or imaginal exposure; Wolmer, Hamiel, & Laor, 2011).

Eye Movement Desensitization and Reprocessing (EMDR)
Eye Movement Desensitization and Reprocessing combines an exposure component (e.g., holding a distressing traumatic memory), a cognitive component (e.g., identifying a negative cognition), and a relaxation techniques (e.g., deep breathing), with guided eye-movements (Rodriguez, 2013).

Additional Treatment Options
Other therapeutic options include psychoeducation, group therapy and supportive services for family and caregivers, hypnosis, relaxation techniques, imagery rehearsal therapy, neurofeedback, spiritual support, psychosocial rehabilitation, and complementary and alternative medicine (CAM) approaches. These approaches are not recommended as first line treatments for PTSD. They may be used as adjunctive treatments to facilitate a relaxation response, reduce hyperarousal symptoms, increase engagement in care, and address co-morbid conditions such as pain control (Adams, 2010).

Resources:
Adams, E. (2010). Brief Overview UPDATE: Complementary and Alternative Therapies for Post-traumatic Stress Disorder. Veterans Health Administration, Office of Patient Care Services, Technology Assessment Program. Retrieved from http://www.ptsd.va.gov/professional/treatment/overview/complementary_alternative_for_ptsd.asp.

American Psychiatric Association: Practice guideline for the treatment of patients with acute stress dis- order and posttraumatic stress disorder: http://www1.appstate.edu/~hillrw/PTSD%20CBT%20TX/PTSD/Articles/APAGuideline.pdf

Counseling Today: Treating Trauma: http://ct.counseling.org/2010/04/treating-trauma/.

Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. (Eds.). (2008). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: Guilford.

International Society for Traumatic Stress Studies: Effective treatments for PTSD: http://www.istss.org/treating-trauma/effective-treatments-for-ptsd,-2nd-edition.aspx

Institute of Medicine: Treatment of PTSD: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2007/Treatment-of-PTSD-An-Assessment-of-The-Evidence/PTSDReportBriefFINAL2.pdf

National Center for PTSD: Treatment: http://www.ptsd.va.gov/professional/treatment/overview/index.asp

The Cochrane Library: Cochrane Evidence Aid: resources for post-traumatic stress disorder following natural disasters: http://www.cochranelibrary.com/app/content/special-collections/article/?doi=10.1002/(ISSN)14651858(CAT)EvidenceAidFreeaccesstoreviews(VI)SC000022

VA/Department of Defense: Clinical Practice Guidelines for Management of PTSD: http://www.healthquality.va.gov/guidelines/MH/ptsd/

USDHHS, SAMHSA’s National Registry of Evidence-Based Programs and Practices: http://www.samhsa.gov/nrepp 

Culture and PTSD

The effect of race, ethnicity, cultural values, degree of acculturation, perceived discrimination, or limited reporting have not been routinely examined in trauma studies. Information on intervention retention and attrition is also limited. Culture or ethnicity may affect individuals’ likelihood of developing PTSD and seeking treatment. Provision of culturally competent therapy may positively affect the treatment out- comes of minority clients (Alcántara, Casement, & Lewis-Fernández, 2013).

Resource:
National Alliance on Mental Illness: http://www.nami.org/Learn-More/Mental-Health-Conditions/Posttraumatic-Stress-Disorder