Assessing PTSD: Measurement-Based Therapy

Barbara Rothbaum, Ph.D.

This presentation is an excerpt from the online course “Prolonged Exposure for PTSD: A Comprehensive Guide for Clinicians”.

Highlights

  • Measurement-based therapy is recommended.
  • For PTSD this includes clinician-rated scales and self-report scales.
  • These should be administered at a minimum at pre- and post-therapy and follow-up assessments.

 

Transcript

Welcome to video 6 on Assessment Strategies.
A thorough initial evaluation should be conducted to determine whether your patient with a history of trauma is a good candidate for PE.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

This evaluation is used to obtain a detailed trauma history and determine the index or target trauma. The index trauma is the trauma that the patient identifies as the most distressing and causes the most symptoms in the present. And that’s going to be the focus of treatment. That’s going to be what we start exposure therapy with. One way that we determine the index trauma is by linking it to current re-experiencing symptoms.
The evaluation is also used to confirm the presence of significant PTSD symptoms and determine their severity and to assess the presence of comorbid disorders. We evaluate to establish the severity of any other current disorders and whether they’ll require immediate intervention. For example, if someone is so depressed that they’re not going to be able to make it to therapy or do what we ask them to do in therapy, we need to know that and maybe address the depression first. If someone is abusing substances or drugs to the point that we think it’s going to interfere with what they learn from therapy, then we’ll need to address that.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

We first gather information concerning the history of criterion A traumatic events. And if there are multiple events, which is the most distressing? Which is the target trauma?

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

We use the Clinician Administered PTSD Scale for DSM-5 or the CAPS-5. This is a structured interview that can diagnose and assess the severity of PTSD. To assess comorbid axis I disorders, there are a number of interviews that a clinician can use. One is the Structured Clinical Interview for DSM-5 or the SCID-5. Another is the Mini-International Neuropsychiatric Interview for DSM-5 or the M.I.N.I.

References

Weathers, F., Bovin, M., Lee, D., Sloan, D., Schnurr, P., Kaloupek, D., Keane, T., & Marx, B. (2018). The Clinician-Administered PTSD Scale for DSM–5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment, 30(3), pp.383-395

First, M.B., Williams, J.B.W., Karg, R.S., & Spitzer, R.L. (2016). Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV). Arlington, VA, American Psychiatric Association.

Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. The Journal of Clinical Psychiatry, 59(Suppl 20), 22–33.

Self-report measures to measure PTSD include the PTSD Symptom Checklist for DSM-5 and to measure depression include the PHQ-9, that’s the Patient Health Questionnaire-9 or the BDI-II, the Beck Depression Inventory.

References

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.

Beck, A. T., Steer, R. A., & Brown, G. (1996). Beck Depression Inventory–II. APA PsycTests

We routinely evaluate patient’s symptoms in two ways and we recommend that you do the same. First, with both the interviewer and self-report measures, we use them pre- and post-treatment and at follow-up evaluations to determine their overall symptoms and the change in the target symptoms. Second, we use the self-report measures. And for us, we usually use the PCL and the PHQ-9 and we administer them about every other session. And these help us take a reading, take a temperature of how the patient is doing in therapy, how they’re responding and what we need to continue paying attention to.

References
Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

So who’s an appropriate patient for PE? It’s really anyone with PTSD or even what we call subclinical PTSD with severe clinically significant symptoms following all types of trauma. Sometimes, I’ll hear military folks saying combat PTSD is different. But in general, I see that PTSD is more similar than different. It’s important that patients have a memory of their traumatic experience. If they don’t have a memory for it, they’re not good candidates for PE, even if they have an interrupted memory. So for example, it’s not uncommon for motor vehicle accident survivors who lost consciousness during the crash to say, I remember hearing the screeching of brakes and then the next thing I know, I woke up in the hospital. That’s enough of a memory to work with if they have PTSD.
If someone comes in with a vague feeling that they might have been assaulted, that something might have happened, I think my grandfather might have abused me, if there is no clear memory of the trauma, then we are not going to use PE because we certainly don’t want to implant a trauma memory. As we mentioned, the comorbidity with multiple life difficulties, financial difficulties, chronic health problems, relationship and family troubles, social isolation are so common in PTSD. And PE has been successful with patients who suffer from all of this. As we mentioned earlier, if another disorder is life threatening, then we need to decide if we need to pay attention to that first. If someone is suicidal to the point that they might be harming themselves, then we need to pay attention to that first to make sure they’re safe going through this. But if PTSD is primary, definitely PE should be initiated first because as we said PE reduces depression, anxiety, anger, guilt, shame, substance use as well as PTSD.

References

Foa, E., Hembree, E. A., Rothbaum, B. O., & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences – Therapist guide (2nd ed.). Oxford University Press, USA.

In conclusion, our key points from this video, we recommend measurement-based therapy. Measurement-based therapy for PTSD includes clinician-rated PTSD scales such as the CAPS-5 and self-report scales such as the PCL-5 and PHQ-9. These should be administered at a minimum at pre- and post-therapy and follow-up assessments but best practices include administering some measures about every other session to monitor progress.

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