# Evidence-based assessment/Traumatic brain injury (assessment portfolio)/extended version

HGAPS is finding new ways to make psychological science conferences more accessible!
Here are examples from APA 2022 and the JCCAP Future Directions Forum. Coming soon... ABCT! ~ More at HGAPS.org ~
* Medical disclaimer: This page is for educational and informational purposes only and may not be construed as medical advice. The information is not intended to replace medical advice offered by physicians. Please refer to the full text of the Wikiversity medical disclaimer.

## What is an assessment "portfolio"?

For background information on what assessment portfolios are, click the link in the heading above.

## Preparation Phase
### Demographic information

This section describes the demographic settings of the populations sampled, base rates of PTSD diagnoses, country/region sampled, and the diagnostic methods that were used. Using this information, clinicians will be able to anchor the most appropriate rate of PTSD that they are likely to see in their clinical practice.

### Base rates of PTSD in different clinical settings and populations

| Setting | Reference | Base Rate | Demography | Diagnostic Method |
| Non-clinical: Population based | Kessler et al., 2005 | 6.8% | United States, nationally representative, age 18 and older | National Comorbidity Survey - Replication |
| Non-clinical: Population based | de Vries & Olff, 2009 | 7.4% | Netherlands, nationally representative, age 18-80 | Composite International Diagnostic Interview (CIDI) |
| Non-clinical: Population based | Pietrzak et al., 2011 | 6.4% | United States, nationally representative, age 18 and older | Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions |
| Non-clinical: Population based | Bunting et al., 2013 | 8.8% | Northern Ireland, representative sample, age 18 and older | Northern Ireland Study of Health and Stress |
| Non-clinical: Population based | 23819543 Atwoli et al., 2013 | 2.3% | South Africa, nationally representative sample, age 18 and older | South African Stress and Health Study, using the Composite International Diagnostic Interview (CIDI) |
| U.S. Service Members | Hoge et al., 2004 | 11.5% - 19.5% ♦ | U.S. Army and Marine Soldiers Deployed to Iraq and Afghanistan | PTSD Checklist |
| Non-clinical: Population based | Merikangas et al., 2010 | 5.0% | United States, nationally representative, ages 13-18 | National Comorbidity Survey Replication—Adolescent Supplement (NCS-A) |
♦ Note: These rates were using broad PTSD Checklist scoring criteria of being scored positive if subjects reported at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptom that were categorized as at the moderate level. The 11.5% is for soldiers returning from deployment in Iraq, 19.5% is for soldiers returning from Afghanistan. Another common practice is to use a strict cutoff of 50 on the PCL, above which someone screens positive for PTSD. With this cutoff, rates are 6.2% and 12.9% for Service Members returned from Afghanistan and Iraqi, respectively.

## Prediction Phase
### Diagnosis
#### DSM-5 criteria

The DSM-5 criteria are copyrighted by the American Psychiatric Association, which restricts access. We are working on getting permission to reproduce or link to them here.

#### Diagnostic changes

The DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV and also are different from the current definition in the International Classification of Diseases (ICD). Changes between DSM-IV and -5 and are as follows:
* Stressor criterion (Criterion A) is more specific regarding the individual experience of "traumatic events";
* Criterion A2 (subjective reaction) no longer exists;
* The three major symptoms clusters in DSM-IV (re-experiencing, avoidance/numbing, and arousal) are now four symptom clusters in DSM-5.
** The avoidance/numbing cluster is now divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood;
** The persistent negative alterations in cognitions and mood cluster contains most of the DSM-IV arousal symptoms and includes irritable or aggressive behavior and reckless or self-destructive behavior;
* Diagnostic thresholds have been lowered for children and adolescents to be more sensitive to development;
* There are additional separate criteria for children 6 years of age or younger.

### Developmental sensitivities

* Diagnostic thresholds have been lowered for children and adolescents to account for development.
* Separate and additional criteria have been added for children age 6 or younger.
Posttraumatic stress disorder is now more sensitive to development in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate and additional criteria have been added for children age 6 years of age or younger.

### Screening and diagnostic instruments for PTSD

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity | Highly recommended |
| Glasgow Coma Scale | Clinician Administered | adult and pediatric versions available | 5 minutes | N/A | G | E | G | X |
| CAPS (Clinician Administered PTSD Scale) | Clinician Administered Self-Report | adult and child versions available | 40-60 minutes | E | E | E | E | X |
| SCID-IV (Structured Clinical Interview for DSM-IV) | Interview (Patient) | adult | 1-2 hours | A | A | G | G | X |
| PSS-I (PTSD Symptom Scale Interview) | Interview (Patient) | adult | 20 minutes | E | G | G | G | |
| SI-PTSD (Structured Interview for PTSD) | Interview (Patient) | adult | 20-30 minutes | E | A | G | G | |
| ADIS (Anxiety Disorder Interview Schedule) | Interview (Patient) | adult | 2-4 hours | G | A | G | G | |
| UCLA PTSD Reaction Index for DSM-5 | Self-Report, Caregiver Report | child | | | | | | |
| CPSS (Children's PTSD Symptom Scale) | Self-Report | child | 10-20 minutes | | | | | |
| IES-R (Impact of Event Scale-Revised) | Self-Report | adult | 10-15 minutes | N/A | A | G | G | |
| M-PTSD (Mississippi Scale for Combat Related PTSD) | Self-Report | adult, specific versions for veterans and civilians | 10-15 minutes | N/A | G | E | E | |
| PK Scale (Keane PTSD Scale of the MMPI-2) | Self-report | adult | 60-90 minutes (entire MMPI-2) | N/A | G | E | G | |
| PDS (Post-traumatic Diagnosis Scale) | Self-Report | adult | 10-20 minutes | N/A | G | E | G | X |
| LASC (Los Angeles Symptoms Checklist) | Self-Report | adult | 5-10 minutes | N/A | G | G | G | |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

## Process Phase
### Treatment
#### Behavioral interventions

* Recommended:
** Brief Cognitive Behavioral Therapy (CBT; 4-5 sessions) has significant benefit.
*** This includes stress inoculation training, trauma-focused therapy including components of cognitive restructuring, Cognitive Processing Therapy (CPT), imaginal, virtual, and in-vivo exposure as in Prolonged Exposure psychotherapy (PE)$^2$
*** Patient education is recommended as part of psychotherapy for patients and family members
** EMDR may help both acute and chronic PTSD, especially individuals who have trouble with prolonged exposure or have trouble verbalizing their trauma. Long term gains require further study.
* Treatments with weaker evidence:
** Patient education, imagery rehearsal therapy, psychodynamic therapy, hypnosis, relaxation techniques, and group
therapy may have some benefit. Web-based CBT, Acceptance and commitment therapy, and Dialectical Behavioral Therapy have unknown benefit.

#### Medication

* SSRIs are more effective than placebo in treating PTSD.
* There is no evidence to support a medication to prevent the development of PTSD.
** Imipramine, propranolol, prazosin, other antidepressants, anticonvulsants, and atypical antipsychotics have unknown benefit.
** Strongly recommend against the use of benzodiazepines$^2$ and typical antipsychotics since they have no benefit and potential harm.

## Process and outcome measures
### Severity and outcome
#### Clinically significant change benchmarks with common instruments for PTSD

| Measure | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Benchmarks Based on Published Norms |||||||
| | A | B | C | 95% | 90% | SE$_{difference}$ |
| Primary Care PTSD Screen | 1.0 | 3.1 | 2.0 | 1.0 | .8 | .5 |
| PTSD Checklist Scores | 28.8 | 40.8 | 34.9 | 4.6 | 3.8 | 2.3 |
| Clinician Administered PTSD Scale | 28.8 | 40.8 | 34.9 | 8.3 | 7.0 | 4.2 |