3 CRITERION AExposure to actual of threatened death, serious injury, or sexual violence in one (or more) of the following ways:Directly experiencing the traumatic event(s).Witnessing, in person, the event(s) as it occurred to others.Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual death, the events must have been accidental or violent.Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to the details of child abuse).
4 CRITERION B - INtrusion (5 Sx – Need 1) Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the event(s) occurred:Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the trauma are expressed.Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event.Note: In children there may be frightening dreams without recognizable content.Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)Note: In children, trauma-specific reenactment may occur in playIntense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).Marked physiological reaction to external or internal cues that symbolize or resemble an aspect of the traumatic event(s).
6 CRITERION C - Avoidance (2 Sx – Need 1) Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing, memories, thoughts, or feelings about or closely associated with the traumatic event(s).
7 CRITERION D – negative alterations in cognition & Mood (7 Sx – Need 2) Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the event(s) occurred, as evidenced by two or more of the following:Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol or drugs).Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that leads the individual to blame himself/herself or others.Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).Marked diminished interest or participation in significant activities.Feelings of detachment or estrangement from othersPersistent inability to experience positive emotions (e.g., happiness, satisfaction, or loving feelings).
8 CRITERION E – Arousal & Reactivity (6 Sx – Need 2) Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two or more of the following:Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.Reckless or self-destructive behavior.Hypervigilance.Exaggerated startle response.Problems with concentration.Sleep disturbance (e.g. problems falling or staying asleep or restless sleep).
10 20 Symptoms of PTSD DSM V Criterion E. Arousal & Reactivity Criterion B. IntrusionCriterion C. AvoidanceCriterion D. Negative Cognitions and MoodCriterion E. Arousal & Reactivity1221
11 Criterion F / Criterion g / Criterion H Criterion F: Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.Criterion G: The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Criterion H: The disturbance is not attributable to physiological effects of a substance (e.g., medication or alcohol) or other medical condition.
12 specifiersSpecify whether:With dissociative symptoms: The individual’s symptoms meet the criteria for PTSD, and in addition, in response to the stressor, the individual experiences persistent or recurring symptoms of either of the following:Depersonalization: Persistent or recurrent experiences of feeling detached from , and as if one was an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling sense of unreality of self or body or of time moving slowly).Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant or distorted).Note: To use this subtype, the dissociate symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during intoxication) or other medical condition.
13 specifiersSpecify whether:With delayed expression: If the full diagnostic criteria are not met at least 6 months after the event (although the onset and expression of some symptoms may be immediate)
14 CAPS Clinician Administered PTSD Scale National Center for PTSD (www.ptsd.va.gov)20 item structured clinical interviewPrimarily for diagnosisGood psychometrics and inter-rater relaibilty“Gold Standard” for diagnosing PTSD (if diagnosis will be questioned or challanged)Clinician administered and clinician scored (not self-report)Each symptom has a qualitative section used to derive quantitative evaluation of symptomIntensity x Frequency/2 = SeveritySeverity score of > 2 = endorsement of that symptom
15 1. (B1) Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.In the past month, have you had any unwanted memories of (EVENT) while you were awake, so not counting dreams? [Rate 0=Absent if only during dreams]How does it happen that you start remembering (EVENT)?[If not clear:] (Are these unwanted memories, or are you thinking about [EVENT] on purpose?) [Rate 0=Absent unless perceived as involuntary and intrusive]How much do these memories bother you?Are you able to put them out of your mind and think about something else?Circle: Distress = Minimal Clearly Present Pronounced ExtremeHow often have you had these memories in the past month? # of times __________Key rating dimensions = frequency / intensity of distressModerate = at least 2 X month / distress clearly present, some difficulty dismissing memoriesSevere = at least 2 X week / pronounced distress, considerable difficulty dismissing memories0 – absent1 – mild2 – moderate3 – severe4 – extrmeme
16 PCL Posttraumatic Check List National Center for PTSD (www.ptsd.va.gov)Simple, easy to administerSelf-report or clinician administered20 item – all 20 symptomsCRITERION B: Items 1-5CRITERION C: Items 6-7CRITERION D: Items 8 – 14CRITERION E: Items 15 – 20Score of > 2 = endorsement of that symptom
17 TRS Trauma Recovery Scale Gentry, 1996Developed as an outcome instrumentGood psychometrics (Chronbach’s a = .86 & convergent validity with IES = -.71)Solution-focusedMean score = % recovery from traumaScores > 75 = minimal impairmentScores < 75 begin impairment spectrum and need stabilization5a & 5b opportunity to discuss “am safe vs. feels safe”Part I is trauma inventory and administered only at intakePart II is repeated measure for outcomesScores < 50 = treatment plan issue
18 Early SessionsGraphic Time Line of life including ALL significant traumatic experiencesVerbal Narrative using GTL as mapVideo-recordingAsking client to view video (if they can tolerate) with attitude of ACCEPTANCE, COMPASSION & CURIOSITY
19 Graphic Time-Line Narrative Multiple positive personal & professional accomplishments+10GraduationRecoveryPrivate practiceNYCPhDSFSexual AbuseMVADivorce – close of practiceMVAPresentPhysical Abuse & DVActive Addiction-10