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.
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.
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?
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.
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.
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.
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.
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.