managing-psychological-trauma-assessments

# Managing Psychological Trauma Assessments

Guides trauma-informed assessment with PTSD screening using validated instruments, comprehensive trauma history documentation, and differential diagnosis aligned with VA/DoD Clinical Practice Guidelines and APA PTSD Treatment Guidelines.

## Why This Skill Exists

Trauma exposure is nearly universal — approximately 70% of adults worldwide experience at least one traumatic event in their lifetime. While most individuals are resilient, 6-8% of the US population will develop PTSD, with significantly higher rates in military veterans (15-30%), sexual assault survivors (30-50%), and first responders. Trauma's psychiatric impact extends well beyond PTSD: Complex PTSD, major depression, substance use disorders, dissociative disorders, somatic symptom disorders, and personality pathology are all trauma-related sequelae.

The VA/DoD Clinical Practice Guideline for PTSD (2023) and APA PTSD Treatment Guidelines mandate structured, validated assessment using instruments such as the PCL-5 (PTSD Checklist for DSM-5), CAPS-5 (Clinician-Administered PTSD Scale), and the Life Events Checklist. Trauma-informed assessment principles require that the evaluation process itself not re-traumatize the patient. Inadequate trauma assessment leads to missed diagnoses, inappropriate treatment (e.g., benzodiazepines for PTSD, which worsen outcomes), and failure to connect symptoms across multiple body systems to their traumatic etiology.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the assessment context? (clinical evaluation, disability claim, forensic evaluation, treatment planning, pre-therapy intake) — default: clinical evaluation
2. What type of trauma is reported or suspected? (combat, sexual assault, childhood abuse/neglect, intimate partner violence, accident, natural disaster, medical trauma, community violence) — default: assess broadly
3. Is the trauma ongoing or has it ended? (critical for safety planning) — default: assess immediately
4. What is the patient's current safety status? (safe environment, ongoing threat, active DV, active military deployment) — default: assess
5. Does the patient have a known dissociative disorder or high dissociation? (affects assessment approach) — default: screen
6. Has the patient been previously diagnosed with PTSD or trauma-related conditions? — default: obtain history
7. What validated instruments are available? (PCL-5, CAPS-5, LEC-5, CTQ, DES-II) — default: PCL-5 and LEC-5
8. Is the patient currently in substance use or actively suicidal? (stabilize before trauma processing) — default: assess

### Documents to Request

- Life Events Checklist (LEC-5) completed by patient
- PCL-5 (PTSD Checklist for DSM-5) completed by patient
- Prior psychological evaluations and PTSD assessments
- Military service records and DD-214 (for veterans)
- VA disability claim records if applicable
- Police reports, protective orders, or legal documentation of trauma
- Medical records documenting injuries consistent with reported trauma
- Child protective services records if childhood maltreatment
- Prior therapy records (especially trauma-focused therapy)
- Substance use treatment records

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## Step 1: Trauma Exposure Assessment

Administer the **Life Events Checklist for DSM-5 (LEC-5):**
- 17 trauma categories (natural disaster, fire/explosion, transportation accident, serious accident, exposure to toxic substance, physical assault, assault with weapon, sexual assault, unwanted sexual experience, combat exposure, captivity, life-threatening illness/injury, severe human suffering, sudden violent death, sudden accidental death, serious harm/death you caused, any other very stressful event)
- For each: happened to me, witnessed it, learned about it, part of my job, not sure, doesn't apply
- Extended Criterion A Assessment: For the worst event, assess directly experienced, witnessed, learned about close family/friend, repeated/extreme exposure in professional role

**For childhood trauma, administer the Childhood Trauma Questionnaire (CTQ):**
- 28 items across 5 scales: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect
- Each rated 1 (never true) to 5 (very often true)
- Severity cutoffs: None/minimal, Low/moderate, Moderate/severe, Severe/extreme per subscale

**Document each traumatic event with:**
- Type of trauma and age at occurrence
- Duration (single incident vs. chronic/repeated)
- Relationship to perpetrator (if interpersonal)
- Whether the patient received treatment at the time
- Impact on developmental trajectory (for childhood traumas)

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## Step 2: PTSD Symptom Assessment

### PCL-5 (PTSD Checklist for DSM-5) — Self-Report Screening
- 20 items corresponding to DSM-5-TR PTSD criteria
- Each rated 0 (not at all) to 4 (extremely) for past month
- Total score range: 0-80
- Provisional PTSD diagnosis cutoff: ≥31-33 (VA/DoD recommended)
- Can also score by DSM-5-TR symptom clusters for diagnostic alignment

### CAPS-5 (Clinician-Administered PTSD Scale) — Gold Standard Diagnostic Interview
- 30 items assessing frequency AND intensity of each PTSD symptom
- Severity rating: 0-4 per item
- Diagnostic rule: At least 1 Criterion B, 1 C, 2 D, and 2 E symptoms rated ≥2 (moderate)
- Total severity score: Sum of 20 core items (range 0-80)
- Includes dissociative subtype assessment

### DSM-5-TR PTSD Criteria (F43.10)

**Criterion A — Traumatic Exposure:** Exposure to actual or threatened death, serious injury, or sexual violence through direct experience, witnessing, learning about close family/friend, or repeated professional exposure.

**Criterion B — Intrusion (≥1 required):** Recurrent intrusive memories, distressing dreams, dissociative reactions (flashbacks), intense distress at reminders, marked physiological reactions to reminders.

**Criterion C — Avoidance (≥1 required):** Avoidance of distressing memories/thoughts/feelings, avoidance of external reminders (people, places, activities, situations).

**Criterion D — Negative Cognitions and Mood (≥2 required):** Inability to remember key aspects of trauma, persistent negative beliefs about self/others/world, distorted cognitions about cause/consequences, persistent negative emotional state, diminished interest, feelings of detachment, persistent inability to experience positive emotions.

**Criterion E — Arousal and Reactivity (≥2 required):** Irritable behavior/angry outbursts, reckless or self-destructive behavior, hypervigilance, exaggerated startle, concentration problems, sleep disturbance.

**Criterion F:** Duration >1 month
**Criterion G:** Clinically significant distress or functional impairment
**Criterion H:** Not attributable to substance or medical condition

**Specifiers:** Dissociative subtype (depersonalization or derealization), delayed expression (full criteria not met until ≥6 months after trauma)

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## Step 3: Comorbidity and Differential Diagnosis Assessment

Screen for conditions commonly comorbid with or mimicking PTSD:

- **Major Depressive Disorder:** PHQ-9. Overlapping symptoms: anhedonia, sleep disturbance, concentration difficulty, negative cognitions. MDD comorbidity rate in PTSD: ~50%.
- **Substance Use Disorders:** AUDIT, DAST-10. Self-medication is common. Comorbidity rate: 25-50%.
- **Traumatic Brain Injury:** Overlapping symptoms (concentration, irritability, sleep disturbance, memory problems). Screen with Ohio State TBI Identification Method.
- **Panic Disorder:** Panic attacks triggered by trauma reminders vs. spontaneous panic attacks.
- **Generalized Anxiety Disorder:** GAD-7. Chronic worry vs. trauma-specific hyperarousal.
- **Acute Stress Disorder:** Same symptom clusters but duration 3 days to 1 month post-trauma.
- **Adjustment Disorder:** Distress after stressor that does not meet Criterion A for PTSD.
- **Complex PTSD (ICD-11):** PTSD symptoms PLUS affect dysregulation, negative self-concept, interpersonal difficulties. Use ITQ (International Trauma Questionnaire).
- **Dissociative Disorders:** DES-II (Dissociative Experiences Scale). Score ≥30 suggests dissociative disorder requiring further evaluation.
- **Borderline Personality Disorder:** Trauma history is common; distinguish emotional dysregulation of BPD from PTSD arousal symptoms.

Administer suicide risk screening (C-SSRS) — PTSD significantly elevates suicide risk, particularly with comorbid depression and SUD.

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## Step 4: Functional Impact and Recovery Resources Assessment

**Functional domains to assess:**
- Occupational: Work performance, attendance, ability to function in work environments (noise, crowds)
- Social: Relationship quality, social withdrawal, intimacy difficulties, parenting capacity
- Self-care: Hygiene, nutrition, sleep, health-care engagement
- Legal: Legal involvement related to trauma or trauma-related behavior
- Safety: Current safety concerns, ongoing threat, weapons access
- Substance use: Current use patterns and relationship to trauma symptoms

**Recovery resources (protective factors):**
- Social support system quality and availability
- Coping skills and resilience factors
- Prior trauma recovery experiences
- Treatment engagement and motivation
- Spiritual or cultural supports
- Financial stability and housing security
- Employment status

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## Step 5: Treatment Planning and Recommendations

Per VA/DoD and APA guidelines, recommend first-line evidence-based treatments:

**First-line psychotherapies for PTSD (strong recommendation):**
- Cognitive Processing Therapy (CPT): 12 sessions, focuses on challenging maladaptive trauma cognitions
- Prolonged Exposure (PE): 8-15 sessions, systematic in-vivo and imaginal exposure to trauma memories and reminders
- EMDR (Eye Movement Desensitization and Reprocessing): 8-12 sessions, bilateral stimulation during trauma memory processing

**First-line pharmacotherapy (when psychotherapy is unavailable, refused, or as adjunct):**
- Sertraline: 50-200mg/day (FDA approved for PTSD)
- Paroxetine: 20-60mg/day (FDA approved for PTSD)
- Venlafaxine XR: 75-300mg/day (strong evidence, not FDA-approved for PTSD)
- Prazosin: 1-15mg at bedtime for trauma-related nightmares (alpha-1 blocker)

**Do NOT prescribe as monotherapy for PTSD:**
- Benzodiazepines: Worsen PTSD outcomes, impair extinction learning, increase risk of SUD
- Atypical antipsychotics: Limited evidence, significant side effects (consider only as augmentation for partial response)

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is trauma exposure documented using a structured tool (LEC-5 or equivalent)?
2. Are PTSD symptoms assessed with a validated instrument (PCL-5 or CAPS-5)?
3. Are all DSM-5-TR PTSD criteria systematically evaluated and documented?
4. Is comorbidity screening completed for depression, SUD, and TBI?
5. Are first-line evidence-based treatments recommended per VA/DoD or APA guidelines?

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## Quality Audit

- [ ] Trauma exposure assessed with structured instrument (LEC-5)
- [ ] Index trauma identified and documented with Criterion A assessment
- [ ] PTSD symptoms assessed with validated tool (PCL-5 score documented)
- [ ] Each DSM-5-TR PTSD criterion cluster assessed and documented
- [ ] Dissociative subtype screened (depersonalization/derealization)
- [ ] Comorbid depression screened (PHQ-9)
- [ ] Comorbid substance use screened (AUDIT, DAST-10)
- [ ] Traumatic brain injury screened if applicable
- [ ] Suicide risk assessment completed (C-SSRS)
- [ ] Safety assessment completed (ongoing threat, DV, weapons access)
- [ ] Functional impairment documented across domains
- [ ] Childhood trauma assessed (CTQ or clinical history)
- [ ] Evidence-based treatment recommended with guideline citation
- [ ] Benzodiazepine contraindication noted in treatment plan

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## Guidelines

1. Never prescribe benzodiazepines as first-line or monotherapy for PTSD — they worsen outcomes, impair fear extinction learning, and increase risk of substance dependence per VA/DoD CPG (strong against recommendation).
2. Always assess for ongoing safety threats before initiating trauma-focused therapy — active trauma (ongoing DV, combat deployment) requires safety planning and stabilization before trauma processing.
3. Use trauma-informed assessment practices — provide choice and control during the interview, explain the purpose of trauma questions, allow the patient to pace disclosure, and do not require detailed trauma narrative during initial screening.
4. Screen for dissociation before starting trauma-focused therapy — highly dissociative patients may require a stabilization phase (grounding, affect regulation skills) before exposure-based treatments.
5. PTSD assessment in veterans must account for military sexual trauma (MST) — screen for MST specifically, as it is frequently undisclosed and carries distinct treatment implications.
6. Document the index trauma clearly for treatment planning — the specific trauma(s) targeted in CPT or PE must be identified during assessment.
7. When PTSD and SUD co-occur, integrated treatment models are preferred — sequential treatment (requiring sobriety before trauma therapy) is no longer recommended. Seek Safety, CPT, and PE can be delivered concurrently with SUD treatment.