Diagnosing and following clients with PTSD

Here, I present two studies related to diagnosing and treating PTSD. First, Rubin et al. (2023) published, “Low Reliability When Determining Criterion A for Posttraumatic Stress Disorder from Self-report Descriptions of Traumatic Events: The need for transparent methods” in Psychological Trauma: Theory, Research, Practice, and Policy.  Here’s the edited abstract and impact statement:

Exposure to a traumatic event is a primary criterion (Criterion A) for meeting Posttraumatic Stress Disorder (PTSD). Using self-report to establish diagnostic criteria in research has become more common, especially with internet-based research. However, some individuals may construe events as traumatic when they do not meet Criterion A. There has yet to be a test of interrater reliability (IRR) from self-report of traumatic events. Three graduate students in clinical psychology and three licensed psychologists rated Criterion A using the life events checklist (LEC), as well as the three modified LEC versions (specification of up to three index traumas; extension of part 2 of the LEC) aimed to increase IRR. One hundred participants completed each of the four versions of the LEC (N = 400). Bootstrapped permutation tests were used to estimate differences in IRR and to generate 95% confidence intervals (CIs). Overall, findings indicated fair–moderate IRR (Fleiss’s kappa) κ = 0.428, 95% CI [0.379, 0.477]. The other versions of the LEC (including additional clarifying questions in part 2 of the LEC and/or opportunities to describe up to three traumas) did not meaningfully increase IRR. Findings indicate that relying on self-report from the LEC alone and/or single-rater assessment of open-text trauma descriptions is not recommended for determining whether a traumatic event meets Criterion A. We conclude that it is critical when collecting self-reported PTSD symptoms to provide a clear description of how Criterion A was assessed, initial agreement between raters, and how disagreements were resolved. 

Determining whether self-reported traumatic experiences meet Criterion A for posttraumatic stress disorder (PTSD) is a complex and difficult task, but necessary for evaluating PTSD symptoms. PTSD symptoms are only applicable to individuals who meet for Criterion A. We encourage researchers to recognize the challenges associated with using self-report questionnaires to determine Criterion A and provide recommendations that are intended to enhance the quality of PTSD research. 

This study seems important in identifying criteria for diagnosing PTSD. The next speaks to treatment. Schumm et al. (2023) published “Do Changes in Dysfunctional Posttraumatic Cognitions Differentially Predict PTSD Symptom Clusters?” in Journal of Consulting and Clinical Psychology. Symptom clusters include intrusive thoughts or memories, avoidance, negative thought pattern and mood, and changes in physical and emotional reactions. Here’s the edited impact statement and abstract:

In recent years, it has been suggested that the modification of dysfunctional posttraumatic cognitions plays a central role as a mechanism of change in cognitive behavioral therapy (CBT) for posttraumatic stress disorder (PTSD). Indeed, several studies have shown that changes in dysfunctional posttraumatic cognitions precede and predict symptom change. However, these studies have investigated the influence on overall symptom severity—despite the well-known multidimensionality of PTSD. The present study therefore aimed to explore differential associations between change in dysfunctional conditions and change in PTSD symptom clusters. As part of a naturalistic effectiveness study evaluating trauma-focused cognitive behavioral therapy for PTSD in routine clinical care, 61 patients with PTSD filled out measures of dysfunctional posttraumatic cognitions and PTSD symptom severity every five sessions during the course of treatment. Lagged associations between dysfunctional cognitions and symptom severity at the following timepoint were examined using linear mixed models. Over the course of therapy, both dysfunctional cognitions and PTSD symptoms decreased. Posttraumatic cognitions predicted subsequent total PTSD symptom severity, although this effect was at least partly explained by the time factor. Moreover, dysfunctional cognitions predicted three out of four symptom clusters as expected. However, these effects were no longer statistically significant when the general effect for time was controlled for. The present study provides preliminary evidence that dysfunctional posttraumatic cognitions predict PTSD symptom clusters differentially. However, different findings when employing a traditional versus a more rigorous statistical approach make interpretation of findings difficult. 

This study highlights how posttraumatic cognitions, that is, dysfunctional appraisals about the traumatic event and its consequences, predict changes in posttraumatic stress disorder (PTSD) over the course of psychotherapy. It was closely investigated how these cognitions affect different PTSD symptom subgroups. This can inform clinicians and practitioners in their treatment planning. 

This is a tough one, given their caution that different statistical approaches yield different findings makes the need for replication and extension clear. However, the power of posttraumatic cognitions in predicting PTSD severity seems important.