Trauma-Informed Care: The Role of Trauma Theory in Enhancing PTSD Assessments
June is PTSD Awareness Month, a time dedicated to increasing understanding and support for those affected by posttraumatic stress disorder (PTSD). As we continue to see rising numbers of PTSD diagnoses, it becomes increasingly crucial to explore advancements in trauma theory and science and their profound implications for diagnosing and treating PTSD.
PTSD can develop after experiencing a shocking and dangerous event that threatens one’s life or the lives of others. Trauma can be defined as any experience that overwhelms our nervous system by being too intense, happening too quickly, or occurring too soon, especially if we are unable to successfully process it. Trauma isn’t defined by the event itself but by the energy that becomes trapped in the body in response to a real or perceived threat.
In 2013, the American Psychiatric Association updated the PTSD diagnostic criteria in the 5th edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). PTSD was placed in a new category, Trauma- and Stressor-Related Disorders, which includes conditions requiring exposure to a traumatic or stressful event as a diagnostic criterion. The DSM-5-TR, published in March 2022, incorporated scientific advances since the release of DSM-5 but did not change the PTSD diagnostic criteria for adults.
Full criteria for diagnosing PTSD are available from the American Psychiatric Association.
- Criterion A (1 required): Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence through:
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- Direct exposure
- Witnessing the trauma
- Learning about the trauma of a close relative or friend
- Indirect exposure to trauma, usually through professional duties (e.g., first responders)
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Criterion B (1 required): Persistent re-experiencing of the traumatic event through:
- Unwanted memories
- Nightmares
- Flashbacks
- Emotional distress after reminders
- Physical reactions after reminders
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Criterion C (1 required): Avoidance of trauma-related stimuli such as:
- Trauma-related thoughts or feelings
- Trauma-related reminders
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Criterion D (2 required): Negative changes in thoughts or feelings since the trauma, including:
- Inability to recall key aspects of the trauma
- Negative beliefs about oneself or the world
- Blame of self or others for the trauma
- Negative emotions
- Decreased interest in activities
- Feeling isolated
- Difficulty experiencing positive emotions
-
Criterion E (2 required): Increased arousal and reactivity since the trauma, evidenced by:
- Irritability or aggression
- Risky behavior
- Hypervigilance
- Exaggerated startle response
- Difficulty concentrating
- Trouble sleeping
- Criterion F: Symptoms last for more than 1 month.
- Criterion G: Symptoms cause distress or functional impairment in social or occupational areas.
- Criterion H: Symptoms are not due to medication, substance use, or other illnesses.
Specifications:
- Dissociative Specification: High levels of depersonalization (feeling detached from oneself) or derealization (feeling that the world is unreal).
- Delayed Specification: Full criteria are not met until at least 6 months after the trauma, though symptoms may appear immediately after the event.
The symptoms of PTSD are largely similar between DSM-5 and DSM-IV, and there were no changes in DSM-5-TR. Key revisions in DSM-5 include narrowing Criterion A1 to exclude the unexpected natural death of a family member or close friend as a qualifying traumatic event. Criterion A2, which required a response involving intense fear, helplessness, or horror, was removed because it did not enhance diagnostic accuracy. The DSM-IV’s avoidance and numbing cluster (Criterion C) was divided into two criteria in DSM-5: Criterion C (avoidance) and Criterion D (negative alterations in cognition and mood), requiring at least one avoidance symptom for diagnosis. Additionally, three new symptoms were added: overly negative thoughts and assumptions about oneself or the world, negative affect (Criterion D), and reckless or destructive behavior (Criterion E). For more information on the DSM-5 changes to the PTSD criteria and resources for DSM-5-TR updates, visit the American Psychiatric Association’s website on educational resources for DSM-5 and DSM-5-TR.
While most people will encounter at least one potentially PTSD-inducing traumatic event (approximately 70%) in their lifetime, not all stressful events lead to PTSD. Factors such as direct exposure to trauma or injury increase the risk of developing PTSD. Gender differences influence the types of trauma experienced, with women more commonly facing sexual assault and men more frequently encountering accidents, physical assault, combat, or witnessing death or injury. Additionally, transgender and nonbinary individuals are at heightened risk, and more research is needed to understand how trauma risk varies across different social factors like race, ethnicity, religion, sexuality, and disability status.
Estimating the exact prevalence of PTSD is challenging due to various factors, including the variability of study methods and the representativeness of samples. However, it is estimated that about 6% of the U.S. population will experience PTSD at some point in their lives, with around 5% having PTSD in any given year. In 2020, approximately 13 million Americans were living with PTSD. Women are more likely to develop PTSD than men, with about 8% of women and 4% of men affected at some point in their lives, largely due to the nature of traumatic events they are more likely to experience. Veterans, particularly those who have deployed to war zones, are also at higher risk of PTSD compared to civilians.
Trauma theory and science have provided valuable insights into how traumatic experiences affect individuals on psychological, neurobiological, and social levels. These advancements help us recognize the complex and multifaceted nature of PTSD, moving beyond a one-size-fits-all approach to a more nuanced understanding. By integrating these insights into clinical practices, you can enhance your psychological and clinical assessments to be trauma-informed, ensuring they are sensitive to the unique experiences and needs of each individual. Key insights from this field have revolutionized our understanding of how trauma affects the brain and body, influencing our approach to diagnosing and treating PTSD. Each one is outlined below.
Psychological Impact: Traumatic events can lead to profound psychological changes, including alterations in self-perception, worldviews, and emotional regulation. These changes often manifest as hypervigilance, emotional numbing, and intrusive memories, all hallmarks of PTSD.
Neurobiological Impact: Trauma can cause significant changes in brain structure and function. Areas like the amygdala, hippocampus, and prefrontal cortex, which are involved in fear processing, memory, and decision-making, may show altered activity and connectivity in individuals with PTSD.
Social Impact: Traumatic experiences can disrupt social connections and support systems, leading to feelings of isolation and mistrust. Social support is a critical factor in recovery, making it essential to consider in any trauma-informed assessment.
Given the complexity of PTSD, a nuanced understanding of trauma theory and science is vital for accurate diagnosis. Here are some key considerations:
- Comprehensive Assessment: A comprehensive PTSD assessment should go beyond simple symptom checklists. It should include a detailed history of the individual’s traumatic experiences and explore their psychological, neurobiological, and social impacts. This means understanding the full scope of their trauma and how each element of the diagnostic criteria affects them personally. Assessors should ask how often and how intensely symptoms occur, what these experiences feel like physically and emotionally, and how they affect the individual’s personal and professional life, as well as their relationships. Each criterion (B, C, D, E, and F) should be examined in detail: how frequently the symptoms happen, their physical and emotional impact, the predominant emotions (such as guilt, shame, sadness, or anger), and the extent to which these symptoms disrupt the person’s daily life and activities. Use the American Psychological Association’s (APA) Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults.
- Assess for Co-morbidities: Assessing for co-morbidities is crucial in trauma-informed treatment. It is important to look for common co-morbidities in individuals with PTSD, including substance use, suicidality, self-harming behaviors, and risky behaviors. This comprehensive assessment ensures a holistic understanding and effective treatment plan.
- Cultural Sensitivity: Trauma and its expression can vary widely across cultures. Understanding the cultural context and incorporating culturally sensitive practices into assessments can improve diagnostic accuracy and treatment efficacy. Important aspects to consider include an individual’s background, identity, community affiliations, languages they are comfortable with, family origins, ethnicity, and sexual orientation. This holistic approach ensures that assessments and treatments are respectful, relevant, and effective for each individual. Review APA’s Multicultural Guidelines.
Trauma-Informed Clinical Assessment
A trauma-informed approach to clinical assessment recognizes the widespread impact of trauma and prioritizes safety, trust, and empowerment for the client. Here are key elements:
- Safety: Create a safe and supportive environment for assessments by ensuring both physical and emotional safety. This involves being non-judgmental and validating the individual’s experiences. Consider the physical setup of the room to ensure safety for both the patient and the clinician. Clearly explain the purpose of the meeting, what will happen during the assessment, and provide information about your credentials, comfort, and experience in treating trauma. This approach helps build trust and sets the stage for an effective assessment.
- Trustworthiness: Build trust by being transparent about the assessment process, respecting confidentiality, and maintaining consistency in your interactions. Hold firm boundaries in treatment while understanding that no-shows may occur, and some interactions may involve anger or heightened emotions. Strive not to take these personally and regularly assess for safety to ensure a secure and supportive environment.
- Empowerment: Empower clients by involving them in the assessment process, offering choices, and validating their strengths and resilience. Provide options and acknowledge the challenges of treatment, encouraging clients to work towards their ultimate goals. Recognize that it may not always be the right time for certain treatments and meet them where they are. Encourage open communication to help clients direct their own treatment and express their needs.
- Collaboration: Work collaboratively with the client, acknowledging their expertise in their own experiences and fostering a sense of partnership in their care.
- Cultural Competence: Be aware of and sensitive to both the client’s and the clinician’s cultural and social contexts. This involves understanding how cultural factors may influence the treatment process. Consider how the cultural background of both the clinician and the client may impact the therapeutic relationship and treatment outcomes.
Advancements in trauma theory and science have provided invaluable insights into the diagnosis and treatment of PTSD. By incorporating these insights into a trauma-informed approach to clinical assessment, mental health professionals can enhance the accuracy of diagnoses and the effectiveness of interventions. This PTSD Awareness Month, let us commit to adopting a trauma-informed approach in our clinical practices, ensuring that our assessments and treatments honor the experiences and needs of those affected by trauma. By doing so, we can help individuals reclaim their lives and foster healing in a supportive and understanding environment.
References
Banschick, M. (2015, March). Somatic Experiencing: How trauma can be overcome. Psychology Today. Retrieved from https://www.psychologytoday.com/us/blog/the-intelligent-divorce/201503/somatic-experiencing
National Center for PTSD. (n.d.). PTSD and DSM-5. Retrieved from https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp
National Center for PTSD. (n.d.). How common is PTSD in adults? U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/understand/common/common_adults.asp
National Council for Mental Wellbeing. (2022). How to manage trauma [Infographic]. Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2022/08/Trauma-infographic.pdf
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